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Subarachnoid haemorrhage Migraines are described as a pulsating headache whereas this one is continuous cheap zyrtec line allergy symptoms phlegm. Non-focal neurological symptoms such as behavioural changes are a ‘red-fag’ symptom that suggests a serious intracranial cause for the headache such as cer- ebral venous thrombosis cheap zyrtec 5mg with mastercard allergy testing requirements. Dehydration that often occurs during labour is a predis- posing factor to cerebral vein thrombosis buy zyrtec 10 mg with mastercard allergy symptoms fatigue, as is pregnancy. Subarachnoid haemorrhage classically comes on very suddenly – described as a ‘thunderclap’ headache, and this was a subacute onset, but this is still on the differential list. Postpartum headaches are often blamed on leakage of spinal cerebrospinal fuid due to inadvertent dural tap during epidural insertion, but the anaesthetist will know if this has happened and these patients do not usually develop an acute confusional state. She was given antibiotics in labour and tells you that the baby was admitted to the neonatal intensive care unit shortly after delivery. Her partner is not keen for her to have this done as he is having trouble coping with their toddler and wants her to go home immediately. Whilst you are counselling her about puerperal sterili- sation, which of the following statements is correct about this situation? She should defer the decision 24 hours for further discussion to avoid regret Puerperal sterilisation is feasible but not using the laparoscope as the fundus of the uterus is still high – a ‘mini-laparotomy’ will be needed with the incision just below the umbilicus to reach the tubes. The failure rate is higher as it is more diff- cult to get the whole fallopian tube securely included in the clip. The chance of her changing her mind is also higher, and it is worth pointing out that if the decision is delayed until after the baby’s frst birthday, the chance of cot death declines and regret is less likely. On the third day she complains of discomfort and swell- ing in her right leg, which is clearly larger than the left leg, with a tender calf. The most appropriate medication whilst awaiting the results of further investigation is: A. Loading dose of Warfarin You need to protect her against thromboembolism whilst you are awaiting the results of investigations. Twenty and forty milligrams are prophylactic doses rather than treatment so this is not enough heparin. In pregnancy the advice is still to give twice-daily treatment doses despite the change in management for nonpregnant patients on medical wards to use once-daily treatment doses. Which of these statements contains correct advice regarding the management of her diabetes in the puerperium? On examination the newborn infant is well but the genitalia are ambiguous with a small phallus and some scrotal-like development of the skin. Take the baby’s blood for 17-hydroxyprogesterone levels This baby is likely to be a girl with congenital adrenal hyperplasia due to 21- hydroxylase defciency. The ambiguous genitalia are due to exposure to high lev- els of androgen in utero. Although there will be high levels of 17-hydroxyprogesterone in the baby’s blood, it is important to check that the baby does not have the salt-losing form of this condition, which can lead to severe dehydration and death so hospital admission is advisable. She is experiencing bouts of crying, is off her food, and hav- ing trouble sleeping. She delivered her first baby 6 weeks ago and is very upset that she has had to give up breast-feeding as she felt unable to cope. She is at present on the High Dependency Unit having a blood transfusion but her condition seems to have stabilised and her husband is at her bedside looking after the newborn baby. His mother came into hospital with them but only one person was allowed into the operating theatre with her. In the hospital cafe you meet the mother-in-law who is anxiously waiting for news and asks you why the delivery is taking so long. To go to the High Dependency Unit to see the new mother and baby This is an ethical challenge. It is a breach of confdentiality even to acknowledge that the patient is in the hospital but the mother-in-law came in with her, so it is slightly ridiculous to pretend otherwise. However, you are absolutely not allowed to give her any information – family dynamics can sometimes be surprisingly awkward – and the safest thing to do is to send the husband to tell his mother what is going on. Personality disorder A family history of puerperal psychosis is a risk factor but the highest risk is for those patients with a personal history of severe mental illness (which gives about a 50 per cent chance of developing puerperal psychosis). A woman who delivered a stillborn baby this morning is waiting for a prescription for cabergoline to suppress lactation. A woman who had a caesarean section 3 days ago is ready to be dis- charged and is awaiting a prescription for analgesic drugs to take home. A woman who suffered a major postpartum haemorrhage yesterday is waiting for you to prescribe a blood transfusion. A woman who had an emergency caesarean section 2 hours ago is waiting for a prescription of low molecular weight heparin prophylaxis. The woman with sepsis is urgent because her clinical condition is serious, as evi- denced by her low temperature and blood pressure. She shouldn’t even be on the postnatal ward and transferring her to a high dependency ward would be a prior- ity too. She