INTRODUCTION

Laparoscopic surgery is a surgical technique in which short, narrow tubes ( trocars)  are inserted into the abdomen through small ( less than one centimeter ) incisions . Through these trochars long narrow instruments to manipulate, cut and see tissue

ADVANTAGE

In patients terms, laparoscopic surgery has the advantages of avoiding large open wounds or incisions and thus of decreasing blood loss , pain and discomfort . Patients have fewer  unwanted effects from analgesia because less analgesia is required .The fine instruments are less apt to cause tissue trauma and blood loss. Also it has better quality of life outcomes than open surgery for cholecystectomy, splenectomy and esophageal surgery. However open hernioplasty has at least as good if not better , health status outcomes than laparoscopic repair

DISADVANTAGES

It can take longer to perform than open surgery ( if not performed with right technique) . The  longer time under anesthesia may increase the risk of complication. Sometimes complications do not appear right away but occurs few days to few weeks after surgery

SIDE EFFECTS

• Fever or chills
• Abdominal pain that becomes more intense over time
• Redness , swelling , bleeding or drainage at the incision sites
• continuous nausea or vomiting
• Persistent cough
• Shortness of breath
• Inability to urinate
• Lightheadness

HOW IS LAPAROSCOPY PERFORMED ?

It is usually done as an outpatient procedure. General anesthesia is given as intravenous line in one of your veins. In some cases  local anesthesia is also used. During laparoscopy, the surgeon makes an incision below your belly button and then inserts a small tube called a cannula. The cannula is used to inflate your abdomen with carbon dioxide gas. This gas allows your doctor to see your   abdominal organs more clearly. Once abdomen is inflated , the surgeon inserts the laparoscope through the incision. The camera attached to the laparoscope displays the images on a screen, allowing your organs to be viewed in real time. Generally you get from one to four  incisions  that are each between 1 and 2 centimeters in length. These incisions allow other instruments to be inserted . After the procedure is done , the instruments are removed. Your incisions are  then closed with stitches or surgical staples

 

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Knee replacement surgery also known as knee arthroplasty can help relive pain and restore function  in  severely diseased knee joints. The procedure involves cutting away damaged bone and cartilage from your thigh bone , shin bone and knee cap and replacing it with an artificial joint( prosthesis) made of metal alloys high grade plastics and polymers

SIGNS OF NEEDING A KNEE REPLACEMENT

Knee replacement surgery is usually   necessary when the knee joint is worn out or damaged so that your mobility is reduced and you are  in pain even while resting . The most common reason for knee replacement surgery is osteoarthritis. Other health conditions that cause knee damage include rheumatoid arthritis

RISK FACTORS

• Infection
• Blood clots in the leg
• Heart attack
• Stroke
• Nerve damage

PROCEDURE

Before the procedure-

1. Your doctor will explain the procedure to you
2. Consent form is asked to sign
3. Physical examination is done
4. Complete medical history is asked
5. Notify your doctor if you have a history of bleeding disorder
6. You will be asked to fast for eight hours before procedure
7. You may receive a sedative prior to the surgery to help you relax

During the surgery-

Generally knee replacement surgery follows this process

1. You will be asked to remove clothing and will be given a gown to wear
2. An intravenous (IV) line may be started in your arm or hand
3. You will be positioned on the operating table
4. Urinary catheter may be inserted
5. Excessive hair at the surgical site may be clipped off
6. Skin over the  surgical site will be cleaned with an antiseptic solution
7. The doctor will make an incision in the knee area
8. The doctor will remove the damaged surfaces of the knee joint and resurface the knee joint with  the prosthesis . The prosthesis is made up of metal and plastic, A cemented prosthesis  attaches  to the bone with a porous surface onto which the bone grows to attach to the prosthesis. The prosthesis is generally comprised of 3 components-the tibial component, the femoral component and the patellar component
9. The incision will be closed with stitches or surgical staples
10. A sterile bandage or dressing will be applied

After the procedure-

In the hospital -after the surgery you will be taken to the recovery room for observation . Once your blood pressure , pulse and breathing are stable and you are alert you will be taken to your hospital room. Knee replacement  surgery usually requires as in hospital stay of several days

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A hip fracture is a break in  the upper portion of the femur ( thigh bone) . Most hip fractures occur in elderly patients whose bones have become weakened by osteoporosis . When a hip fracture occurs in a younger patient it is typically the result of a high energy event such as a fall from a ladder or vehicle collision

