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The most common inherited causes of thrombophilia in We do not recommend antifibrinolytic agents such as epsilon the United States are factor V Leiden mutation and Prothrombin aminocaproic acid and tranexamic acid to arrhythmia 29 years old cheap coumadin 1mg on-line reduce bleeding in the G20210A gene mutation which result in increased activity of the absence of hyperfibrinolysis hypertension in young adults buy coumadin 2mg without prescription. Use of oral contraceptives is anorgan atrophy in a process called parenchymal extinction (54) pulse pressure 53 cheap coumadin 2mg free shipping. Patients with ciriable extents of the portal vein and presents with acute abdominal rhosis may also be at risk of venous thrombosis at other pain blood pressure vs blood sugar discount coumadin 1 mg without a prescription, often located in the upper abdomen. Mesenthe portal vein), which may be associated with septic shock, teric arterial occlusion is mostly due to cardiovascular and bacteremia, and tender hepatomegaly. This benefit of proor mesenteric vein thrombosis among patients without cirrhosis in phylactic anticoagulation in turn resulted in reduced risk of hethe absence of obvious etiology such as an acute intraabdominal patic decompensation and mortality (76). Other common thrombosis when there is (i) previous history of thrombosis, (ii) associated symptoms include nausea, vomiting, fever, anorexia, and thrombosis at unusual sites such as hepatic veins, and (iii) family jaundice (72,73,77,78). In the absence of hemodynamically significant transformation of the portal vein, the portal vein is not defined, bleeding, anticoagulation is initiated with infusions of unfracbeing replaced by collaterals. Portal cavernoma usually appears as serpiginous delayed in patients with active bleeding. Associated features of thickened bowel wall and mesentery, indistinct bowel wall margins, and ascites raise suspicion for Portal or mesenteric vein thrombosis in the absence of cirrhosis intestinal infarction or gangrene (86). Should anticoagulation be preferred to thrombolytic therapy as the vention of bowel ischemia, reduced hospitalization, and imfirst strategy in the management of acute portal or mesenteric vein proved survival (79,84,90,91). Mild to moderate self-limited bleeding occurred symptomatic portal or mesenteric vein thrombosis in the absence of in 10 cases. Of 50 patients with follow-up imaging available, 50% any contraindication (strong recommendation, low level of evidence). In patients with acute symptomatic portal or mesenteric vein Patients with mesenteric vein thrombosis, who have prothrombosis without a demonstrable thrombophilia, should gressive thrombosis despite anticoagulation and are at risk of anticoagulation be administered for 6 months or indefinitelyfi We suggest at least 6 months of anticoagulation in patients with In an observational case series including 20 patients with acute portal or mesenteric vein thrombosis without a demonstrable mesenteric vein thrombosis who did not improve with antithrombophilia and when the etiology of the thrombosis is reversible. Patients with suspected or confirmed intestinal We recommend nonselective beta-blockers for prevention of infarction or gangrene are treated with surgical resection of the variceal bleeding in patients with high-risk varices and portal and/or compromised bowel. Bowel viability is determined at the time of mesenteric vein thrombosis requiring anticoagulation. Endoscopic surgery as the basis for optimizing the extent of bowel resection variceal ligation may be performed if there are contraindications or and prevention of short bowel syndrome (64). However, pros and cons of either approach should be blockers are considered first choice for primary prevention of varconsidered before initiating either regimen (conditional iceal bleeding and band ligation considered if patients have any recommendation, very low level of evidence). Pros and cons of all approaches including availability of reversal agents should be considered Efficacy Better in malignancy 11 11 before deciding on the specific regimen (conditional Renal function C/I renal failure No dose change No dose change recommendation, very low level of evidence). However, a in a recent meta-analysis, anticoagulation as compared to no Antidote Available Available Available treatment in cirrhotic patients resulted in higher rates of portal aAvailable only in selected centers. In patients with acute portal or mesenteric vein thrombosis and authors did not perform any subgroup analysis based on the cirrhosis without an inherited thrombophilia, should presence or absence of high-risk esophageal varices. In cirrhotic patients listed for transplant, anticoagulation should ideally be continued until the time of transplant. This results in a secondary form of cholangiopathy, termed portal hypertensive cholangiopathy or portal Key concepts cavernoma cholangiopathy (105). Anticoagulation among patients with cirrhosis and portal and/or mesentericveinthrombosis isnotassociatedwithincreasedriskof Patients may present