has just been readmitted a week postpartum with a massive haemorrhage and is on the operating table where the consultant is having difficulty stop- ping the bleeding. Which of the following statements is correct regarding the management of this situation? Transfuse her own blood from the cell saver Unfortunately, there is nothing you can do if she has signed an advanced direc- tive unless you can prove that she was not of sound mind when she did that. This must be one of the most distressing situations medical staff can fnd themselves in, but she cannot be rescued by a blood transfusion. The baby is doing fine but the mother sustained a third-degree tear that has been repaired by your consultant. When debriefing her about the third-degree tear, which of the following statements is true? Third-degree tears do not occur with normal deliveries Third-degree tears usually heal very well and it is uncommon for women to have problems with anal incontinence afterwards. Studies show that 60 to 80 per cent of women are asymptomatic at 12 months postpartum. These tears can happen during a normal birth but are more common with assisted delivery (forceps more so than ventouse). We are uncertain how to advise women to deliver in the next pregnancy and some obstetricians only advise caesarean of she has residual symp- toms after the previous repair such as incontinence of fatus or faeces. The best option from the list is to give her Depo-Provera®, which you would review after 2 years. She wishes to start secure contraception imme- diately before she leaves hospital but does not want to rule out having another child in the future.

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Many of the techniques described in requires particular skill in aligning the graft perfectly with the literature involve morselizations cheap zyrtec 5mg visa allergy forecast louisville ky, incisions buy zyrtec 10mg allergy medicine mold, and resections the surrounding structures; otherwise generic zyrtec 10mg fast delivery allergy nasal spray, a notch may be visible to open the cartilaginous spring of the dorsal pillar of the sep- at the rhinion. It is thus possible to change the strengthening of the dorsal pillar, which makes it possible to alignment of the nasal septum by securing a straight perform reshaping incisions with no fear of weakening of the reshaped portion of it in a dorsal position. The use of a septal crossbar graft to treat crooked nose forms dorsal septum before tracing the incisions, which makes it pos- part of this developing tradition. The rectangular cartilaginous sible to establish the exact measurements of the latter in rela- graft is in fact embedded in the dorsal septum just as a bar is tion to the graft. All this ultimately serves to avoid the risk of used to prevent a door being opened from the outside. The effec- harvesting a graft that is too short for the distance between the tiveness of this mechanism of defense against attack from out- two incisions. The wedge-shaped tapering of the lower section side has been recognized since ancient times. In of the crossbar also constitutes a valid technical development crooked nose, the immediate postoperative result must be ensuring better alignment of the graft with the dorsal septum. To the raising and lateral movement of the upper lateral cartilage this end, it is preferable to harvest the graft before making the by the graft on the concave side makes it possible to restore a incisions. In this connection, it has been a useful improvement correct angle of the internal nasal valve. In cases of of the technique to position the graft temporarily alongside the crooked nose, the upper lateral cartilage is in fact particularly 73 Management of the Septum Fig. Application of the cartilage, thus also enabling it to support small onlay grafts if crossbar graft thus produces both a functional improvement in necessary. The latter can in fact be used at the end of the opera- terms of respiration and a significant aesthetic effect. The final objective is to It should be pointed out in this connection that cases of make the aesthetic lines from eyebrow to tip on the concave and crooked nose brilliantly solved by means of other techniques contralateral sides of the deformity symmetrical. It is, the other hand, the onlay grafts used to disguise this blemish however, sometimes possible also in revisions, because of the often prove ineffective over time both as a result of resorption previous employment of conservative techniques, to harvest a problems and because they worsen the collapse of the upper lat- strip of cartilage from the lower part of the dorsal septum with- eral cartilage. The auricular cartilage does not in 74 Evolution of the Septal Crossbar Graft Technique Fig. It is in fact particularly curved and elastic and not tough enough to counter the cartilaginous memory of the deformity over time. Where a graft of cartilaginous septum is not available, it is therefore preferable to use a strip of the per- pendicular plate of the ethmoid of the same shape and size in its place. The use of ethmoid bone has already been described by other authors both as a graft to strengthen particularly thin cartilaginous septa and as a graft to straighten particularly crooked septa. Finally, clinical experience has shown that it is preferable to adopt an open approach to the nasal pyramid in performing a septal crossbar graft, as this makes it possible to obtain a direct three-dimensional view of the L strut and hence a simultaneous appraisal of all the crooked elements of the