SYMPTOMS

• Inability to get up from a fall or to walk
• Severe pain in your hip or groin
• Inability to put weight on your leg on the side of your injured hip
• Bruising and swelling in and around your hip area
• Outward turning of your leg on the side of your injured hip

RISK FACTORS

• Age
• Osteoporosis
• Other chronic medical conditions
• Nutritional problems
• Physical inactivity

COMPLICATIONS

• Blood clots in your legs or lungs
• Bedsore
• Urinary tract infection
• Pneumonia
• Further loss of muscle mass, increasing your risk of falls and injuries
• Death

TREATMENT

Most hip fractures occurs in one of the two locations on the long bone that extends from your pelvis to your knee

• The Femoral neck- This area is situated in the upper portion of your femur, just below the ball part( femoral head ) of the ball and socket joint
• The intertrochanteric region- This region is a little farther down from the hip joint , in the portion of your upper femur that juts outside

Treatment of hip fracture usually involves a combination of surgery , rehabilitation and medication

Surgery- The type of surgery you have generally depends on the the where and how  severe the fracture is , whether the broken bones aren’t properly aligned and your age and underlying health conditions. The options include :

• Internal repair using screws
• Total Hip replacement
• Partial hip  replacement
• Your doctor might suggest total or partial hip replacement if the blood supply to the ball part of the hip joint was damaged during the fracture

Rehabilitation- Physical therapy will initially focus on  range of motion and strengthening exercises.

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DEFINITION

A bone fracture is a medical condition where the continuity of the bone is broken. A significant percentage of bone fractures occurs because of high force impact or stress. Also it may be due to cancers , osteogenesis imperfecta, osteoporosis etc…

TYPES

• Avulsion fracture- a muscle or ligament pulls on the bone, fracturing it
• Comminuted fracture- the bone is shattered into many pieces
• Compression (crush) fracture- generally occurs in the spongy bone in the spine
• Fracture dislocation – a joint becomes dislocated and one of the bones of joint has a fracture
• Greenstick fracture- the bone partly fractures on one side, but does not break completely because the rest of the bone can bend
• Hairline fracture- a partial fracture of the bone .Sometimes this type of fracture is harder to detect with routine x-ray
• Impacted fracture – when  the bone is fractured , one fragment of bone goes into another
• Intra articular fracture- where break is along the length of the bone
• Oblique fracture- a fracture that is diagonal to a bones long axis
• Pathological fracture- when an underlying disease or condition has already weakened the bone, resulting in a fracture
• Spiral fracture- a fracture where at least one part of the bone has been twisted
• Tortus fracture- bone deforms but does not crack
• Transverse fracture- a straight break right across a bone

SYMPTOMS

The signs and symptoms of a fracture vary according to which bone is affected , the patients age and general health as well as the severity of injury. Some of the following are

• Pain
• Swelling
• Bruising
• Discolored skin around the affected area
• Angulation- affected area may be bent at an unusual angle
• Patient is unable to put weight on the injured area
• Patient cannot move the affected area

DIAGNOSIS AND TREATMENT

Bone healing is a natural process which in most cases well occur automatically. For the natural healing process to begin , the ends of the broken bone need to be lined up this is known as reducing the fracture. The patient is usually asleep under a general anesthesia when fracture reduction is done. Fracture reduction may be done by manipulation closed reduction or surgery.

Immobilization-as soon as the bones are aligned they must stay aligned while they heal

This may include

• Plaster casts or plastic functional braces- these hold the bone in position until it has healed
• Metal plates and screw – current procedures may use minimally invasive techniques
• Intra medullary nails- internal metal rods are placed down the center of long bone
• External fixators- these may be made of metal or carbon fiber , they have steel pins that go into the bone directly through the skin
• Healing – if a broken bone has been aligned properly and kept immobile , the healing process is usually straight forward
• Physical therapy- after the bone has healed , it may be necessary to restore muscle strength as well as mobility to the affected area

COMPLICATIONS

• Heals in the wrong position
• Disruption of bone growth
• Persistent bone or bone marrow infection
• Avascular necrosis or bone death

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Prepared by Dr Sajna Hamza

 

 