with symptoms of cholestasis including variceal bleeding. These patients are also at risk of developing bacterial cholangitis and intraductal stones (105). Diagnosis requires presence of a cholestatic liver chemistry Recommendations profile, portal cavernoma, extrahepatic biliary abnormalities on imaging, and absence of any other etiology to explain the chol11. Should anticoagulation be preferred to thrombolytic therapy angiographic abnormalities (105). Risk of bleeding must be Rarely, biliary decompression may require a surgical approach weighed against benefits as. Patients there is (i) evidence of inherited thrombophilia, (ii) progression of with choledocholithiasis or biliary stricture may also benefit from thrombus, or (iii) history of bowel ischemia due to thrombus endoscopic treatment. In addition, Doppler ultrasonography is nonAsian countries may be due to difierent prothrombotic risk invasive, low cost, and correlates well with pathology and venofactors (113). At present, hepatic venogram and liver Underlying prothrombotic conditions are identified in most biopsy are rarely needed for solely diagnostic purposes. Presence of gastroesophageal varices is not a contraindication to • Factor V Leiden anticoagulation. However, long-term success with angioplasty, even in combination with anticoagulation, is limited to Management about a third of patients (130,131). In another study, 60% of patients failed multidisciplinary stepwise approach is recommended. Recanalization procedures carried Several prognostic indices have been developed to help predict a success rate of 93. Balloon angioplasty of the hepatic vein, with or without stenting, should be reserved for patients with short-segment hepatic vein Key concepts stenosis. Prognostic scoring systems are not helpful in guiding choice of accomplished due to complete hepatic vein occlusion. Surgical management Recommendations Long-term survival has been reported in 1 series to be as high as 17. A survival after transplant has improved in the recent decades, small longitudinal study, with 5-year follow-up, demonstrated an ranging from 70% to 92% (130,143–147). Approximately 25% of thesenodulesmayrepresenthepatic and long-term anticoagulation should be considered in all adenomas, although they carry a distinct immunohistochemical patients because of persistent prothrombotic risk after transplant phenotype compared with conventional adenomas (154). A systematic review including 16 studies mutation, prothrombin gene mutation, protein S and C defifrom distinct geographic regions demonstrated a pooled prevalence ciencies, and antithrombin deficiency. A large, prospective, multicenter European studies, which included 12 studies from Asia, 2 from Africa, and only study on 157 patients, with a median follow-up of 5 years, dem1 from Europe and North America. The European study by Moucari onstrated an overall survival of 77% with this approach (130). Although open repair with arterial reconbest referred to centers of expertise for diagnosis (conditional struction has been recommended for aneurysms of the proper recommendation, low level of evidence). Coil embolization may be considered for aneurysms not involving proper hepatic artery. Mesenteric arterial aneurysms are seen in 10% of pseudoaneurysms treated by embolization. The aneurysms may For patients with portal vein aneurysm, intervention is recbe complicated by rupture and the mortality rate after rupture is ommended only in the presence of thrombosis or symptoms. Little is known about the natural history and patients without liver disease, portal vein aneurysm repair is clinical presentation of mesenteric artery aneurysms. A pseudoaneurysm (“false aneurysm”) is a localized disruption of the intimal and medial layers of the artery. PseudoaRecommendations neurysms are lined by adventitia or perivascular tissue and are 19. Patients with mesenteric artery aneurysms usually present aneurysms of the pancreaticoduodenal and gastroduodenal after the sixth decade of life. Splenic artery aneurysms account for arcade, intraparenchymal hepatic artery branches, women of about 60% of all mesenteric artery aneurysms and are more comchildbearing age, and recipients of a liver transplant, mon in multiparous women. A male preponderance is noted for hewith mesenteric aneurysms,2 cm in diameter and not meeting the aforesaid criteria, follow-up imaging is recommended patic and gastroduodenal artery aneurysms. Both sexes are afiected initially in 6 months, then at 1 year and subsequently every 1–2 equally with celiac and superior mesenteric artery aneurysms. We recommend that mesenteric artery aneurysms Aneurysms are multiple in approximately one-third of patients. Most splanchnic artery aneurysms are asymptomatic and diameter be observed or treatedfi Therefore, the uncertainty behind even when asymptomatic (strong recommendation, low level of management decisions needs thorough discussion with the patient. It is generally recognized that pseudoaneurysms have a higher risk of rupture than true aneurysms. In the largest type associated with activin receptor-like kinase type 1 mutations.

