Program Director, University of Chicago Pritzker School of Medicine
There is also a range of external genitalia from microphallus with a normal urethra muscle relaxant bruxism 100 mg voveran sr free shipping, to the creation of a pseudovagina and lack of scrotal fusion muscle relaxant esophageal spasm buy voveran sr mastercard. These males typically have gynecomastia and normal pubic and axillary hair but no chest or facial hair spasms hand generic 100 mg voveran sr fast delivery. However spasms shoulder generic 100 mg voveran sr with visa, some surgical procedure is often performed to modify the ambiguous genitalia to facilitate gender assignment. Clinical manifestations include an externally female appearance, with nonfunctioning gonads. Therefore, girls often present with delayed puberty, both lack of menstruation and failure of secondary sex characteristics development, such as breast development. Diagnosis can be suspected in the setting of delayed puberty, with elevation in measured gonadotropins. This suggests that the pituitary is functioning normally, but the gonads are not responding. Hormonal supplementation for initiation of puberty with estrogen alone, followed by addition of progesterone to facilitate regular menstruation as uterus is present. Presentation is in adolescence or adulthood with hirsutism, irregular menstruation, or infertility. Diagnosis is made by measuring 17-hydroxyprogesterone which will be elevated due to the 21-hydroxylase deficiency. E 5-Alpha reductase deficiency is a disease in which the 5-alpha reductase enzyme is not present, and testosterone is not converted to dihydrotestosterone in peripheral tissues. Dihydrotestosterone is required in utero for normal development of male external genitalia. Clinical manifestations range from the appearance of normal male external genitalia, normal female genitalia, or ambiguous genitalia. These infants are born with testes and wolffian duct structures, but can have the appearance of female primary sex characteristics. At puberty, these individuals can present with primary amenorrhea and may also have increased virilization, with testicular descent, and normal male-pattern hirsutism. Diagnosis is considered with the presentation of the above-mentioned constellation of clinical manifestations. There is usually a low or low-normal testosterone level, decreased levels of dihydrotestosterone, and a higher testosterone/dihydrotestosterone ratio. Those assigned to the male gender can be given exogenous dihydrotestosterone before puberty to increase the size of the penis. Psychological support is also important given the difficulties that can occur with specific gender identity. Estrogen replacement to promote puberty and breast development with subsequent addition of progestin to regulate menstruation. Estrogen dosing should be higher than postmenopausal woman to promote bone growth and secondary sexual characteristics. Pregnancy can be achieved with assisted reproductive technology and donor oocytes. There is also a high risk of developing a gonadoblastoma, and as a result, removal of the gonads is recommended. A Elevated serum testosterone B Vaginal agenesis, absent uterus C Scant/absent pubic hair, normal axillary hair D Gonads should be removed E Pregnancy possible with gestational carrier 2. A 15-year-old female is referred to you because of worsening dysmenorrhea, associated with nausea and vomiting. She has had such severe vomiting that she has not been able to go to school for the past 6 months and has forced out of the cheerleading squad because of her frequent absences. The rest of her medical history is notable for asthma, irritable bowel, and renal agenesis diagnosed during her fetal ultrasound. Her pediatrician has given her a diagnosis of "cyclic vomiting syndrome" and is treating her with antinausea medication and antidepressants and has referred her to a psychiatrist. Estrogen replacement needed to induce puberty, gonads do not need to be removed 5. Estrogen therapy needed to induce puberty, gonads need to be removed at diagnosis 6. Associated with blue bulging introitus with valsalva due to obstruction 248 Chapter 21-Answers and Explanations Answers and Explanations 1. The vagina and uterus are underdeveloped or absent, but the ovaries are not affected and are normal. Both the axillary and pubic hair are normal for a female as the androgen receptors are intact. Pregnancy is possible with a gestational carrier as the oocytes are normal and can be fertilized and transplanted into a surrogate uterus. The gonads are testes and should be removed after puberty due to the increased risk of malignant transformation.
