In pregnancy diabetes diet menu in tamil buy losartan without prescription, the physiological white discharge usually increases owing to the increased shedding of epithelial cells and an increased vascularity of the cervix diabetes type 2 how many carbs per day buy losartan on line amex, which in turn leads to an increase in secretion production blood glucose graph after meal buy losartan paypal. Poor hygiene again is not uncommon and appropriate advice should be given to the mother diabetes medications emedicine discount losartan 25 mg visa. One needs to be cautious if sexual abuse is suspected, in which case the paediatric lead for child protection should be consulted. Reproductive age Vaginal discharge in women of reproductive age is most likely to be caused by infection. However, cervical polyps and malignancy may present with excess discharge or mucus production; these conditions are covered in the relevant chapters. The causes of vaginal discharge in this age group can be classified as: Non-infective Pathological discharge Pre-pubertal the causes of vaginal discharge in this age group can be classified as: Non-infective foreign body; poor hygiene; sarcoma botryoides. In all cases, a relevant history should be obtained, followed by any appropriate physical examination plus a vaginal speculum examination in order to take the relevant swabs, as discussed below. Candida this is a common infection in women and is often over-diagnosed and treated. It gives rise to characteristic white patches of thrush on the vagina walls and cervix. It causes itching, discomfort, redness, external dysuria, and superficial dyspareunia. Vaginal and vulval examination may be normal or show non-malodorous discharge, mild inflammation of the vagina or vulva with fissuring, redness, and oedema. It can occur as a complication of diabetes, immunosuppression, during pregnancy, following the use of antibiotics, and also in women using the combined oral contraceptive pill. A swab may be taken for recognition of the mycelium and spores of Candida albicans in stained smears and for culture. Women typically present with vaginal discharge which is homogenous, grey/white, thin, watery, copious, and with an offensive fishy smell. Unless associated with another infection such as Candida, it usually does not have other symptoms as itch and soreness. Examination shows discharge coating the vagina and the vestibule and the absence of vaginal inflammation. It also causes dysuria (urethral infection is seen in 90 per cent of cases) and lower abdominal pain (symptoms are absent in 50 per cent of women). The discharge is green or greenish yellow with small bubbles of gas and has a characteristic odour. Genital examination may be normal or show evidence of vulvitis, vaginitis, or cervicitis (<15 per cent of women do not show signs of inflammation or vaginal discharge). Rarely (only in <2 per cent of cases), the so-called strawberry cervix (typical red-stippled appearance) can be seen. Both patient and partner should be advised to avoid sex until treatment is completed. It usually infects the mucous membranes of the endocervix, urethra, rectum, pharynx, and conjunctiva. There is nothing characteristic of gonorrhoeal discharge visible to the naked eye. This is often a matter of difficulty because it is only in the few days immediately after infection that the organism can be found in the discharge. It is caused by an intracellular obligate pathogen which usually affects the mucous membranes of the endocervix, urethra, rectum, pharynx, and conjunctive. The risk factors for chlamydia include women below the age of 25, more Figure 6 Chlamydia trachomatis infection of the cervix. It can present with vaginal discharge, post-coital or intermenstrual bleeding, dysuria, lower abdominal pain, deep dyspareunia, and cervicitis, or can be asymptomatic (70 per cent of women) and only detected on screening for fertility problems or prior to a termination of pregnancy. Speculum examination reveals an oedematous, congested friable cervix which bleeds on touch. Treatment involves doxycycline (100 mg oral twice daily for 14 days) or azithromycin 1 g oral stat (can be used if compliance is the issue). The first-line antibiotics include doxycycline (100 mg oral twice daily for 14 days) and metronidazole (400 mg oral twice daily for 15 days) plus ceftriaxone (500 mg intramuscular stat dose) or ofloxacin (or levofloxacin) plus metronidazole. Moxifloxacin (400 mg oral once daily for 14 days) is used as second line (the addition of metronidazole is not needed). Erythromycin (500 mg oral twice daily for 14 days) should be used during pregnancy instead of doxycycline (contraindicated during pregnancy). Retained tampons/foreign bodies Any retained foreign body will start to cause discharge, which may become offensive after 24 hours. A ring pessary inserted for prolapse should be changed regularly; otherwise, discharge may develop. Women with this condition may be asymptomatic or present with bilateral lower abdominal pain, abnormal vaginal discharge, abnormal vaginal bleeding (intermenstrual, post-coital, and menorrhagia), lowgrade pyrexia, tachycardia, and deep dyspareunia. The differential diagnosis of abdominal pain in such women in the reproductive age includes ectopic pregnancy, endometriosis, acute appendicitis, complication of ovarian cyst (rupture or torsion), urinary tract infection, and irritable bowel syndrome, and it can be functional. In postmenopausal women, unless they are receiving hormone replacement therapy the amount of vaginal discharge produced is reduced and the squamocolumnar junction retreats along the endocervical canal.