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Subjective: Symptoms New or gradual onset Pain (cramps) blood pressure levels up and down order coumadin from india, usually Mid-cycle pain days Symptoms wax and of menstrual pain arteria ulnar purchase 2mg coumadin with mastercard. Colicky pain associated dyspareunia worse to blood pressure 5545 coumadin 1 mg sacrum hypertension diagnosis discount coumadin american express, vagina and Gradual onset of crampy with a feeling of rectal during menses, sacral inner thigh area. Objective: Signs Abd exam may elicite Physical exam will be May have diffuse mild Diffuse tenderness on mild tenderness. Often note ovaries often very will have significant may be present or excessive discomfort painful. Primary Dysmenorrhea a major cause of chronic pelvic pain and the easiest to diagnose. Dysmenorrhea (painful menstruation) is classified as primary when there is no underlying organic cause other than prostaglandin release from the uterus itself during the time of menstruation. Symptoms: Once a woman’s cycles become ovulatory, anywhere from 6 months to 2 years after the start of her periods, she can experience dysmenorrhea and most do. It is described as cramping in nature and is felt in the sacral area, low pelvis and inner thigh area. Women may have associated nausea, vomiting and diarrhea (due to excessive prostaglandin release from the uterus). Occasionally vasovagal loss of consciousness may occur usually with the early years of menstruation only. Fever is not present; anorexia is rare other than with the first day of a severe menstrual cycle. If the patient is examined during her menstrual cycle, her bimanual examination may be notable for a tender uterus that is of normal shape and size. Patients who do not respond to the above treatments should be referred to a gynecologist. Endometriosis very common cause (60-70%) of chronic pelvic pain in premenopausal women. Caused by the presence of functional ectopic endometrial glands, which may be located in the ovaries, uterus, uterosacral ligaments or any area within the pelvis. Essentially small bits of the uterine lining are growing in areas where they should not be the body reacts to these implants causing tissue damage. Symptoms: Dysmenorrhea (pain with menstruation) will occur in most women with endometriosis. This is usually a change for them with worsening from the normal minor menstrual discomfort; it will often start at least a week prior to the onset of menstruation and may last a few days after blood flow stops. Pain with intercourse (dyspareunia) is common and sometimes the only complaint; it becomes worse during menses. It is not uncommon for women with endometriosis to have daily pelvic pain these women will often have more severe disease. There also appears to be a certain genetic component with 5-10% having a family history positive for the disease. Pain with initial penetration that occurs at the entrance to the vagina is of other origin. The pain may be reproduced with deep abdominal palpation but this is not a reliable finding. As endometriosis can cause scarring in the pelvis, one can find that the uterus and ovaries are immobile due to adhesions. Often the examination is unremarkable other than in the fact that you can reproduce the patient’s pain. Treatment: As endometriosis is a common cause of pelvic pain it is best keep this disease high in the differential diagnosis. Birth control pills suppress ovulation, which will decrease the activity of the endometriosis implants. Some women have midcycle pain due to either distension of the ovarian capsule or spillage of the ovarian contents at the time of ovulation. This pain usually coincides with the 12th-16th day of the menstrual cycle (count the first day of bleeding as day #1). Symptoms: Gradual or rapid onset of pelvic pain that will usually peak in 24 hours and then remit. The most significant piece of history is the timing of the painMittelschmerz will usually be on the 12th-16th day. In women with irregular and/or infrequent periods the diagnosis will be more difficult. Pelvic Examination: Often the exam is only significant for generalized lower pelvic discomfort that is mild to moderate in nature. The ovary will sometimes be enlarged (a woman ovulates from only one side each month so the pain is often lateralizing and changes sides month-to-month). The patient can mark the first day of her cycle and then each day that she has pain. The discomfort that occurs is often left lower quadrant and lower abdominal causing many women to interpret their symptoms as related to the uterus and/or ovaries. Symptoms: Colicky abdominal pain with a sensation of rectal fullness and bloating. Abdominal pain is usually accompanied by diarrhea and/or constipation but occasionally may be the only complaint. It is best not to examine these patients in the week prior to and during menses as they may have increased sensitivity to examination. Fluid intake is often inadequate and should be increased, caffeine should be minimized. Common food triggers include fried and other excessively fatty foods, milk products, rice and beans (in patients not used to a primarily vegetarian diet). Warm baths or heating pads to the abdomen are often helpful during acute exacerbations. She should note pain on a scale of 1-10 and any other accompanying symptoms, including physical and psychological symptoms. If available, radiographs of the pelvis and lumbo-sacral spine can identify other potential explanations of chronic pelvic pain. Treatment Primary: See Differential Diagnosis Chart Primitive: Warm compresses, rest and warm baths can be helpful for many types of chronic pain. Patient Education General: Most chronic pain can be successfully treated in a systematic fashion. Always remember that