Enter medially muscle relaxant 5658 cheap voveran sr 100mg with amex, perpendicular to the skin uterus spasms 38 weeks voveran sr 100mg overnight delivery, and advance the needle directly down past the midline of the width of the foot to the plantar fascia until you can feel its thick and gritty substance spasms detoxification generic voveran sr 100mg with amex. Inject the mixture slowly and evenly through the middle one third of the width of the foot while the needle is being withdrawn (Figure 125-1) spasms back muscles voveran sr 100 mg lowest price. Finish by putting the injected region through passive range of motion to spread the medication. Patients should be cautioned that they may experience worsening symptoms during the first 24 to 48 hours. Studies are presently ongoing to evaluate the efficacy of injecting botulinum toxin into the foot. Initial studies have shown benefit; however, more investigation needs to be performed before suggesting this as a treatment. What Not To Do: Do not inject into the heel pad itself, which may cause fat atrophy. Discussion the plantar fascia provides an intimate attachment to the overlying skin and functions to provide protection to the underlying muscles, tendons, arteries, and nerves. The fascia assists in the maintenance of the foot arch and keeps the foot in relative supination through the push-off phase of ambulation. During heel strike, the plantar fascia remains supple and allows the foot to adjust to the ground surface and absorb shock. Then, during the toe-off phase of ambulation, the plantar fascia becomes taut and thereby renders the foot a rigid lever, thus facilitating forward movement. Plantar fasciitis, the most common cause of heel pain in adults, typically results from repetitive use or excessive load on the fascia. Persons who are overweight, female, or older than 40 years or who spend long hours on their feet are especially at risk for developing plantar fasciitis. Tightness of the Achilles tendon contributes to increased tension on the plantar fascia during walking or running and is therefore an important contributor to plantar fasciitis. Stretching of the Achilles tendon can therefore alleviate some of the pain caused by plantar fasciitis. It should be relayed to the patient, however, that this can initially make the discomfort worse. Mechanical causes of heel pain are generally synonymous with plantar fasciitis, but some cases are enigmatic in etiology and are deemed idiopathic. Although the word fasciitis implies inflammation, recent research indicates that it is more likely to be a noninflammatory, degenerative process that might be more appropriately called plantar fasciosis. Acute onset of severe plantar heel pain after trauma or vigorous athletics may indicate rupture of the plantar fascia. Findings suggestive of rupture include a palpable defect at the calcaneal tuberosity accompanied by localized swelling and ecchymosis. If conservative treatment of plantar fasciitis fails to alleviate symptoms, radiographs are advisable to check for other causes of heel pain, such as stress fractures, arthritis, or skeletal abnormalities. Radiographs may show a spur on the leading edge of the calcaneal inferior surface, but this radiographic finding is not pathognomonic of the condition, nor is it necessary for the diagnosis. Ankylosing spondylitis, Reiter disease, rheumatoid arthritis, systemic lupus erythematosus, and gouty arthritis all may cause medial calcaneal pain. The benefits of using injectable steroids for plantar fasciitis has become somewhat controversial; therefore they should be used only when conservative measures have failed. The main concern with the use of steroid injections is delayed rupture of the plantar fascia. Rupture is typically associated with resolution of plantar fasciitis symptoms, but a majority of these patients may go on to develop long-term sequelae, such as longitudinal arch strain, lateral plantar nerve dysfunction, stress fracture, and development of hammertoe deformity. For the 10% or fewer with heel pain that persists for at least 1 year despite treatment, surgery should be considered, especially when the symptoms of plantar fasciitis are disabling. Determining the source of repetitive stress to the plantar fascia and addressing it as part of the treatment is crucial to both facilitating recovery and reducing the risk of recurrence. Chronic recurrences may indicate biomechanical imbalances in the foot, which may resolve with custom orthotics from a podiatrist. The patient may have actually heard or felt a "snap," described as being like the "pop" of a champagne cork, at the time of injury or may think someone actually kicked or shot him in the calf. The deep calf pain persists and may be accompanied by mild to moderate swelling and ecchymosis. Perform a physical examination, which should reveal calf tenderness, especially along the medial musculotendinous junction of the medial gastrocnemius. Swelling will usually be asymmetric, and over time, any ecchymosis may be found spreading to a more dependent site over the ankle or foot. Rule out an Achilles tendon rupture, because this needs orthopedic evaluation for possible surgery. Palpate the Achilles tendon for a defect or deformity, which represents a torn segment. Squeeze the gastrocnemius muscle just distal to its widest girth, with the patient kneeling on a chair or lying prone on a stretcher with the legs overhanging the end (Figure 126-1) to examine for normal plantar flexion of the foot. The resultant plantar flexion will be totally absent with a complete Achilles tendon tear. A defect in the contour along the length of the Achilles tendon, pain distal to the body of the gastrocnemius, and lack of pain with palpation of the muscle belly are all typical of Achilles tendon rupture and not plantaris tendon rupture or a gastrocnemius tear.
Buy 100mg voveran sr visa. How Whatsapp Earn Money Yahoo Answer | Urdu Hindi | 2018.
