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Water excess: this is uncommon but can occur following unrestricted administration of fluids in the presence of inadequate urinary output and in patients with cortisol deficiency arthritis in feet and running discount celebrex 200 mg on-line. In mild cases arthritis in index fingers cheap celebrex 200 mg overnight delivery, the patient may develop headache arthritis exercises order genuine celebrex online, nausea arthritis in middle foot buy generic celebrex on-line, vomiting and mental confusion. The symptomatology is probably due to hypotonicity of body fluids with resultant cerebral edema. The presence of oliguria, in spite of adequate hydration of subcutaneous tissues, low serum sodium level, and an awareness on the part of physician that such a possibility may exist, help to diagnose the water excess. The treatment of water intoxication consists of restriction of intake of non-saline fluid. Isotonic saline is not useful in water intoxication as it does not help to raise the plasma Na + level. In patients with renal disease with oliguria, water intoxication must be avoided by restricting the water intake as guided by the urinary output. There is a considerable amount of sodium in bones, which act as a sodium reservoir. The total body sodium can be measured by (i) direct carcass analysis and (ii) isotope dilution technique using radioactive sodium. The distribution is proportional to the sodium content of various body compartments and tissues. Note that a considerable amount of sodium is in the bone and is not exchangeable with radiosodium within 24 hours of equilibrium Nae: Exchangeable Na; T. Thus, an average Indian male weighing 60 kg will have 2700 mMol of exchangeable sodium. Although the exchangeable sodium may vary over a wide range, the serum sodium level is maintained remarkably constant at 140. Body content of sodium over a long period depends on the balance between intake and output. In tropical countries, the loss of sodium in sweat can be considerable, particularly with occupations that involve heavy labour. Sodium absorption: the rate of absorption of sodium and water from isotonic saline solutions is though very similar in the human jejunum and ileum, there are important differences. In contrast to jejunum, in the ileum sodium can be absorbed against large concentration gradients and it is not affected by water flow nor by the addition of glucose or bicarbonate. These findings have an important clinical application in oral fluid therapy (see management of dehydration). Urinary excretion of sodium: Normally about 13-20 mMoles of sodium is filtered out, every minute at the glomeruli. Of this, over 98% is reabsorbed by the renal tubules and only 2% is excreted in the urine. Hence, even a slight interference with the tubular reabsorption can produce a marked increase in the urinary sodium loss. Increasing the amount of sodium filtered at the glomeruli has a less marked effect on urinary sodium. Hormonal control of sodium metabolism: the bulk of sodium filtered by the glomeruli is reabsorbed in the proximal tubules independently of hormonal control. However, the adrenal salt retaining steroid, aldosterone, promotes sodium reabsorption and potassium excretion, by acting on distal renal tubule. It also modifies the sodium concentration of sweat, saliva and intestinal juices and the movement of sodium and potassium across the cell membrane (Chapter 66). In normal man, sodium depletion increases while sodium loading decreases the plasma renin levels. The Yanomamo Indians inhabiting the tropical rain forests of Brazil, who do not use salt in their diet and thus have life-long very low levels of sodium intake have raised plasma aldosterone and renin levels. These peptides are inactivated by the enzyme neutral peptidase (vasopeptidase) present on the surface of endothelial cells, cardiac myocytes, smooth muscle cells, kidney epithelium and in the brain. Other hormones such as hydrocortisone, estrogens and testosterone can produce sodium retention.

