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In addition buy cheap zithromax online infection after wisdom tooth extraction, a collaborative relationship facilitates communication about side effects order 250mg zithromax visa bacteria 2 in urine test. Antihypertensive regimens may consist of several drugs taken multiple times a day discount zithromax online master card antibiotic joint pain cause. Therefore, to promote adherence, the dosing schedule should be as simple as possible. After an effective regimen has been established, dosing just once or twice daily should be tried. Adherence can be promoted by giving positive reinforcement when therapeutic goals are achieved. Also, adherence can be promoted by scheduling office visits at convenient times and by following up when appointments are missed. For many patients, antihypertensive therapy represents a significant economic burden; devising a regimen that is effective but inexpensive will help. Drugs for Hypertensive Disorders of Pregnancy Hypertension is the most common complication of pregnancy, with an incidence of about 10%. When hypertension develops, it is essential to distinguish between chronic hypertension and preeclampsia. Chronic hypertension is relatively benign, whereas preeclampsia can lead to life-threatening complications for the patient and the fetus. Chronic Hypertension Chronic hypertension, seen in 5% of pregnancies, is defined as hypertension that was present before pregnancy or that developed before the 20th week of gestation. Potential adverse outcomes include placental abruption, maternal cardiac decompensation, premature birth, fetal growth delay, central nervous system hemorrhage, and renal failure. The goal of treatment is to minimize the risk for hypertension to the patient and fetus while avoiding drug-induced harm to the fetus. When drug therapy is initiated during pregnancy, methyldopa and labetalol are the traditional agents of choice. These drugs have limited effects on uteroplacental and fetal hemodynamics and do not adversely affect the fetus or neonate. In contrast, there is little evidence that treating mild hypertension offers significant benefit. Patients who have chronic hypertension during pregnancy are at increased risk for developing preeclampsia (see later). Risk factors for preeclampsia include black race, chronic hypertension, diabetes, collagen vascular disorders, and previous preeclampsia. Risks for the fetus include intrauterine growth restriction, premature birth, and even death. The mother is at risk for seizures (eclampsia), renal failure, pulmonary edema, stroke, and death. Management of preeclampsia is based on the severity of the disease, the status of mother and fetus, and the length of gestation. The objective is to preserve the health of the mother and deliver an infant who will not require intensive and prolonged neonatal care. Management of mild preeclampsia is controversial and depends on the duration of gestation. If preeclampsia develops near term, and if fetal maturity is certain, induction of labor is advised. However, if mild preeclampsia develops earlier in gestation, experts disagree about what to do. Suggested measures include bed rest, prolonged hospitalization, treatment with antihypertensive drugs, and prophylaxis with an anticonvulsant. Studies to evaluate these strategies have generally failed to demonstrate benefits from any of them, including treatment with antihypertensive drugs. Because preeclampsia can deteriorate rapidly, with grave consequences for the patient and fetus, immediate delivery is recommended. However, if the fetus is not sufficiently mature, immediate delivery could threaten its life. Do we deliver the fetus immediately, which would eliminate risk for the patient but present a serious risk for the fetus—or do we postpone delivery, which would reduce risk for the fetus but greatly increase risk for the patient? Because severe preeclampsia can be life threatening, treatment must be done in a tertiary care center to permit close monitoring. Because severe preeclampsia can evolve into eclampsia, an antiseizure drug may be given for prophylaxis. In one study, prophylaxis with magnesium sulfate reduced the risk for eclampsia by 58% and the risk for death by 45%. If eclampsia develops, magnesium sulfate is the preferred drug for seizure control. To ensure therapeutic effects and prevent toxicity, blood levels of magnesium, as well as presence of patellar reflex, should be monitored. The target range for serum magnesium is 4 to 7 mEq/L (the normal range for magnesium is 1. When started before 16 weeks of gestation, low-dose aspirin reduces the risk