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By: E. Quadir, M.A., M.D., Ph.D.

Assistant Professor, Edward Via College of Osteopathic Medicine

Chapter 53 t Concentration of Urine 327 Due to continuous diffusion gastritis onions generic esomeprazole 40 mg line, the concentration of urea increases in the inner medulla resulting in hyperosmolarity of interstitium in inner medulla gastritis in the antrum buy 20 mg esomeprazole with visa. From here gastritis with duodenitis buy esomeprazole from india, it passes through distal convoluted tubule and reaches the collecting duct gastritis omeprazole order 20mg esomeprazole fast delivery. By this way urea recirculates repeatedly and helps to maintain the hyperosmolarity of inner medullary interstitium. It is responsible for the maintenance of medullary gradient, which is developed by countercurrent multiplier. Role of Vasa Recta in the Maintenance of Medullary Gradient Vasa recta acts like countercurrent exchanger because of its position. Its descending limb runs along the ascending limb of Henle loop and its ascending limb runs along with descending limb of Henle loop. The sodium chloride reabsorbed from ascending limb of Henle loop enters the medullary interstitium. Simultaneously water diffuses from descending limb of vasa recta into medullary interstitium. So, a large quantity of sodium chloride accumulates in descending limb of vasa recta and flows slowly towards ascending limb. By the time the blood reaches the ascending limb of vasa recta, the concentration of sodium chloride increases very much. Simultaneously, water from medullary interstitium enters the ascending limb of vasa recta. If the vasa recta would be a straight vessel without hairpin arrangement, blood would leave the kidney quickly at renal papillary level. Numerical indicate osmolarity (mOsm/L) interstitium and thereby the hyperosmolarity will be decreased. Therefore, when blood passes through the ascending limb of vasa recta, sodium chloride diffuses out of blood and enters the interstitial fluid of medulla and, water diffuses into the blood. Thus, vasa recta retains sodium chloride in the medullary interstitium and removes water from it. The blood passing through the ascending limb of vasa recta may carry very little amount of sodium chloride from the medulla. From medullary interstitium, along with sodium chloride, urea also enters the descending limb of vasa recta. When blood passes through ascending limb of vasa 328 Section 5 t Renal Physiology and Skin recta, urea diffuses back into the medullary interstitium along with sodium chloride. Thus, sodium chloride and urea are exchanged for water between the ascending and descending limbs of vasa recta, hence this system is called countercurrent exchanger. Normally, the distal convoluted tubule and collecting duct are not permeable to water. A large quantity of water is removed from the fluid while passing through distal convoluted tubule and collecting duct. Numerical indicate osmolarity (mOsm/L) Chapter 53 t Concentration of Urine 329 So, the osmolarity of fluid remains the same as in the case of Bowman capsule, i. Reabsorption of large quantity of water increases the osmolarity to 1,200 mOsm/L. This segment is highly permeable to water and so the osmolarity of tubular fluid becomes equal to that of the surrounding medullary interstitium. In the short loops of cortical nephrons, the osmolarity of fluid at the hairpin bend of loop becomes 600 mOsm/L. And, in the long loops of juxtamedullary nephrons, at the hairpin bend, the osmolarity is 1,200 mOsm/L. Due to concentration gradient, sodium chloride diffuses out of tubular fluid and osmolarity decreases to 400 mOsm/L. Osmotic Diuresis Diuresis is the excretion of large quantity of water through urine. Osmotic diuresis is the diuresis induced by the osmotic effects of solutes like glucose.

