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Co-Director, VCU School of Medicine, Medical College of Virginia Health Sciences Division

I-Inflammation and intoxication suggest posterior urethritis anxiety symptoms last for days order sinequan mastercard, prostatitis anxiety symptoms feeling unreal discount sinequan 25 mg visa, and cystitis anxiety 4 year old buy cheap sinequan line, as well as aphrodisiac drugs such as sildenafil citrate, alcohol, cannabis, indica, camphor, and damiana. N-Neoplasms suggest two common causes of priapism-chronic lymphatic or myeloid leukemia and nasal polyps. The N also suggests neurologic disorders such as neurosyphilis, multiple sclerosis, and diabetic neuropathy. T-Trauma recalls not only direct trauma to the penis producing a local hematoma but also trauma to the spinal cord with fractures or contusion. Approach to the Diagnosis the diagnosis of priapism usually depends on the association of other symptoms and signs. The former presents a diffuse enlargement, soft in consistency, and the prostate varies in size from a plum to an orange. Prostate carcinomas, in contrast, present as a stony, hard nodule in the lateral superior or inferior areas in the early stages or as a diffuse, hard, nodular enlargement in the more advanced stages. The approach is different for the patient presenting with a urethral discharge or difficulty voiding, because then one must include acute and chronic prostatitis and prostatic abscess in the differential. The only trick that might be useful in remembering it is to keep in mind the ages 20, 40, 60, and 80. In general, 20-year-old men usually have acute prostatitis from gonorrhea or other bacteria. The 40-year-old men usually have chronic prostatitis from previous gonorrhea or from nonspecific prostatitis. The 60-year-old men generally have prostatic hypertrophy, and 684 the 80-year-old men most likely have prostatic carcinoma. However, it is important to remember that any one of these diseases may appear at the ages of 40, 60, and 80. Approach to the Diagnosis the main consideration in diagnosing a prostatic mass is to rule out carcinoma. If the mass is located in the posterior lobes, there is further support for the diagnosis. Ultrasonography can be done for further localization before proceeding with a biopsy. If there is no urethral discharge, one can elicit a discharge by prostatic massage. However, this should not be done if the patient has fever and significant tenderness of the prostate. It is better to proceed with antibiotic therapy and reexamine the patient after the fever has subsided. If benign prostatic hypertrophy is suspected, cystoscopy and retrograde pyelography can be done. In addition to the common bacterial infection, one should not forget tuberculosis, schistosomiasis, viral hepatitis, syphilis, and malaria. N-Neoplasm category includes Wilms tumor, renal cell carcinoma, papilloma of the renal pelvis and bladder, and multiple myeloma. I-Intoxication category includes toxic reactions to gold, mercury, gentamicin, penicillamine, captopril, and anticonvulsants. C-Congenital causes should bring to mind polycystic kidneys, Alport syndrome, Fabry disease, horseshoe kidney, and other congenital anomalies.