for preeclampsia by about 50%. By contrast, several other preparations— magnesium, zinc, vitamin C, vitamin E, fish oil, and diuretics—appear to offer no protection at all. Treatment guidelines have been released by several organizations, including the American Society of Hypertension, the Canadian Hypertension Education Program, the European Society of Hypertension in conjunction with the European Society of Cardiology, and the World Health Organization in conjunction with the International Society of Hypertension. The disease affects nearly 5 million Americans and, every year, is responsible for 12 to 15 million office visits, 6. With improved evaluation and care, many hospitalizations could be prevented, quality of life could be improved, and life expectancy could be extended. However, because many patients do not have signs of pulmonary or systemic congestion, the term heart failure is now preferred. The syndrome is characterized by signs of inadequate tissue perfusion (fatigue, shortness of breath, exercise intolerance) and/or signs of volume overload (venous distention, peripheral and pulmonary edema). Other causes include valvular heart disease, coronary artery disease, congenital heart disease, dysrhythmias, and aging of the myocardium. As cardiac performance declines further, blood backs up behind the failing ventricles, causing venous distention, peripheral edema, and pulmonary edema. Cardiac Remodeling In the initial phase of failure, the heart undergoes remodeling, a process in which the ventricles dilate, hypertrophy, and become more spherical. Remodeling occurs in response to cardiac injury, brought on by infarction and other causes. In addition to promoting remodeling, neurohormonal factors promote cardiac fibrosis and myocyte death. The net result of these pathologic changes— remodeling, fibrosis, and cell death—is progressive decline in cardiac output.

As the inflammatory pro­ cess progresses buy zithromax 500 mg without prescription antibiotic japan, there is an increase in capillary permeability 100mg zithromax with visa zombie infection symbian 94, leading to increase in alveolar fluid that increases the distance for oxygen difusion to occur order zithromax 100mg amex antibiotics for sinus infections best ones. Identification of a P/F ratio of <300 indicates that the patient has acute lung in­ jury. The goal for treatment of these patients is to con­ tinue to provide adequate oxygenation without further damage to the alveoli. This lung-protective ventilation strat­ egy decreases the incidence of volutrauma and barotrauma, and also decreases the levels of inflammatory mediators. This is why early management of resuscitation is extremely important in critically ill patients. This combina­ tion results in loss of efective preload, contractility, and afterload. However, this treatment may contribute to the worsening of the system, as the fuids administered may not stay intravascular because of the increased vascular permeability. The use of pressors is advocated only once it is determined that the intravascular volume has been repleted. Likewise, the blood and blood products can be used to increase intravascular volume, but are associated with complications. The injudicious use of vasopressors and blood transfsions is known to increase morbidity and mortality. The use of ScV0 (central venous oxy­2 gen saturation obtained via central venous catheter), lactate, and base excess can help guide the initial resuscitation. The ScV0 refects2 the upper body/head extrac­ tion of oxygen and is usually higher than the mixed venous 0 in situations of2 shock. The elevation of bilirubin is most likely a result of leakage of bile from hepatic canaliculi that have been damaged by cytotoxins and infammatory mediators. There is no specific supportive therapy aimed directly at the liver, so continued support of the other systems is all that is necessary. Release of pancreatic enzymes into the circulation, degrading level of serum proteins B. He had mul­ tiple small bowel enterotomies repaired and a short segment of bowel was resected. After 36 hours, he remains intubated and develops increasing white blood cell count, tachycardia, and fevers. Atypical pneumonias are mostly encountered in immunocompromised hosts; therefore, not a likely diagnosis in this otherwise healthy man. While the other mechanisms may be the instituting and contributing factors, the systemic infammatory response is secondary to the release of cyto­ kines from monocytes that have been activated. Occasionally, the infammatory cascade does not subside and becomes a positive feedback loop. Given the circumstances of his injury, missed