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By: P. Tangach, M.B. B.CH. B.A.O., Ph.D.
Vice Chair, Johns Hopkins University School of Medicine
Develops from an outgrowth of the mesonephric duct (called the ureteric bud) and from a condensation of mesoderm within the nephrogenic cord called the metanephric mesoderm asthma treatment by zubaida apa cheap advair diskus 500mcg otc. The metanephros begins to form at week 5 and is functional in the fetus at about week 10 asthma treatment differences discount 500 mcg advair diskus mastercard. The fetal kidney is divided into lobes, in contrast to the definitive adult kidney, which has a smooth contour. A B C Gonad Mesonephros Kidney Mesonephros G Hindgut Mesonephric duct Allantois Metanephric mesoderm Urogenital sinus Week 6 Urogenital sinus Week 9 Week 12 Gonad Ureteric bud Figure 8-1 Early development of the kidney. The ureteric bud initially penetrates the metanephric mesoderm and then undergoes repeated branching to form the ureters, renal pelvis, major calyces, minor calyces, and collecting ducts. The inductive influence of the collecting ducts causes the metanephric mesoderm to differentiate into metanephric vesicles, which later give rise to primitive S-shaped renal tubules that are critical to nephron formation. Nephron formation is complete at birth, but functional maturation of nephrons continues throughout infancy. At the tip of the each collecting duct, the formation of metanephric vesicles is induced. The fetal metanephros is located at vertebral level S1-S2, whereas the definitive adult kidney is located at vertebral level T12-L3. The change in location results from a disproportionate growth of the embryo caudal to the metanephros. During the relative ascent, the kidneys rotate 90, causing the hilum, which initially faces ventrally, to finally face medially. During the relative ascent of the kidneys, the kidneys will receive their blood supply from arteries at progressively higher levels until the definitive renal arteries develop at L2. Arteries formed during the ascent may persist and are called supernumerary arteries. The urinary bladder is formed from the upper portion of the urogenital sinus, which is continuous with the allantois. The allantois becomes a fibrous cord called the urachus (or median umbilical ligament in the adult). The lower ends of the mesonephric ducts become incorporated into the posterior wall of the bladder to form the trigone of the bladder. It is asymptomatic and compatible with life because the remaining kidney hypertrophies. It causes oligohydramnios, which causes compression of the fetus, resulting in Potter syndrome (deformed limbs, wrinkly skin, and abnormal facial appearance). In some cases, two pelvic kidneys fuse to form a solid mass, commonly called a pancake kidney. A horseshoe kidney occurs when the inferior poles of the kidneys fuse across the midline. Normal ascent of the kidneys is arrested because the fused portion gets trapped behind the inferior mesenteric artery. A horseshoe kidney may also cause urinary tract obstruction due to impingement on the ureters, which may lead to recurrent urinary tract infections as well as pyelonephritis. The computed tomography in Figure 8-3 shows the isthmus of renal tissue (arrow) that extends across the midline. If there is severe uteropelvic atresia, a multicystic dysplastic kidney is found, in which the cysts are actually dilated calyces. In this case, the kidney consists of grape-like, smoothwalled cysts of variable size. The photograph in Figure 8-6 shows numerous cysts usually confined to the collecting ducts and tubules. The photograph in Figure 8-7 shows the Wilms tumor extending from normal kidney tissue (arrow). The term duplex kidney refers to a configuration where two ureters drain one kidney.