Syndromes
Mycobacteria
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Rubella that damages the acoustic nerve
Shower the night before or the morning of your surgery.
Arterial occlusive disease
Pyeloplasty removes scar tissue from the blocked area and connects the healthy part of the kidney to the healthy ureter.
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Painful areas are called tender points. Tender points are found in the soft tissue on the back of the neck, shoulders, chest, lower back, hips, shins, elbows, and knees. The pain then spreads out from these areas.
Chest x-ray
Pressure sores
Podocytes extend their processes around the capillaries and develop numerous secondary processes called pedicels (foot processes) early signs diabetes mellitus discount losartan master card, which interdigitate with other foot processes of the neighboring podocytes diabetes type 1 treatment without insulin generic losartan 50mg online. The spaces between the interdigitating foot processes form filtration slits that are covered by the filtration slit diaphragm diabetes insipidus specific gravity buy losartan pills in toronto. Mesangial cells are involved in phagocytosis and endocytosis of residues trapped in the filtration slits diabetes type 2 you can reverse it naturally purchase losartan discount, secretion of paracrine substances, structural support for podocytes, and modulation of glomerular distention. The juxtaglomerular apparatus includes the macula densa (monitors Na concentration in tubular fluid), juxtaglomerular cells (secrete renin), and extraglomerular mesangial cells. This tubule is the initial and major site for reabsorption of glucose, amino acids, polypeptides, water, and electrolytes. Reabsorption of the ultrafiltrate continues as it flows from the proximal convoluted into the proximal straight tubule (the thick descending limb of the loop of Henle) that descends into the medulla. The loop of Henle, with both the descending limb (highly permeable to water) and ascending limb (highly permeable to Na and Cl), concentrates the ultrafiltrate. The distal straight tubule (thick ascending limb) ascends back into the cortex to reach the vicinity of its renal corpuscle, where it makes contact with the afferent arteriole. The distal convoluted tubule empties it into the cortical collecting duct that lies in the medullary ray. The medullary collecting duct is lined by cuboidal cells, with a transition to columnar cells as the duct increases in size. The collecting ducts open at the renal papilla, and the modified ultrafiltrate, now called urine, flows sequen- tially via the excretory passages. Transitional epithelium is a specialized stratified epithelium with large dome-shaped (umbrella) cells that bulge into the lumen. The dome-shaped cells have a modified apical membrane containing plaques and fusiform vesicles that accommodate the invaginated excess of the plasma membrane, which is needed for the extension of the apical surface when the organ is stretched. It is lined by transitional epithelium, underlying smooth muscle arranged in three distinct layers, and connective tissue adventitia. The urinary bladder is also lined by transitional epithelium and possesses many mucosal folds, except in the trigone region. The urethra conveys urine from the urinary bladder to the external urethral orifice. The female urethra is short and lined by transitional epithelium (upper half), pseudostratified columnar epithelium (lower half), and stratified squamous epithelium (before its termination). The male urethra is much longer than the female and is divided into three regions: the prostatic urethra (lined by transitional epithelium), a short membranous urethra that pierces the external urethral sphincter (lined by stratified or pseudostratified columnar epithelium), and a long penile urethra (lined by pseudostratified columnar epithelium). The kidneys conserve body fluid and electrolytes and remove metabolic wastes such as urea, uric acid, creatinine, and breakdown products of various substances. They produce urine, initially an ultrafiltrate of blood that is modified by selective resorption and specific secretion by kidney tubule cells. The kidneys also function as endocrine organs, producing erythropoietin, a growth factor that regulates red blood cell formation, and renin, a hormone involved in blood pressure and blood volume control. They also hydroxylate vitamin D, a steroid prohormone, to produce its active form. The concave medial