A Aminoglycoside-containing ear drops must be avoided in perforated tympanic membranes gastritis jaw pain quality esomeprazole 40mg. Which of the following statements regarding benign paroxysmal positional vertigo are true E During treatment gastritis definition esomeprazole 20mg lowest price, patients should be advised to keep the affected eye open to prevent deterioration in vision gastritis diet 9000 discount generic esomeprazole canada. C Treatment options are complex and involve factors including tumour size and hearing levels gastritis diet purchase cheapest esomeprazole and esomeprazole. C the external ear canal is approximately 3 cm in length, the outer two-thirds are cartilage, extending from the elastic cartilage of the pinna to the bony medial third. Epithelium migrates from the tympanic membrane outwards along the ear canal, making the ear self-cleaning. D the tympanic membrane consists of an inner mucosal, middle fibrous and an outer stratified squamous epithelial layer. The inferior section of the membrane, below the lateral process of the malleus, is called the pars tensa, and the section superior to the lateral process is called the pars flaccid. A the facial nerve enters the temporal bone at the internal acoustic meatus, winding its way through labyrinthine, tympanic and mastoid segments in the bony fallopian canal. It exits the skull at the stylomastoid foramen, which is identified during parotid surgery. Hair cells on the basilar membrane within the cochlea vibrate and transduce mechanical energy into electrical energy. E the three semicircular canals lie within the temporal bone at right angles to one another. They react to angular acceleration, whilst the utricle and saccule react to linear acceleration and gravity. As in the cochlea, shearing forces produce hair cell movement which is transduced into electrical activity carried in the vestibular nerve. This variation of sensory supply explains the varied causes of referred otalgia, classically laryngeal cancer. The shearing of the perichondrium from the cartilage results in bleeding into the space which develops. As cartilage derives its blood supply from this perichondrium, cartilage necrosis can occur, resulting in a lasting deformity. Although aspiration of a haematoma will result in temporary resolution, recurrence is the rule and incision and drainage with antibiotic cover and postoperative pressure dressing forms the treatment of choice. A Otitis externa is a generalized inflammatory condition of the external ear canal. Topical antibiotics and steroids are the initial treatment of choice, followed by debris removal with microscopic assistance if this fails. E this condition, which results in osteomyelitis of the skull base, presents with unilateral severe otitis externa. Patients are often immunocompromised, and elderly diabetics with otitis externa should be suspected of the condition. B Most malignancies of the external ear are basal cell or squamous cell carcinomas. The ear canal, which is surrounded on all sides, may be invaded by tumours from the parotid gland or postnasal space. A Traumatic perforations tend to heal spontaneously, although perforations secondary to welding and blast injuries do worse. In ossicular trauma the incus is usually involved, and ossicular damage can be reconstructed by reshaping the damaged ossicle or by using a prosthetic implant. C Suppurative otitis media is most common in children, and results in a purulent fluid building up behind an intact tympanic membrane. The rise in pressure results in pain, which subsides on perforation of the ear drum.

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Third heart sound is a mild sound and it is not heard by using stethoscope in normal conditions gastritis diet lunch esomeprazole 40mg with visa. Four types of factors are responsible for the production of the first heart sound gastritis not healing buy cheap esomeprazole 40 mg on line. Valvular factor Synchronous closure of atrioventricular valves set up the vibrations in the valvular leaflets and chordae tendineae gastritis english buy esomeprazole pills in toronto. These vibrations are mainly responsible for the production of the first heart sound symptoms of gastritis mayo clinic order esomeprazole. Vascular factor Rush of blood from the ventricles into aorta and Applied Physiology 1. Reduplication of first heart sound Reduplication means splitting of the heart sound. First heart sound is split when the atrioventricular valves do not close simultaneously (asynchronous closure). Splitting of first heart sound in normal conditions (physiological splitting) is rare. Pathological splitting of first heart sound occurs in stenosis of atrioventricular valves and atrial septal defect. Soft first heart sound Heart sound becomes soft when the intensity of sound decreases. A soft first heart sound is heard in low blood pressure, severe heart failure, myocardial infarction and myxedema. Loud or accentuated first heart sound First heart sound becomes louder or accentuated (becoming prominent) in conditions like mitral stenosis, Wolff-Parkinson-White syndrome and acute rheumatic fever. Cannon sound Cannon sound refers to the loud first heart sound that is heard intermittently. Muscular factor Myocardial tension and the contraction of ventricular muscle during isometric contraction and the ejection periods also add to the production of the first heart sound. Atrial factor Vibrations produced by the atrial systole also play a role in the production of the first heart sound. It is also called ventricular gallop or protodiastolic gallop, as it is produced during earlier part of diastole. Usually, the third heart sound is inaudible by stethoscope and it can be heard only by using microphone. Causes Third heart sound is produced by the rushing of blood into ventricles and vibrations set up in the ventricular wall during rapid filling phase. Conditions when Third Heart Sound becomes Audible by Stethoscope Third heart sound can be heard by stethoscope in children and athletes. Pathological conditions when third heart sound becomes loud and audible by stethoscope are aortic regurgitation, cardiac failure and cardiomyopathy with dilated ventricles. When third heart sound is heard by stethoscope, the condition is called triple heart sound (see below). Third heart sound is usually heard best with the bell of stethoscope placed at the apex beat area, when the patient is in left lateral decubitus (lying on left side) position. Cause Second heart sound is produced due to the sudden and synchronous closure of the semilunar valves. Reduplication of second heart sound Splitting of second heart sound occurs due to asynchronous closure of semilunar valves. Interval between the two valves widens during inspiration and narrows during expiration. Increased negative intrathoracic pressure during deep inspiration increases lung expansion and venous return into right atrium. However, the venous return from lungs to left atrium is reduced during this condition. Because of increased venous return in right atrium and subsequent increase in blood volume in right ventricle, pulmonary valve is kept open for slightly longer time than the aortic valve. So, the pulmonary valve closes little later than the aortic valve causing splitting of second heart sound.

