Arthritis Australia

By V. Garik. University of Saint Thomas, Houston.

Fluid safe 10mg claritin, electrolyte and acid base disturbance a) Volume expansion and contraction (edema order claritin 10mg free shipping, dehydration) As long as water intake does not exceed the capacity for free water clearance, the extra cellular fluid volume expansion will be isotonic and the patient will remain normonatremic. On the other hand, hyponatremia will be the consequence of excessive water ingestion. With advancing renal failure, total urinary net daily acid excretion is usually reduced markedly. Renal osteodetrophy and Metabolic bone disease: Is due to disturbance in bone phosphate and calcium metabolism. Note that the low serum level of Ca is attributed to secondary hyperparathyroidism. The abnormal vitamin D metabolism may be related to the renal disease itself (since the active vitamin D metabolite is normally produced in the proximal tubule) and to the hyperphosphatemia, which has a suppressive effect on the renal 1-hydroxylase enzyme. Some of the resulting bony abnormalities are o Ostitis fibrosa cystica : is due to osteoclastic bone resorption of specially terminal phalanges, long bones and distal end of clavicle o Renal rickets ( Osteomalacia ) o Osteosclerosis : enhanced bone density in the upper and lower margins of vertebrae 3. Cardiovascular complications a) Congestive heart failure and/or pulmonary edema : it may be due to Volume over load Increase pulmonary capillary permeability b) Hypertension : Is the most common complication of end stage renal disease. Gastro intestinal abnormalities Early symptoms : anorexia, hiccup, nausea and vomiting Uremic fetor: the patients breathe smells like urine. Endocrine and Metabolic abnormalities Hypogonadism is common o In men : decreased plasma testosterone level, impotence m oligospermia o In women: amenorrhea, inability to carry pregnancy to term. Physical Examination: - Particular attention should be paid to: Blood pressure Funduscopy Precordial examination Examination of the abdomen for bruits and palpable renal masses Extremity examination for edema Neurologic examination for the presence of asterixis, muscle weakness, and neuropathy In addition, the evaluation of prostate size in men and potential pelvic masses in women should be undertaken by appropriate physical examination. Diagnostic work up These should also focus on a search for clues to an underlying disease process and its continued activity. The occurrence of normal kidney size suggests the possibility of an acute rather than chronic process. However in some diseases, chronic renal failure may be present with normal sized or even enlarged kidneys. Amyloidosis, polycystic kidney diseases, Diabetic nephropathy Management of chronic renal failure The general management of the patient with chronic renal disease involves the following issues 1) Treatment of reversible causes of renal dysfunction 2) Preventing or slowing the progression of renal disease 3) Treatment of the complications of renal dysfunction 4) Identification and adequate preparation of the patient in whom renal replacement therapy will be required 1. Treating reversible causes of renal dysfunction In addition to exacerbation of their original renal disease, patients with chronic renal disease, with a recent decrease in renal function may be suffering from an underlying reversible process such as : o Hypotension or dehydration o Administration of nephrotoxic drugs o Urinary tract obstruction 323 Internal Medicine o Sever hypertension o Infection Correcting these reversible causes can improve the renal function. Treatment of the complications of renal dysfunction : a) Volume overload Dietary sodium restriction Diuretic therapy, usually with a loop diuretic given daily. An intake of 324 Internal Medicine about 800 mg/day may be desirable but can be accomplished only by limiting protein intake. Thiazide diuretics have additive effect when administered with a loop diuretic for refractory edema. Overall, the diet of most patients with chronic renal failure should provide approximately 30 to 35 kcal/kg per day. Preparation for renal replacement Therapy o Education o Informed choice of renal replacement therapy i. Urinary Tract infection Learning Objective: At the end of this unit the student will be able to 1. Describe the most commonly used tests for the diagnosis of urinary tract infections. In most instances, growth of more than 10 organisms per milliliter from a properly collected midstream "clean-catch" urine sample indicates infection. Chronic pyelonephritis: refers to chronic interstitial nephritis believed to result from bacterial infection of the kidney. Catheter-associated (or nosocomial) infections and The vast majority of acute symptomatic infections involve young women. Ascent of bacteria from the bladder may follow and is probably the pathway for most renal parenchymal infections. Whether bladder infection ensues depends on interacting effects of the pathogenicity of the strain, the inoculum size, and the local and systemic host defense mechanisms. Gender and Sexual Activity: The female urethra appears to be particularly prone to colonization with colonic gram-negative bacilli because of its proximity to the anus, its short length (about 4 cm), and its termination beneath the labia. Pregnancy: Is clearly associated with altered uretheral smooth muscle function and higher incidence of asymptomatic bacteriuria and 20 to 30% of pregnant women with asymptomatic bacteriuria subsequently develop pyelonephritis. Symptomatic upper urinary tract infections, in particular, are unusually common during pregnancy. Vesicoureteral reflux: Defined as reflux of urine from the bladder cavity up into the ureters and sometimes into the renal pelvis. Obstruction: Any impediment to the free flow of urine caused tumor, stricture, stone, or prostatic hypertrophy results in hydronephrosis.