Rather similar tumours sometimes develop in the body of the uterus in old women hip pain arthritis vs bursitis 100mg celebrex with visa, and in this way three types of mixed tumours osteoarthritis hip diet buy celebrex 100 mg visa, namely the vaginal tumours of children arthritis in neck wiki discount celebrex 200 mg, the grape-like sarcoma of the cervix arthritis ketogenic diet cheap 100 mg celebrex amex, and the mixed tumours of the body of the uterus of old women can be distinguished. Choriocarcinoma Choriocarcinoma is rare, but it is one of the most malignant growths arising in the body of the uterus. The nongestational choriocarcinoma appears as part of a germ cell gonadal neoplasm, both in males and in females. Treatment the treatment of sarcoma of the uterus consists of total hysterectomy with bilateral salpingo-oophorectomy, followed by a full course of radiation therapy. The long period that elapses between the pregnancy and the development of choriocarcinoma makes the clinical suspicion of malignancy rather difficult. A primary choriocarcinoma arising in the placenta during pregnancy that led to fetal metastasis in the liver has been documented. Postmolar gestational trophoblastic disease may be an invasive mole or choriocarcinoma, but non-molar gestational trophoblastic disease is always a choriocarcinoma. Incidence Choriocarcinoma exhibits a geographical distribution very similar to that of a hydatidiform mole. An older woman with high parity and belonging to a low socioeconomic group runs a high risk of developing this malignancy. A Morbid Anatomy To the naked eye, the growth appears as a solid purple friable mass. The majority of primary growth arises in the body of the uterus and develops first within the endometrial cavity (Figure 39. In such cases, the growth projects into the cavity of the uterus, quickly ulcerates and causes a blood-stained discharge, which later becomes offensive and purulent as the growth becomes infected and necrotic. Growths of this kind superficially resemble placental polypi, but choriocarcinoma always infiltrates the wall of the uterus, while a placental polypus is clearly demarcated from the myometrium and can be easily detached. Choriocarcinoma does not necessarily develop primarily in the endometrium, and it is not uncommon for the growth to start in the myometrium in the deeper tissues of the uterine wall. Primary choriocarcinoma of the uterus may erode through into the broad ligament or peritoneal cavity and cause profuse bleeding, or it may cause enlargement of the uterus to such a degree that the fundus of the uterus reaches upwards to the level of the umbilicus. Metastases form early and dissemination usually occurs by way of the blood stream. Ones which can be detected easily are those found in the lower third of the vagina and at the vulva. Such metastases form purple haemorrhagic projections either into the vagina or around the vaginal orifice. These metastases are interesting pathologically, for they are comparable to the vaginal metastases B Figure 39. Such metastases are produced by retrograde spread along the venous channels of the vaginal plexuses of veins. The general metastases probably develop early, the growth disseminating by way of the blood stream. Deposits are frequently found in the kidneys, brain, spleen and liver, but when the dissemination is widespread, almost any organ may be affected and large emboli may get held up in the large arteries of the systemic circulation. The most common metastases are seen in the lungs (80%), brain and liver (10% each). The cells are actively growing and show such malignant characters as typical mitotic division and anaplastic changes. In some areas, the cells are translucent or vacuolated and may resemble decidual cells. No relics of chorionic villi can be detected, the growth consisting solely of embryonic syncytium, cytotrophoblast and degenerated blood cells. The absence of villi must be stressed as a differential diagnostic feature which separates the malignant choriocarcinoma from the benign and invasive mole in which villi are demonstrable. This is because the trophoblast grows in such extensive columns as to completely obliterate the villous pattern. The other distinguishing feature of malignancy is invasion of the uterine wall by trophoblastic cells, with destruction of muscle tissues accompanied by necrosis and haemorrhage (Figure 39. The primitive infiltrating properties of the embryonic cytotrophoblast are retained in choriocarcinoma so that vessels are eroded and local haemorrhages are produced, which cause the typical macroscopical appearances.

Other causes are hypothyroidism arthritis in fingers bumps buy celebrex with amex, chest wall injury arthritis treatment raisins and gin purchase celebrex 100mg amex, herpes zoster arthritis jingle bell run celebrex 100 mg online, stress and oestrogen and dopamine receptor blocking agents arthritis foods to avoid proven 100mg celebrex. It is usually a single tumour, rarely grows more than 5 cm and accounts for 15% of all breast tumours. Before the age of 30 years, the tumour runs a benign course, and if the investigations prove the benign nature of the tumour, it is safe to leave it behind. However after this age, the possibility of malignant change cannot be ruled out, and excision biopsy is recommended. If the benign tumour in a young woman becomes tender or increases in size, surgery is a wise decision. Breast Lump Less than 10% of women presenting with a breast lump have breast cancer. Nevertheless, systematic examination and investigations are required to rule out malignancy. Blood-stained fluid, recurrence after aspiration and multiple cysts should be treated surgically. Nipple discharge and retracted nipples are clinical features often associated with smoking, though the cause is not clear. Another possibility is direct toxic action of smoking on the vascular structure of ductal epithelium. Nipple discharge can be hormonal but blood-stained discharge is due to ductal papilloma and periductal mastitis, rarely malignancy. Premenstrual Mastalgia It is treated with toremifene, which is an anti-oestrogen and belongs to the tamoxifen group of drugs; 60 mg daily is given only in the luteal phase. Breast carcinoma is more prevalent in elderly women, and needs prompt investigations and treatment, comprising surgery followed by radiotherapy and chemotherapy as the need be. A woman with ovarian cancer should be screened for breast tumour, as the ovarian tumour could be a metastasis from the breast. Nulliparity, late first pregnancy after 30 years of age and nonlactation are the high-risk factors. Early menarche and late menopause with greater number of menstrual cycles and shorter cycles expose the breast tissues to oestrogen hormones and make them susceptible to the development of breast cancer. It is equally important to carefully monitor a woman on tamoxifen for breast and uterine cancer. Obesity increases the risk of cancer because of peripheral conversion of oestrogen. Using only mammography as the investigation tool is unreliable in 50% women below 40 years, because of dense breast tissue. Mammography identifies cancer in 75% cases between 40 and 49 years, and reliability increases with age. It must be mentioned that interpretation of mammography findings may be difficult if a woman had previous breast surgery. Mammography should include two views of both breasts: mediolateral side view and cranio-caudal view. Between 40 and 49 years, accuracy is 80%; between 50 and 59 years, 90%; and over 60 years, accuracy is 95%. Selfexamination increases the awareness in a woman and brings her to the doctor at an early stage for the treatment. Mammography is indicated in the following cases: n n n n n n n n n n Alteration in density of breast tissue Microcalcification Thickening of skin Presence of fibrous streaks Nipple alteration Detection of fibroadenoma, lymph nodes, galactocele Cysts and solid tumour. It is required in young women, pregnant and lactating woman, and in duct papilloma. Ultrasound however fails to identify microcalcification, which is the hallmark of early cancer. In cancer of the breast, ovarian screening by ultrasound is important, as one cancer spreads to the other.

