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The haemoglobin tetramer can bind up to four molecules of oxygen in the iron containing sites of the haem molecules depression comic purchase 300mg wellbutrin fast delivery. The breakdown of red cells liberates iron for recirculation via plasma transferrin to marrow erythroblasts depression in test discount 300mg wellbutrin with visa, and protoporphyrin which is broken down to bilirubin depression definition american psychological association order wellbutrin 300 mg without a prescription. Bilirubin circulates to the liver where it is conjugated to its diglucuronide which is excreted in the gut via bile and converted to stercobilinogen and stercobilin excreted in the faeces. Part of stercobilinogen and stercobilin is reabsorbed and excreted in the urine as urobilinogen and urobilin. Globin chains are broken down to amino acids and reused for protein synthesis in the body. Based on these normal values, a series of absolute values or red cell indices can be derived which have diagnostic importance. For example, fragmented red cells have a tiny size while the macrocytes and reticulocytes have large size. Erythroid series are a series of recognisable nucleated red cells normally seen in the marrow and include proerythroblast, polychromatic erythroblast, orthochromatic erythroblast and reticulocytes. Red cell membrane is a trilaminar structure having a bimolecular lipid layer interposed between two layers of proteins. Haemoglobin consists of a basic protein, globin, and the iron-porphyrin complex, haem. Essential functions performed by red cells are oxygen carrying and carbon dioxide transport. Newborn infants have higher haemoglobin level and, therefore, 15 g/dl is taken as the lower limit at birth, whereas at 3 months the normal lower level is 9. This, in turn, initiates compensatory physiologic adaptations such as follows: i) Increased release of oxygen from haemoglobin ii) Increased blood flow to the tissues iii) Maintenance of the blood volume iv) Redistribution of blood flow to maintain the cerebral blood supply. Eventually, however, tissue hypoxia develops causing impaired functions of the affected tissues. The degree of functional impairment of individual tissues is variable depending upon their oxygen requirements. The speed of onset of anaemia: Rapidly progressive anaemia causes more symptoms than anaemia of slow-onset as there is less time for physiologic adaptation. The severity of anaemia: Mild anaemia produces no symptoms or signs but a rapidly developing severe anaemia (haemoglobin below 6. The age of the patient: the young patients due to good cardiovascular compensation tolerate anaemia quite well as compared to the elderly. The elderly patients develop cardiac and cerebral symptoms more prominently due to associated cardiovascular disease. As a result, oxyhaemoglobin is dissociated more readily to release free oxygen for cellular use, causing a shift of the oxyhaemoglobin dissociation curve to the right. In older patients, there may be symptoms of cardiac failure, angina pectoris, intermittent claudication, confusion and visual disturbances. Pallor Pallor is the most common and characteristic sign which may be seen in the mucous membranes, conjunctivae and skin. Cardiovascular system A hyperdynamic circulation may be present with tachycardia, collapsing pulse, cardiomegaly, midsystolic flow murmur, dyspnoea on exertion, and in the case of elderly, congestive heart failure. Ocular manifestations Retinal haemorrhages may occur if there is associated vascular disease or bleeding diathesis. Reproductive system Menstrual disturbances such as amenorrhoea and menorrhagia and loss of libido are some of the manifestations involving the reproductive system in anaemic subjects. Renal system Mild proteinuria and impaired concentrating capacity of the kidney may occur in severe anaemia. Gastrointestinal system Anorexia, flatulence, nausea, constipation and weight loss may occur.