simple vaginitis does not cause pelvic pain or systemic signs of illness such as fever, nausea and vomiting, or pelvic pain. Subjective: Symptoms Symptoms are localized to the vagina rather than throughout the pelvis: a gray-yellowish, thin vaginal discharge with a foul-fishy odor made worse after intercourse; vulvar burning and irritation; pain during and after intercourse due to vaginal irritation. Objective: Signs Using Basic Tools: Pelvic exam: Thin, homogenous, gray or greenish-yellow discharge adherent to side walls of the vagina; pooled fluid in the posterior vaginal cul-de-sac; normal vaginal epithelium; amine (fishy) odor to discharge; erythema of external genitalia; normal uterus and ovaries. Assessment: Diagnosis based on the discharge having three of the following four characteristics: pH greater than 4. Alternatively, use vaginal clindamycin gel or metronidazole gel in the first trimester of pregnancy. Patient Education General: Take medications as prescribed, abstain from intercourse during treatment period. Activity: Regular Diet: As tolerated Medications: No alcohol consumption (including mouthwash or topical alcohol-containing products) during treatment with Metronidazole due to Antabuse-like effect (extreme fatigue, vomiting, anxiety, etc. Prevention and Hygiene: None No Improvement/Deterioration: Return immediately Follow-up Actions Return evaluation: If symptoms do not resolve, the most likely cause of persistent disease is noncompliance with medical therapy. If patient has been compliant, may re-treat with metronidazole 500 mg po bid x 14 days. Consider that patient may have trichomonas and be reinfected from a sexual partner. Other than the localized symptoms there are no long-term or immediate sequelae of vaginal/vulvar candidiasis although a small percentage of females will have frequent recurrence requiring prolonged treatment. Subjective: Symptoms Vulvar and vaginal itching are the most common complaints; thick, curdy white discharge increased from baseline; external irritation and occasionally dysuria and pain with intercourse; no systemic symptoms. Plan: Treatment Patients with vaginal or vulvar itching only may be treated without physical examination. A thorough disease-specific history must be taken to evaluate for complicating factors such as pelvic pain, lesions, fever and risk factors for sexually transmitted disease. If any of these are present, evaluate accordingly; if not, prescribe intravaginal therapy. Patient Education General: Complete all medication as prescribed since incomplete treatment is a reason for recurrence.

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Instruct patients to blood pressure 34 weeks pregnant discount generic coumadin uk check ketones (when possible) if symptoms consistent with ketoacidosis occur even if blood glucose is not elevated hypertension over 60 discount coumadin 1 mg amex. Serious Urinary Tract Infections Inform patients of the potential for urinary tract infections blood pressure spike symptoms purchase coumadin online from canada, which may be serious blood pressure chart excel cheap coumadin 5 mg online. Severe and Disabling Arthralgia Inform patients that severe and disabling joint pain may occur with this class of drugs. Bullous Pemphigoid Inform patients that bullous pemphigoid has been reported during use of linagliptin. Instruct patients to seek medical advice if blisters or erosions occur [see Warnings and Precautions (5. The other brands listed are trademarks of their respective owners and are not trademarks of Boehringer Ingelheim Pharmaceuticals, Inc. Contact your doctor right away if you have any of the following symptoms: o increasing shortness of breath or trouble breathing, especially when you lie down o swelling or fluid retention, especially in the feet, ankles or legs o an unusually fast increase in weight o unusual tiredness these may be symptoms of heart failure. Dehydration may cause you to feel dizzy, faint, light-headed, or weak, especially when you stand up (orthostatic hypotension). You may be at higher risk of dehydration if you: o have low blood pressure o take medicines to lower your blood pressure, including diuretics (water o are on low sodium (salt) diet pills) o are 65 years of age or older o have kidney problems Talk to your doctor about what you can do to prevent dehydration including how much fluid you should drink on a daily basis. Talk with your doctor about the best way to control your blood sugar while you are pregnant. Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. If you do not remember until it is time for your next dose, skip the missed dose and go back to your regular schedule. Tell your doctor if you have any signs or symptoms of a urinary tract infection such as a burning feeling when passing urine, a need to urinate often, the 2 need to urinate right away, pain in the lower part of your stomach (pelvis), or blood in the urine. Signs and symptoms of low blood sugar may include: o headache o irritability o confusion o dizziness o drowsiness o hunger o shaking or feeling jittery o sweating o weakness o fast heartbeat • A rare but serious bacterial infection that causes damage to the tissue under the skin (necrotizing fasciitis) in the area between and around the anus and genitals (perineum). Seek medical attention immediately if you have a fever or you are feeling very weak, tired or uncomfortable (malaise), and you develop any of the following symptoms in the area between and around your anus and genitals: o pain or tenderness o swelling o redness of skin (erythema) • Vaginal yeast infection. Other symptoms of a yeast infection of the penis include: o redness, itching, or swelling of the penis o rash of the penis o foul smelling discharge from the penis o pain in the skin around penis