this is part 1, the pathophysiology was not included due to formatting trouble. this document is solely for educational purposes only, this is not to be reprinted and distributed.
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I. INTRODUCTION The immune system is a complex system within the body that is designed to fight infectious agents, such as bacteria and other foreign microbes. One of the ways that the immune system fights infections is by producing antibodies that bind to the microbes. Lupus is an autoimmune disease characterized by acute and chronic inflammation of various tissues of the body; autoimmune diseases, meaning, illnesses that occur when the body's tissues are attacked by its own immune system. Patients with lupus produce abnormal antibodies in their blood that target tissues within their own body rather than foreign infectious agents. Because the antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, lupus has the potential to affect a variety of areas. Sometimes lupus can cause disease of the skin, heart, lungs, kidneys, joints, and/or nervous system. Systemic Lupus Erythematosus (SLE) is a form of an autoimmune disease that causes a chronic inflammatory condition in which a person's immune system attacks several various organs or cells of the body causing damage and dysfunction. This is called a multisystem disease because it can affect many different tissues and organs in the body. Women, especially African- American and Asian women, are at highest risk for developing SLE. Some patients with lupus have a very mild condition, which can be treated with simple medications, whereas others can have serious, life-threatening complications. As for our client, Patient X, she was diagnosed with SLE in September of 2008, and was recently admitted at XU-Community Health Care Center (XUCHCC), or German Doctors Hospital on February 10, 2009. She was admitted at the said hospital under the care of Dr. Gabatan for her 2 nd monthly chemotherapy to go on for 6 months, which was advised to her by Dr. Saavedra of Cagayan de Oro Medical Center (COMC). Her stay in the hospital was extended, however, because her chemotherapy had to be 1
Transcript
I. INTRODUCTION
The immune system is a complex system within the body that is designed to fight infectious agents, such as bacteria and other foreign microbes. One of the ways that the immune system fights infections is by producing antibodies that bind to the microbes.
Lupus is an autoimmune disease characterized by acute and chronic inflammation of various tissues of the body; autoimmune diseases, meaning, illnesses that occur when the body's tissues are attacked by its own immune system. Patients with lupus produce abnormal antibodies in their blood that target tissues within their own body rather than foreign infectious agents. Because the antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, lupus has the potential to affect a variety of areas. Sometimes lupus can cause disease of the skin, heart, lungs, kidneys, joints, and/or nervous system.
Systemic Lupus Erythematosus (SLE) is a form of an autoimmune disease that causes a chronic inflammatory condition in which a person's immune system attacks several various organs or cells of the body causing damage and dysfunction. This is called a multisystem disease because it can affect many different tissues and organs in the body. Women, especially African-American and Asian women, are at highest risk for developing SLE. Some patients with lupus have a very mild condition, which can be treated with simple medications, whereas others can have serious, life-threatening complications.
As for our client, Patient X, she was diagnosed with SLE in September of 2008, and was recently admitted at XU-Community Health Care Center (XUCHCC), or German Doctors Hospital on February 10, 2009. She was admitted at the said hospital under the care of Dr. Gabatan for her 2nd monthly chemotherapy to go on for 6 months, which was advised to her by Dr. Saavedra of Cagayan de Oro Medical Center (COMC). Her stay in the hospital was extended, however, because her chemotherapy had to be postponed due to cutaneous lesions on her leg, one of which erupted. However, her wound has shown progress; manifesting decreased swelling and less exudate draining from the wound; thus, her chemotherapy was pushed through and she was then discharged on the 23rd of February.
In conclusion, the group aims to present Patient X’s case comprehensively and discuss the ideal and actual management done to improve the condition of the client, including the individualized nursing care plan done to relieve the nursing problems identified by the team in the small span of time that we were able to care for the patient. In the process, we will be able to enhance our knowledge, skills and attitude and be more effective with our nursing practice.
At the end of 1 hour of case presentation, we will be able to increase our
knowledge on conducting case studies especially for medical-surgical patients and on
the different concepts applied; enhance our critical thinking skills in formulating and
rationalizing individualized medical & nursing interventions appropriate for the
betterment of the patient and in delivering reports on our patient’s case; and lastly,
develop teamwork and a good attitude when interrelating with our patients, colleagues
and everyone in the health care setting.
B. SPECIFIC OBJECTIVES
At the end of 1 hour, we will be able to:
1. Establish effective communication between our group and the Clinical Instructors.
2. Present and describe the condition of the patient.
3. Present the development of the pathological condition and its clinical
manifestations.
4. Clearly and intelligibly report every part of our case study.
5. Present the various Nursing Care Plans we have devised specifically for the
patient.
6. Maintain confidentiality of the patient’s personal information and background.
7. Evidently show knowledge and confidence in reporting on assigned portions of the
case study.
8. Correctly and efficiently answer all the necessary questions thrown by the Clinical
Instructors after the case presentation.