septum. This type of approach also makes it easier to secure the graft to the septum by means of sutures in otherwise unreachable areas to the rear. The end effect obtained is structural reinforcement and maximum resistance to cartilaginous memory over time. The method has proved very effective from the outset in treating the most severe cases of crooked nose, where the use of just one spreader graft on the concave side of the septum can prove insufficiently thick to correct the deformity. Ann Plast straightened L structure of the septum remains impervious to Surg 1978; 1: 443–449 the postoperative deforming forces. The deviated nose and septum: a septorhinoplasty revision has extended the range of applica- panel discussion. The extracorporeal septum plasty: a technique to correct difficult nasal deformities. Plast Reconstr Surg 2003; 111: 629–638 porous polyethylene extended spreader grafts. Spreader graft: a method of reconstructing the roof of the middle Dallas Rhinoplasty Symposium 2000:239–242 nasal vault following rhinoplasty. Secondary rhinoplasty: analysis of the deformity and lar surgery in correcting airway obstruction in primary and secondary rhino- guidelines for management. Plast Reconstr Surg 1996; 98: 38–54, discussion 55–58 76 Twenty-five Years of Experience with Extracorporeal Septoplasty 10 Tw enty-five Years of Experience w ith Extracorporeal Septoplasty Wolfgang Gubisch extramucosal dissection of the junction of the border between 10. If dorsal hump reduction was planned, it of the nose, which is often neglected even today. So the devi- was undertaken at this point in the operation to enable dissec- ated septum may be the base for many deviated noses, and if tion of the mucosa from a cranial approach, especially from the the septum is not corrected properly the deviated axis will stay. This approach seems easier and safer when dealing Marked septal deformation often cannot be corrected properly with such severe septal deformities. Therefore, in the 1950s King and Ash- was not planned, the upper lateral cartilages were incised bilat- ley1 as well as Perret2 suggested taking out the whole septum erally at their junction with the septum after extramucosal dis- in such cases and replanting the straight parts. With these maneuvers, the nasal septum became more 1980s, we started to use this technique consequently in all flexible and made mucosal dissection easier and more precise. If dorsal hump reduction was not performed, a parame- dian osteotomy was necessary to remove the bony septum from Markedly deviated septums are often combined with a devia- the dorsum. In the past 2 years, these osteotomies were done tion of the external nose and may be caused by different rea- with a motor drill because this is more accurate and at the same sons. In patients with a unilateral cleft lip and palate deformity, time we are able to remove the bony triangle at the most cranial the nose is always affected and presents a deviation of the sep- point of the junction of the nasal bones. In noses that underwent bad trauma, plete cartilaginous and bony septum was removed in one piece. The ideal reconstructed plate would be as large as possi- tured and healed in dislocation, there are often sharp angled ble with stable upper and anterior borders. Redundant and dis- deformities, which are difficult to correct by the classical tech- located cartilage can be excised and straight pieces sutured niques. We refer to a difficult septum if there has been a preop- together to provide positioning the anterior nasal spine in the eration and big parts of the septum have been resected, but the midline, a notch and hole was drilled; then the septal border remaining framework is still bent and causes a deviated exter- was adjusted and a double suture was placed through the drill nal nose. In all these cases, we feel that a permanent straight hole and the lower septum border to anchor it firmly to the septum can be achieved only by an extracorporeal septal recon- nasal spine. To avoid postoperative irregularities of the nasal struction, and therefore this technique is prerequisite for a per- dorsum, homologous fascia onlay grafts have been placed onto manent straight axis of the external nose. Then the flap was repositioned and sutured with 6–0 nylon; a horizontal mattress suture from caudal to cranial and back helps to approximate the nasal mucosa, prevent dead 10. Then splinting silicone foils were sewn and positioned, prepared, and draped in a standard fashion. Exter- antibiotic-soaked (neomycin sulfate and bacitracin [Nebacetin] nal noses as well as internal nasal septum underwent local and xylometazoline hydrochloride [Otrivin]) foam tampo-nades anesthesia with 0. Partial thickness releasing the closed approach was used exclusively; after that time, we incisions (scoring) on the concave side of the cartilage made introduced the open approach and all extracorporeal septal with a knife may straighten the bent cartilage. If the cartilage became fixion incision into an intercartilaginous incision to gain enough straight but soft and unstable with this procedure, smoothly space for proper dissection and handling. During an open filed pieces of the perpendicular plate could be sutured onto approach, a standard midcolumellar incision (stair step or the cartilaginous septum. Subperichondral dissection was In post-traumatic cases with multiple fracture sites and cartila- started on the concave side of the nasal septum to minimize the ginous fragments healed in dislocation, we dissected preserved risk of tearing the mucosa.