INTRODUCTION

Pneumonia is an infection in one or both lungs, Bacteria , viruses and fungi cause it. The infection causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus making it difficult to breath

SYMPTOMS

The signs and symptoms vary from mild to severe , depending on factors such as the type of germ causing the infection and your age and overall health. Mild signs and symptoms often are similar to those of a cold or flu but they last longer

Signs and symptoms of Pneumonia may include

• Chest pain when you breath and cough
• Confusion or changes in mental awareness
• Cough may produce phlegm
• Fatigue
• Fever  , sweating and shaking chills
• Lower than normal body temperature
• Nausea , vomiting, or diarrhea
• Shortness of breath

CAUSES

The most common are bacteria and viruses in the air we breath. Your body usually prevents these germs from infecting your lungs . But sometimes these germs can over power your immune system , even if your health id generally good. Pneumonia is classified  according to the types of germs that cause it and where you get the infection

• COMMUNITY ACQUIRED PHEUMONIA- It is the most common type of pneumonia .It occurs outside of hospitals or other health care facilities. It may be caused by  a) Bacteria b)Fungi c) Viruses
• HOSPITAL ACQUIRED PNEUMONIA- From the people catch pneumonia during a hospital stay for another illness.  Hospital acquired pneumonia can be serious because the bacteria causing it may be more resistant to antibiotics and because the people who get it are already sick
• HEALTH CARE ACQUIRED PNEUMONIA- It is a bacterial infection that occurs in people who live in long term care facilities or who receive care in out patient clinics , including kidney dialysis centers
• ASPIRATION PHEUNOMIA- It occurs when you inhale food , drink , vomit or saliva into your lungs . Aspiration is most likely if something disturbs your normal gag reflex such as a brain injury or swallowing problem or excessive use of alcohol or drugs

RISK FACTORS

• Children who are 2 years old or younger
• People who are age 65 or older
• Being hospitalized
• Chronic disease
• Smoking
• Weakened or suppressed immune system

COMPLICATIONS

• Bacteria in the blood stream
• Difficulty breathing
• Fluid accumulation around the lungs
• Lung abscess

TREATMENT

Treatment for pneumonia involves curing the infection and preventing complications. Specific treatments depend on the type and severity of your pneumonia , your age and your overall health. The options include

• Antibiotics
• Cough medicine
• Fever reducers
• Pain relievers

HOSPITALIZATIONS-

• You are older than 65
• You are confused about time , people or places
• Your kidney function has declined
• Your systolic blood pressure is below 90 mm Hg or your diastolic blood pressure is 60 mm Hg below
• Breathing is rapid
• You need breathing assistance
• Your heart rate below 50 or abv 100

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DEFINITION

It is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain .This causes increased pressure inside the skull

SYMPTOMS

Babies:

• Rapid head growth
• vomiting
• sleepiness
• seizures
• Downward pointing of eyes

Adults

• Headache
• Double vision
• Poor balance
• Urinary incontinence
• Personality changes
• Mental impairment
• Sleepiness

CAUSES

• Too much CSF is produced
• One of the ventricles in brain is blocked or narrowed, stopping or restricting the flow of CSF so that it cannot leave the brain
• CSF cannot filter into the blood stream

Congenital hydrocephalus

• CMV
• German measles
• Mumps
• Syphilis
• Taxoplasmosis

Acquired hydrocephalus

• Brain hemorrhage
• Brain lesions
• Brain tumors
• Meningitis
• Stroke

TYPES

1. Congenital Hydrocephalus: It is one of the most common developmental disabilities , more common than Down’s Syndrome or deafness. It may be caused by an infection in the mother during pregnancy such as rubella, or mumps or a birth defect such as spina bifida
2. Acquired Hydrocephalus: This develops after birth, usually after a stroke , brain tumor , meningitis etc
3. Communicating Hydrocephalus: This type occurs when the CSF becomes blocked after leaving the ventricles. It is called communicating because CSF can still flow between the brain ventricles
4. Non communicating: Also called Obstructive hydrocephalus occurs when the thin connections between the ventricles become blocked

RISK FACTORS

• Premature birth infants born preterm have a higher risk of intraventricular hemorrhage or bleeding within the ventricles of the brain which may result in hydrocephalus
• Problems during pregnancy
• Problems with fetal development, cord or brain
• Infections of the nervous system
• Bleeding in the brain
• Severe head injury