Estrogen increases blood flow to the uterus spasms vs spasticity cheap voveran sr 100 mg without a prescription, which ensures an adequate supply of oxygen and nutrients to the fetus spasms near elbow 100 mg voveran sr otc. Estrogen plays a role in inhibiting maternal pituitary gonadotropin synthesis and release; placental gonadotropins are primarily responsible for gonadotropic function muscle relaxants yahoo answers purchase 100mg voveran sr with mastercard. Estrogen activates oxytocin secretion and myometrial gap junction formation during parturition muscle relaxant safe in pregnancy cheap voveran sr 100mg without prescription. Measurement of maternal salivary estriol levels has been proposed as a predictor of preterm birth. Labor and delivery may be delayed in anencephalic fetuses and fetuses with placental sulfatase deficiency when large amounts of estrogen cannot be produced. Estrogen stimulates epithelial cell proliferation in human breast tissue during lactation. Because estriol is an index of normal function of the fetus and the placenta, reduced maternal estriol levels may reflect abnormalities in fetal or placental development. Endocrinology of Pregnancy 7 Study Questions for Chapter 1 Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. A 26-year-old female presents to the emergency room complaining of severe right lower quadrant pain. Anencephaly causes lack of production of this hormone Endocrinology of Pregnancy 9 Answers and Explanations 1. Removing the corpus luteum at this early stage of pregnancy will have an adverse effect on the pregnancy because until 8 weeks of gestation the pregnancy is dependent on the production of progesterone from the corpus luteum for support. Estrogen production from the corpus luteum will be affected since the corpus luteum has been removed. The answers are 5-D [I F 2 d], 6-A [I C 3], 7-B [I D 2 a], 8-C [I E 1 a], 9-E [I G 2 g], 10-D [I F 1 c], 11-E [I G 3 c], 12-A [I C 4 b], and 13-E [I G 3 b]. Progesterone suppresses production of maternal lymphocytic cytokines, which contribute to immune rejection of the fetus. Prolactin is produced not only by the decidual tissue of the uterus, but also by the maternal and fetal pituitary glands. Lactation does not occur during pregnancy because estrogen inhibits the action of prolactin on the breast. Progesterone produced by the corpus luteum is essential for pregnancy maintenance until the eighth week of gestation. Progesterone suppositories are prescribed during the first 8 weeks of gestation in women with suspected corpus luteum deficiency. These structures, the functioning units of the placenta, are formed of invading placental tissue (trophoblast) and contain the terminal fetal capillaries of the umbilical arteries. The villi are surrounded by the intervillous space into which maternal blood from the spiral arteries (branches of the uterine arteries) is forced by maternal arterial pressure. Gases and nutrients pass from the maternal blood in the intervillous space, across the plasma membrane of the trophoblast to the basement membrane of the fetal capillary, and then through the single endothelial cell layer of the fetal capillary to the fetal blood. The fetal capillaries drain into the fetal veins that join to form the umbilical vein. Placental cotyledons (lobes) are formed from the branching villi supplied by one terminal arterial branch and its partner venous branch of the fetal umbilical vessels. The maternal side of the placenta is divided by septa into lobes (10 to 40 lobes). It transfers nutrition and oxygen from the mother to the fetus and removes carbon dioxide and other metabolic waste products from the fetus (to be eliminated by the mother). It also synthesizes proteins and hormones that support fetal development and important maternal physiologic changes. The essential substances for fetal growth and development move from the mother to the fetus in four ways: (1) Active transport: amino acids and calcium (2) Facilitated transport: glucose (3) Endocytosis: cholesterol, insulin, iron, and immunoglobulin G (IgG) (4) Sodium pumps and chloride channels: ions b. Solute size and lipid solubility are also important factors that influence transport. This process involves supplying oxygen to the fetus and removing carbon dioxide from the fetus. These exchanges are achieved through passive diffusion and their flux is dependent on the concentration gradients across the membrane. Progesterone is produced by the placenta from maternal cholesterol, is secreted into the maternal circulation, and is important for maintaining pregnancy. Estrogen plays an important role in maternal physiologic changes in pregnancy, labor, and lactation. They are important for placental growth, fetal growth and development, and the maternal physiologic changes necessary to ensure adequate nutrition to the fetus. They supply fetal blood to all portions of the placenta for gas, solute, and nutrients exchange. Contrary to what is seen in the neonatal and adult circulations, the umbilical arteries carry deoxygenated blood to the placenta. A single umbilical artery is associated with intrauterine growth restriction and congenital anomalies (cardiac and renal) in some infants. B Umbilical vein One umbilical vein returns nutrient-rich, oxygen-rich blood to the fetus.
