Obstructive nephropathy may produce chronic interstitial damage buy cialis 10mg low cost impotence trials, especially when the obstruction is partial or intermittent and longstanding purchase cialis 10 mg amex erectile dysfunction za. In persons older than 60 years, benign prostatic hyper- trophy and prostatic and gynecologic cancers are common etiologies. The pathologic findings show dilatation of the collecting ducts and distal tubules. Ultrasonography usually shows dilatation of the urinary collecting system and hydronephrosis. A 38-year-old man comes to your office for evaluation of a urinalysis that revealed proteinuria. Further evaluation demonstrated proteinuria in the nonnephrotic range and a creatinine level of 1. The patient has celiac disease with steatorrhea, which was diagnosed many years ago. You suspect he has chronic interstitial nephritis that is associated with celiac disease. Which of the following scenarios is NOT associated with tubulointerstitial nephritis? A patient who several years ago underwent stomach bypass surgery for morbid obesity B. A 35-year-old woman who has non-Hodgkin lymphoma with bulky disease and is 2 days post chemotherapy C. A patient with vitamin D deficiency who presents with tetany and paresthesias D. A 68-year-old man with hypertension who ingested moonshine for 40 years Key Concept/Objective: To understand the metabolic disturbances that can produce renal tubu- lointerstitial abnormalities, as well as environmental factors that can cause renal damage Oxalic acid is a dicarboxylic end product of metabolism that is removed from the body only by renal excretion. Precipitation of calcium oxalate can produce nephrolithiasis, acute renal failure, or chronic tubulointerstitial damage. Patients with steatorrhea from various intestinal diseases—including celiac disease, Crohn disease, Wilson disease, and chronic pancreatitis—or from small bowel resection or bypass operations for obesity may hyperabsorb oxalate from the large bowel. The pathogenesis of oxalate hyperab- sorption involves the abnormal binding of intraluminal gut calcium to fats, which frees more oxalate for absorption. In addition, the solubilizing effect of bile acids on the large bowel permits greater absorption of oxalate. The result can be nephrolithiasis, acute renal insufficiency, or chronic tubulointerstitial damage. Hyperuricemia and hyperuri- cosuria can lead to uric acid and acute oliguric renal failure from urate deposition. These conditions occur after massive release of uric acid, as occurs in the tumor lysis syndrome or chronic renal failure. Hypercalcemia and hypercalciuria can also produce a number of adverse renal effects. Hypercalcemia may lead to chronic tubulointerstitial damage. Chronic elevations of the calcium level can lead to calcium salt deposition in the tubules and interstitial regions; such depositions are associated with chronic inter- stitial inflammation, tubular atrophy, and fibrosis. Two heavy metals—lead and cad- mium—clearly produce tubulointerstitial damage. Exposure to lead can occur from the ingestion of lead-based paints, the ingestion of beverages stored in crystal decanters made with lead, the ingestion of moonshine whiskey made in a lead-containing still, the manufacture or destruction of lead batteries, or the ingestion of lead-containing aerosols in the workplace. A 56-year-old black man presents with bone pain, anemia, hypercalcemia, and renal insufficiency. Bone marrow biopsy indicates a diagnosis of multiple myeloma. Excessive filtration of Bence-Jones proteins, causing direct tubular cell damage B. Renal artery thrombosis associated with tubular atrophy C. Hyperuricemia from urate overproduction or lysis of plasma cells, causing precipitation of urate crystals D.