Talk to your doctor about what to do if you get symptoms of a yeast infection of the vagina or penis. Talk to your doctor right away if you use an over-the-counter antifungal medicine and your symptoms do not go away. Tell your doctor right away if you develop blisters or the breakdown of the outer layer of your skin (erosion). The film coating contains the following inactive ingredients: hypromellose, mannitol, talc, titanium dioxide, polyethylene glycol. G-2 Analyzer Icon Displays with an Busy Status when a Sample Is Not Being Processed. Failure to follow these instructions may adversely affect results as well as the safety features of the analyzer. Laser Flow Cytometry With laser flow cytometry, the system performs two separate analyses: • Red blood cell optical—analyzes mature red blood cells, reticulocytes, and platelets • White blood cell differential—analyzes and classifies the five-part differential the cellular suspensions are hydrodynamically focused through a narrow orifice that is exposed to focused red laser light. These optical signatures provide information on the size, complexity, contents, and structure within each cell. Avalanche Photodiode (fluorescent light) Dichroic Mirror Semiconductor Laser (fi = 633 nm) Photodiode (side-scattered light) Flow Cell Photodiode (forward-scattered light) Optical Fluorescence With optical fluorescence, the ProCyte Dx Leukocyte Stain and Reticulocyte Stain bind to nucleic acids in the cells and are excited by the red laser light. With this method, a diluted sample is focused through the center of a detection aperture and an electrical signal is disrupted by each cells presence. For example, if the clouds of dots are more dense than normal, an increased count for that particular cell will likely be evident in a blood film. Due to their smaller size, they spend less time in front of the laser beam, absorb less light, and therefore fall closer to the bottom on the y axis. These are generally in tact red blood cell membranes that have released their hemoglobin. Conversely, they are more optically complex than the mononuclear cells, therefore they have the least fluorescence but higher scatter than lymphocytes and monocytes. In feline samples, eosinophils are unique in that they have the nearly the highest fluorescence and the most scatter of all of the cells. In General, they have a more fluorescence than neutrophils, and also have more side scatter. In canine, equine, bovine, and ferret samples, they appear just above neutrophils in fluorescence, and to the right of the lymphocytes on side scatter. In feline samples, basophils appear below the eosinophils in fluorescence and to the right of lymphocytes in side scatter. Components the ProCyte Dx analyzer is a self-contained system that analyzes animal blood and control samples. Compatible Species the ProCyte Dx analyzer can analyze blood from the following species: • Canine • Feline • Equine • Bovine • Ferret • Other‡ ‡The “Other” species was incorporated for research purposes. The canine algorithm incorporates known cellular size, scatter pattern, and unique distributions customized for that species. This mode can be used by experienced professionals with knowledge of hematology dot plots and who can make visual updates to the displayed pattern of the dot plot. Ensure the tubing is not bent and that the power cord is securely plugged into the outlet. The ProCyte Dx analyzer has three sample tube adapters so you can use various tube sizes, if necessary. Select the sample tube adapter that is appropriate for the sample tube you are using. Note: If you are using a micro tube, you must remove the cap before beginning the sample analysis process. A dialog box appears with information about the selected patient and options to start or cancel the sample run. A second dialog box appears with information about the selected patient and instructions for processing the sample on the analyzer. If necessary, press the Open/Close button on the analyzer to open the sample drawer. In a patient-specific job status area on the Home screen, tap a Ready to Run or Busy ProCyte Dx icon. On the Records: Select Results screen, tap the set of results that you want to view and then tap View Results. On the Records: Test Results screen, tap the ProCyte Dx tab to view the analyzer’s test results for the selected patient. The diagnostic results report is a comprehensive report of all the test results specified in a laboratory request for that patient on a specific day. Patient test results can be printed automatically each time a set of results are returned or you can manually print the results when needed. If you are on the Home screen, the affected analyzer’s icon also appears with an Alert status. Customizing the Settings You can customize some of the settings on the ProCyte Dx analyzer using the ProCyte Dx Settings button on the ProCyte Dx Instruments screen. Important: Reagent kits and stain packs must be kept at room temperature (15°C–30°C/ 59°F–86°F) when connected to the analyzer. Changing a Reagent Kit/Stain Pack An alert displays when the reagent kit/stain pack is empty or expired. When the reagent kit/stain pack is low or close to expiration, you can choose to change it immediately or be reminded to change it later. Remove the caps from the 3 bottles, the System 4 Diluent, and the waste container in the new reagent kit and set them aside. Extra reagents have been added to the bottles to ensure that the analyzer does not run out of reagent and aspirate air. If you do not have a reader, type the bar code into the Enter a Reagent Code text box. Ensure the Quick-Connect Top is placed securely on the reagent kit and tap Start Prime. Important: It is essential that the Quick-Connect Top is placed securely on the reagent kit when priming reagents.