TREATMENT

One of two surgical treatments may be used to treat hydrocephalus

SHUNT:

The most common treatment of hydrocephalus is the surgical insertion of a drainage system , called shunt. It consists of a long flexible tube with a valve that keeps fluid from the brain flowing in the right direction and at the proper rate. One of the tubing is usually placed in one of the brains ventricles. The tubing is then tunneled under the skin to another part of the body where the excess CSF can more easily absorbed

ENDOSCOPIC THIRD VENTRICULOSTOMY:

It is a surgical procedure , in which your surgeon uses a small video camera to have direct vision inside the brain. Your surgeon makes a hole in the bottom of the one of the ventricles  or between the ventricles to enable CSF to flow out of the brain

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Prepared by :Dr Sajna Hamza

INTRODUCTION

Leukemia is a broad term of cancer of the blood cells . The type of leukemia depends on the type of blood cells that becomes cancer and whether it grows quickly or slowly

SYMPTOMS

Symptoms vary depending on the type of leukemia. Common signs and symptoms include

• Fever and chills
• Persistent fatigue ,weakness
• Frequent or severe infections
• Losing weight without trying
• Swollen lymph nodes enlarged liver or spleen
• Easy bleeding or bruising
• Recurrent nose bleeds
• Tiny red spots in your skin
• Excessive sweating, especially at night
• Bone pain or tenderness

TYPES

Leukemia is broadly categorized as acute or chronic. Acute Leukemia are more aggressive and involve immature blood cells where chronic leukemia tend to develop more slowly and involve mature blood cells. Leukemia is further classified by the type of cells that are affected.

• Acute lymphocytic leukemia
• Acute myelogenous leukemia
• Chronic lymphocytic leukemia
• Chronic myelogenous leukemia

RISK FACTORS

• A genetic predisposition
• Downs syndrome
• Human lymphotropic virus
• Exposure to petro chemicals
• Extensive exposure to artificial radiations
• Tobacco use
• Use of certain hair dyes

STAGING

• Acute lymphocytic leukemia- staged based  of type of lymphocyte and  the maturity of the cells
• Acute myelogenous leukemia- staged using the French-American -British system ,which takes into account the number of healthy blood cells , the size and number of leukemia cells the changes in the chromosomes of the leukemia cells and other abnormalities
• Chronic lymphocytic leukemia-Staged using the Rai system which considers 3 main factors , the number of lymphocytes in the blood, the degree of lymph node ,spleen, or liver enlargement and the presence of anemia or thrombocytopenia
• Chronic myelogenous leukemia- Staged based on the number of diseased cells found in blood and bone marrow tests

TREATMENT

Common treatment to fight leukemia include

• Chemotherapy- it is the major form of treatment for leukemia. Depending on the type of Leukemia you have , you may receive a single drug or a combination of drugs
• Targeted therapy- It focus on specific abnormalities present within cancer cells
• Radiation therapy- You may receive radiation  in one specific area of your body where there is collection of leukemia cells or may receive radiation over your whole body
• Bone marrow transplant- Prior to bone marrow transplant , you receive very high doses of chemo therapy or radiation therapy to destroy your leukemia producing cells
• Immuno therapy – Immuno therapy uses your immune system to fight cancer . Your body’s disease fighting immune system may not attack your cancer cells produce proteins that help them hide from the immune system cells. Immunotherapy works by interfying with that process

 

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DEFINITION

Lung cancer occurs when cells divide in the lungs uncontrollably .This causes tumors to grow .These can reduce a persons ability to breathe and spread to other parts of the body

TYPES

Main types are

• Non small cell lung cancer – there are three subtypes

1. adenocarcinoma
2. squamous cell cancer
3. large cell carcinoma

• Small cell lung cancer- these type tend to grow more quickly than non small cell lung cancer

SYMPTOMS

Early symptoms

• A cough that wont quit or changes
• Breathing changes or wheezing
• Body pain
• Raspy ,hoarse voice
• Drop in weight

Advanced symptoms

• Fatigue
• Pain
• Breathing
• Persistent coughing
• Loss of appetite
• Coughing blood

CAUSES

90 % are caused by smoking .From the moment you inhale smoke into your lungs it starts damaging your lung tissue .  Once cells get damaged they behave abnormally and eventually cancer may develop

