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By: Lisa M Holle, PharmD, BCOP, FHOPA Associate Clinical Professor, Department of Pharmacy Practice, University of Connecticut School of Pharmacy; Assistant Professor, Department of Medicine, School of Medicine, Farmington, Connecticut

The attractive cleus of an atom is called the mass number force between the positively charged nu­ and is symbolized by the letter A purchase 25mg clomid with mastercard womens health 3 week abs. For ex­ cleus and the negatively charged electron ample discount 25mg clomid with visa menopause weight loss, stable gold (Au) has a nucleus with is the force that keeps the electrons in the 79 protons (Z = 79) and 118 neutrons (A atom buy cheap clomid on-line pregnancy 0-0-1-0. Therefore buy cheap cialis soft 20mg, of an element have the same number of a K electron has a larger binding force than protons in the nucleus; that is order tadalafil line, they have an L electron. Of course, the binding force the same atomic number but have different of the electron is directed toward the nu­ numbers of neutrons and therefore difer­ cleus, and the electron would move toward ent atomic masses. An electron by the nucleus keeps the electrons moving can move to either a higher or lower energy in a circular path. Electron movement to a lower energy tational force toward the sun, but it con­ shell (for example, from an L to a K shell) tinues to move around the sun in a stable results in the emission of energy. Similarly, electrons are in stable or­ amount of energy is equal to the difference bital shells. By defni­ example, from a K to an L shell, or from tion, kinetic energy must be positive, but the K shell to a free electron) requires the potential energy can be either positive or addition of energy to the electron. Bound particles always have source of this addition may be the absorp­ negative energy. To free an the K shell, has subshells of slightly differ­ electron from an atom, the energy must be ent energies. The three subshells and an electron in the L energy that an electron in a shell must be shell may have one of three energy values. Tungsten has a K-shell energy of In a transition from the L shell to the K 70 keV and an L-shell energy of 11 keV. If an L electron leaves the highest the electron must be given 70 keV of en­ subshell and goes to the K shell, it will emit ergy, while only 11 keV are required to free some value of energy. The L electron has 59 ke V shell and goes to the K shell, however, it more energy than the K electron. An L binding energy of the electron shells varies electron in the lowest subshell may not go from one element to another. Atomic structural laws, how­ radiology the circular orbit model is suff­ ever, prohibit small additions or subtrac­ ciently accurate. The diameter of the nucleus of an atom An electron cannot have any more, or less, is about 5 X 10-15 m and the diameter of energy than that associated with its energy the entire atom is about 5 X 10-10 m. We previously encountered a an empty space, and this explains why a joule as a watt-second. We leave it as an high-speed electron may go through many exercise in unit management to determine atoms before colliding with any of the com­ that a watt-second is equal to a coulomb­ ponents of an atom. We must clearly dis­ (assuming electron density to be equal to tinguish between kVp and keV (kiloelec­ proton density) would be a ball � in. The K shell would have a di­ that the maximum voltage across the tube ameter of 1.

Treatment Physiologic Gynecomastia Microscopic Excision in the form of microdochectomy or Most examples of gynecomastia are physi- Necrotic area is replaced by acute infam- total duct exicion is curative purchase clomid 50mg overnight delivery breast cancer in young women. Neonatal period-Due to the presence cholesterol crystals buy 100 mg clomid amex womens health 6 10, hemosiderin and granu- It is encysted milk secretion and is treated by of placental estrogens acting on neonatal lation tissue purchase 25mg clomid amex women's health clinic mackay. Adolescence-Due to an excess of estra- Treatment Sebaceous Cyst diol relative to testosterone order generic kamagra line. Mondor’s disease is thrombophlebitis of the Silicone Granulomas Terefore order discount super viagra on line, common to each of the above is superfcial veins of the breast and anterior Silicone used in breast augmentation may an excess of estrogens in relation circulating chest wall. In the absence of injury or infec- escape from the silastic capsule inducing the testosterone. Other diferen- • In the nonobese patient at least 2 cm of months, without recurrence, complications tial diagnoses are periductal mastitis and duct subareolar breast tissue must be present or deformity. Changes in breast size-Tis occurs in the causes are Drugs pregnancy, carcinoma, giant fbroadenoma, a. Pain and tenderness but no lump-the • Hepatocellular carcinoma Treatment causes may be C. Liver disease Surgery-The only indication for excision is • Cyclical mastalgia (including premen- • Nonalcoholic and alcoholic cirrhosis. Genetic: Occurs in women more com- Over 90 percent of breast cancers arise in lump in 50 percent of cases. When the carci- thelial cells (Paget’s) cells in lower epidermis ble for about 75 percent of all hereditary noma infltrates the basement membrane with dermal infammation and fbrosis. Dietary factor: Diets rich in saturated not, it is called noninfltrating type of there is no associated lump. Infltrating duct carcinoma (accounts Scirrhous Carcinoma for 75% of all breast carcinomas) It accounts for 65 percent of all invasive i. Tese Microscopic cancers have no specifc microscopic • Contains islets of malignant cells in the appearance. T2 – Tumor > 2 cm but < 5 cm in its greatest be erythema, peau–d-orange, ulceration Macroscopic dimension. N – Lymph Node • Nipple changes – Destroyed, deviated, 10 years survival is >80 percent. Mammography: Mammography should Microscopically there are small islands N3 – Metastasis in ipsilateral supra- or infra- be done in women over 35 years both as a of tumor cells foating in masses of pale blue clavicular nodes. Prognosis is favorable with lower inci- M = Distant Metastasis Infltrating radiopaque mass with dence of nodal metastases.