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C. SCOPES AND LIMITATIONS
Our case presentation revolves around our 25 year old female client with
Systemic Lupus Erythematosus (SLE). This includes the patient’s assessment gathered
during the Medical Rotation at Community Health Care Center (CHCC) – German
Hospital. The patient was assessed on February 15, 17, 19 and 20, 2009. Only the
present laboratory tests and results were obtained because the patient wasn’t able to
provide us with her past laboratory results pertaining to her condition, especially when
she was diagnosed with the disease in 2008. Also, the information we were able to
gather about her past admissions, such as her medications and laboratory tests, are
only verbalizations from the patient. No actual documents were seen by the group that
could make certain these verbalizations. The patient, also, wasn’t able to recall all the
drugs that were prescribed to her after her diagnosis of SLE. Further assessment of the
patient wasn’t possible for the group because she was discharged on February 23,
2009.
The study is limited only to the case of patient X. All the information gathered
about the patient was obtained from the patient herself, her husband, and her chart. The
general management presented in this study is the actual management given and done
to the patient as advised by her attending physician. The nursing management, on the
other hand, is formulated by the group to appropriately care for the patient, with basis
on the information obtained upon assessment and from the chart. This study also
covers the pathophysiology of SLE, as manifested specifically by the patient. Moreover,
related literatures were taken from the Medical and Surgical nursing book, Anatomy and
Physiology books, Nursing Care Plan book, Drug Handbook and internet sources.
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II. ASSESSMENT
A. ASSESSMENT TOOL
I - GENERAL INFORMATIONName: Patient X Age: 25 years oldBirthday: December 7, 1983 Civil Status: MarriedSex: Female Religion: Roman Catholic Occupation: Housewife Informant: Patient X Relation: PatientAdmission Date: February 10, 2009 Time: 1:35 pmChief Complaint: NoneReason for admission: Scheduled ChemotherapyAttending Physician: Dr. GabatanDiagnosis/Impression: Systemic Lupus ErythematosusHistory of Present Illness: (Refer to appendix A)
Past Medical/Surgical History:
History DateGave birth to a healthy full term baby boy through a normal spontaneous vaginal delivery (NSVD) at Northern Mindanao Medical Center (NMMC)
November 9, 2002
Hospitalized and Diagnosed with GI Ulcer (admitted at Maria Reyna Hospital)
Late February 2008 (pt. can’t recall the exact date)
Diagnosed with SLE by Dr. Fabia at Maria Reyna Hospital
Around April 2008 (pt. can’t recall the exact date)
Hospitalized at German Doctors Hospital for Patient’s symptoms of SLE worsened
January 10, 2008
Scheduled first chemotherapy with Diagnosis of Lupus Nephritis by Doctor Saavedra
January 12, 2008
Vital Signs: HR = 80 bpm RR= 19 cpm BP = 100/60 mmHg Temp = 37 C
Vital Signs: Temperature Heart Rate Respiratory Blood Pressure
SubjectiveUsual activities/hobbies: Doing household chores, cooking and selling foods and snacks, and hang-out with familyLeisure time activities: Watching TV, reading booksLimitations imposed by condition: Cannot perform usual activities due to stay in
hospital and difficulty walking due to her wound at left lower leg
Sleep number of hours: 3-4 hours Naps: twice/day (9-10am and 3-4pm) Aids: noneDifficulty in sleeping: noneFeeling on awakening: Patient doesn’t feel well rested even after sleeping Others/Comments:
“Lisod kayo ko maglihok tungod sa hubag ug samad sa akong tiil, dapat alalayan pajud ko aron dli kaau sakit, lisod na matumba palang ko” as verbalized by the patient.
“Gakatulog ko’g 12 sa gabii dayon mata2x jud ko permi tungod sa saba ug sa mga tao dani sa akong palibot ug tungod kay sakit akong tiil.” as verbalized by the patient.
“Pangbawi sa akong tulog matulog ko ug ginagmay sa buntag ug hapon” as verbalized by the patient.
“Dili ko galisod og tulog pero kajut rapud lagi akong tulog,” as verbalized by the patient.
ObjectiveObserved response to activity:Cardiovascular: Increased PR- 94bpm Respiratory: Increased RR-25cpmMental Status: Alert Posture: SlouchedLOM: Slow movement Tremors: NoneOthers/Comments: Patient is cautious with movements to prevent pain and injury at left lower leg.
III – CIRCULATION
SubjectiveHistory of hypertension: (+) Paternal Heart trouble: NoneAnkle/leg edema: Present; Facial and bipedal Slow healing: PresentClaudication: (+) Left lower leg Cough/hemoptysis: NoneExtremities: Numbness: (+) Left lower leg Tingling: (+) Left lower legChange in frequency/amount of urine: NoneOthers/Comments:
“High blood man ang akong papa,” as verbalized by the patient.
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“Karon pajud ko nasamad nga ingon ani dayon pagmasamad ko dugay2x pud siya maayo” as verbalized by the patient.
“Katong mang-gahi akong mga tudlo kada panglaba nako, ako ra man pud silang ibalik… dili na kinahanglan iingon sa doctor.”, as verbalized by the patient.
