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Because many hepatic enzymes are also found in other tissues breast cancer lump feels like 20 mg fluoxetine otc, it may be necessary to confirm the hepatic origin of the enzyme when the underlying disease is uncertain women's health clinic waco tx safe fluoxetine 10 mg. Three patterns of liver injury are seen: necrosis women's health clinic on wright street fluoxetine 20 mg for sale, cholestasis womens health 8 week challenge purchase cheap fluoxetine, and infiltration (Table 147-1). Necrosis accompanied by enzyme release is typically viral or toxic in origin and is characterized by elevated serum aminotransferase levels. Cholestasis reflects reduced biliary secretion of bile acids and bilirubin, due either to reduced bile formation by liver cells or to obstruction of bile flow at any level within the biliary tree. Infiltration of the liver by tumor or granulomas may also present as a predominant elevation of the alkaline phosphatase. Aminotransferases are metabolized but are not cleared from the blood by excretion into urine or bile. Conversely, serum aminotransferase levels may fall during the clinical course of massive hepatic necrosis because the liver is so severely damaged that little enzyme activity remains (see Chapter 154). Serum aminotransferase levels provide a relatively specific screening test for hepatobiliary disease. In the context of other clinical and laboratory findings, identification of the source of increased serum aminotransferase activity is usually easy. Aminotransferase values are also useful in monitoring the activity of acute or chronic parenchymal liver disease after the diagnosis has been made. However, aminotransferase levels correlate poorly with prognosis and disease severity as assessed by liver biopsy, and they are often completely normal in advanced cirrhosis. Normally, serum alkaline phosphatase activity reflects mainly the hepatic and bone isozymes, although the intestinal form may account for 20 to 60% of the total after a fatty meal, particularly in blood groups O and B. A less common variant, called the Regan isozyme, is associated with tumors (especially hepatoma and lung cancer) and appears identical to the placental form (see Chapter 156). In some cases, the source is obvious because of other clinical and laboratory findings. When the source is less apparent, methods such as heat stability and electrophoretic separation are available to differentiate hepatobiliary alkaline phosphatase from other isozymes. In liver disease, increased serum alkaline phosphatase activity, which reflects increased enzyme synthesis rather than decreased biliary excretion or leakage from damaged cells, may be triggered by high tissue bile salt concentrations in cholestasis. Because its half-life in serum is approximately 1 week, serum levels may remain elevated for days to weeks after resolution of biliary obstruction. Slight to moderate increases in serum alkaline phosphatase activity (up to three times normal) occur in many parenchymal disorders of the liver such as hepatitis and cirrhosis. In the absence of bone disease, larger increases (3 to 10 times normal) usually indicate intrahepatic or extrahepatic obstruction of bile flow. Although the highest levels typically occur with common bile duct obstruction, very high levels may also be seen with intrahepatic cholestasis and with infiltrative or mass lesions (primary or metastatic cancer, lymphoma, leukemia, sarcoidosis, or Mycobacterium avium-intracellulare infection). A normal serum bilirubin in the setting of chronic elevation of the alkaline phosphatase suggests localized infiltrative disease or obstruction of a portion of the biliary tree due to stricture, tumor, or other localized lesions. Alkaline phosphatase is a relatively sensitive screening test for primary or metastatic tumors of the liver; however, up to one third of patients with isolated elevations of serum hepatobiliary alkaline phosphatase activity have no demonstrable liver or biliary disease. The serum activity of both enzymes usually increases in cholestasis, and their major clinical value is to help determine if an elevated serum alkaline phosphatase activity originates from the liver. In liver disease, clearance of these compounds may be impaired owing to loss of parenchymal cells, obstruction of bile flow, impaired cellular uptake or metabolism, or reduced or uneven hepatic blood flow. When a metabolite is produced at a relatively constant rate (as is usually true for bilirubin), its serum level can be a sensitive indicator of liver function. The removal rate of certain exogenous drugs and dye compounds from plasma can be used similarly. Higher plasma bilirubin levels are associated with a poorer prognosis in alcoholic hepatitis, primary biliary cirrhosis, and fulminant hepatic failure. Normal serum bilirubin is almost entirely unconjugated and reflects a balance between bilirubin production and hepatic elimination. Chronic hemolysis cannot produce elevations of serum bilirubin above 5 mg/dL in the absence of liver disease. Plasma conjugated bilirubin is elevated in liver disease owing to reflux from liver cells, but the level cannot reliably be used to distinguish parenchymal from obstructive causes. Because conjugated bilirubin is excreted in urine, plasma levels greater than 30 mg/dL are uncommon in the absence of renal failure.