N-Neoplasms suggest carcinoma of the tongue (ulceration) anxiety disorder 100 symptoms generic 25mg sinequan otc, leukoplakia (white plaques) anxiety supplements cheap sinequan online mastercard, diffuse lymphoma (small vesicles and a large tongue) anxiety keeping me up at night cheap sinequan 75mg, fibroma (pediculated lesion on tongue), hemangioma (port-wine stain), and lingual warts. D-Deficiency diseases include pernicious anemia (smooth tongue), iron deficiency anemia (smooth tongue), vitamin A deficiency, sprue, pellagra, and riboflavin deficiency (red and smooth tongue). I-Intoxication suggests bromism (tremulous tongue with excessive salivation), alcoholism (tremulous, white furry tongue), mercury poisoning (ulcers), and lead poisoning (atrophy). C-Congenital disorders include Down syndrome (large, coarsely papillate tongue), geographic tongue, and cerebral palsy. A-Autoimmune diseases include amyloidosis (swollen tongue), erythema multiforme (swollen tongue with ulcers and blisters), angioneurotic edema, and multiple sclerosis (tremulous tongue with fibrillary twitching). T-Trauma to the tongue is important to look for in cases of undiagnosed epilepsy. E-Endocrine disorders include acromegaly (swollen tongue), myxedema (large tongue), lingual thyroid, and thyroglossal cysts. Approach to the Diagnosis the approach to the diagnosis will depend largely on the clinical picture. A smooth tongue with pallor of the nails and conjunctiva suggests pernicious anemia or iron deficiency anemia. A swollen tongue and protruding jaw suggest acromegaly, whereas a swollen tongue and nonpitting edema prompt a diagnosis of myxedema. Other conditions, however, may present with sneezing, and the clinician needs to be able to recall these while examining the patient. I-Inflammation suggests pertussis, acute viral influenza, the common cold, chronic rhinitis, measles, and other upper respiratory infections. The I also suggests immunologic disorders; allergic rhinitis and bronchial asthma head the list. T-Toxic disorders suggest reactions to substances such as pepper, tear gas, phosphine, chlorine, and iodine compounds. Further analyzing the differential (because so many causes of sore throat are infectious), one may recall the inflammatory etiologies in a systematic fashion by starting with the smallest organism and working to the largest. V-Vascular disorders remind one of blood dyscrasias such as leukemia, agranulocytosis of numerous causes, and Hodgkin lymphoma. I-Inflammatory diseases include the most common causes of sore throat, streptococcal or viral pharyngitis, but one must also consider the less frequent infectious diseases here. Next, bacterial causes such as group A hemolytic Streptococcus (with or without scarlet fever), diphtheria, Listeria monocytogenes, and meningococcemia should be considered. Tuberculosis should also be mentioned, although it is rare in contemporary affluent societies. Consider among bacterial causes sinusitis, tonsillar or peritonsillar abscess (quinsy), and retropharyngeal abscess: Staphylococcus organisms may cause these, but they rarely cause the common sore throat. Moving to the next largest organisms, the spirochetes, think of syphilis and Vincent angina. D-Degenerative diseases are an unlikely cause of sore throat, just as they are unlikely to cause pain anywhere. Agranulocytosis may also be included in this category, because it is so often drug induced.

The ovary Both the ovary and the testis develop from a germinal ridge of mesoderm situated in the posterior wall of the abdominal cavity medial to the mesonephros at about the level of the first lumbar vertebra anxiety symptoms heart pain buy sinequan 25mg. This germinal ridge is attached to a strand of connective tissue termed the gubernaculum anxiety loss of appetite cheap sinequan online amex. The ovary too descends anxiety eating proven 25 mg sinequan, dragging its blood supply, lymphatics, and nerve supply with it, but it impacts against the posterior aspect of the broad ligament. The gubernaculum persists as the ovarian ligament, which passes from the ovary across the posterior aspect of the broad ligament to the side of the uterus and, from there, as the round ligament, passing across the front of the broad ligament to the side wall of the pelvis to traverse the inguinal canal and end in the labium majus (Figure 2. The anterior part of the pelvic diaphragm where the vagina and urethra pass through (the urogenital hiatus) lacks muscle support and is weak as a result. For this reason, the levator ani does not act on the urethra and does not contribute to its continence. The urogenital diaphragm is constructed on the anterior aspect and underside of the pelvic diaphragm to reinforce this deficient area (again, skeletal muscle enclosed within two fascial membranes). The surface of the inferior fascia of the urogenital diaphragm (also known as the perineal membrane) provides attachment for the crura and bulb of the penis in the male. Whereas the crura have bony attachment, the bulb does not, being only attached to the perineal membrane. This lack of bony attachment leaves the bulb of the penis and the urethra travelling through it vulnerable to avulsion/detachment following severe pelvic trauma, leading to extravasation of urine into the scrotum and the anterior abdominal wall. The breast this is a modified skin gland found entirely within the superficial fascia. The medial half of the breast drains its lymph to the parasternal chain of nodes, whilst the nipple, the areola, and the lateral half of the breast drains to the axillary lymph nodes. There is usually some cross drainage between breasts, a common route of metastatic disease. The author presumes foundation knowledge level and recommends that the reader reviews the details of the physiology of the cardiac muscle cell and the differences between cardiac, skeletal, and smooth muscle cells. Within the heart differences also exist between the regular ventricular muscle cell and the specialized pacemaker tissues, and these should also be reviewed. In summary: Voltage-dependent (gated) K+ channels these channels are open at rest. Regular contracting ventricular fibres have a stable resting membrane potential (phase 4), unlike the specialized pacemaker and conducting fibres, which have unstable resting membrane potentials. Unlike the skeletal muscle, which has a short action potential, the action potential of the ventricular muscle cell is a long electrical event with a prolonged plateau phase, meaning there can only be one electrical event per mechanical event. The single electrical to mechanical event relationship ensures that, unlike the skeletal muscle, the cardiac muscle cell cannot be tetanized. Cardiac muscle cells have regions of low electrical resistance between fibres (junctional complexes between fibres including gap junctions) so that action potentials can move from cell to cell as a syncitium. Phase 1 (slight repolarization) Membrane channels the cardiac muscle cell membrane has channels for K+, Na+, and Ca2+ ions, which control the flow of ions in and out of the cell in response to the electrical events. The direction of flow of ions through these channels is governed by the large gradients in the concentrations of the ions and the status of the channels. Phase 2 (plateau) Un-gated K+ channels these channels are always open and there is always an efflux of K+ out of the cardiac muscle cell, as K+ equilibrium potential is never reached. The slow voltage-dependent Ca2+ channels are open, resulting in Ca2+ influx into the cell. The Ca2+ influx participates in the contractile response and also triggers additional Ca2+ release from intracellular storage in the sarcoplasmic reticulum. Voltage-dependent K+ channels are closed (only the un-gated channels are open, so K+ conductance is low allowing just the usual efflux of K+ but no more). The Ca2+ influx balances the K+ efflux, which produces the stable plateau phase and delays repolarization (Figure 3.