border of each kidney contains a hilum, an indented region through which blood vessels, nerves, and lymphatic vessels enter and leave the kidney. The funnel-shaped origin of the ureter, the renal pelvis, also leaves the kidney at the hilum. A cut, hemisected fresh kidney reveals two distinct regions: a cortex, the reddish-brown outer region, and a medulla, a much lighter inner part continuous with the renal pelvis. The cortex is characterized by renal corpuscles and their tubules, including the convoluted and straight tubules of the nephron, the cortical collecting ducts, and an extensive vascular supply. A frontal section through the cortex and medulla of an unembalmed kidney obtained from autopsy is shown here. The visible hilar region consists of minor calyces (grey/ white) surrounded by yellow in appearance adipose tissue. The medulla consists of renal pyramids, which have their base facing the cortex and their apex in the form of a papilla (P) directed toward the hilum. The majority of the outer part of the pyramid on the left has not been included in the plane of section. The minor calyces drain into major calyces, and in turn, these open into the renal pelvis, which funnels urine into the ureter. An interesting feature in this specimen is that the blood has been retained in many of the vessels, thereby allowing for visualization of several renal vessels in their geographic location. Also seen in the cortex are groups of tubules that are more or less straight and disposed in a radial direction from the base of the medulla (arrows); these are the medullary rays. In contrast, the medulla presents profiles of tubular structures that are arranged as gentle curves in the outer part of the medulla, turning slightly to become straight in the inner part of the medulla. The disposition of the tubules (and blood vessels) gives the cut face of the pyramid a slightly striated appearance that is also evident in the gross specimen (see figure above). They are responsible for the production of urine and correspond to the secretory part of other glands. The collecting ducts, responsible for the final concentration of the urine, are analogous to the ducts of exocrine glands. The tubular parts of the nephron are the proximal thick segment (consisting of the proximal convoluted tubule and the proximal straight tubule), the thin segment, which constitutes the thin limb of the loop of Henle, and the distal thick segment, consisting of the distal straight tubule and the distal convoluted tubule. The loop of Henle is the U-shaped portion of the nephron consisting of the thick straight portions of the proximal and distal tubules and the thin segment between them. The distal convoluted tubule joins the cortical collecting duct via either the connecting tubule or arched connecting tubule. The convoluted tubules, particularly the proximal, because of their tortuosity, present a variety of profiles, most of which are oval or circular; others, more elongate, are in the shape of a letter J, a C, or even an S.
Distal convoluted tubule is less tortuous than the proximal convoluted tubule; thus diabetes mellitus overview buy 25 mg losartan otc, in a section showing the cortical labyrinth blood glucose conversion chart purchase 25 mg losartan mastercard, there are fewer distal tubule profiles than proximal tubule profiles diabetic jam discount losartan 50 mg with amex. At its termination managing uncontrolled diabetes buy 50mg losartan free shipping, the distal convoluted tubule empties into a cortical collecting duct that lies in the medullary ray via either an arched connecting tubule or a shorter tubule simply called the connecting tubule. The proximal straight tubule, the thin descending limb with its hairpin turn, the thin ascending limb, and the distal straight tubule are collectively called the loop of Henle. In some nephrons, the thin descending and ascending segments are extremely short; therefore, the hairpin turn may be made by the distal straight tubule. Types of Nephrons Several types of nephrons are identified based on the location of their renal corpuscles in the cortex. They are typical of the nephrons described previously, wherein the hairpin turn occurs in the distal straight tubule. They have long loops of Henle and long ascending thin segments that extend well into the inner region of the pyramid. These structural features are essential to the urine-concentrating mechanism, which is described in a further section. Intermediate nephrons or midcortical