intra-abdominal injury and intra-abdominal infections are distinct possibilities. Similarly, this patient who is a trauma victim and who recently underwent emergency laparotomy for intraabdominal injuries is at risk for the development of pneumonia. Additionally, there is currently no evidence of acute kidney injury or hepatic injury or pulmonary injury. Ye sterday, he was extu­ bated from mechanical ventilation, and had been doing well up to this morning. This morning, the patient has persistent pulse rates ranging from 100 to 110 beats/ minute, and he is noted to be somnolent and does not interact with his fa mily. What are the manifestations of endocrine disorders associated with critical illnesses? To learn the cardiovascular, metabolic, behavioral, and immune disorders that may be produced by endocrine changes associated with critical illnesses. Even though he has taken steps toward improvement, his persistent tachycardia and mental status change now requires that we further investigate for the causes. At this point, complete blood count, chemistries, arterial blood gas, chest x-ray, electrocardiogram, and cardiac enzymes may be usefl in identifing cardiopulmonary causes. Potential new sources of infections may be evaluated with a thorough physical examination, appropriate cultures, and imaging studies. Subsequent to these initial responses, critically ill individuals may enter into a state of hypercatabolism, which could be produced by thyroid dysfunction and manifest clinically as tachycardia, atrial fibrilla­ tion, or agitation. Elevated metabolic activity secondary to hyperthyroidism can be evaluated by thyroid fnction studies. The exact causes of these neuropsychiat­ ric changes have not been determined; however, it has been theorized that intense inflammatory mediator and cytokine responses may alter neurohormonal homeostasis and lead to neuropsychiatric dysfunctions. Transfsion ofpacked red blood cells may also be initiated for a general hemoglobin goal of 7 to 9 g/dL; however, for patients with lactic acidosis, hemorrhage, or coronary ischemia, the hemoglobin goal should be 10 g/dL. Source control with broad-spectrum antibiotics should be started immediately, with subsequent narrowing of coverage as soon as culture results are available. In managing critical illness, physi­ cians should remain vigilant in considering endocrine derangements such as adrenal insuficiency, hyper- or hypoglycemia, vasopressin defciency, and thyroid dysfnction. Endocrine Response to Critical Illness Tw o physiologic pathways are activated during periods of acute stress: the sympathetic nervous system and the endocrine system. The sympathetic nervous system is activat­ ed via secretion ofcatecholamines fom the adrenal medulla, leading to changes in the cardiovascular, metabolic, immunologic, and endocrine systems. In the acute phase of illness, the endocrine system is responsible for an adaptive response to maintain organ perfusion, decrease anabolism, and up-regulate the immune response. In the chronic phase of illness, the endocrine system may play a role in the development of persistent hypercatabolism and contribute to organ dysfunction. Sympathetic Nervous System and Arginine Va sopressin The "fight or fight" response fom the sympathomimetic system is produced by nor­ epinephrine, epinephrine, and dopamine release fom the adrenal medulla. Catecholamines are also released fom mesenteric organs during stress, which contrib­ ute to a significant percentage of total levels in the body. Some patients with sepsis have insuficient host catecholamine responses and therefore, may benefit from exogenous administration of vasoactive medication to maintain end-organ perfsion. Dopamine or norepinephrine is often given as a first­ line agent when septic shock patients are refractory to appropriate fluid manage­ ment. Arginine vasopressin is a neurohypophyseal hormone that acts on V1 vascular smooth muscle cell receptors and V2 renal tubular cell receptors to cause hemostasis, arterial vasoconstriction, and antidiuresis. With sepsis, some patients may develop relative vasopressin deficiency with down-regulation of V1 receptors, and may ben­ efit from low-dose exogenous vasopressin. Thus, patients with septic shock that is refractory to fuid management and high-dose conventional vasopressors may be candidates for vasopressin. Cortisol has several important physiologic actions on metabolism, including stimulatory efects on the cardiovascular and immune system. During stress, cortisol increases blood glucose concentration by activating hepatic gluconeogenesis and inhibiting glucose uptake by peripheral tissues.