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The priorities for this patient are to limit the ext ent of h is brain injur y by limit ing secondar y brain injur y generic zyrtec 10mg mastercard allergy immunology associates, wh ich is best accomplished wit h t he avoidance of hypoxia purchase zyrtec 5mg overnight delivery allergy treatment uk, hypercarbia purchase zyrtec 5 mg amex allergy symptoms weather, and hypotension. Alar m- ing findings in t his pat ient are findings t hat suggest t hat t here is already significant right-hemispheric intracranial hypertension causing unequal papillary responses and left -side hemiparesis. Once this patient is intubated and ventilated,and has appropriateintravenous access placed, intravenous mannitol should be given at a dose of 0. The patient must be sufficiently resuscitated before the administration of manni- tol, since this medicat ion can produce hypotension in hypovolemic patient s. Epidural hematoma patients generally have a better prognosis than other types of cerebral hematomas. This procedure can be life-saving; however, there is significant risk of causing harm wit hout pat ient benefit s when unt rained individu- als att empt t his procedure. W ith the mass effect and pressure exertion on the temporal lobe, uncal herniation can occur. Uncal herniation compresses the parasympathetic nerve fibers that travel along t he t hird cranial nerve; t his leads t o unopposed sympat het ic act ivit y t o t he pupil, which produces ipsilateral pupil dilation and the classic finding of a “blown” pupil. Ma n a g e m e n t o f Pa t ie n t s o n An t i c o a g u la n t s a n d / o r An t i p l a t e l e t Ag e n t s With the general increasing age of our population, there are more numbers of indi- vid u als r eceivin g lon g-t er m an t ico agu lan t s an d / or an t ip lat elet agen t s as p r im ar y, secondary, or tert iary prevent ion st rategies for cardiovascular and cerebral vascu- lar diseases. Op t im ize oxyg e n at io n, monitoring and many will in t o this g ro u p ventilation, and b lood p re ssure need neurosurgical invasive support. Co n c u s s i o n s a n d Sp o r t s - Re l a t e d Br a i n In j u r i e s An est imated 3. Females have been re po rt ed t o s ust ai n higher rat es o f co ncus s i o ns when performing similar athletic activities as male athletes. O ver all, con cu ssion s in male athletes are more likely to go unreported in comparison to injuries in female athletes. Athelet ic acit ivies wit h t he highest reported incidences of concussions are foot ball, h ockey, soccer, r ugby, an d basket ball. W it h great er number an d severit y of concussions and increases in the duration of symptoms following a concussion, the greater the likelihood that the recoveries will be prolonged. An athlete with a history of concussion is also at an increased risk of sustaining another concussion (~ 2-6-fold increased probability). The important steps and goals of concussion management are: (1) initial evaluat ion and diagnosis; (2) post injury evaluat ion; (3) symptoms manage- ment; (4) safe return to activities participation. The identification of concus- sions is critical to protect the individual from premature return to potentially injurious act ivit ies. There is evidence to suggest that excessive cognitive or physical activity before complete brain recovery contributes to prolonged brain dysfunction. Of the many signs and symptoms of a concussion, headache and dizziness are the most and second most common reported symptoms, respectively (see Table 38– 3 for the list of sign s an d sympt oms). In most studies, 8 0 %to 90 %of athletes with concussions have symptom resolution by 7 days after the injury; however, it is important to note that based on neuropsychiatric testing, persistent deficits may linger even after symptom resolution. Because the pr esen ce an d sever it y of n eu- ropsychiatric deficits can be difficult to determine, some authorities have recom- mended