RISK FACTORS

• Smoking
• Exposure to secondary smoke
• Previous radiation therapy
• Exposure to radon gas
• Exposure to asbestos and other carcinogens
• Family history

COMPLICATIONS

• Shortness  of breath
• Coughing up blood
• Pain
• Fluid in chest ( pleural effusion)
• Metastasis

TESTS

• Imaging tests-X ray, CT
• Sputum cytology
• Tissue sample ( biopsy)

TREATMENT 

• SURGERY-During surgery your surgeon works to remove the lung cancer and a margin of healthy tissue. Procedures to remove lung cancer include:

a)Wedge resection – to remove a small section of lung that contains the tumor alone with a margin of                                                                                                     healthy tissue

b)Segmental resection- to remove a larger portion of lung but not an entire lobe

c)Lobectomy- to remove the entire lobe of one lung

d)Pneumonectomy-to remove entire lung

• RADIATION THERAPY – For people with locally advanced lung cancer ,radiation may be used before surgery  before surgery or after surgery. Its often combined with chemotherapy treatment
• CHEMOTHERAPY- Chemotherapy is often used after surgery to kill any cancer cells that may remain .It can be used alone or in combined  with radiation therapy. Chemotherapy may also be used before surgery to shrink cancers and make them easier to  remove
• TARGETED DRUG THERAPY- These treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities , targeted drug treatments can cause cancer cells to die
• IMMUNO THERAY- Immuno therapy uses your immune system to fight cancer. Your body’s  disease fighting immune system may not attack your cancer because the cancer cells produce proteins that help them hide from the immune system cells
• PALLIATIVE CARE-People with lung cancer often experiences signs and symptoms of the caner as well as side effects of the treatment .Supportive care also known as palliative care is a specialty area of medicine  that involves working with a doctor to minimize your signs and symptoms

 

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DEFINITION

A cancer in a mans prostate , a small walnut sized gland that produces seminal fluid . A mans prostate produces the seminal fluid that nourishes and transports sperm. It is one of the most common types of cancer. Many prostate cancers grow slowly and are confined to the prostate gland, where they may not cause serious harm. However while some types  of prostate cancer grow slowly and may need minimal or even no treatment other types are aggressive and can spread quickly.

SYMPTOMS

Symptoms and signs of prostate cancer may include

• Frequent urination
• Weak or interrupted urine flow or the need to strain to empty the bladder.
• The urge to urinate frequently at night
• Blood in the urine
• New onset of erectile dysfunction
• Pain or burning during urination which is much less common
• Discomfort or pain when sitting caused by an enlarged prostate

Other noncancerous conditions of the prostate such as BPH or an enlarged prostate can cause similar symptoms .Or the cause of a symptom may be a different medical condition that is also not related to cancer .Urinary symptoms also can be caused by an infection of the bladder or other conditions

If cancer spread outside of the prostate gland symptoms may include

• Pain in the back , hips ,thigh ,shoulders or other bones
• Swelling or fluid build up in the legs or feet
• Unexplained weight loss
• Fatigue
• Change in bowel habits

CAUSES

Its  not clear what causes prostate cancer. Prostate cancer begins when cells in the prostate develop changes in this DNA. A  cells DNA contains the instruction that tell the cells to grow and divide more rapidly than normal cells do. The abnormal cells continue living , when other cells would die. The accumulating abnormal cells form a tumor that can grow to invade nearby tissue . In time some abnormal cells can break away and spread metastasize to other parts of the body

RISK FACTORS

• Age
• Race
• Family history
• Hereditary breast and ovarian cancer  (HBOC)
• Other genetic changes
• Eating habits

COMPLICATIONS

• Erectile dysfunction
• Incontinences
• Metastasis

STAGES OF PROSTATE CANCER

TNM Staging:

TNM system is a way of staging prostate cancer. TNM stands for Tumor, Node, Metastasis

T1-T1 means the cancer is too small to be seen on a scan , or felt during examination of the prostate. Its  divided into T1a, T1b, T1c.T1ameans that the cancer is in less than 5% of the removed tissue.T1b means that the cancer is in 5 % or more of the removed tissue . T1c cancers are found by biopsy for example after a raised PSA level

T2-T2 means the cancer is completely inside the prostate gland. Its divided into T2a, T2b and T2c.T2a means the cancer is  in only half of one side of the prostate gland.T2b  means the cancer is in more than half of one side of the prostate gland , but not both sides.T2c means the cancer is in both sides but is still inside the prostate gland

T3-T3 means the cancer has broken through the capsule of the prostate gland. Its divided into T3a and T3b.T3a means the cancer has broken through the capsule of the prostate gland.T3b means the cancer has spread into the tubes that carry semen.