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In reviewing our patients discount zithromax online visa antibiotic resistance threats in the united states cdc, we also found that mind that alteration of the nasolabial angle by surgery on the actual spine removal was performed in 5% of patients purchase zithromax discount infection of the brain. Conse- columella-labial complex of cartilage order zithromax 500 mg with mastercard bacteria botulism, bone, and soft tissue quently, the caudal septum was altered in more patients. The attachments of the upper lip to the col- fore, treatment of this area of the columella-labial complex is umella and medial and lateral aspects of the alae help form the extremely important in achieving a balanced rhinoplasty. Therefore, when one is referring to the junc- We describe six categories of nasal analysis in which the tion of the philtrum to the base of the columella, a more appro- nasolabial angle, the length of the septum, and/or the presence priate designation would more ideally be termed the “colum- of a pushing philtrum is evaluated. On nasal plastic surgeon to perform alteration of the columella- profile view, the desired nasolabial angle is 95 to 100 degrees in labial structures that will complement changes made elsewhere men and 100 to 110 degrees in women. The nasal spine can be approached through a hemi-transfixion or full transfixion incision in intranasal rhinoplasty or via exter- 46. It is important to carry the incision down to the junction of the caudal septum and nasal spine. The surgeon can address the (Obtuse) Nasolabial Angle depressor septi nasi muscle at this juncture, bearing in mind that this muscle usually needs to be fully elevated if the entire An open nasolabial angle is one that is greater than the desired nasal spine is going to be resected. If the caudal septum needs 95 to 100 degrees in men and 100 to 110 degrees in women. For complete removal, a vertical osteotomy is per- length of the caudal septum remains normal, no alterations to formed from an inferior approach, followed by mobilization of the cartilage are necessary. Conservatism cannot be overem- A closed nasolabial angle is less than 95 to 100 degrees in men phasized to the beginning rhinoplasty surgeon. In a patient who presents with a long septum and an acute columella-labial angle, angled resection of the caudal portion of the nasal septum should suf- fice. A triangular resection is performed with the apex of the triangle oriented posteriorly. Normal Nasolabial Angle This also gives the remainder of the medal crura room to rotate No treatment is necessary unless a pushing philtrum is present. Reduction rhinoplasty; the nasal spine was normal so there was no treatment for the caudal septum or nasal spine. Rhinoplasty with partial resec- tion of the nasal spine to prevent and counter further nasal tip rotation. The premise of this Nasolabial Angle maneuver is to reset the caudal portion of the nose cephalically These patients have a high nasolabial angle, yet on measure- to create a balanced nasolabial angle and counter any nasal tip ment the nose is excessively long. There was no treatment for rotation that may occur from modifications of the nasal dor- the caudal septum is due to a long nasal septum. Therefore, more septum is resected at the base to help close the nasolabial angle. If the nasolabial angle is close to desirable, a rectangular segment of the cartilage should be Patients with a short septum and an open nasolabial angle tend excised to effectively shorten the columella. Partial reduction of to have a posteriorly sloping upper lip and a small-appearing the nasal spine should be performed to help close the angle. Modified Goldman tip with triangular resection of caudal nasal septum with the apex oriented posterior to allow tip rotation. Partial nasal spine resection with triangular resection of caudal septum with the apex oriented anterior to reduce the nasola- bial angle. Complete removal of the nasal spine is usually necessary to help patient with a short septum and a closed nasolabial angle. This graft is from lay- may require much more extensive nasal lengthening procedures. A single thin layer of carti- Lengthening techniques are outside the purview of this chapter lage is rarely sufficient. Silastic or extended-polytetrafluoro- but may include extended spreader grafts, columellar extension ethylene implants placed caudal to the nasal spine may also be grafts, or stacked onlay grafts. However, This type of nose is more often encountered in platyrrhine and creation of an aesthetically pleasing rhinoplasty requires evalu- Asian noses. There