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Fetal size should be monitored socks for arthritic feet 100mg celebrex with visa, and patients may be referred for cesarean section if macrosomia is present arthritis of neck exercises purchase celebrex 100 mg mastercard. Fetal/neonatal: Macrosomia; cardiac arthritis laser treatments cheap celebrex 200mg line, renal arthritis diet chocolate cheap 100mg celebrex with mastercard, and neural tube defects; birth injury (shoulder dystocia); neonatal hypoglycemia; perinatal mortality. The goal in the mother with preexisting diabetes is good control before conception. This will total serum levels of T4 and T3, but free hormone levels should remain normal. Tx: Antithyroid medications: All antithyroid medications cross the placenta and have the potential to cause fetal hypothyroidism in the newborn. Surgery: In the setting of uncontrolled hyperthyroidism, thyroidectomy should be considered and performed during the second trimester if possible. Cx: If left untreated, complications may include the following: Fetal complications: Congenital anomalies, perinatal mortality, impaired mental and somatic development. Maternal complications: Anemia, preterm labor, preeclampsia, placental abruption, postpartum hemorrhage. Etiologies include the following: Factors related to the male partner: Includes quantity and quality of sperm. Look for hirsutism, goiter, galactorrhea, an abnormal pelvic exam in the female partner, and testicular size/masses in the male partner. Conduct a postcoital test (examination of cervical mucus after coitus at a fertile time in the cycle). Consider hysterosalpingography, pelvic ultrasound, endometrial biopsy, and/or laparoscopy. It is important to rule out male infertility first, as it is the source of the problem in 40% of cases and is easy to evaluate. Subtypes include the following: Menorrhagia: Prolonged and/or excessive uterine bleeding that is cyclic. Additional testing: Diagnostic tests used to determine the cause of bleeding include ultrasound (fibroids), hysteroscopy (endometrial polyps, some fibroids), and endometrial biopsy (endometrial polyps, hyperplasia, cancer). Women > 35 years of age should routinely undergo endometrial biopsy for irregular bleeding. Irregular cycles and no symptoms preceding the onset of menses suggest anovulation. Basal body temperature measurement and luteal-phase progesterone levels can help confirm ovulatory status. Other features of endocrinologic disorders; history of physical or mental stress; eating disorders; high-intensity exercise. Premature menopause/ovarian failure is cessation of menses in patients < 40 years of age. Vasomotor instability (hot flashes, night sweats) and symptoms of urogenital atrophy are also common (dryness, dyspareunia, dysuria). There are no clear advantages to one mode of administration (oral, transdermal) over another. Women with a uterus need to take estrogen plus a progestin to protect against endometrial cancer. Etiologies include endometrial atrophy (most common), exogenous hormones, nongynecologic sources, endometrial hyperplasia or polyps, endometrial cancer, and cervical cancer. Conduct a pelvic exam to look for anatomic abnormalities, including vaginal atrophy, vaginal lesions, or cervical polyps, and palpate for uterine masses. Ultrasound is an alternative first test; if the endometrial lining is < 5 mm thick, endometrial biopsy may be deferred unless unexplained bleeding continues. The mortality from com678 plications of hip fractures is equal to that from breast cancer in women > 50 years of age. Osteoporosis can be diagnosed clinically in the presence of vertebral or other fragility fractures.

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