nephrons have their renal corpuscles in the midregion of the cortex. The portions of the straight proximal and straight distal tubules and the descending thin and ascending thin limbs of the loop of Henle in the cortex are located in and make up the major portion of the medullary rays. The thin descending and thin ascending limbs of the loop of Henle are always located in the medulla. Thus, the arrangement of the nephrons (and the cortical collecting ducts) accounts for the characteristic appearance of the cut surface of the kidney, as can be seen in Figure 20. Urinary System Collecting Ducts the cortical collecting ducts begin in the cortex from the merger of either connecting tubules or arched connecting tubules of many nephrons and proceed within the medullary rays toward the medulla. When the cortical collecting ducts reach the medulla, they are referred to as outer or inner medullary collecting ducts. These ducts travel to the apex of the pyramid, where they merge into larger collecting ducts (up to 200 m), the papillary ducts (ducts of Bellini) that open into the minor calyx. The area on the papilla that contains the openings of these collecting ducts is called the area cribrosa. In summary, the gross appearance of the kidney parenchyma reflects the structure of the nephron. The renal corpuscle and the proximal and the distal convoluted tubules the renal corpuscle is spherical and has an average diameter of 200 m. These fenestrations are larger (70 to 90 nm in diameter), more numerous, and more irregular in outline than fenestrations in other capillaries. Note the layers of the filtration barrier that include fenestrated glomerular endothelial cells, glomerular basement membrane, and podocytes with filtration slit diaphragms spanned between their foot processes. In addition, the endothelial surface layer of glycoproteins and subpodocyte spaces are shown on this diagram. The wall of the capillary shows horizontal ridges formed by the cytoplasm of the endothelial cell. The product of these reactions is often seen within the glomerulus as a crescent, a characteristic microscopic feature of glomerulonephritis. Individuals with Goodpasture syndrome present with both respiratory and urinary symptoms. These include shortness of breath, cough, and bloody sputum as well as hematuria (blood in urine), proteinuria (proteins in the urine), and other symptoms of progressing kidney failure. The main therapeutic goal in treating Goodpasture syndrome is to remove the circulating pathogenic antibodies from the blood. This is achieved by plasmapheresis, in which blood plasma is removed from the circulation and replaced by fluid, protein, or donated plasma. In addition, treatment with immunosuppressive drugs and corticosteroids is beneficial to keep the immune system from producing pathogenic autoantibodies. In this Mallory trichrome-stained specimen obtained from a kidney biopsy, the collagen molecules in the mesangial matrix and glomerular capillaries are stained dark blue. The bright red stain within the renal corpuscle represents fibrin, which leaked out of the glomerular capillary loops into the urinary space. A cellular crescent (outlined in dashed line) is formed by deposition of fibrin infiltrated by macrophages and proliferated parietal cells of the Bowman capsule. The light blue color surrounding the glomerulus is reflective of edematous reaction containing cells mediating inflammatory reactions. This immunofluorescence image of the renal corpuscle shows the glomerular basement membrane labeled with antibodies directed against human IgG and visualized with secondary antibodies conjugated with fluorescent dye. The podocytes arise during embryonic development from one of the blind ends of the developing nephron through invagination of the end of the tubule to form a double-layered epithelial cup. The cup eventually closes to form the spherical structure containing the glomerulus. As they differentiate, the podocytes extend processes around the capillaries and develop numerous secondary processes called pedicels or foot processes. Recent studies of the filtration slit diaphragm revealed its complex protein structure as a zipper-like sheet configuration with a central density. A transmembrane protein, nephrin is a key structural and functional component of the slit diaphragm. Nephrin molecules emerging from opposite foot processes interact in the center of the slit (homophilic interactions), forming a central density with pores on both sides.