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It is more common clinically0 Thalassemia minor (also called than the major variant and offers resistance against falciparum malaria order clomid us womens health 092012. These Thalassemia trait): HbA2 is patients are usually asymptomatic with only mild anemia buy clomid on line amex menstrual symptoms after hysterectomy. Peripheral smear shows microcytic discount clomid 25 mg amex women's health clinic alaska, hypochromic cells with basophilic stippling and presence of target cells purchase genuine viagra sublingual online. In this test 2 blood samples (1of a normal person serving as control and 1 of patient) Naked Eye Single Tube Red cell are added to 2 tubes with 0 discount cialis super active uk. The features of the disease are intermediate between the two other types of thalas- semia discussed above. The clinical picture in β-thalassemia trait is similar to that discussed in β-thalassemia minor which means there is presence of microcytosis, minimal or no anemia, and no abnormal physical signs. Hydrops fetalis is the most dangerous form of α-thalassemia and severe tissue anoxia leads to intrauterine fetal death. Complications of massive blood transfusion are: • Coagulopathy: Most common cause of bleeding after massive transfusion is dilutional thrombocytopenia. Clinically, signifcant hypocalcemia usually do not develop because citrate is metabolized by liver to bicarbonate. It results from conversion of citrate (present in stored blood) and lactate (accumulated due to hypoperfusion) to bicarbonate. Splenectomy • Indications of splenectomy include traumatic or iatrogenic splenic rupture (most common), symptom control in patient with massive splenomegaly, correction of cytopenias in patients with hypersplenism, staging of patients with Hodgkin’s disease, treatment of hairy cell leukemia and prolymphocytic leukemia. Acute manifestations of splenectomy include leukocytosis (up to 25000/µl) and thrombocytosis (up to 1 × 106/µl) but return back to normal levels within 2-3 weeks. Chronic Manifestations of splenectomy include: • Anisocytosis and poikilocytosis • Howell-Jolly bodies (nuclear remnants) • Heinz bodies (denatured hemoglobin) • Basophilic stippling • Target cells • Pappenheimer bodies (contain sideroblastic granules) • Irregular contracted red cells. When such erythrocyte abnormalities are seen without splenectomy, splenic infltration by tumor should be suspected. This condition is similar to endometriosis (presence of endometrial tissue at non- endometrial sites). Which of the following surface glycoproteins is most (b) Spherocytosis often expressed in human hematopoietic stem cell? Burr cell is seen in: (Jharkhand 2003) (d) Howell-Jolly bodies (a) Uremia (e) Cabot ring (b) Hepatocellular carcinoma (c) Gastric carcinoma 6. Which of the following surface glycoproteins is most (d) Ovarian carcinoma often expressed in human hematopoietic stem cell? A 74 year-old female Lajo Devi with renal failure (a) Renal cell carcinoma presents for hemodialysis. On further (c) High altitude investigations, she is found to be anemic and is given a (d) Benign liver tumor dose of erythropoietin.