Cardiovascular Cyanotic congenital heart disease Infective endocarditis Gastrointestinal Cirrhosis buy claritin 10 mg line, especially primary biliary Non-respiratory chest pain cirrhosis Central chest pain cheap claritin 10mg without prescription, particularly if radiating to the neck Inammatory bowel disease Coeliac disease or arms, is more likely to be cardiac. Pericarditis causes Idiopathic Familial usually before puberty a sharp retrosternal/precordial pain which may mimic Idiopathic pleuritic pain as it may be exacerbated by deep inspira- Rare Thyroid acropachy tion, but is classically relieved by leaning forwards. Pain Pregnancy at the shoulder tip is often referred pain from the di- Unilateral clubbing Bronchial arteriovenous aneurysm aphragm, and may reect an abdominal cause such as Axillary artery aneurysm cholecystitis. Inspiration is However, theseconditionsmayoccurwithoutwheeze, slightly louder and longer than despite severe obstruction. Crackles/crepitations: Normally the airways do not col- Reduced Bilaterally: Chronic obstructive pulmonary disease, severe acute asthma. They are differentiated sounds from the larger airways better, so the whole of inspiration and by their timing and nature: r Early inspiratory crackles come from the airways, expiration are heard. Wheezes are musical sounds caused by airway ob- struction and are usually heard in expiration. It is caused by bronchial carcinoma or inhaled foreign body, and is frequently inspiratory. The in obstructive airways disease, although both may be best of three tries is recorded. Other useful testing which can be done by the bedside It is most useful in monitoring disease patterns, e. Laboratory testing Spirometry: This is now possible with bedside elec- More comprehensive tests can be performed in the pul- tronic spirometers, which are more portable and con- monary function laboratory, but the equipment requires venient than the older Vitalograph models. In reversible obstructive 1 Flowvolume loops: These can localise the site of airways disease this gives the graph shown in Fig. It depends not only on the Investigations thickness of the alveolar-capillary membrane but also r Biopsy: Central bronchial lesions are easily biopsied, on the ventilation/perfusion matching (which is com- there is a small risk of haemorrhage particularly if it is monly abnormal in lung disease) and on lung vol- avascular lesion or carcinoid tumour. It carries a small but signicant risk of r The K falls in severe emphysema, pulmonary pneumothorax. Ap- Flexiblebreopticbronchoscopyismostcommonlyused propriate staining and culture is needed. Therapies Topical local anaesthetic is applied to the nose and r Aspiration of mucus plugs. Following sedation the exible bronchoscope is r Laser therapy for obstructing bronchial carcinoma. Once in the r Transbronchialstentingforobstructingbronchialcar- trachea further topical anaesthesia is administered. Radiographic screening can be used for peripheral cardiac arrhythmias (usually transient), pneumothorax, lesions which cannot be directly visualised. The potential space created by the removal is The virus enters via the airway by droplet inhalation lled with remaining lung, elevation of the diaphragm and causes local inammation, inducing secretions and and mediastinal shift. The hilar vessels are ligated and the bronchus is divided and Clinical features closed close to the carina. The the operation not occupied by shift of other struc- patient may feel short of breath, wheezy and complain tures lls with blood and serum which organises and of chest tightness and retrosternal discomfort. Thecoughthenbecomeswet Thoracoscopy is used for diagnosis of pleural disease, and productive of yellow or green sputum. Discoloured mediastinoscopy to sample upper mediastinal lymph sputum signies infection, which may be of bacterial or nodes and mediastinotomy to sample lower mediasti- viralorigin. Single lung ventilation is used to allow the collapse of the lung being operated on, e. The airway mucosa becomes red and oedematous, there Specic complications following thoracic surgery in- is often an overlying mucopurulent exudate. Respiratory infections Investigations Acute bronchitis These are usually not required, there may be a mild neu- trophil leucocytosis even in viral infections. Patients presenting with acute bronchitis during an inuenza epidemic may ben- Incidence et from treatment with a neuraminidase inhibitor if Very common. Only if secondary bacterial infection is suspected should a course of antibiotics be Age prescribed. Any Prognosis Sex The illness usually lasts up to a week in healthy adults, M = F prolonged symptoms may occur. Conditions impairing Defence mechanism defence mechanism Pneumonia Cough Coma/anaesthesia Respiratory depression Denition Neuromuscular weakness Pneumonia is an infective, inammatory disease of the Ciliary function Smoking, inuenza, colds lung parenchyma. Bronchiectasis (including cystic brosis and Kartageners syndrome) Aetiology Ciliary function can also be It is useful to classify pneumonia according to the impaired mechanically by causative organism or the clinical setting, e. This helps to determine the choice of carcinoma Phagocytosis Smoking antibiotics for treatment. Alcohol Pneumonia most often occurs in children and the el- Hypoxia derly, but may also affect young, t adults. Viralpneumonia is less common, but bacterial pneumo- r Atypical pneumonias cause predominantly interstitial nia may be a secondary complication.