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A combination of vincristine purchase cialis 2.5 mg amex erectile dysfunction frequency age, prednisone purchase 10mg cialis overnight delivery erectile dysfunction herbal treatment options, and daunorubicin cures about one third of patients with Philadelphia positive (Ph+) ALL B. A combination of L-asparaginase and cyclophosphamide cures about one third of patients with Ph+ ALL C. Allogeneic stem cell transplantation cures about one third of patients with Ph+ ALL D. There are currently no regimens that are known to cure this disease Key Concept/Objective: To know the regimen that is associated with cure of Ph+ ALL Ph+ ALL is identified by the t(9;22)(q34;q22) or the bcr-abl fusion gene. It is currently the major challenge in curing ALL because it makes up 25% to 30% of adult cases and perhaps one half of B-lineage ALL. Approximately 70% of patients achieve CR, but the remission durations are markedly shorter (median, 7 months) for Ph+ cases than for those without a Ph chromosome (remission of almost 3 years). As yet, no chemotherapy regimen alone appears to have the potential to cure this group of patients. In contrast, allogeneic stem cell transplantation cures about one third of patients with Ph+ ALL. The probability of relapse after transplantation is approximately 30% to 50%, further attesting to the thera- py-resistant nature of this disease. The treatment for Ph+ ALL should include an intensive remission-induction chemotherapy program, followed by allogeneic stem cell transplan- tation in the first CR if a donor is available. Considerable interest exists in investigating new agents, especially the tyrosine kinase inhibitor imatinib mesylate, in this high-risk group of patients. A 50-year-old man is referred to your clinic by the blood bank for a positive HTLV-I serology. What advice would you give this patient at this time? He has a 20% lifetime risk of developing leukemia B. He has a 40% lifetime risk of developing leukemia C. He is unlikely to have any medical problems associated with this virus E. He is at risk for developing an AIDS-like illness Key Concept/Objective: To be able to recognize that most patients exposed to the HTLV-I virus will not develop leukemia Blood banks commonly screen donated blood for HTLV-1. This virus had been linked to acute T cell leukemia and cutaneous T cell lymphoma in adults. However, most people with antibodies to HTLV-I remain free of these associated diseases, which suggests a multifactor- ial process in the development of leukemia. Burkitt lymphoma is associated with Epstein- Barr virus. Which of the following groups has an increased incidence of acute leukemia? All of the above Key Concept/Objective: To know the risk factors for acute leukemia All of the groups listed have a higher risk of developing acute leukemia than does the gen- eral population. Other risk factors include Jewish ethnicity, prior exposure to ionizing radi- ation (either through environmental exposure or as part of a treatment regimen), exposure to some industrial chemicals, several chemotherapy agents, a genetic predisposition, and the presence of specific diseases such as Down syndrome. Which of the following statements is more commonly associated with acute myeloid leukemia (AML) than with ALL? It accounts for the majority of cases of acute leukemia in adults B. Patients are more likely to have hepatosplenomegaly and lym- phadenopathy at presentation D. Maintenance chemotherapy generally lasts 1 to 3 years E. The Philadelphia chromosome–positive (Ph+) variant is more resistant to standard treatment Key Concept/Objective: To know the differences between AML and ALL in adults AML accounts for about 80% of acute leukemias in adults and is most likely to present with hemorrhage or infection. Standard induction therapy with cytarabine and daunoru- bicin (7 + 3 regimen) is followed by consolidation chemotherapy but generally no long- term maintenance regimen. ALL typically presents with constitutional symptoms (fatigue, weight loss, night sweats), and organomegaly and lymphadenopathy are more likely to be present on exam. Because CNS involvement occurs in 5% of patients with ALL, CNS pro- phylaxis is a standard part of treatment, as is maintenance chemotherapy. Ph+ ALL is less responsive to standard chemotherapy regimens.

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S1 represents the beginning of systole generic 10 mg cialis fast delivery erectile dysfunction protocol by jason; S2 represents the beginning of diastole buy generic cialis 10mg on-line erectile dysfunction pump hcpc. Sl systole S2 diastole Sl systole S2 diastole M1T1 A2P2 M1T1 A2P2 Normally, the S1 and S2 occur as single sounds. There are conditions in which these sounds may be split and occur as two sounds. There are also conditions in which there are third and fourth heart sounds that occur under both normal and pathologic conditions. In healthy young adults, a physiologic split of S2 may be detected in the second and third left interspaces during inspiration as a result of changes in the amount of blood returned to the right and left sides of the heart. During inspiration, there is an increased filling time and, therefore, increased stroke volume of the right ventricle, which can delay closure of the pul- monic valve, thus causing the second heart sound to be split. This physiologic split differs from other splits that are pathologic in origin because it occurs with inspiration and dis- appears with expiration. Pathologic split heart sounds include the following. Cardiac and Peripheral Vascular Systems 119 • Fixed splitting of S2 occurs with atrial septal defect and right ventricular