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Rectal examination pregnancy back pain purchase fluoxetine 10mg line, although usually disclosing a markedly tender prostate that is swollen menopause doctors order fluoxetine with a visa, firm menstruation questions buy 10mg fluoxetine overnight delivery, and warm women's health center jamaica ave buy fluoxetine 10 mg lowest price, is not recommended because of the possibility of inducing sepsis. The infecting pathogen can usually be identified simply through culture of the voided urine. In addition, transurethral instrumentation and catheterization should be avoided in the acute stages of bacterial prostatitis. When complete urinary retention is present, a catheter should be placed for temporary diversion. Acute bacterial prostatitis often responds dramatically to intravenous antibiotic therapy. Chronic bacterial prostatitis is a non-acute infection of the prostate usually caused by one or more specific bacteria similar to those seen in acute bacterial prostatitis. The course of chronic bacterial prostatitis is usually that of a relapsing, recurring urinary tract infection in men. The initial symptoms are similar but less dramatic than those seen in acute bacterial prostatitis and include irritative as well as obstructive voiding symptoms. The discomfort associated with chronic bacterial prostatitis can often be debilitating and focuses around the suprapubic, perineal, lower sacral, scrotal, and penile area. The diagnosis is usually based on quantitative bacterial localization cultures as previously described. Transurethral prostatectomy is only curative if the infectious etiology (stone or tissue) has been completely removed. Reinfection of the prostate and reappearance of symptoms often occur after surgery. Non-bacterial pros-tatitis/prostatodynia is an inflammatory process of the prostate of indeterminate cause. Non-bacterial prostatitis is the most common of the prostatitis syndromes, yet its etiology remains unknown. Although men with non-bacterial prostatitis have increased numbers of inflammatory cells in their prostatic secretions, no causative infectious agent can usually be found by culture or other means. Earlier reports have classified prostatodynia as a "special type" of non-bacterial prostatitis; however, the symptoms, differential diagnosis, and therapy for both entities are similar. As early as 1986, Meares and colleagues were the first to suggest that there is no reason to distinguish prostatodynia from non-bacterial prostatitis. Furthermore, their work with video-urodynamics has recently revealed similar functional findings in men with prostatodynia and men with non-bacterial prostatitis. Typically, the symptoms, physical findings, and microscopic and microbiologic findings of segmented cultures of the lower urinary tract are similar for both of these disease entities. Patients with non-bacterial prostatitis, however, do not have a history of a documented urinary tract infection. The differential diagnosis of non-bacterial prostatitis and prostatodynia requires the exclusion of fungal, anaerobic bacterial, trichomonal, and viral causative agents as the etiology of the symptoms. One pathophysiologic hypothesis explaining the symptoms thought to be due to non-bacterial prostatitis/prostatodynia is smooth muscle spasm of the bladder neck and prostatic urethra. These spasms elevate pressure in the prostatic urethra and thereby result in intraprostatic and ejaculatory duct urinary reflux causing chemical prostatitis and the ensuing symptom complex. Regardless of the actual etiology of the non-bacterial prostatitis/prostatodynia complex, the symptoms are most likely the result of failure of the internal urinary sphincter to relax and failure of the pelvic floor striated musculature to function properly, either alone or in combination. Elevated prostatic urethral pressures and intraprostatic urinary reflux may initiate an inflammatory response and induce a chemical irritation within the prostatic ducts. The majority of men with significant lower urinary tract symptoms require urologic evaluation. The differential diagnosis of men with lower urinary tract irritative symptoms should include consideration of transitional cell carcinoma, carcinoma in situ, or the presence of calculi in the bladder. Examination of the urethra for urethral stricture disease and urethral carcinoma may also need to be performed. Cystoscopic examination of the lower urinary tract may rule out prostatic obstruction as a cause of the symptoms. Other differential diagnoses include perirectal abscess, neurogenic bladder, diabetes mellitus, detrusor-sphincter dyssynergia, and both self-inflicted and iatrogenic trauma. Because the symptoms of men with non-bacterial prostatitis are similar to those with flat "in situ" carcinoma of the bladder, a urinary cytology study and cystoscopic examination should be routinely performed to exclude the presence of malignancy.