liberal testing policies to help identify individuals who may benefit from cou n selin g an d t r eat ment. There are a number of validated assessment systems utilized in the initial assessment of injured at hletes, and it has been demonst rated t hat t he sensit ivit y and specificit y of t he assessment s improves when several are applied in combi- nation. During this initial observation period, it is import ant to t ry t o avoid sedat ives and medicat ions t hat may mask pat ient ’s symp- toms or alter the individual’s level of mentation. The patients and their families should be inst ruct ed regarding pot ent ial sleep, cognit ive, and mood disturbances. Aft er init ial st abilizat ion of sympt oms, the recommendat ion for most individuals wit h concussions is to t ake a graduated return to work, school, or play schedule, wit h monitoring of progress during each of the steps. For cont act -sport at hletes, the schedule for their returning to sports activities will progress in a step-wise manner, with initially no activity, followed by progression to light aerobic activi- ties, to sport-specific activity, to non-contact drills, to limited full contact partici- pation, and ultimately to full participation. T here is insufficient evidence to support t heir pract ical use in an ongoing basis, but t h ere is hope for future use. H e presented wit h a pulse rate of 130 beat s/ minute, blood pressure of 90/ 62 mm H g, and respiratory rate of 32 breat hs/ minute. H is pupils are 5 mm and are equally round and react ive t o light bilat erally; he does not open h is eyes t o painful stimuli, moans with painful stimuli, and withdraws from painful st imuli. Short ly t hereafter, he underwent placement of bilateral chest tubes for pneumothoraces. H e also received a bolus of 1000 mL of lactated Ringers solution that improved his blood pressure to 120/ 80 and reduced his heart rate to 100 beats/ minute. With painful stimuli, the patient does not open his eyes and withdraws all ext remit ies. M ech an ical ven t ilat io n, in t r aven o u s flu id s, an d p lacem en t of I C P monitor C. H e p r esen t s wit h a n or m al blood p r essu r e, d oes n ot op en his eyes to painful stimuli, has abnormal flexion of the upper extremities with pain, and moans with painful stimuli. H e is brought to the emergency center where he is noted to be screaming random words and phrases, localizing to pain, and opening his eyes to his name. Following your initial evaluation, you contact the neu- rosurgeon for advice and consultation. The degree of disability is related to the number of concussions that the individual has suffered B. T h e t yp e of sp or t an d p layer st yle st r o n gly in flu en ce the r isk of con cu ssion s C. Male athletes are more likely to sustain concussions than female athletes, and this is related to the types of sports that male athletes compete in, and the gen er al d iffer en ce b et ween player st yles of m ale an d fem ale at h let es. O ver all, the rates of concussions are higher for female athletes competing in the same types of sports activities. Improving t his pat ient ’s oxygenat ion and ven- tilation are the immediate priorities for this patient. At this t ime, he is found t o have bifront al cerebral con- tusions, cerebral swelling, and subarachnoid hemorrhage. Midline shifts and focal mass lesions are generally consid- ered injuries t hat are more amenable t o operat ive int ervent ions. The primary goals for this patient are t o op t im ize h is oxygen at ion, vent ilat ion, an d blood pressures with ventilation and intravenous fluids. Intracranial pressure moni- toring is also helpful to guide the management of ventilation and direct phar- macologic therapy if needed (eg, mannitol administration). Balance dist urbance is a specific indicat or of concussion, alt h ough it is not a highly sensit ive indicator. Balance t est ing of at hlet es on t he sidelines can be helpful in identifing individuals with concussions.