failure. In addition to the first and second heart sounds, there are two additional heart sounds, S3 and S4, heard both in normal and pathologic conditions. Both S3 and S4 occur during dias- tole: an S3 is heard early in diastole right after S2, and an S4 is heard in late diastole just before S1. An S3 can occur physiologically or pathologically depending on the age and dis- ease status of the patient; an S4 usually occurs under pathological conditions. It is low pitched and is heard best at the apex or left sternal border with the bell of the stethoscope. The sound is the same as a physio- logic S3 and is heard with the patient supine or in the left lateral recumbent position. Possible causes of a left-sided S4 include hypertension, coronary artery disease, car- diomyopathy, or aortic stenosis. Possible causes of a right-sided S4 include pulmonic stenosis and pulmonary hypertension. Heard with the patient supine or in the left lateral recumbent position. Other heart sounds may occur in pathological conditions and include opening snaps and pericardial friction rubs. It is high pitched and heard best with the diaphragm of the stethoscope. The sound is a high-pitched grating, scratching sound—resulting from inflammation of the pericardial sac—that issues from the parietal and visceral surfaces of the inflamed pericardium as they rub together. The Cardiac Cycle The cardiac cycle is diagramed in Figure 6-2. Blood is returned to the right atrium via the superior and inferior vena cava, and to the left atrium via the pulmonary veins. As the blood fills the atria during early diastole, the pressure rises until it exceeds the relaxed pressure in the ventricles, at which time the mitral and tricuspid valves open and blood flows from the atria to the ventricles. At the end of diastole, atrial contraction produces a slight rise in pres- sure termed the “atrial kick. As ventricular pressure rises, it exceeds the pressure in the aorta and pulmonary artery, thus forcing the aortic and pulmonic valves to open. As the blood is ejected from the ventricles, the pressure declines until it is below that of the aorta and pulmonary artery, causing the aortic and pulmonic valves to close and thus Copyright © 2006 F. As the ventricles relax, the pressure falls below the atrial pressure, the mitral and tricuspid valves open, and the cycle begins again. HISTORY General History In many instances, the history may be more telling than the physical exam.

The pain can be quite severe and requires analgesics and discount 10mg cialis free shipping erectile dysfunction causes prescription drugs, if infection is pres- ent 5mg cialis erectile dysfunction medication, antibiotics, until dental referral can be made. With the eruption of wisdom teeth, the pain is milder and generally not constant. Decay and abscess are quite obvious with a simple oral exam, whereas other forms of dental disease require in-depth dental evaluation. BRUXISM The term is used to define the clenching or grinding of teeth during sleep. The most common causes are malocclusion or tension and stress. Over the long term, bruxism can cause the teeth to wear down, erode, and loosen. Patients are usually not aware of the problem because it occurs during sleep, but they may experience TMJ pain. The diagnosis is usually made via the report of family members or through a routine dental exam. Occlusal guards for the teeth are helpful to prevent dental injury. PAROTITIS There are two types of parotid infection, suppurative (usually caused by Staphylococcus aureus) and epidemic, more commonly called mumps (caused by a paramyxovirus). In developed countries, mumps is rarely seen because children are immunized against it within the first 2 years of life. Patients with Sjögren’s syndrome are also predisposed to inflammation of the salivary glands (Figure 3-2)—parotid or submandibular—termed sialadenitis. In bacterial parotitis, the symptoms include fever, chills, rapid onset of pain, and swelling, usually in the preauricular area of the jaw. The gland is firm on palpation, with tenderness and erythema overlying the gland. Symptoms are similar to those of mumps, with both glands usually being affected. Clinical signs and symptoms most often make the diagnosis of infectious parotitis. The examiner should attempt to express pus from Stensen’s duct, which helps to make the diag- nosis of infection. Treatment includes antibiotic therapy and massage of the gland to promote drainage. Surgery is rarely neces- sary in infectious parotitis. Parotid duct Sublingual gland and ducts Submandibular Parotid gland gland and duct Submandibular gland Sublingual gland Figure 3-2. Head, Face, and Neck 39 SALIVARY GLAND TUMORS The majority of these tumors occur in the parotid gland, and over 80% are benign. Those occurring in the submandibular gland are more likely to be malignant (about 50%). Salivary gland tumors are often painless and may go unnoticed for months. If malig- nancy is present, the facial nerve is often affected. Magnetic resonance imaging or a CT scan is recommended once a mass is found. Fine needle aspiration is necessary for diagnosis and treatment. Surgical excision is necessary and radiation is warranted for large tumors. SALIVARY DUCT STONE (SIALOLITHIASIS) The submandibular glands are most often affected rather than the parotid. Often these patients have a history of recurrent sialadenitis, and the stones are composed of calcium phosphate as a result of the pH of the saliva. Anything that causes the affected salivary gland to be stimulated, usually related to eat- ing, will elicit pain. Swelling also may be apparent over the affected gland.

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