is a lack of supporting skeletal structure ation of all aspects of the nose. The intricate relationship require significant support to enhance structure and strengthen of the caudal septum, nasal spine, upper lip, and lobule that weak cartilages. The nasal spine and septum are not altered in a form this angle should be considered in all rhinoplasties. Nasal augmentation with columellar strut, extended shield graft, radix graft, and 4mm thick extended-polytetrafluoro- ethylene premaxillary graft. Intimate knowledge of nasal tip projection, tip rotation, and lateral cartilages, which will decrease the amount of middle the consequences of all surgical maneuvers performed are well vault bulk; caudal resection of the caudal septum; and the use known to be necessary for quality surgical results; additionally, of struts or grafts in the columella. Nasal tip dynamics can fall under two cat- septum with the apex in either the posterior or an anterior egories: a drooping tip and a dependent tip. A drooping tip position to open or close the angle, thus creating a potential relies on the action of the nasalis and depressor septi nasi space for the tip to rotate. When these structures are combined Despite nasal tip rotation maneuvers, the result may be sub- with a prominent nasal spine and caudal septum, they may optimal unless the effect of the columella-labial complex on the protrude, causing an unnatural appearance. A dependent tip is a geon must identify the presence of a pushing philtrum; other- passive phenomenon that causes an acute nasolabial angle, wise the patient will continue to have a displeasing upper lip which in turn results from weak support mechanisms of the that appears to “precede itself’’ and may actually be exagger- nasal tip. Patients with a large dorsal hump and Tardy et al11 described three major and six minor tip-support a relatively large nasal spine may have a nose that is large, yet mechanisms. Reducing the hump without addressing the spine dis- shape, size, and resilience of the lateral and medial crura; the turbs that balance, giving the appearance of a “fixed” nose. The attachment of the lower lateral cartilages to the caudal border spine would appear too large for the now straightened dorsum. The six minor tip support mechanisms are (1) the attach- Partial or complete resection of the nasal spine alone will not ment of the domes of the lower lateral cartilages; (2) the carti- affect projection, unless coupled with alteration of the other laginous septal dorsum; (3) the sesamoid complex, which major tip support mechanisms. In most circumstances, all extends the support of the lateral crura to the pyriform aper- structures of the nasal tip and columella-labial complex are ture; (4) the attachment of the alar cartilages to the underlying altered in some manner. Nasal spine resection will result in skin and musculature; (5) the nasal spine; and (6) the membra- resetting the caudal portion of the nose at the base of the col- nous septum. Reestablishment or preservation of these support umella superiorly, thus creating a balanced nasolabial angle. It mechanisms is necessary to ensure proper tip projection during has been our observation that removal of the nasal spine alone rhinoplasty. In two patients who had spine removal without modi- (1) interruption of the continuity of the lower lateral cartilages fication of the nasal tip or caudal septum, no detectable to its attachment on the maxilla, (2) vertical dome division, and changes were recorded in nasal tip projection or angle. Flowers and Smith13 have trimming to reduce tip width; caudal trimming of the upper described a unique technique for correcting a retracted colum- 363 Tip Rhinoplasty ella, an acute columellar-labial angle, and a long upper lip. A a minority of patients and the caudal septum in considerably decorticated centrally based transverse flap from the lip and more. However, failure to recognize contributions of the nasola- nostril is transposed into a columellar pocket that effectively bial complex may result in an unsatisfactory result, which is an shortens the upper lip, corrects the retracted columella, and unacceptable aesthetic complication. This technique also avoids ters for altering or preserving the nasolabial angle and its struc- alloplastic or autogenous grafting. Cachay-Velasquez and Laguinge14 advocate excising a rhom- boidal/diamond portion of both the depressor muscle and the orbicularis muscle and suturing the remaining ends with a mat- References tress suture. Columella-labial changes in solution of rhino- nasolabial angle, and reducing the interalar distance without plastic problems.