Syndromes
- Nausea and vomiting
- Swelling
- Cloudy or bloody urine, which may have a foul or strong odor
- Loss of language or communication skills
- Vomiting
- Hair or skin changes
The red arrow points to gas in the fundus of the stomach asthma definition resolution purchase 500 mcg advair diskus overnight delivery, which you saw on the chest radiograph asthma symptoms fatigue order advair diskus visa. Red outlined arrow points to a relatively horizontal left mainstem bronchus, which is elevated by an enlarged left atrium, secondary to mitral valvular stenosis. Note that it does not silhouette out the left heart border or left pulmonary artery. The red outlined arrows point to the posterior margin of a descending thoracic aortic aneurysm. Red arrow points to another double density in the mediastinum, this time representing gas density, but not in a location for hiatus hernia. Barium in the esophagus demonstrates a large diverticulum (red arrows) containing a bezoar (yellow arrow) and air (blue arrow) which accounts for the double density seen on the plain film radiograph. Also note a calcified granuloma (green arrows) which was present in figure 54 but not well demonstrated in the underpenetrated film. This is where the value of the lateral projection comes in handy to explain any double densities or shadows you are worried about. The silhouette sign is extremely important in assessing for fluid or pleural thickening, and in order to tell the difference a lateral decubitus view will answer the question of free fluid, especially if no prior films are available for comparison. There is also a variant of the diaphragm with which you should become familiar which is an eventration, simply a weakness of the muscle fibers of the diaphragm usually congenital in origin, and which can effect either leaf. Eventrations cause the hemidiaphragm to appear elevated, but usually are of no clinical significance or importance in asymptomatic adults. Eventrations in the newborn may cause respiratory distress in some cases and are subject to surgical intervention. Images in figures 56 and 57 courtesy of Madigan Army Medical Center via the Internet. A Bochdalek hernia, demonstrated below, is the most common of the diaphragmatic hernias and the most common surgical emergency of the neonate when it compromises lung capacity. White -contrast in distal stomach Pink - herniated stomach Orange-spleen Red - aorta Yellow- kidneys Blue - rt. Red arrows point to diaphragmatic calcifications in this patient with documented asbestos exposure. The last major system to evaluate in the chest radiograph aside from a couple of other tips is the bony thorax. I tell my students that after looking at chest radiographs for 30 years I can usually see everything at once but that it took years of practice and looking at every bone before I felt comfortable with it. I still carefully examine every bone, (now using a magnifying glass) if looking for fractures or metastatic pathology. I further inform them that to reach a level of competence, the practice of scrutinizing each bone is an absolute necessity, and that to program that computer between their ears to easily spot abnormalities of the bony thorax can not be done in a short period of time. Just to illustrate the point, see if you can spot the bony abnormalities in the following figures before reading the answers under each picture. See if you can spot any bony abnormalities (subtle) before referring to the sketch below. The negative study of an aortic arch angiogram in this same patient shows the coarctation (white arrow) in Figure # 63b (below). The next case (below) demonstrates another bony abnormality that may be difficult to see for the inexperienced eye. Tomograms of this area shown in figures 66 and 67 on the next page demonstrate the bone destruction caused by metastatic carcinoma. Thus by "stepping through" an area of interest fine line detail can be ascertained). This sounds like a lot to consider, but in actuality the student will quickly make a decision as to whether or not the pattern is normal. If it is not, one then has to decide why not, and also if the pattern is specific or non-specific. The chest film is included for two reasons: 1) Many chest conditions such as pneumonia or pleural effusions can present as abdominal pain and 2) It gives us a chance to look at the diaphragm and for free air. The upright or decubitus view lets us look for localizing signs such as air fluid levels or isolated and dilated loops of bowel. Sometimes we are only given a single view to interpret, especially when the film comes from an outside source (St.
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Easy onset of voicing asthma 49390 buy cheapest advair diskus and advair diskus, light articulatory contacts asthma exacerbation discount advair diskus uk, and use of computer-assisted feedback to train the patient in fluency are treatment methods designed to establish fluent speech. Fluency intervention is provided to improve aspects of speech fluency and concomitant features of fluency disorders to optimize activity/participation, such as reduction of avoidance behaviors. Communication requires a complex interplay between cognition, language, and speech, with cognitive processes ranging from basic to complex and includes attention, memory, reasoning, and executive functions. Communication involves listening, reading, writing, speaking, and gesturing at all levels of language. Treatment Intervention is tailored to the unique needs of the individual and may focus on such skills as attention, memory, pragmatics, problem solving, and functional communication. The goal of cognitive-communication intervention is for the person to achieve the highest possible level of communicative participation in daily living. Velopharyngeal Dysfunction (See also Cleft Lip and Palate, Voice and/or Resonance Treatment, Voice and/or Resonance Disorder) the purpose