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Identify the portions of the nephron and explain how each functions in urine formation blood pressure chart by age nhs discount coumadin 5mg overnight delivery. Each collecting tubule empties into a urine-collecting area called a calyx (from the Latin word meaning “cup”) blood pressure procedure discount coumadin on line. Each of these microscopic structures is basically a single tubule coiled and folded into various shapes pulse pressure quizlet purchase coumadin online from canada. Longitudinal section through the kidney showing its internal structure blood pressure 7744 2 mg coumadin sale, and an enlarged diagram of a nephron. Blood leaves the kidney by a series of vessels that finally merge to form the renal vein, which empties into the inferior vena cava. The main waste material is urea, the nitrogenous (nitrogen-containing) byproduct of protein metabolism. Removal of Urine Urine is drained from the renal pelvis and carried by the ureter to the urinary bladder (Fig. A variety of other substances may appear in urine in cases of disease (root ur/o). Box 13-1 Words That Serve Double Duty Some words appear in more than one body fundus means the back part or base of an organ. The the uterus has a fundus, the upper rounded medulla of the kidney is the inner portion of portion farthest from the cervix, and so does the organ. There is spinal cord, and to the part of the brain that also a macula in the ear, which contains recepconnects with the spinal cord, the medulla tors for equilibrium. Use the appropriate root to write a word for each of the following definitions: 22. The infecting organisms are usually colon bacteria carried in feces, particularly Escherichia coli. Cystitis is more common in females than in males because the female urethra is shorter than the male urethra and the opening is closer to the anus. As in cystitis, signs of this condition include dysuria, painful or difficult urination, and the presence of bacteria and pus in the urine, bacteriuria and pyuria, respectively. Urethritis is infiammation of the urethra, generally associated with sexually transmitted diseases such as gonorrhea and chlamydial infections (see Chapter 14). It is usually a response to infection in another system, commonly a streptococcal infection of the respiratory tract or a skin infection. Because of damage to kidney tissue, blood and proteins escape into the nephrons, causing hematuria, blood in the urine, and proteinuria, protein in the urine. These compounds affect the central nervous system, causing irritability, loss of appetite, stupor, and other symptoms. There is rapid loss of kidney function with oliguria and accumulation of nitrogenous wastes in the blood. Renal failure may lead to a need for kidney dialysis or, ultimately, renal transplantation. Dialysis refers to the movement of substances across a semipermeable membrane; it is a method used for removing harmful or unnecessary substances from the body when the kidneys are impaired or have been removed (Fig. In hemodialysis, blood is cleansed by passage over a membrane surrounded by fiuid (dialysate) that draws out unwanted substances. Causes of stone formation include dehydration, infection, abnormal pH of urine, urinary stasis, and metabolic imbalances. This results in great pain, termed renal colic, and obstruction that can promote infection and cause hydronephrosis (collection of urine in the renal pelvis). A cellophane membrane separates the blood compartment and dialysis solution compartment. This membrane is porous enough to allow all of the constituents except the plasma proteins and blood cells to diffuse between the two compartments. A semipermeable membrane richly supplied with small blood vessels lines the peritoneal cavity. With dialysate dwelling in the peritoneal cavity, waste products diffuse from the network of blood vessels into the dialysate. If treatment is not effective in permanently removing the tumor, a cystectomy (removal of the bladder) may be necessary. In this case, the ureters must be vented elsewhere, such as directly to the surface of the body through the ileum in an ileal conduit (Fig. Additional means for diagnosing cancer and other disorders of the urinary tract include ultrasound, computed tomography scans, and radiographic studies such as intravenous urography (Fig. In a routine urinalysis, the urine is grossly examined for color and turbidity (a sign of bacteria); specific gravity (a measure of concentration) and pH are recorded; test are performed for chemical components such as glucose, ketones, and hemoglobin; and the urine is examined microscopically for cells, crystals, or casts. In more detailed tests, drugs, enzymes, hormones, and other metabolites may be analyzed and bacterial cultures may be performed. Calyx Pyramids of medulla Renal capsule 2 Renal medulla Renal pelvis Renal cortex Ureter 5 3 6 4 1 7 1. The tube that carries urine from the kidney to the bladder is the. The main nitrogenous waste product in urine is. Urinalysis revealed no albumin, glucose, bacteria, or blood; there was evidence of cells, crystals, and casts. Most of the staghorn was removed from the renal pelvis with no remaining stone in the renal calices. Each room had a new cystoscopy bed with padded knee crutches for lithotomy position, a drainage drawer for irrigation solution collection, and radiology capability. Each room had a machine to collect and decontaminate the liquid waste, instead of the former fioor