Cortisol is catabolic to muscles and therefore delivers the resultant amino acids to the liver for gluconeogenesis anxiety symptoms 35 buy cheap sinequan 75 mg online. Glucagon requires cortisol to work and if cortisol is absent anxiety hives sinequan 10mg otc, fasting hypoglycaemia develops rapidly anxiety symptoms red blotches purchase 25mg sinequan. Steroid and thyroid hormones are transported in plasma attached to carrier proteins, except for adrenal androgens, which are conjugated with sulphate moieties in the liver. This renders them water-soluble such that they can be transported dissolved in plasma. Testosterone in males (and adrenal androgens in females) exerts the mineralization of the epiphyseal plates of the long bones at the end of puberty. Administration of testosterone in puberty may lead to a short stature and conversely excessive growth during puberty may be terminated by testosterone administration. Miscellaneous Recall that Sertoli cells possess aromatase activity, therefore Sertoli cell tumours are associated with elevated oestrogens. It may be used beneficially to improve sleep patterns and can be used to treat sleep disturbances associated with jet lag. The cell may respond by adaptation or death, depending on the type, duration, and severity of the injury, and also on the cell type and its metabolic state. Infection: Micro-organisms can damage cells directly, or via their toxins, or as a result of host response. Nutritional injury: Examples of nutritional injury include marasmus (total deficiency of calories) and kwashiokor, which is selective protein deficiency. This leads to cellular oedema, swelling of the endoplasmic reticulum, formation of membrane blebs, and loss of specialized cell structures such as the microvilli. Glycogen is used up in fuelling glycolysis with resultant lactate production and a fall in pH as lactic acid accumulates, with adverse effects for cellular enzyme function. Basic Sciences for Obstetrics and Gynaecology Cellular death There are two mechanisms of cell death: 1. Cellular adaptation In general cellular adaptation follows a prolonged and persistent cellular stress. All forms of cellular adaption are potentially reversible if the stress is removed, although some forms of adaptation are premalignant. Necrosis 122 Coagulative necrosis-usually due to protein denaturation but with the shape of the organ maintained by the proteins sticking together, although the nuclei and other organelles are disrupted, dislocated, and dead. Liquefactive necrosis-due to the action of tissue digestive enzymes, classically seen in the brain and the pancreas. The organ is semi-solid and semi-liquid with granulomas, multi-nucleated giant Langerhans cells, and epitheloid cells evident under the microscope. Fat necrosis-caused by the action of lipases and seen in the breast, pancreas, omentum, and skin. When fat cells die, they liberate negatively-charged free fatty acids from triglycerides, which attract positive calcium ions leading to calcium deposition in fat or saponification. Fibrinoid necrosis, which appears pink on hematoxylin and eosin (H & E) staining due to protein deposition. Gangrenous necrosis-a gross descriptive term for dead, necrotic, jet-black tissue. Hypertrophy-there is an increase in cellular organelles and structural proteins, often secondary to increased demands on the organ. Atrophy-the cell decreases in size and functional ability due to a reduced blood supply, nutrition, hormone stimulation, or aging.

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