By Ian Allan
While numerous generations of small boys can have dreamed of changing into engine drivers, and the top-link motive force at the nice named expresses of the age of steam can have been the top of the railways, by way of renowned belief, those contributors may basically have gotten there with the help of myriad different trades and after years of progressing during the extra junior grades of footplate employees. From the common-or-garden junior porter via to the chairman of the board, the railways hired an enormous array of alternative trades, all of whom have been crucial in maintaining the trains working. a few of these jobs, akin to that of the tune gangs, are nonetheless an incredible a part of the upkeep of the fashionable railway, yet many others, reminiscent of blacksmiths, have now disappeared.
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Do not insert chest tube. 03% 2 sprays/nostril BID–TID, nasal corticosteroids, nasal saline rinses BID), surgical correction for anatomical abnormalities findings; consider sinus imaging TREATMENTS —reduce irritant exposure, antihistamine- decongestant combinations (diphenhydramine 25–50 mg PO q4–6 h PRN, · Hemoptysis DIFFERENTIAL DIAGNOSIS NONC ARDIOPULMONARY —epistaxis, upper GI bleed, coagulopathy CARDIAC—HF, mitral stenosis PULMONARY · AIRWAY —bronchitis (acute, chronic), bronchiectasis, malignancy, foreign body, trauma · PARENCHYMA · MALIGNANCY—lung cancer, metastasis INFECTIONS —necrotizing pneumonia (Staphylococcus, Pseudomonas), abscess, septic emboli, TB, fungal · ALVEOLAR HEMORRHAGE—granulomatosis with polyangiitis (Wegener's), Churg– Strauss, Goodpasture disease, pulmonary capillaritis, connective tissue disease VASCULAR—pulmonary embolism, pulmonary hypertension, AVM, iatrogenic · · PATHOPHYSIOLOGY MASSIVE HEMOPTYSIS—100–600 mL blood in 24 h.
3 mmol/L [<60 mg/dL])—parapneumonic, TB, paragonimiasis, malignancy, rheumatoid arthritis, Churg–Strauss, hemothorax · FLUID EOSINOPHILIA (>10%)—paragonimiasis, malignancy, Churg–Strauss, asbestos, drug reaction, pulmonary embolism, hemothorax, pneumothorax, idiopathic (20%) · CYTOLOGY FOR MALIGNANCY—the yield for diagnosis with single attempt is 60%, two attempts is 85%, three attempts is 90–95%; obtain as much fluid as possible to increase diagnostic yield · FLUID FOR AFB—obtain as much fluid as possible and ask laboratory to centrifuge collection and to culture sediment to increase diagnostic yield MANAGEMENT SYMPTOM CONTROL—O2, diuresis (furosemide), drainage (thoracentesis, pigtail catheter, PleurX catheter, chest tube), pleurodesis (talc slurry or poudrage), surgery (talc slurry, pleuroperitoneal shunt, pleural abrasion, pleurectomy) TREAT UNDERLYING CAUSE SPECIFIC ENTITIES PARAPNEUMONIC EFFUSION · UNCOMPLICATED—exudative effusion that resolves with resolution of pneumonia.
Commonly caused by closed fractures of long bones, but may also occur with pelvic fractures, orthopedic procedures, bone marrow harvest, bone tumor lysis, osteomyelitis, liposuction, fatty liver, pancreatitis, and sickle cell disease CLINICAL FEATURES —triad of dyspnea, neurological abnormalities (confusion), and · · petechial rash (head and neck, chest, axilla). May also have fever, thrombocytopenia, and DIC DIAGNOSIS—clinical diagnosis (rash is pathognomonic). Investigations may include CXR, V/Q scan, CT chest, and MRI head TREATMENTS—supportive care as most patients will fully recover.
All In A Day's Work by Ian Allan