Combination (estrogen plus progestin) oral contraceptive agents eliminate ovulation muscle relaxant herniated disc safe 100mg voveran sr. Be cyclic and have a consistent and predictable relationship to the luteal phase of the menstrual cycle bladder spasms 4 year old generic 100 mg voveran sr amex, and are relieved within 4 days of the onset of menses b spasms symptoms order voveran sr 100mg on-line. Physical (1) Bloating or weight gain (2) Breast tenderness (3) Headache (4) Extremity swelling b infantile spasms 4 months order generic voveran sr canada. Mood-related (1) Anxiety (2) Anger (3) Irritability (4) Depressive symptoms or dysphoria (5) Withdrawal from social activities (6) Confusion 5. This phenomenon is known as "menstrual magnification," and occurs in both medical conditions, such as migraines, as well as psychiatric disorders, such as depression and anxiety disorders. In disorders with overlapping symptoms, such as with depressive disorders, timing persisting outside the luteal phase can lead to the correct diagnosis. These agents should be limited to short-term use because of long-term effects of hypoestrogenism and the resultant osteoporosis. Add back therapy with norethindrone or low dose estrogen/progestin may alleviate the hypoestrogenic side effects and decrease associated bone loss. Alprazolam, a benzodiazepine that acts on the -aminobutyric acid receptor complex. Because of the addictive potential of alprazolam, it should be reserved for patients who can be monitored reliably and should be restricted to the luteal phase of the menstrual cycle. An 18-year-old college student presents to your office feeling depressed and irritable from 3 days prior to her menses until the day after her menses start. She reports that she frequently has to stay home from classes and is worried about its potential impact on her performance. Providing that her symptoms are prospectively documented and confirmed, what would be possible treatments for this woman A Ibuprofen B Norgestimate plus ethinyl estradiol C Calcium carbonate D Leuprolide E Only answer A would not be an appropriate therapy 2. During in vitro fertilization, medical stimulation causes multiple follicles to develop to the stage of ovulation, rather than just one dominant follicle. She learned from her niece, a medical student, that all women are born with a finite number of eggs, and that when they are gone, you undergo menopause. Hormone Z is responsible for the conversion of primary oocytes to secondary oocytes. A Hormones X and Y are the same B Hormones Y and Z are the same C Hormones X and Z are the same D Hormone X is Inhibin-A E Hormone Y is Activin the Menstrual Cycle 221 Answers and Explanations 1. Calcium supplementation is one therapy that may be of use to this patient and is the best answer given. Lifestyle changes and serotonin reuptake inhibitors are other potentially appropriate therapies for this patient. There is continuous growth and atresia of primordial follicles occurring from fetal life through menopause. Therefore, women lose a certain number of their follicles every month whether they ovulate or not. Follicular atresia can be increased by chemotherapy and radiation used for treatment of cancer as these agents destroy the oocytes. The only correct answer is that hormone X and hormone Y are the same: that is, both are estradiol. Particular care is essential in addressing gynecologic concerns in this age group because both physical and emotional trauma may be inadvertently inflicted. It is important to establish rapport and reassurance in a young patient who may be uncomfortable with pelvic or genital examinations. A female adolescent does not need a pelvic examination unless she is experiencing abnormal symptoms. A mucoid vaginal discharge and even vaginal bleeding in an infant for up to 2 weeks after birth; caused by maternal estrogens 2. An introitus that is located more anteriorly than normal and a clitoris that is more prominent than normal (1 to 2 cm) 3. A redundant hymen that may protrude on straining and that remains essentially the same size until 10 years of age 4. A cervical os that is covered with glandular epithelium and normally appears red (ectropion) B Normal findings in an adolescent patient 1. Postpubertal gynecologic examination in an adolescent is similar to an adult female C Visualization of the vagina Instruments for visualizing the vagina include the vaginoscope, the urethroscope, and the pediatric speculum. Stirrups are usually not necessary for the preadolescent; a simple "frog-leg" position is usually sufficient. Occasionally, intravenous sedation may be necessary to accomplish a thorough genital examination. D Rectal examination is often more informative than a vaginal examination because the short posterior vaginal fornix cannot be distended and a cul-de-sac does not exist. A hypopigmented lesion may cover the vulvar and perianal regions in an hourglass shape and punctate 222 Pediatric and Adolescent Gynecology 223 hemorrhages may be seen. As the disease progresses, there may be loss of normal architecture, including loss of demarcation of the labia and scarring of the clitoral hood. Biopsy, which shows superficial hyperkeratosis with basal atrophic and sclerotic changes in adults, is rarely indicated in the pediatric population. Initial treatment starts with twice daily application for 2 weeks and the patient should be reassessed after 2 weeks to determine response to treatment. Treatment duration is usually 6 to 12 weeks: once signs and symptoms of disease resolve, steroids should be slowly tapered to avoid a rebound effect.