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In the 90 to 95% of pheochromocytomas that are sporadic women's health workout abs cheap 10mg fluoxetine, the cause of the neoplastic process remains obscure pregnancy x ray lead apron buy generic fluoxetine online, although loss of heterozygosity on chromosomes 1p breast cancer awareness products buy generic fluoxetine 20mg, 3p breast cancer quilt pattern discount fluoxetine, 17p, and 22q suggests somatic cell deletion mutation of one autosomal allele at as-yet-uncharacterized tumor suppressor loci. Because pheochromocytoma is a potentially curable form of hypertension, the diagnosis is worth considering in each new case of hypertension. However, because hypertension is so commonly encountered in clinical practice (20 to 25% of the adult population) and pheochromocytoma is so distinctly unusual (0. Paroxysmal symptoms (such as the triad of episodic palpitations, diaphoresis, and headache) are the classic features of pheochromocytoma. These paroxysmal "attacks" characteristically begin abruptly, may last for minutes to hours, and subside gradually, with a frequency varying from many times daily to one or more per week (most commonly) or even every few months. Less common symptoms include apprehension or anxiety, tremulousness, pain in the chest or abdomen, weakness, or weight loss. In some series, more than 90% of patients have experienced paroxysmal symptoms of one or more of the classic triad. Autopsy series indicate that as many as 50 to 75% of pheochromocytomas may be undiagnosed during life, thus suggesting that many pheochromocytomas do not give rise to these classic symptomatic features. Patients older than 60 years with pheochromocytoma are especially likely to report minor or no symptoms. Affected patients may report an increase in blood pressure after receiving certain antihypertensive drugs, especially beta-adrenergic antagonists and guanethidine, or they may experience a remarkable fall in blood pressure after receiving alpha1 -adrenergic antagonists such as prazosin. Paroxysmal symptoms on micturition or bladder distention or painless, gross hematuria may suggest pheochromocytoma of the bladder; the diagnosis is confirmed by cystoscopy. Hypertension (usually severe and refractory to antihypertensive medications) is the cardinal sign of pheochromocytoma, although it is non-specific and may be insensitive. In about half of patients, hypertension is sustained, with intermittent blood pressure surges in half or more of these; in about 40%, hypertension is paroxysmal, with relatively normal blood pressure between surges. Hypertensive surges may be precipitated by abdominal manipulation, but generally no antecedent is noted. The heart rate is usually elevated during blood pressure surges but may decline as a result of physiologic reflex bradycardia. Because hypertension is so common and pheochromocytoma so rare, further biochemical evaluation for pheochromocytoma in hypertensives should be selective and focused on subjects who display some relevant clue to pheochromocytoma on history, physical examination, or screening laboratory evaluation. If interpretation of urinary measurements is not clear-cut, evaluation should proceed to plasma measurements, which require more careful sampling technique. The number and diversity of biochemical tests obtained should parallel the clinical index of suspicion. If suspicion is low, a single screening test may suffice, usually 24-hour urinary metanephrine excretion. Because anatomic or imaging studies may detect non-specific adrenal abnormalities in up to 2% of the population, such studies should not be undertaken unless biochemical tests are positive. Results of routine screening tests obtained for other purposes (such as general health maintenance) may provide tipoffs. Hyperglycemia is common, and about half of patients with pheochromocytoma manifest carbohydrate intolerance; frank diabetes requiring insulin is unusual. Widely available tests measure urinary free (unconjugated) catecholamines and catecholamine metabolites: the metanephrines and vanillylmandelic acid. A 24-hour urine sample is collected, and creatinine is measured in the same sample as an index of adequacy and completeness of collection. Of the available tests, increased urinary metanephrines have the highest diagnostic sensitivity and specificity for pheochromocytoma. Urinary excretion of metanephrines and vanillylmandelic acid remains normal until the very end stage of renal disease, so elevated levels validly diagnose pheochromocytoma. Artifactual false-positive assay results have been greatly minimized in recent years with the introduction of more specific assay methods based on separation of catecholamines and metabolites in urine by high-pressure liquid chromatography. Misleading elevations of endogenous catecholamines may occur as a consequence of the sympathoadrenal responses to shock, hypoglycemia, physical exertion, increased intracranial pressure, or withdrawal of central alpha2 -agonists such as clonidine. Biochemical tests on blood samples offer the advantage of patient convenience but the disadvantage that even minor physical or mental stress can result in false-positive elevations. Plasma catecholamines are best sampled from a supine, resting patient in whom an indwelling antecubital venous cannula has been in place for at least 15 minutes. Plasma assay methods generally provide reliable results with the usual normal resting norepinephrine value being 200 to 400 pg/mL and the normal resting epinephrine value being 20 to 60 pg/mL. Most patients with pheochromocytoma have markedly elevated (>2000 pg/mL) resting plasma catecholamine (norepinephrine plus epinephrine) values; plasma concentrations elevated beyond this point strongly suggest pheochromocytoma.