T4z-T4 means the cancer has spread into other body organs nearby such as  the back passage ,bladder or the pelvic wall

NODES-N

NODES(N) describes whether the cancer has spread to lymph nodes. N is split into N0 and N1 . No means that the nearby lymph nodes does not contain cancer cells.N1 means there are cancer cells in lymph node near the prostate

METASTASIS-M

M describes whether the cancer has spread to different part of the body

There are two stages- M0 and M1.M0 -cancer has not spread to other parts of the body,M1 -cancer has spread to other parts of the body

TREATMENT

Considering the factors like

• The size of your tumor and how far it has spread .This is called the stage of your disease
• How quickly the tumor is likely to grow
• Your age and how healthy you are
• Your personal preferences

1. Surgery-Its an option if you are healthy and your cancer has not spread. There are several types. Your doctor may only remove your prostate gland or they might take it and the tissue around it
2. Radiation- this treatment uses high energy beams to kill the cancer cells. Its often a chance if your cancer is low grade  or  still only in your prostate
3. Proton beam radiation -This special type of radiation therapy uses very small particles to attack and kill cancer cells that have not spread
4. Hormone therapy- Prostate cancer cells need male hormone testosterone to keep growing . This treatment keeps the cancer cells from getting them
5. Chemo therapy- Drugs that you take by mouth or through  IV travel  through your body, attacking and killing cancer cells and shrinking tumors
6. Immuno therapy- This treatment works with your immune system to fight the disease
7. Cryotherapy- If you have early  prostate cancer your doctor may choose to kill cancer cells by freezing them
8. High intensity focused ultra sound- This device produce sound waves that deliver heat energy to kill cancer cells

 

 

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Prepared by : Dr Sajna Hamza

 

 

INTRODUCTION

Radiation therapy is a type of cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors .Radiation therapy most often uses X-rays but protons or other types of energy also can be used

The term radiation therapy most often refers to external beam radiation therapy. During this type of radiation the high energy beams come from a machine outside of your body that aims the beams at a precise point on your body. Radiation therapy damages cells by destroying the genetic material that controls how cells grow and divide . While both healthy and cancerous cells are damaged by radiation therapy is to destroy as few normal healthy cells as possible .Normal cells can often repair much of the damage caused by radiation

TYPES OF RADIATION THERAPY

There are two broad types of radiation therapy-Internal and external

External beam radiation : It is the most common type of radiation treatment for cancer. External means that the energy beams come from a machine outside of the body. A health care professional precisely aims  the beams to reach the cancer site .Another name for external beam radiation is teletherapy

Internal beam radiation : The second main type of radiation treatment is internal radiation therapy also known as brachy therapy. During this treatment a doctor places an implant containing radiation in or near the cancer site

Systemic radiation therapy : Systemic radiation therapy is another kind of internal radiation therapy . It requires a person to swallow a radioactive substance,  which travels throughout the body to find and kill the cancerous cells. Alternatively a health care professional may inject the radio active substance into a persons vein.

GOALS

Radiation oncologists use radiation therapy to destroy cancer cells and slow tumor growth while limiting the harm to nearby healthy tissue. Sometimes doctors recommend radiation therapy as the first cancer treatment .Other times people receive radiation therapy after surgery or therapies using meditation like chemotherapy .This is called adjuvant therapy. It targets cancer cells remaining after the initial treatment . When it is not possible to destroy all the cancer , the doctors may use radiation therapy to shrink tumors and relieve symptoms. This is called palliative radiation therapy. Palliative radiation therapy may reduce pressure , pain and other symptoms. The goal is to improve a persons quality of life.

SIDE EFFECTS

• Hair loss
• Appetite changes
• Mouth and throat changes
• Trouble swallowing
• Swelling
• Coughing
• Diarrhea
• Nausea and vomiting
• Urinary and bladder changes
• Sexual changes
• Fatigue
• Skin reactions

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Prepared by: Dr Sajna Hamza