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Vitamin supple- Signs and symptoms are not noticed until vision mentation may help slow dry macular degen- loss occurs cheap 50 mg clomid with mastercard pregnancy nesting period. The diagnosis of glaucoma includes eration order 100 mg clomid fast delivery women's health center santa fe, but this should only be done under a tonometry clomid 50 mg visa womens health 4 way body toner, which measures intraocular pressure discount proscar 5mg fast delivery. For a few patients purchase vytorin australia, sur- Visual field testing measures the field peripheral gical implant of a telescopic lens can improve vision. Macular degeneration cannot be prevented, although some risk factors, such as smoking, can be controlled. Retinal Detachment Retinal detachment is an emergency condition in which the retina pulls away from the back of the eyeball. It can result in blindness in the affected eye because the underlying layer of the eyeball provides oxygen and nutrients to the retina. Risk factors include aging, extreme nearsightedness, advanced dia- betes, and eye trauma. Signs and symptoms include sudden appear- ance of floaters (floating debris) in the affected eye. Sudden flashes of light or dark shadows like a curtain also indicate a retinal detach- ment. Symptoms of cataracts depend on the extent Pachymetry, which measures the thickness of the of lens opacity and whether one or both eyes are cornea, prevents this kind of misdiagnosis. Age-associated cataracts occur in both Treatments for glaucoma are aimed at decreas- eyes, whereas congenital cataracts may occur ing intraocular pressure and include medications in one eye. Medicated eye drops reduce distortion, blurred vision, and glare, especially the production of fluid and promote fluid drain- in bright light or when driving at night. Laser surgery involves piercing the anterior stages, a cataract can be seen through a dilated chamber with a laser beam to promote drain- pupil with an ophthalmoscope or slit lamp. Glaucoma cannot be the cataract continues to develop, the retina cured, and its damage cannot be reversed. Early detection ation of intraocular pressure can help identify allows planning for treatment or preventative developing disease. Prevention is almost impossible because this is a condition related to Cataracts aging (See Figure 14–4). By age 65, almost half of all Americans have some degree of Infectious and Inflammatory Diseases cataract formation and resulting impaired vision; Conjunctivitis Conjunctivitis is an inflammation after age 75 the figure is close to 70%. Risk fac- of the conjunctiva, the superficial covering of the tors for cataracts include trauma, smoking, alco- sclera (white of the eye), and the inner linings hol use, exposure to radiation or ultraviolet rays, of the eyelids (Figure 14–6 ). About 30% of all systemic diseases such as diabetes or hyperten- eye complaints are for conjunctivitis, commonly sion, poor nutrition, and intrauterine infections. Viral and bacte- caused by cytomegalovirus, herpes simplex, rial infections are contagious, so children with Toxoplasma, and Candida. Uveitis can be Signs and symptoms of bacterial conjunctivitis treated with corticosteroids and systemic or topi- include itchy, light-sensitive, red eyes with yel- cal medications, depending on the location and low or white discharge. Reinfection occurs by rubbing ment with systemic medications or corticoste- or touching the eye with contaminated hands.

They are commonly found in the midline of the Excision of the tumour with a wide surgical hard palate (torus palatinus) and on the lingual margin is essential and may require major recon- aspect of the mandible (torus mandibularis) where struction discount generic clomid canada womens health 3 week workout plan. Their bony hard consistency is diagnostic and There is no cytotoxic drug regimen of any value generic 50 mg clomid otc womens health initiative study results. Conservative treatment is appropriate for the majority as they are usually symptomless and present as incidental clinical findings clomid 50 mg visa women's health clinic saginaw mi. A ranula is a mucus-containing cyst in the floor Odontogenic cysts of the mouth generic accutane 10 mg without prescription, usually in young people best purchase propecia, caused by damage to the ducts of the sublingual salivary A wide variety of the pathological abnormalities gland. Clinical diagnostic indicators Dental cysts are relatively common and produce A ranula has the same bluish tinge as a mucocele of radiolucent swellings within the jaws. Dentigerous cysts arise from the follicle that surrounds the enamel of unerupted teeth. They Investigation have an epithelial lining that sheds cells into the Imaging cyst cavity, which then degenerate to produce a cholesterol-rich content. Plain radiographs may show the multilocular Odontogenic keratocysts arise from the oral ‘soap bubble’ appearance of an ameloblastoma epithelium that gives rise to the dental follicles. Management The presence of multiple keratocysts is a car- Surgical excision is the preferred treatment. The dinal feature of basal cell naevus syndrome (an entire lesion with a surrounding cuff of normal bone autosomal dominant condition which is character- must be removed. In the mandible, reconstruction ized by keratocysts, calcification of the falx cerebri, may be required. Lichen planus (white and red patches) Investigation Lichen planus may be found anywhere in the Imaging mouth without associated skin desease. Malignant Many odontogenic cysts present as incidental find- transformation is rare. Investigation Clinical diagnostic indicators Tissue biopsy Lichen planus frequently appears as lacy white Larger swellings should be biopsied as they might patches on a red background (striate type). Diagnostic pitfall: ameloblastoma It may be symptomless or be painful after eating Ameloblastoma can be misdiagnosed as a dental cyst. Although the clinical appearance of lichen pla- Management nus is often diagnostic, particularly when the lesions Infection is treated initially with antibiotics. Ulcers 275 Tissue biopsy important to make sure that the patient has good Incisional biopsies are for diagnosis not treatment, oral hygiene and does not wear any removable but if there is doubt about the true diagnosis it may dental prosthesis at night. This situation arises most often with an asym- Lesions on the tongue have the highest risk. Surgical metrical area on the tongue, where there is a high excision has the advantage that the whole lesion is possibility of cancer. Squamous cell carcinoma Management In North America and Europe the commonest site Topical steroids are employed in a variety of for oral squamous cell carcinoma to develop is the ways to treat the affected area of oral mucosa. In the Indian subcon- More potent immunosuppressive agents such as tinent, tobacco is chewed not smoked, which makes cyclosporin and tacrolimus should only be used in cancer in the buccal sulcus and cheek more common.

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