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Children with kwashiorkor also have typical skin and hair changes (see the sections on hair and skin changes below) menstruation graph fluoxetine 20mg visa. The abdomen is protuberant because of weakened abdominal muscles menstruation jewelry order 20mg fluoxetine with amex, intestinal distention menopause mayo clinic buy fluoxetine 20 mg low price, and hepatomegaly women's health clinic in new orleans discount fluoxetine master card, but ascites is never present. In fact, the presence of ascites should prompt the clinician to search for liver disease or peritonitis. Children with kwashiorkor are typically lethargic and apathetic when left alone but become quite irritable when picked up or held. Kwashiorkor is not caused by a relative deficiency in protein intake as has previously been believed; in fact, protein and energy intake is similar in children with kwashiorkor and those with marasmus. Kwashiorkor is related to the physiologic stress of an infection that induces a deleterious metabolic cascade in an already malnourished child. Kwashiorkor is characterized by leaky cell membranes that permit the movement of potassium and other intracellular ions to the extracellular space. Children with failure to thrive may have normal weight for height but short stature and delayed sexual development. Providing appropriate feeding can stimulate catch-up growth and sexual maturation. In addition, although kwashiorkor and marasmus can occur in adults, most studies of adult protein-energy malnutrition have evaluated hospitalized patients who had secondary protein-energy malnutrition and coexisting illness or injury. The current methods that are used clinically to evaluate protein-energy malnutrition in hospitalized adult patients shifts nutritional assessment from a diagnostic to a prognostic instrument in an attempt to identify patients who can benefit from nutritional therapy. Therefore, common nutritional assessment parameters are affected by non-nutritional factors, which makes it difficult to separate the influence of the disease itself from the contribution of inadequate nutrient intake. At present, no "gold standard" exists for determining protein-energy malnutrition in ill patients. The most commonly used methods include a careful history, physical examination, and selected laboratory tests (see Chapter 225). By 24 hours of fasting, the use of glucose as a fuel has decreased; only 15% of liver glycogen stores remain, and the rates of hepatic glucose production and whole-body glucose oxidation have decreased. After 3 days of fasting, the rate of glucose production is reduced by half and the rate of lipolysis is more than double the values found at 12 hours of fasting. The increase in fatty acid delivery to the liver, in conjunction with an increase in the ratio of plasma glucagon to insulin, enhances hepatic ketone body production. In contrast to fatty acids, ketone bodies can cross the blood-brain barrier and provide a water-soluble fuel derived from water-insoluble adipose tissue triglycerides. The use of ketone bodies by the brain greatly diminishes glucose requirements and thus spares the need for muscle protein degradation to provide glucose precursors. Furthermore, thyroid hormone inactivation and plasma ketones inhibit muscle protein breakdown and prevent rapid protein losses. As fasting continues, the kidney becomes an important site for glucose production; glutamine, released from muscle, is converted to glucose in the kidney and accounts for almost half of the total glucose production. At this time, adipose tissue provides more than 90% of the daily energy requirements. Total glucose production has decreased to 75 g/day and provides fuel for glycolytic tissues (40 g/day) and the brain (35 g/day). Muscle protein breakdown has decreased to less than 30 g/day, which causes a marked decrease in urea nitrogen production and excretion. The diminished urea load to the kidneys decreases urine volume to 200 mL/day, thereby minimizing fluid requirements. All body tissue masses are affected by undernutrition, but fat mass and muscle mass are the most affected. Therefore, the loss of weight that occurs in malnourished patients is principally due to loss of muscle and fat mass. Body adipose tissue can be almost completely depleted and up to half of muscle mass can be consumed before death from starvation occurs. The child manifests some of the classic features of kwashiorkor, including leg edema, reddish blond hair discoloration, and irritability. Many patients who are malnourished have intravascular volume depletion because of inadequate water and sodium intake. However, the percentage of body weight that is composed of water may be increased.

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