drains. Renal dialysis can be performed by shunting venous blood through a dialysis machine and returning the blood to the patient’s arterial system. Label a diagram of the male reproductive tract and describe the function of each part. The gametes are generated by meiosis, a process of cell diTvision that halves the chromosome number from 46 to 23. When male and female gametes unite in fertilization, the original chromosome number is restored. The sex hormones aid in the manufacture of the gametes, function in pregnancy and lactation, and also produce the secondary sex characteristics such as the typical size, shape, body hair, and voice that we associate with the male and female genders. The Testes the male germ cells, the spermatozoa (sperm cells), are produced in the paired testes (singular, testis) that are suspended outside of the body in the scrotum (Fig. Their development requires the aid of special Sertoli cells and male sex hormones, or androgens, mainly testosterone. These hormones are manufactured in interstitial cells located between the tubules. A short continuation, the ejaculatory duct, delivers the spermatozoa to the urethra as it passes through the prostate gland below the bladder. Finally, the cells, now mixed with other secretions, travel in the urethra through the penis to be released. This may be performed for medical reasons, but is most often performed electively in male infants for reasons of hygiene, cultural preferences, or religion. Some of the work of learning medical terminolsterilize a man is still called a vasectomy and not ogy is made more difficult by the fact that a “ductusectomy. Dorsal is also posterior; ventral could be occur because different names have been asanterior. Human growth hormone is also called signed at different times or places or because somatotropin. In the nervous system, the little swellings at the tube that leads from the testis to the urethe ends of axons that contain neurotransmitthra in males was originally called the vas deferters are variously called end-feet, end-bulbs, ens, vas being a general term for vessel. It contains, in addition to sperm cells, secretions from three types of accessory glands. The first of these, the paired seminal vesicles, release their secretions into the ejaculatory duct. The second, the prostate gland, secretes into the first part of the urethra beneath the bladder. As men age, enlargement of the prostate gland may compress the urethra and cause urinary problems. The two bulbourethral (Cowper) glands secrete into the urethra just below the prostate gland.

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Renal colic followed by hematuria is suggestive of stones arteria doo buy coumadin 2mg on-line, while hematuria followed by colic may result from a tumor pulse pressure fluid responsiveness buy coumadin paypal. Medical History Asking the patient: have you ever had any medical problem arteria basilar purchase coumadin with american express, or been to blood pressure medication drug test cheap 1 mg coumadin with visa hospital for anythingfi It is important to record hospitalizations (dates, locations, service) within the past medical history. Allergies and Reactions: Any adverse effects or reactions to medications and contrast mediafi Bilharziasis (Schistosomiasis): Bilharziasis is endemic in Egypt and has a causal relationship to a wide range of clinical syndromes and systemic complications. Features of Uro-genital Bilharziasias Pathological features Clinical features Urinary A. Cancer of bilharzial bladder: Hyperplasia and dysplasia, Severe progressive cystitis with Cystitis glandularis, alterations and additions: Squamous metaplasia and 1. Epithelial changes: ureteritis lead to chronic renal failure or cystica, glandularis and calcinosa. Manifestations of bilharzial Hydronephrosis, pyelonephritis, obstructive uropathy, infection, stones, pyonephrosis and renal and stone formation failure B. Bilharzial changes in roof of Watering can perineum develops when bulbous urethra urethrocutaneous fistulas occur. Primary hyper-parathyroidism and immobilization Drugs: A list of medications should be developed including: type, dosage, route of intake, frequency, and duration. Of particular interest are the drugs relevant to urologic symptoms and planning for surgery (table 6). For example, the use of aspirin, which may be considered too simple to mention, can increase bleeding during surgery. Urologic complications of diabetes include bladder dysfunction, urinary tract infections, and chronic 33 kidney disease. Sexual problems in men with diabetes include erectile dysfunction and retrograde ejaculation. Note: Type, medications taken, and recent evaluation Age of onset, duration, organ involvement Development of complications. Adrenal disorders include Cushing syndrome, hyper-aldosteronism, congenital adrenal hyperplasia, adrenal insufficiency, and pheochromocytoma. Primary hyperparathyroidism is caused by parathyroid adenoma, and characterized by abdominal groans, psychic moans, cystic bones, kidney stones and fatigue overtones. Primary increased activity of parathormone will cause osteitis fibrosa cystica, hypercalcemia, hypophosphatemia, nephrocalcinosis and stones. Secondary hyperparathyroidism is a result of parathyroid hyperplasia in cases of chronic renal insufficiency, and characterized by accumulation of phosphates, hypocalcemia and bone demineralization. Tertiary hyperparathyroidism: Long term stimulation of parathyroid glands may lead to