Attempting to obtain biopsy material from small kidneys is associated with risk depression symptoms online quiz trusted wellbutrin 300 mg, and even if a biopsy is performed anxiety 4th hereford purchase 300 mg wellbutrin with visa, histologic assessment may simply show nonspecific chronic scarring rather than diagnostic features that explain the cause of kidney damage zyrtec depression symptoms wellbutrin 300mg lowest price. Whether or not proteinuria is detected by dipstick, further measurement of urinary protein excretion should be conducted. Proteinuria is an important diagnostic and prognostic marker, and its presence indicates a higher risk for both progression of kidney disease and cardiovascular complications. However, often the best guide to future change in kidney function is the previous pattern of decline, highlighting the importance of considering results of previous blood and urine testing during the initial assessment. They may be caused by reversible factors, such as intravascular depletion or high meat intake, so repeat testing may be required. Furthermore, because an arteriovenous fistula takes several weeks to mature, patients presenting late start hemodialysis with central venous catheters. Catheters are prone to infectious complications and inevitably damage central veins, leading to thromboses and stenoses, which may manifest at a later stage when venous return from one or the other arm is increased by the subsequent construction of an arteriovenous fistula (see Chapter 91). Such criteria are not absolute but should provide a guide to the primary care physician as to which patients are likely to benefit from specialist care. Late referral is often avoidable, although in some cases, patients may have had a truly silent illness or an acute presentation of a disease with rapid decline in kidney function. However, in light of growing evidence about the adverse effects of hypotension, the paradigm has moved toward less-intensive and individualized blood pressure control. Lifestyle modifications, including maintenance of a healthy weight, reductions in salt and alcohol intake, and regular exercise, should be encouraged (see Chapter 35). Although current recommendations are based on office blood pressure recordings, recent studies suggest that readings obtained from home and ambulatory monitoring correlate better with cardiovascular and kidney outcomes. Salt substitutes containing potassium should be avoided because of the risk for hyperkalemia. The causes are multifactorial but include anorexia, acidosis, insulin resistance, inflammation, oxidative stress, and urinary protein loss. Biochemical indicators may demonstrate a decrease in serum albumin, transferrin, and cholesterol. Serum creatinine concentrations, which in part reflect muscle mass, may stop rising despite a progressive loss of kidney function, because of compromised nutritional status. In light of this, recommendations to restrict protein intake have been controversial. Although there is evidence that reduced protein intake may slow progression of decline of kidney function, many patients develop protein-calorie malnutrition on a low-protein diet. When this recommendation is followed, detailed dietary assessment and supervision are needed to ensure that malnutrition is prevented. Anemia may have multiple adverse effects, including worsening cardiac dysfunction by increasing cardiac output and exacerbating left ventricular hypertrophy, exacerbating the decline of kidney function, and reducing cognition and concentration. Anemia Hyperphosphatemia, together with a deficiency of 1,25dihydroxyvitamin D3, contribute to secondary hyperparathyroidism and ultimately to the development of renal bone disease. Phosphate-binding drugs may be required, and their choice is discussed in Chapter 85. Acidosis aggravates hyperkalemia, inhibits protein anabolism, and accelerates calcium loss from bone where the hydrogen ions are buffered. Neutrophil activation is defective, and although serum immunoglobulin levels are normal, antibody responses to immunization may be poor.
The water and electrolytes are distributed nearly constantly in different body fluid compartments: 1 depression xanax order discount wellbutrin on-line. Water is normally absorbed into the body from the bowel or is introduced parenterally; average intake being 2800 ml per day great depression definition apush purchase wellbutrin with visa. Water is eliminated from the body via: i) kidneys in the urine (average 1500 ml per day); ii) via the skin as insensible loss in perspiration or as sweat (average 800 ml per day) depression symptoms recurring purchase discount wellbutrin on-line, though there is wide variation in loss via sweat depending upon weather, temperature, fever and exercise; iii) via the lungs in exhaled air (average 400 ml per day); and iv) minor losses via the faeces (average 100 ml per day) and lacrimal, nasal, oral, sexual and mammary (milk) secretions. The cell wall as well as capillary endothelium are entirely permeable to water but they differ in their permeability to electrolytes. Capillary wall is completely permeable to electrolytes while the cell membrane is somewhat imperme able. The osmotic equilibrium between the two major body fluid compartments is maintained by the passage of water from or into the intracellular compartment. These substances exert pressures responsible for exchange between the interstitial fluid and plasma. Since the protein content of the plasma is higher than that of interstitial fluid, oncotic pressure of plasma is higher (average 25 mmHg) than that of interstitial fluid (average 8 mmHg). There is considerable pressure gradient at the two ends of capillary loop-being higher at the arteriolar end (average 32 mmHg) than at the venular end (average 12 mmHg). Tissue tension is the hydrostatic pressure of interstitial fluid and is lower than the hydrostatic pressure in the capillary at either end (average 4 mmHg). Normal Fluid Exchanges Normally, the fluid exchanges between the body compartments take place as under: At the arteriolar end of the capillary, the balance between the hydrostatic pressure (32 mmHg) and plasma oncotic pressure (25 mmHg) is the hydrostatic pressure of 7 mmHg which is the outwarddriving force so that a small quantity of fluid and solutes leave the vessel to enter the interstitial space. At the venular end of the capillary, the balance between the hydrostatic pressure (12 mmHg) and plasma oncotic pressure (25 mmHg) is the oncotic pressure of 13 mmHg which is the inwarddriving force so that the fluid and solutes reenter the plasma. Tissue fluid left after exchanges across the capillary wall escapes into the lymphatics from where it is finally drained into venous circulation. Oedema is defined as abnormal and excessive accumulation of "free fluid" in the interstitial tissue spaces and serous cavities. The presence of abnormal collection of fluid within the cell is sometimes called intracellular oedema but should more appropriately be called hydropic degeneration (page 17). Free fluid in body cavities: Commonly called as effusion, it is named according to the body cavity in which the fluid accumulates. For example, ascites (if in the peritoneal cavity), hydrothorax or pleural effusion (if in the pleural cavity), and hydropericardium or pericardial effusion (if in the pericardial cavity). Free fluid in interstitial space: Commonly termed as oedema, the fluid lies free in the interstitial space between the cells and can be displaced from one place to another. In the case of oedema in the subcutaneous tissues, momentary pressure of finger produces a depression known as pitting oedema. The other variety is non-pitting or solid oedema in which no pitting is produced on pressure. Generalised (anasarca or dropsy) when it is systemic in distribution, particularly noticeable in the subcutaneous tissues. Depending upon fluid composition, oedema fluid may be: transudate which is more often the case, such as in oedema of cardiac and renal disease; or exudate such as in inflammatory oedema. The following mechanisms may be operating singly or in combination to produce oedema: 1. Tissue factors (increased oncotic pressure of interstitial fluid, and decreased tissue tension) 5. Living membranes such as cell wall and vascular endothelium play important role in exchanges of fluid, electrolytes, nutrients and metabolites. Total body water is about 60% of the body weight and is divided into intracellular (33%) and extracellular compartments (27%).