of the velopharyngeal mechanism is to close off the nasal cavity from the oral cavity during speech, normalizing both resonance and articulation for pressure sensitive phonemes. Instrumentation may be used to assess this problem (see Speech-Language Pathology Instrumentation). Resonance can be assessed as normal, hypernasal, hyponasal, or mixed hyper/hyponasal. If a cleft palate/craniofacial team is involved, for example, team members will have access to: a nasometer that analyzes acoustic energy emitted through the oral cavity and nasal cavity during the production of speech aerodynamic assessment, measuring oral pressure and oral airflow during speech, and estimating the size of the velopharyngeal gap/orifice nasopharyngoscopy (a procedure using a flexible fiberoptic nasopharyngeal scope) to visualize the velopharyngeal mechanism and its function by viewing the nasal surface of the velum and the velopharyngeal port during connected speech videofluoroscopy and lateral cephalographs to assess velopharyngeal closure during speech and phonation, respectively. Speech-Language Pathology Medical Review Guidelines 50 Treatment Improving articulatory placement and eliminating compensatory errors to improve velopharyngeal function and decrease the perception of hypernasality may be a focus of treatment. Eliminating inappropriate velopharyngeal patterns by looking, listening, and feeling for nasal air flow using auditory feedback, tactile feedback, and visual feedback may also be a focus of treatment. Voice and/or Resonance Disorder (See also Velopharyngeal Dysfunction, Cleft Lip and Palate, Voice and/or Resonance Treatment; Laryngectomy) Voice disorder, or dysphonia (an impairment of the speaking voice), arises from an abnormality of the structures and or functions of the voice production system and can cause bodily pain, a personal communication disability, and an occupational or social handicap. Genetic factors may predispose an individual to voice disorders; chronic and acute variables such as occupational vocal demands, medications, health problems, environment, physical trauma, and lifestyle choices may precipitate dysphonia. Loudness is the perceived volume (or amplitude) of the sound; quality refers to the distinctive attributes of a sound. Treatment is provided for individuals with resonance or nasal airflow disorders, velopharyngeal incompetence, or articulation disorders caused by velopharyngeal incompetence and related disorders such as cleft lip/palate. In complex disorders, such as paradoxical vocal fold motion, voice therapy helps to reduce longterm costs of treatment by minimizing expensive emergency room visits and hospitalizations. Benign vocal fold lesions are a common cause of dysphonia, and most laryngologists consider voice therapy, often together with medical management, the initial treatment of choice for benign lesions. Many studies have documented excellent outcomes after voice therapy in patients with a variety of benign lesions (Blood, 1994; Gordon, Pearson, Paton, & Montgomery, 1997; Holmberg, Hillman, Hammarberg, Sodersten, & Doyle, 2001; Lancer, Snyder, Jones, & Le Boutillier, 1988; McCrory, 2001; Murry & Woodson, 1992; Smith & Thyme, 1976; Speyer, Weineke, Hosseini, Kempen, Kersing, & DeJonckere, 2002. Increasingly, otolaryngologists are using Speech-Language Pathology Medical Review Guidelines 51 response to voice therapy to help differentiate among benign mucosal lesions, inform the treatment decision for surgery, and optimize surgical outcome. When surgery is necessary, preand postoperative voice therapy may shorten the postoperative recovery time, allowing faster return to work and limiting scar tissue and permanent dysphonia. Most otolaryngologists consider voice therapy essential as definitive treatment or as adjunctive to surgery for patients with unilateral vocal fold paralysis (Benninger et al. Evidence suggests that preoperative voice therapy improves voice outcomes for greater than 50% of patients with unilateral vocal fold paralysis and may render surgery unnecessary (Heuer, et al. See also Voice and Resonance Instrumentation under Voice and/or Resonance Treatment. The final analysis and interpretation of an instrumental assessment should include a definitive diagnosis, identification of the swallowing phase(s) affected, and a recommended treatment plan, including compensatory swallowing techniques and/or postures and food and/or fluid texture modification. An instrumental assessment is not indicated if findings from the clinical evaluation fail to support a suspicion of dysphagia or if they suggest dysphagia but (1) the patient is unable to cooperate or participate in an instrumental evaluation or (2) the instrumental examination would not change the clinical management of the patient. The effects of compensatory maneuvers and diet modification on aspiration prevention and/or bolus transport during Speech-Language Pathology Medical Review Guidelines 55 swallowing can be studied radiographically to determine a safe diet and to maximize efficiency of the swallow. Therapeutic maneuvers are attempted during this examination to determine a safe diet and to maximize the efficiency of the swallow. Individuals of all ages are treated on the basis of swallowing function assessment. At the conclusion of the assessment, the presence, severity, and pattern of dysphagia should be determined, and recommendations made with collaboration among the therapist, physician, and patient/family. Electrolarynx An electrolarynx is a handheld device held against the throat region (or mouth with an oral adapter immediately post-op) to provide vibrations that allow speech sound.
Diseases
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- Parastremmatic dwarfism
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- Fan death
- Cataract aberrant oral frenula growth retardation
- Juvenile gastrointestinal polyposis
- Pseudo-Turner syndrome