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The endocrine system is the mechanism by which in- Endocrine dysfunction generally results in over or un- formation is communicated around the body using der functioning of a gland purchase cheapest super viagra and super viagra erectile dysfunction age 25. For example purchase genuine super viagra online erectile dysfunction medication uk, hypothy- secreted by glands and may be transported through the roidismmayresultfromafailureoftheanteriorpituitary bloodstream to a distant target organ (endocrine ac- gland or a failure of the thyroid gland order discount super viagra on line stress and erectile dysfunction causes. Endocrine test- tivity) or may act directly on local tissue (paracrine ing is used to both identify the lack of hormone and to activity) order generic levitra on-line. For example order accutane 40 mg with mastercard, tides, glycoproteins, steroids or amines such as cate- r measurement of thyroid hormones is used to detect cholamines. Steroid hormones and thyroid hormones circulate Clinical features of apparent hormone deciency may freely and bound to plasma proteins. The bound hormone acts as a buffer against rapid In these cases a single random hormone sample will not changes in hormone levels. In such ins- intracellular receptors, which travel to the cell nucleus tances either testing at specic times of day (e. Dynamic endocrine testing uses techniques to The sensitivity of target organs to a hormone is depen- stimulate or suppress hormone secretion. The hypothalamus and pituitary form the basis of the Introduction to the hypothalamus central control of various endocrine axes, which are vital and pituitary to everyday function (see Fig. The optic chiasm lies just above the pituitary fossa and the cavernous sinuses Pituitary adenomas run lateral to it. It consists of two lobes: Denition r The posterior lobe is a physical and functional exten- Pituitary adenomas are benign slow growing tumours sion of the ventral hypothalamus. Gene though the anterior lobe is of separate origin to the hy- mutationshavebeencharacterisedinsomepituitaryade- pothalamus,itisunderitsclosecontrol. The hy- Pathophysiology pothalamussecretespolypeptidehormonesthatregulate Seventy per cent of pituitary adenomas are functioning, anterior pituitary hormone secretion, mostly by stim- i. Increasingly asymptomatic hormone (10%) pituitary adenomas are found at incidental imag- ing. Continuing growth disrupts other hormone secretion and can result in hypopituitarism. Denition Macroscopy Hypopituitarism is a clinical term referring to under- r Tumours less than 1 cm in diameter without enlarge- function of the pituitary gland. This may imply a de- ment of, or extension outside the pituitary fossa are ciency of single or multiple hormones. The commonest causes are pituitary or hypothalamic r Tumours 12 cm may extend outside the fossa to- tumours, or secondary to pituitary surgery or cranial wards the hypothalamus and optic chiasm, laterally radiotherapy (see Table 11. Pathophysiology Hypopituitarism may be primary due to destruction of Investigations the anterior pituitary gland or secondary to a deciency r A mass within the sella turcica (pituitary fossa) may of hypothalamic stimulation (or excess of inhibition).

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This method has a sensitivity and specificity of approximately 80% for detection of splenic enlargement and is helpful for detection of a minimally enlarged spleen that may not be palpable cheap 160 mg super viagra amex impotence natural food. Palpation of the spleen should begin in the right lower quadrant and proceed toward the left upper quadrant in order to follow the path of splenic enlargement buy cheap super viagra impotence causes and treatment. Palpation should initially be carried out in the supine position with a bimanual technique using the left hand to gently lift the lowermost portion of the left rib cage anteriorly purchase super viagra 160 mg fast delivery erectile dysfunction treatment centers in bangalore. The fingertips of the right hand are used to palpate gently for the spleen tip on inspiration purchase genuine antabuse line. The hand is moved from the right lower quadrant buy 10mg nolvadex visa, advancing toward the left upper quadrant. If the spleen is not palpated in the supine position, the patient should be moved into the right lateral decubitus position and again with bimanual technique the spleen tip should be sought using the fingertips of the right hand on inspiration. This technique has a sensitivity of about 70% and specificity of 90% for splenic enlargement. Examination for Suspected Ascites The presence of ascites, free fluid within the abdominal cavity, is always due to an underlying pathological process (see section 16). It is easy to identify large-volume ascites clinically, but the sensitivity of the examination techniques falls with lower volumes of fluid. Ultrasound, which can detect as little as 100 mL of free fluid, is the gold standard against which the clinical diagnostic maneuvers are compared. An approach involves inspection for bulging flanks, palpation for the presence or absence of fluid waves, and percussion to demonstrate shifting dullness. Bulging flanks are suggestive of ascites since fluid sinks with gravity, while gas filled bowel loops float to the top. To demonstrate a fluid wave it is necessary to enlist the aid of the patient or another individual. With the patient in the supine position, the examiner places one palm on the patients flank. This is to apply sufficient pressure to dampen any wave that may pass through adipose tissue in the anterior abdominal wall. The sensitivity of this technique is approximately 50% but it has a specificity of greater than 80%. To test for shifting dullness, percuss from resonance in the mid-abdomen to dullness in the flanks. The area of transition is then marked and the patient rolled to the opposite side.