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The incidence of cervical cancer in women under 25 years is low and screening these women has not been shown to reduce the incidence of cervical cancer order zithromax 100mg fast delivery when you need antibiotics for sinus infection. In view of the above reasons cervical screening is not recommend in women under the age of 25 zithromax 100mg lowest price antibiotic resistance can come about by. It is associated with lichen sclerosus and is a high risk for developing into a squamous cell carcinoma discount zithromax 100mg free shipping antibiotics ointment. The following drugs can be used in the treatment of her condition except which one of the following? Fourth-degree tear involves injury to the anal sphincter complex, but not anal mucosa. Intact perineal skin excludes the possibility of damage to the anal sphincter complex. The degree of trauma in a right mediolateral episiotomy is equivalent to a second-degree tear. Question 5 A 22-year-old Caucasian para 0 woman attends maternal medicine clinic at 13 weeks’ gestation following her normal dating scan. She gives a history of deep venous thrombosis following a pelvic fracture afer a trip over the stairs 2 years ago. Choose the most appropriate management option for this woman with regards to thrombopropylaxis. Her medications box reveals that she has taken tranexamic acid for the whole previous month. Infundibulopelvic ligament Instructions For each clinical scenario below, choose the single most appropriate anatomical structure from the above list of options. You are assisting a total abdominal hysterectomy and bilateral salpingo- oophorectomy procedure on a 58-year-old woman with complex endometrial hyperplasia. The surgeon has to clamp and cut one of the above structures to excise ovaries from the pelvic side wall. She presents with history of 6 weeks, amenorrhoea, lower abdominal pains and a positive pregnancy test. Ultrasound confrms a right-sided ectopic pregnancy and at laparoscopy, Filshie clip was found on this ligament on the right side, instead of the fallopian tube. A 26-year-old nulliparous woman attends the gynaecology clinic with history of severe dysmenorrhoea and dyspareunia. On examination, the uterus is retroverted, fxed and tender with irregular nodules in the pouch of Douglas. At laparoscopy, you notice extensive endometriosis on these structures obliterating the pouch of Douglas. Autonomy Instructions For each clinical scenario below, choose the single most appropriate principle from the above list of options. A 36-year-old para 5 woman is a practicing Jehovah’s witness and has signed the advanced directive declining blood transfusion under any circumstances. She had fve normal deliveries in the past and had uncomplicated antenatal period during this pregnancy. A 38-year-old woman with a previous caesarean section presents in active labour at term and wishes to have vaginal birth afer caesarean section. At 8 cm dilatation, there is fetal bradycardia followed by maternal hypovolemia and loss of consciousness. Afer making the decision that this patient is not in a ft state to consent, you proceed with an emergency laparotomy. Afer an episode of unprotected intercourse a 15-year-old girl attends the family planning clinic for emergency contraception. As she has been sexually active for the last 3 months she is also requesting a reliable contraceptive method. Ureteric injury Instructions For each clinical scenario below, choose the single most likely surgical complication from the above list of options. A 26-year-old woman attends the emergency department with a history of lower abdominal pain and feeling unwell, 5 days afer an emergency caesarean section for failure to progress in the second stage afer a failed instrumental delivery. On examination, she was tender in the lower abdomen with guarding and bowel sounds were present. Tough there is some clinical improvement afer admission with intravenous antibiotics, she still has swinging temperatures. At delivery, there was an extension of the lef uterine angle with massive haemorrhage, which was controlled by placing multiple haemostatic sutures and securing uterine angles. A 28-year-old woman attends the emergency department with severe lower abdominal pain and feeling unwell, on day 2 afer a diagnostic laparoscopy for chronic pelvic pain and subfertility. On examination, there is severe tenderness in the lower abdomen with rigidity, guarding and rebound tenderness. The following treatments have been used in the management of utero-vaginal prolapse: A. The following are standard treatment modalities used to treat stage 1a grade 1 endometrioid adenocarcinoma of the uterus: A. A 29-year-old para 1 woman presents to the emergency department with a history of 6 weeks’ amenorrhoea and abdominal pain. She has a transvaginal scan the following day that reveals a 3 cm ectopic pregnancy in the lef fallopian tube. A 38-year-old para 1 woman presents to labour ward at 34 weeks’ gestation with regular painful contractions. Her ultrasound scan at 20 weeks’ gestation shows placenta covering the cervical os completely. She is requesting caesarean section as she had forceps delivery during her last pregnancy. A 29-year-old para 1 woman presents to the labour ward at 39 weeks’ gestation with regular painful contractions. While performing vaginal examination you notice multiple vesicular lesions on bilateral labia and mons pubis consistent with primary active genital herpes infection. A 38-year-old para 1 woman presents to the labour ward at 38 weeks’ gestation with painful labour contractions. Open myomectomy is associated with an increased operative morbidity compared to open hysterectomy. The following are the correct classifcations for the urgency of caesarean section in these clinical scenarios: A. Midwife performs speculum examination, which reveals 3 cm cervical dilatation and umbilical cord in the vagina. Abdominal examination reveals a tense and tender uterus and speculum examination reveals active vaginal bleeding. She is keen to have caesarean section and this should be performed as a category 2 caesarean section. Twenty-four hours later vaginal examination reveals no progress in cervical dilatation. The following should be discussed when counselling a woman with one previous uncomplicated caesarean section wanting to try for a vaginal birth: A. Women should be informed that there is virtually no risk of uterine rupture in women undergoing elective caesarean section.