Diseases
Costello syndrome
Hereditary angioedema
Chemodectoma
Mental retardation hip luxation G6PD variant
Osteosclerose type Stanescu
Collagen disorder
A significant factor that may prevent or diminish the myocardial damage is the development of collateral circulation through anastomotic channels over a period of time anxiety 911 buy wellbutrin 300 mg mastercard. A regular and well-planned exercise programme encourages good collateral circulation and improved cardiac performance depression symptoms of cancer 300mg wellbutrin fast delivery. About 5% of heart attacks occur in young people under the age of 40 years anxiety medication order wellbutrin no prescription, particularly in those with major risk factors to develop atherosclerosis like hypertension, diabetes mellitus, cigarette smoking and dyslipidaemia including familial hypercholesterolaemia. After menopause, this gender difference gradually declines but the incidence of disease among women never reaches that among men of the same age. Myocardial ischaemia Myocardial ischaemia is brought about by one or more of the following mechanisms: i) Diminished coronary blood flow. Role of platelets Rupture of an atherosclerotic plaque exposes the subendothelial collagen to platelets which undergo aggregation, activation and release reaction. These events contribute to the build-up of the platelet mass that may give rise to emboli or initiate thrombosis. Transmural versus subendocardial infarcts There are some differences in the pathogenesis of the transmural infarcts involving the full thickness of ventricular wall and the subendocardial (laminar) infarcts affecting the inner subendocardial one-third to half. Critical coronary narrowing (more than 75% compromised lumen) is of great significance in the causation of such infarcts. Atherosclerotic plaques with superimposed thrombosis and intramural haemorrhage are significant in about 90% cases, and non-atherosclerotic causes in the remaining 10% cases. This is because subendocardial myocardium is normally least well perfused by coronaries and thus is more vulnerable to any reduction Figure 14. Superimposed coronary thrombosis is frequently encountered in these cases too, and hence the beneficial role of fibrinolytic treatment in such patients. According to the anatomic region of the left ventricle involved, they are called anterior, posterior (inferior), lateral, septal and circumferential, and their combinations like anterolateral, posterolateral (or inferolateral) and anteroseptal. According to the degree of thickness of the ventricular wall involved, infarcts are of two types. According to the age of infarcts, they are of two types: i) Newly-formed infarcts called as acute, recent or fresh. Right ventricle is less susceptible to infarction due to its thin wall, having less metabolic requirements and is thus adequately nourished by the thebesian vessels. Atrial infarcts, whenever present, are more often in the right atrium, usually accompanying the infarct of the left ventricle. Left atrium is relatively protected from infarction because it is supplied by the oxygenated blood in the left atrial chamber. The region of infarction depends upon the area of obstructed blood supply by one or more of the three coronary arterial trunks. Stenosis of the left anterior descending coronary artery is the most common (40-50%). The region of infarction is the anterior part of the left ventricle including the apex and the anterior two-thirds of the interventricular septum. The figure shows region of myocardium affected by stenosis of three respective coronary trunks in descending order shown as: 1) left anterior descending coronary, 2) right coronary and 3) left circumflex coronary artery. It involves the posterior part of the left ventricle and the posterior one-third of the interventricular septum. Stenosis of the left circumflex coronary artery is seen least frequently (15-20%).
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