They increase in size during pregnancy and with administration of oestrogen and shrink when gonadotrophin-releasing-hormone analogues are given and after the menopause diabetes test strips amazon order losartan 50 mg mastercard. Their size can range from a few millimetres to several centimetres low blood sugar yahoo buy genuine losartan on-line, and they are usually present in the main body of the uterus diabetes diet oatmeal 25mg losartan otc, occasionally occurring in the cervix or the broad ligament managing diabetes type one order losartan 25 mg online. Confirmation of diagnosis is generally straightforward with physical examination and pelvic ultrasonography. Leiomyomas can be divided into four categories based on their position in the myometrium. Intramural leiomyomas are the most common and, when large, may distort the uterine outline, resulting in a large, irregular mass. This type of myoma can give rise to menstrual problems and to complications of pregnancy. Submucosal leiomyomas are found beneath the mucosal surface of the uterus and can cause bleeding, even when small, secondary to compression of the overlying endometrium and compromise of its vascular supply. As they become larger, they may bulge into the endometrial cavity and increase the surface area of the endometrium. Rarely, this kind of myoma can become pedunculated and prolapse through the cervix. Subserosal leiomyomas develop beneath the peritoneum that covers the external surface of the uterus, and are either sessile or pedunculated. The latter may undergo torsion, infection, and even separation from the uterus itself. When separation occurs, attachment to another Figure 3 Hysterectomy specimen showing enlarged uterus due to fibroids. Pendunculated subserous Intramural Subserous displacing and obstructing fallopian tube Pendunculated subserous Subserous Submucous Cervical Pendunculated Figure 4 Transverse section across a fibroid showing a whorled appearance. Intraligamentous leiomyomas are so called because they develop between the anterior and posterior peritoneal leaves of the broad ligament. These myomas can compress adjacent organs, resulting in intestinal and urinary symptoms. Constipation up to and including bowel obstruction, urinary frequency, urge incontinence, urinary retention, and possibly ureteric obstruction may also occur. Necrosis and haemorrhage can also be found in large fibroids during pregnancy or after administration of high-dose progestin therapy. Cystic degeneration occurs, and leiomyomas often become extensively calcified as identified on plain abdominal X-ray. Adenomyomas (circumscribed nodular aggregates of smooth muscle, endometrial glands, and endometrial stroma located within the myometrium) can mimic uterine leiomyomas. Adenomyosis is a condition characterised by the presence of endometrial glands and stroma within the endometrium, and can result in a bulky uterus that is tender on bimanual examination. Other benign causes Among the infective causes of uterine swelling, tuberculous endometritis deserves mention. It is secondary to a systemic infection by Mycobacterium tuberculosis, generally presenting in women of reproductive age. The endometrium is the second most commonly infected site in the female genital tract, after the Fallopian tubes. Infection develops by haematogenous spread from a primary focus in the lungs or gastrointestinal tract, and uterine infection is usually by direct transmission from the Fallopian tubes. This is usually asymptomatic but may result in a distended uterine cavity on imaging. In this age group, the presence of a haematometra (cavity containing blood) or pyometra (cavity containing pus) requires further investigation (usually dilatation of the cervix, drainage, and cervical/endometrial biopsy), as the presence of a malignancy must be excluded. In these cases, the distended uterus may present with pain and may be palpable on physical examination. Causes include cervical scarring secondary to trauma (lacerations following parturition or abortion), surgery (cone biopsy, cryotherapy, cervical cauterisation), and radiotherapy for primary cervical cancer. Benign endometrial polyps may also result in an enlarged uterus and should be included in this section. Approximately 90 per cent of women diagnosed with endometrial cancer present with postmenopausal bleeding, and up to 10 per cent of women with this symptom will be diagnosed with the disease. The recommended initial investigation is a transvaginal ultrasound scan for measurement of endometrial thickness and identification of ovarian masses. The most commonly used threshold for further investigation is an endometrial thickness of over 5 mm. Outpatient endometrial biopsy correctly diagnoses cancer in over 80 per cent of women and can be preceded by outpatient hysteroscopy if necessary, for example where endometrial polyps are suspected on ultrasound. Hysteroscopically directed biopsy is also useful in the evaluation of women with bleeding while taking tamoxifen. The overall 5-year survival rate is high, reflecting early presentation in most cases, but outcomes for advanced disease remain poor. Over 80 per cent of primary endometrial cancers are endometrioid adenocarcinomas which are usually presented early and carry a very good prognosis (Figs 7 and 8). The cornerstone of treatment is total hysterectomy and bilateral salpingoophorectomy, and laparoscopic surgery is recommended as a means of reducing morbidity.
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