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This sug- gest s an in t r at h or acic m ass cau sin g br on ch ial obst r u ct ion an d imp air m en t of the recurrent laryngeal nerve order zithromax paypal infection under fingernail, causing vocal cord paralysis buy generic zithromax 500 mg online antibiotics chicken. Eighty-five percent of patients with lung cancer of all histologic types have a smoking history zithromax 500mg lowest price antibiotic resistance webmd. The most common form of lung cancer found in nonsmokers, young patients, and women is adenocarcinoma. Tissue diagnosis is essential for proper treatment of any malignancy and should always be t he first st ep. O nce a specific t issue diagnosis is obt ained, the cancer is staged for prognosis and to guide therapy, whether that is sur- gical r esect ion, ch em ot h er apy, or r adiot h er apy. Q u est ion s for this pat ient include t he t issue t ype, locat ion of spread, and whet her the pleural effusion is cau sed by malign an cy. Ma s s ive h e m o p t ys is m a y re s u lt in d e a t h b y a s p h yxia t io n. For large r lesions, a b iop sy, whethe r b ronchoscop ic, percutaneous, or surgical, should be considered. Non-small cell lung cancer may be curable by resection if it is e a rly st a g e, a n d the p a t ie n t h a s su fficie n t p u lm o n a ry re se rve. He was in his usual state of good health until 1 week ago, when he developed mild nasal congestion and achiness. He otherwise felt well until last night, when he became fatigued and feverish, and developed a cough associated with right-sided pleuritic chest pain. His physical examination is unremarkable except for bronchial breath sounds and end-inspiratory crackles in the right lower lung field. He is febrile to 102°F, but not tachypneic, and is normotensive with good oxygenation. H is physical examination is unremarkable except for bronchial breath sounds and end-inspiratory crackles in t he right lower lung field, and t here is a right lower lobe consolidation on chest x-ray. Next step: O ral antibiotic therapy, pain relievers, antipyretics, and cough sup- pressants for relief of symptoms. Discuss the role of radiologic and laboratory evaluation in the diagnosis of pneumonia. Understand the difference between aspiration pneumonitis and aspiration pneumonia. Co n s i d e r a t i o n s This previously healthy 44-year-old man has clinical and radiographic evidence of a focal consolidat ion of t he lungs, which is consist ent wit h a bact erial process, such as infect ion wit h Streptococcus pneumoniae. T h e specific cau sat ive or gan ism is usually not definit ively est ablished, so you will need t o init iat e empiric ant imicrobial therapy and risk stratify the patient to determine whether he can safely be treated as an outpat ient or requires hospit alizat ion. Patient s may present with any of a combination of cough, fever, pleurit ic chest pain, sputum product ion, short- ness of breath, hypoxia, and respiratory distress. Certain clinical presentations are associated with part icular infect ious agent s. For example, the “t ypical” pneumonia is often described as having a sudden onset of fever, cough wit h product ive sputum, often associated with pleurit ic chest pain, and possibly rust- colored sputum. The “a t y p i c a l ” p n e u m o n i a is ch ar act er ized as h avin g a more insidious onset, with a dry cough, promin ent ext ra- pulmonary symptoms such as headache, myalgias, sore throat, an d a ch est radio- gr aph that app ear s mu ch wor se t h an the clin ical or au scu lt at or y fin d in gs. Alt h ough t h ese ch ar act er izat ion s are of som e d iagn ost ic valu e, it is ver y difficu lt t o r eliably d ist in - gu ish bet ween t ypical an d at yp ical or gan ism s based on clin ical h ist or y an d ph ysical examinat ion as t he cause of a specific pat ient ’s pneumonia. T herefore, pneumonias are t ypically classified according to the immune st atus of t he host, the radiographic fin d in gs, an d the set t in g in wh ich the in fect ion was acqu ir ed, in an at t emp t t o id en - tify the most likely causative organisms and to guide initial empiric therapy. Community-acquired pneumonia, as opposed t o n osocomial or h ospit al-acquir ed pneumonia, is most commonly caused by S