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Features are: • Initially viral-like illness with high fever buy zyrtec 5 mg otc allergy medicine costco, chill and rigor order 10 mg zyrtec fast delivery allergy medicine kid, malaise discount 5mg zyrtec with mastercard allergy testing wheal, myalgia and headache, dry cough, later productive and purulent. Treatment: • Clarithromycin 500 mg twice daily orally or I/V or Erythromycin 500 mg 6 hourly orally or I/V for 7 to 10 days. Systemic features High-grade fever with chill and Low-grade fever, headache and rigor. Less common (respiratory complains are less common) and constitutional symptoms are more. Chest X-ray Lobar or segmental homogeneous Mottling or reticular pattern or opacity with air bronchogram. Presentation of a Case: (Supposing Right Sided, Mention the Findings in Right Side): On inspection: • Restricted movement. On auscultation: • Breath sound: Bronchial or diminished or absent (mention accordingly). Also, emaciated and radiation mark (indicates underlying cause is bronchial carcinoma). A: In consolidation, trachea and apex beat will not be shifted, percussion is woody dull. However, some fndings are highly suggestive of fbrosis, as it is a chronic process: • Flattening of chest. To be confrmed, chest X-ray will help, which shows: • In collapse, the X-ray shows homogeneous opacity. Evidence of bronchial obstruction (mass lesion) may be seen and diaphragm may be elevated. Compression collapse (passive): Due to pleural effusion, pneumothorax and hydropneumothorax. Causes of collapse according to age: • Neonate: Congenital due to low or absent surfactant, aspiration of meconium. A: Middle lobe syndrome is the recurrent or persistent atelectasis of right middle lobe, which origi- nates at acute angle and is completely surrounded by lymph nodes. Presentation of a Case (Supposing Left Sided): • There is fattening of upper part of chest, crowding of ribs, drooping of the shoulder. A: Fibrosis of the left lung, because there is fattening of upper part of chest, crowding of ribs, droop- ing of the shoulder, which indicates fbrosis (i. Drooping of left shoulder with flattening • O: Others (drugs: bleomycin, busulphan, nitrofuran- of the chest toin, methotrexate and amiodarone). A: As follows: • Focal fbrosis due to inhalation of mineral dust (pneumoconiosis). A: Because in consolidation, there is fever with cough, initially dry but later rusty. Also, there is no fever and patient is not toxic (unless there is secondary infection). Causes of lung abscess: • Aspiration of nasopharyngeal or oropharyngeal contents: Such as in vomiting, anaesthesia, tooth extraction, tonsillectomy, unconscious patient, alcoholism and achalasia cardia. A: As follows: • Severe cough with profuse foul-smelling sputum, may be foetid (anaerobic). If deep seated within the lung parenchyma, there may not be any physical fnd- ings. A: If the sputum is kept in a bottle, there are 3 layers (as in bronchiectasis): • Lower: Sediment (epithelial debris and bacteria). If it is due to aspiration, commonest site depends on the posture of the patient during aspiration. Presentation of a Case: On inspection: • The patient is dyspnoeic with pursing of lips, respiratory rate is 30/min. On palpation: • Trachea is central, tracheal tug is present (descent of trachea during inspiration). On auscultation: • Breath sound is diminished vesicular with prolonged expiration. A: Chronic obstructive pulmonary disease is a preventable and treatable disease characterized by per- sistent airfow limitation that is usually progressive, and associated with an enhanced chronic infam- matory response in the airways and the lung to noxious particles or gases. Features are: • Chronic cough and sputum production, which is progressively increasing. A:Muscular weakness, peripheral oedema due to impaired salt and water excretion, weight loss due to altered fat metabolism, increased osteoporosis, increased circulating infammatory markers. Other less common organisms are Moraxella catarrhalis, Chlamydia pneumoniae and Pseudomonas aeruginosa. Moderate Above treatment plus: • Regular treatment with one or more long-acting bronchodilator: b2 agonist (e. Very severe Above treatment plus: • Longterm oxygen, if chronic respiratory failure. Surgical intervention: • Bullectomy: If young patient, large bulla compressing surrounding lung tissue, no general- ized emphysema. The aim is to increase the PaO2 to at least 8 kPa (60 mmHg) at sea level during rest or SaO2 to at least 90%. Low-fow oxygen is due to its effect in the chemo-responsiveness of the respiratory centre in the medulla (part of the brainstem). High-fow oxygen blunts responsiveness of the respiratory centre in the medulla and causes carbon dioxide retention, so aggravates respiratory failure (type 2 respiratory failure). A:Oral steroid is useful during exacerbation, but maintenance therapy should be avoided. If not, air travel should be avoided or undertaken only with inspired oxygen therapy. A: As follows: • Oxygen: Continuous low concentration oxygen via Venturi mask to raise PaO2. Indications of hospitalization are: • Severe symptoms or acute worsening that fails to respond to outpatient management. A: As follows: • The patient is clinically stable and no parenteral therapy should be there for 24 h. A: It is defned clinically as ‘the presence of cough, productive of sputum, not attributable to other causes, on most of the days, for 3 consecutive months, at least for 2 successive years’. Usual presentations are: • Cough with sputum: Cough is more marked in the morning, also on exposure to cold and during winter. Bronchodilator: • Inhaled b-agonist: Salbutamol (200 µg 4 to 6 hourly), terbutaline. In severe case, oral prednisolone 30 mg for 2 weeks, followed by maintenance dose. Mucolytic agents like bromhexine or N-acetylcysteine (200 mg 8 hourly orally for 8 weeks) may be given.