development of autonomous adenoma, with persistent overproduction of the hormone, even after renal transplantation, leading to osteolysis and soft tissue calcification. Abnormal development: 1Undescended testis 2Micropenis 3Gynecomastia 4Delayed puberty 5Precocious puberty Reproductive disorders in adults: 34 1Hypogonadism 2Impotence 3Infertility 4Gynecomastia Table 7. Klebsiella, and Candida albicans Bacteremia Tuberculosis Diabetic nephropathy Microalbuminuria Chronic kidney disease Genitalia Men: Impaired neurogenic and Erectile dysfunction. Female disorders of desire and Female sexual dysfunction arousal; inhibited orgasm and sexual pain. Some cold receptors will discharge a brief action potential as a response to high temperatures, and this is known as paradoxical cold sensation. Kidney: Acute pyelonephritis, renal abscesses Prostate: Acute prostatitis and prostate abscess Testis: Acute epididymo-orchitis b) Acute urinary tract obstruction: In cases of infected hydronephrosis, pyonephrosis and emphysematous pyelonephritis; fever with chills indicate impending septicemia and require urgent management and relief of obstruction. Infections related to original surgery: Wound infection Abscess formation Peritonitis B. Hormonal hypertension of urologic importance: High renin hypertension: 1) Renovascular abnormalities 2) Juxtaglomerular cell tumors are rare and benign. They occur in young people less than 20 years and are curable by surgical excision. There are high peripheral renin and secondary hyperaldosteronism leading to hypokalemia, nocturia and polyuria. They have muscle weakness and cramps, hypokalemia, metabolic alkalosis and suppressed plasma renin levels. Secondary hyperaldosteronism can be due to renal artery stenosis, heart failure, and liver cirrhosis, pregnancy, and juxtaglomerular cell tumors. It is important to remember that essential hypertension treated with diuretics is the most common cause of hypokalemia. Pheochromocytoma: 38 Symptoms may occur in paroxysms that include palpitations, headache, episodic sweating (diaphoresis), and orthostatic hypotension. Fractionated metanephrines and catecholamines are high in a 24-hour urinary specimen. Neuroblastoma: While hypertension is due to high levels of catecholamines in neuroblastoma, renin is responsible in children with nephroblastoma. Kidneys radiological brunt usually is apparent Renal mass problem with different on one side. Caseation Renal failure occurs with bilateral Cavitation renal or ureteric disease. Calcification (curvilinear) Ulceration Fibrosis Autonephrectomy Stricture formation Obstructive uropathy: Ureters ureterovesical junction hydronephrosis, pyonephrosis. Differential diagnosis of filling pelviureteric obstruction defects in urinary tract. Contracted bladder: late Granuloma, cavitation, calcification Painless epididymal mass adherent Male sexual and fibrosis. Hard nodular prostate Adrenal gland Bilateral calcifications and Generalized lassitude hypofunction Skin hyperpigmentation Addisonian crisis 41 Past Surgical History Was the patient ever subjected to surgical operation(s)fi Rapid deceleration may cause renal vascular damage, resulting in renal artery thrombosis, renal vein disruption, or renal pedicle avulsion. The degree of tissue destruction exceeds the pathway of the bullet, because of the change of kinetic energy into thermal energy. Alcohol alone is implicated in liver cirrhosis and may contribute to cancers of the breast and large bowel. Overseas travel: Has the patient been abroad recently or spent any time abroad in the pastfi Gastrointestinal symptoms of urologic diseases: Acute pyelonephritis is associated with generalized abdominal pain and distension. Neurologic disorders: A) Neurologic lesions cause urinary and sexual dysfunction: Diabetes mellitus Multiple sclerosis: Urinary symptoms are the first manifestations in 5%. Vascular disorders: Hypertension may be a manifestation of renal vascular disorders or adrenal masses. Congenital disorders: Adult polycystic kidney, von Hippel-Lindau and tuberous sclerosis complex are autosomal dominant diseases. Symptoms of metastases: Bones: Pain, swelling, nerve compression, spontaneous fracture. Asymptomatic: Men may be concerned and attend requesting for a prostate health check following the information about prostate cancer in the media. It is important particularly when any first-degree relative has developed the disease. Metastatic disease: Asymptomatic (occult) Anorexia, anemia, asthenia Bone aches and pathological fractures Swelling of the lower limb due to lymphatic obstruction Neurological manifestations due to spinal cord compression Hemoptysis or dyspnea Jaundice 49 Kidney cancer: 1. Asymptomatic: Kidney cancer used to be the internist’s tumor, may now be the radiologist’s tumor as more than 50% of cases are diagnosed incidentally on abdominal imaging carried out to investigate unrelated symptoms. Paraneoplastic syndromes (table 9): the most common paraneoplastic syndrome with renal cell carcinoma is hypertension. This definition excludes cases in which symptomatic adrenal-dependent disorders are "missed" because of an incomplete history taking and clinical examination. Functioning adrenal masses could be cortisol-secreting adenoma, pheochromocytoma, primary hyper-aldosteronism, and adrenal cortical carcinoma. About 5% of all incidentalomas are pheochromocytomas, and about 25% of all pheochromocytomas are found incidentally.

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