pneumoniae, M pneumoniae, Haemophi- lus influenzae, Chlamydophila pneumoniae, or r espir at or y vir u ses, such as in flu en za and adenovirus. D espite careful history and physical and rout ine laboratory and radiographic investigation, it is difficult to determine a specific pathogen in most cases. Epid emiology an d r isk fact or s may pr ovid e some clu es: Chlamydia psittaci (bird exposure), coccidioidomycosis (travel to the American southwest), or his- toplasmosis (endemic to the Mississippi Valley) may be the cause. In addit ion t o t hese scores, pat ient’s abilit y to t ake oral medicat ion and the availabilit y of outpat ient support resources should be considered. Although outpatients usually are diagnosed and empiric treatment is begun based on clinical findings, further diagnostic evaluation is important in hospital- ized pat ient s. Un less the patient cannot mount an immune response, as in severe neutropenia, or the process is very early, every patient with pneumonia will have a visible pulmonary opacity. Infection with S pneumoniae classically pr esent s wit h a d en se lobar con solidat ion, oft en wit h an associat ed par a- pneumonic effusion. Diffuse interstitial opacities are common in Pneumocystis pneumonia and viral processes. Appearance of cavitation suggests a necrotizing infection such as S a ur eus, t uber- culosis, or gram-negative organisms such as P aeruginosa or Klebsiella pneumoniae. Serial chest radiography of inpatients usually is unnecessary, because many weeks are required for t he infilt rate to resolve; serial chest radiography t ypically is per- formed if the pat ient does n ot sh ow clin ical improvement, h as a pleural effu sion, or has a necrotizing infection. A repeat radiograph to show complete resolution of the opacities may be prudent in patients at high risk for a postobstructive pneumonia from a p ot en t ial u n d iagn osed lu n g m align an cy. Microbiologic studies, such as sputum Gram stain and culture, and blood cul- tures are important to try to identify the specific etiologic agent causing the illness. However,useof sputum Gram stain and cultureislimited bythefrequent contami- nation by upper respiratory flora as the specimen is expectorated. H owever, if the sput um appears purulent and it is minimally cont aminat ed (> 25 polymorphonu- clear cells an d < 10 epit h elial cells p er low-p ower field), the d iagn ost ic yield is good. Addit ionally, blood cult ures can be h elpful, because 30% t o 40% of pat ient s wit h pneumococcal pneumonias are bacteremic. Finally, fiberopt ic bronchoscopy wit h bronchoalveolar lavage often is performed in seriously ill or immunocompromised pat ient s, or in t hose pat ient s wh o are not responding to therapy, to try to obtain a specimen from the lower respiratory tract for rout in e G ram st ain an d cult ure, as well as more soph ist icat ed t est ing, su ch as direct fluorescent antibody testing for various organisms, for example, Legionella. Initially, empiric treatment is based on the most common organisms given the clin ical scen ar io. For out pat ient t h er apy of community- acquired pneumonia, macro- lide ant ibiot ics, such as azithromycin, d oxycyclin e, or ant ipn eu mococcal quino- lones, su ch as moxifloxacin or levofloxacin, are good ch oices for t reat ment of S pneumoniae, Mycoplasma, an d ot h er common or gan isms. Recent u se of ant ibiot - ics and known communit y resist ance patt erns t o common organisms should be con sid er ed in makin g this ch oice. D u r at ion of t h er apy for com mu n it y-acqu ir ed pneumonia should be minimum of 5 days. Hospitalized patients with community- acquired pneumonia usually are t reat ed wit h an intravenous third-generation cepha- losporin plus a macrolide or with an antipneumococcal quinolone. For immuno- comp et ent pat ient s wit h h ospit al-acqu ir ed or vent ilat or-associat ed pn eu mon ias, the causes include any of the organisms that can cause community-acquired pneumonia, P aeruginosa or S a ur eus, as well as mor e gr am-n egat ive ent er ic bac- teria and oral anaerobes. Accordingly, the initial antibiotic coverage is broader and includes an antipseudomonal beta-lact am, such as piperacillin or cefepime, plus an aminoglycoside.

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