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A gastritis diagnosis generic esomeprazole 40mg line, B Surgery is performed in mitral valve disease to relieve symptoms and to improve survival (prognostic) lymphocytic gastritis diet purchase esomeprazole 20mg otc. For mitral regurgitation gastritis symptoms tiredness discount 40 mg esomeprazole with mastercard, progressive left ventricular dilatation and/or dysfunction and severe onset of regurgitation are the other indications gastritis diet nz discount esomeprazole 20mg with mastercard. For mitral stenosis, the other indications are the severity of stenosis (moderate and severe stenosis with valve area of 1. The onset of mitral regurgitation has implications for changes in cardiac morphology and function, and consequently the strategy for surgical correction. In mitral regurgitation, retrograde ejection leads to an increase in left ventricular volume load. The amount of retrograde ejection increases slowly in chronic mitral regurgitation, allowing adaptive changes like progressive left ventricular dilatation and hypertrophy, and left atrial dilatation, to develop without substantial pressure increase. As a result the pulmonary circulation is protected from developing a sudden increase in pressure. High-volume retrograde flow into a small left atrium causes a sudden surge in left atrial pressure and a back pressure increase affecting the pulmonary venous circulation, leading to pulmonary congestion and oedema. Chronic mitral regurgitation, however, ultimately causes congestive cardiac failure when the compensatory mechanisms are overwhelmed. Acute mitral regurgitation presents with sudden onset and rapidly progressive dyspnoea with clinical and radiological evidence of pulmonary oedema. Chronic mitral regurgitation is usually asymptomatic until pulmonary congestion and left ventricular failure develop. Then symptoms like fatigue, dyspnoea on exertion, orthopnoea and atrial fibrillation (due to left atrial enlargement) occur, and left ventricular enlargement becomes apparent radiologically. A loud apical pansystolic murmur is audible in both acute and chronic mitral regurgitation. C Aortic stenosis and chronic aortic regurgitation are usually asymptomatic until cardiac decompensation occurs. Compensatory mechanisms include ventricular hypertrophy (increase in wall thickness) to overcome the left ventricular outflow obstruction of aortic stenosis, and left ventricular dilatation to accommodate the increased left ventricular volume load due to aortic regurgitation. With cardiac decompensation, and acute aortic regurgitation, patients develop exertional dyspnoea and angina. A harsh systolic ejection murmur, heard loudest in the aortic area and radiating to the carotids, is typical of aortic stenosis. In aortic regurgitation also, the apex beat is often visible and displaced laterally. The characteristic murmur of aortic regurgitation is high-pitched, mid-diastolic and best heard at the left sternal border. The electrocardiographic and radiological appearances are not usually distinctive. While valves obtained from humans (homograft and autograft) are harvested and implanted without major alteration of the configuration, valves made from animal tissue (heterograft) are constructed to resemble human valves and are mounted on a frame (stented) or frameless (stentless). Among biological valves, heterografts are most commonly used; specifically, stented heterografts are the most frequently implanted. Biological valves are non-thrombogenic so do not require lifelong anticoagulation. Biological valves, unlike mechanical valves, are subject to degenerative changes which lead to structural failure, and hence their durability is limited. The need to replace a prosthetic valve also arises if there is a paravalvular leak causing haemodynamic instability or haemolytic anaemia, thrombosis of the valve, thromboembolism related to the valve and infection of the valve (prosthetic valve endocarditis). Homografts and autografts (entirely human tissues) are less susceptible to thrombosis/thromboembolism and infection. Mechanical valves and the other biological valves have low risks of paravalvular leak, infection and thrombosis/thromboembolism. D Three main types of atrial septal defect (defect in the septum between the right and left atria) described are: ostium secundum, ostium primum and sinus venosus.