Penile prosthesis remains a satisfactory approach for patients who do not respond to either oral or intracavernous pharmacotherapy or to a vacuum device (29) cheap claritin 10mg overnight delivery. Testosterone deficiency is either a result of primary testicular failure or secondary to pituitary/hypothalamic causes cheap claritin 10 mg visa, including a functional pituitary tumour resulting in hyperprolactinaemia. Testosterone replacement therapy (intramuscular, oral, or transdermal) is effective, but should only be used after other endocrinological causes for testicular failure have been excluded (30). There is limited evidence suggesting that such treatment may not pose an undue risk of prostate cancer recurrence or progression (32). Patients given androgen therapy should be monitored for clinical response, elevated hematocrit and development of hepatic or prostatic disease. Testosterone therapy is contraindicated in patients with untreated prostate cancer or unstable cardiac disease. The lesion must be demonstrated by duplex Doppler study of the penis and confirmed by penile pharmacoarteriography. Vascular surgery for veno-occlusive dysfunction is no longer recommended because of poor long-term results (35). Psychosexual therapy requires ongoing follow-up and has had variable results (36). The recommended starting dose is 50 mg and should be adapted according to the patients response and side effects. Adverse events (Table 8) are generally mild in nature and self-limited by continuous use. The recommended starting dose is 10 mg and should be adapted according to the patients response and side effects. Nevertheless diabetic patients remain poor responders to tadalafil on demand, with a successful intercourse rates incresing from 21. In vitro, it is 10-fold more potent than sildenafil, although this does not necessarily mean greater clinical efficacy (47). Adverse events (Table 8) are generally mild in nature and self-limited by continuous use, with a drop-out rate similar to that with placebo (48). Nevertheless, again, diabetic patients remain poor responders to vardenafil on-demand with a successful intercourse rates increasing from 23% with placebo to 49% and 54 % with 10 and 20 mg of vardenafil on-demand, respectively (51). Absorption is unrelated to food intake and they exhibit better bioavailability compared to film-coated tablets (52). Two major randomised double-blind studies, using 5 and 10 mg/day tadalafil for 12 weeks (n = 268) (64) and 2. An open-label extension was carried out for both studies in 234 patients for 1 year and 238 patients for 2 years. Tadalafil, 5 mg once daily, therefore provides an alternative to on-demand dosing of tadalafil for couples who prefer spontaneous rather than scheduled sexual activities or who anticipate frequent sexual activity, with the advantage that dosing and sexual activity no longer need to be temporally linked. Nevertheless, in the 1-year open-label 5 mg tadalafil extension study followed by 4 weeks wash-out, erectile function was not maintained after discontinuation of therapy in most patients (about 75%). This has been confirmed in another study of chronic sildenafil in men with type 2 diabetes (70). This regimen provides an alternative to on-demand treatment for some men with diabetes (71). Sildenafil does not alter cardiac contractility, cardiac output or myocardial oxygen consumption according to available evidence. The main ways in which a drug may be incorrectly used are: failure to use adequate sexual stimulation; failure to use an adequate dose; failure to wait an adequate amount of time between taking the medication and attempting sexual intercourse. Even though all three drugs have an onset of action in some patients within 30 min of oral ingestion, most patients require a longer delay between taking the medication, with at least 60 min being required for men using sildenafil and vardenafil, and up to 2 h being required for men using tadalafil (78-80). Absorption of sildenafil can be delayed by a meal, and absorption of vardenafil can be delayed by a fatty meal (81). Absorption of tadalafil is less affected provided there is enough delay between oral ingestion and an attempt at sexual intercourse (77). The half- life of sildenafil and vardenafil is about 4 h, suggesting that the normal window of efficacy is 6-8 h following drug ingestion, although responses following this time period are well recognised. It is important to check that the patient has had an adequate trial of the maximal dose of the drug. Data suggest an adequate trial involves at least six attempts with a particular drug (82). Patients taking tadalafil were advised to wait at least 2 h between oral ingestion and attempting intercourse. Erectile dysfunction is typically a symptom of an underlying condition, such as diabetes, hypertension, or dyslipidaemia.