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Last but not least our deepest gratitude extended to Ato Aklilu Mulugeta generic super viagra 160mg line impotence 40 year old, for his tremendous effort order super viagra canada erectile dysfunction zinc supplements, close follow-up and contribution in facilitating the completion of this lecture note buy 160 mg super viagra visa erectile dysfunction diabetes permanent. Diseases of Metabolism and the Endocrine System Associate professor of Internal medicine generic extra super levitra 100 mg without a prescription, Faculty of Medical sciences order genuine kamagra gold online, Jimma University Zenebe Assefa, M. Diseases of the Nervous system Assistant professor of Internal medicine, Faculty of Medical sciences, Jimma University Abera Bekele, M. Diseases of the Kidneys Assistant professor of Internal medicine, Faculty of Medical sciences, Jimma University iii Woldecherkos Abebe, M. Diseases of the Cardiovascular System Assistant professor of Internal medicine, Faculty of Medical sciences, Jimma University Fetih Mohammed, M. Hematologic diseases Lecturer in the department of Internal medicine Dejuma Yadeta, M. Gastrointestinal diseases Lecturer in the department of Internal medicine, Health sciences Faculty, Hawassa University iv Table of Contents Prefece. Other connective tissue diseases : Systemic Sclerosis, Mixed connective tissue disorders. Introduction to infectious diseases Generally infectious diseases result from bacteria, viruses, fungi, and parasites. Despite decades of dramatic progress in their treatment and prevention, infectious diseases remain a major cause of death and are responsible for worsening the living conditions of many millions of people around the world especially in the developing countries. Infections frequently challenge the clinicians diagnostic skill and must be considered in the differential diagnosis of syndromes affecting a multitude of organ systems. Infectious diseases often do not occur in isolated cases; rather they spread through a group exposed from a point source (e. Many factors affect the likelihood of acquiring infections which include, host, environmental microbial factors. Host and Environmental Factors For any infectious process to occur, the parasite and the host must first encounter each other. Microbial Factors Infection involves complicated interaction of parasites and host and inevitably affects both. In most cases a pathogenic process consisting of several steps is required for the development of infections. For example, meningococci and gonococci penetrate and traverse mucosal epithelial cells by transcytotic mechanism. Tropism; In order to infect a host successfully, many pathogens occupy highly specific place within the host and thus are tropic to a particular body site or cell type. For example, malaria sporozoites are rapidly cleared from the blood into the hepatocyts, where they undergo maturation and release into the circulation; trophozoites in turn can infect only the erythrocytes. Microbial virulence strategies; Microbes have developed a variety of strategies for escaping the immunity. For example, some pathogenic organisms elaborate toxins and enzymes that facilitate the invasion of the host and are often responsible for the disease state and many bacteria are encapsulated with polysaccharides that allow them to invade and deposit in the absence of specific antibodies. Immune response: Is a defense mechanism developed by the host for recognizing and responding to microorganisms.

Key Interventions q The risk and severity of diabetic ketoacidosis can be reduced by the provision of guidance and advice to people with diabetes on how to manage changes in blood glucose control that occur during other illnesses (sick day rules) buy cheap super viagra 160 mg online erectile dysfunction treatment on nhs. Training will also need to be provided for local health and other relevant workers to ensure that they are aware of the local services available for the management of diabetic emergencies order super viagra from india erectile dysfunction injection. Standard 8 All children purchase super viagra with amex impotence remedy, young people and adults with diabetes admitted to hospital cheap lasix uk, for whatever reason generic super cialis 80 mg on line, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes. People with diabetes are admitted to hospital twice as often and stay twice as long than those without diabetes. They also frequently describe poor experiences of inpatient care, particularly in relation to: q inadequate knowledge of diabetes among hospital staff q inappropriate amounts and timings of food and inappropriate timings of medication q the lack of information provided q delays in discharge resulting from their diabetes, especially when diabetes was not the original reason for their admission. Timely liaison with the diabetes team can both prevent the need for diabetes-related admissions and, where hospital admission is unavoidable, prevent complications during admission and delayed discharge. The employment of a specialist nurse to oversee the diabetes management of people with diabetes during their admission to hospital can reduce their length of stay and release bed space. Patients are also more knowledgeable about, and satisfied with, care provided in this way. This can be reduced by adherence to locally agreed evidence-based guidelines for the management of people with diabetes during surgical procedures. Key Interventions q Outcomes for people with diabetes following admission to hospital can be improved by better liaison between the diabetes team and ward staff. These protocols will need to encompass: q the involvement people with diabetes in decisions concerning their diabetes care q the provision of healthier food and snack choices q the monitoring and maintenance of blood glucose control, including the provision of intravenous infusions of insulin and fluids q diabetic wound management q the appropriate timing of investigations or operative procedures q the particular needs of people from different minority ethnic and religious groups, including access to appropriate food choices q the provision of clear information to people with diabetes about the management of their diabetes during their hospital stay and after discharge q liaison with and referral to the diabetes team. The aim of maternity care is to ensure that all pregnant women have a positive experience of pregnancy and childbirth and receive care that promotes their physical health and psychological well-being and optimises the health of their baby. Although some womens experience of a medicalised and high-intervention labour and delivery can be a negative or frightening one, this need not be the case if they and their partner are involved in decision-making and kept fully informed. Women with pre-existing diabetes are much more likely to lose their baby than women who do not have diabetes, either during pregnancy as a result of a miscarriage or an intrauterine death, or after birth. These result from abnormal fetal development during the six weeks following conception. Later in pregnancy, the main risks to the baby are excessive fetal growth (macrosomia), which can result in damage to both the baby and the mother during delivery. These risks can be reduced if near-normal blood glucose levels are achieved before and around the time of conception, throughout pregnancy and during labour. Pregnancy results in increasing insulin resistance and, if this is not matched by more insulin, hyperglycaemia ensues. Pregnancy can also result in the progression, if present, of diabetic retinopathy and diabetic nephropathy.