“Nanghupong man ko adtong pagka-admit nako. Dani sa akong nawong og tiil. Naa pa gani sya hantud karun,” as verbalized by the patient.
“Init akong paminaw. Tan-awa daw kung gihilantan ba ko,” as verbalized by the patient.
Vascular Bruit: None Breath Sounds: BronchovesicularJugular Vein Distention: NoneExtremities: Temperature: warm to touchColor: Normal skin color of patient: DarkCapillary Refill: Immediate return of color(less than 2 secs.) Homan’s sign: NoneVaricosities: NoneColor/Cyanosis: Nail beds: Pale Lips: Dry, pinkishMucous membranes: Moist, pinkishSclera: slightly yellowish sclera, capillaries sometimes evidentOthers/Comments: Patient has normal sinus rhythm; noted facial and bipedal edema is only mild which makes the pulses palpable.
IV - EGO INTEGRITY
SubjectiveReport of Stress Factors: Physically and emotionally stressed due to conditionWays of handling stress: Rest, patient also wants to be alone Financial Concerns: Present, always a problem felt by the familyRelationship Status: Married; Husband is very supportive and caring to the patient
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Lifestyle: Patient does not smoke, does not practice alcohol and substance abuse; however, she does not practice exercise and safety measures. Recent changes: Patient is in bed and can’t perform usual activities independently due to pain experienced at left lower legFeelings of: Helplessness: None Hopelessness: None
Powerlessness: None
Other/Comments:
“ Gaka-guol jud ko mapangit najud ko ug samot, Dili na gani ko ganahan mag tan-aw sa samin kay mga rashes ra nako ako gakakit-an’” as verbalized by the patient.
“Gusto ko ako ra isa dili ko ganahan makit-an sa uban na inani akong nawong Sakit pud akong tiil maypag magpuyo, arang2x pa kung ako nalang isa.” as verbalized by the patient.
“Dili man ko gakawad-an ug pag-asa kay o.k raman ko” as verbalized by the patient.
“Akong bana ra gyud ang gabantay sa ako karon kay akong mga ginikanan layo, naa sa Medina”, as verbalized by the patient.
ObjectiveEmotional status (Check those that apply)
Observed physiologic response: Response and behavior are appropriateOthers/Comments: Patient is very cooperative.
V – ELIMINATION
SubjectiveUsual Bowel Pattern: Every morning before breakfastCharacter of Stool: Soft, formed, yellowish brown in color, aromatic and moderate in amount Last BM: 06:30 AM (Feb. 15, 2009) Laxative use: none History of bleeding: None Hemorrhoids: None Constipation: None Diarrhea: None Usual voiding pattern: 8x a day; scanty in amount Incontinence: None Urgency: None Retention: None Frequency: (+) Pain/Burning/Difficulty in voiding: NoneHistory of kidney/bladder disease: (+), diagnosed with Lupus Nephritis by Dr. Saavedra Last January 12, 2009
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Others/Comments:“Ok man akong pagkalibang, kas-a ra jud ko sa isa ka adlaw malibang” as verbalized by the patient.
“Dili man jud ko palainom of tubig pero sige lang gihapon ko og ihi-ihi2x. Sa isa ka adlaw mga ka-siyam siguro ko gapangihi,” as verbalized by the patient.
Bladder palpable: Not palpable Distended: No distentionOthers/Comments: Urinary elimination is altered. Patient has urinary frequency with scanty amount of urine.
VI - FOOD/FLUID
SubjectiveUsual diet (type): DAT Number of meals daily: 3 meals a dayLast meal/intake: Lunch (12:00nn)(Feb. 15, 2009) Loss of appetite: (+) sometimesNausea/Vomiting: None Dentures: 4 in lower front teethAllergy/Food intolerance: (+) Crabs and shrimpHeartburn/Indigestion: (+)Mastication/swallowing problems: NoneUsual Weight: 65 Kg Changes in weight: Increased-70kgDiuretic use: NoneOthers/Comments:
“Mahilig jud ko ug karne labin nag baboy. Usahay pag walay kwarta, isda
nalang. Dili kayo ko hingaon ug gulay, makabuot man pud ko kay ako man ang galuto. Dili pud kaau ko makakaon ug prutas kay wala may kwarta”as verbalized by the patient.
“Dili pud ko mahilig ug gatas, Kape nuon kaisa sa usa ka adlaw. Usahay pud juice kung wala jud, tubig akong ga.imnon” as verbalized by the patient.
“Niniwang jud ko sauna kay dili naman kaayo ko gakaon. Sauna pud, katong wala pa ko nagsugod ug tumar sa tambal, pait akong baba dli ko kasabot murag taya, ambot basta murag ingana. Mawala raman pud pag tootbrushan pero mubalik napud mao na di kaau ko ganahan magkaon kay pait jud akong paminaw” as verbalized by the patient.
“Kabuhion jud ko usahay labon na kung mapasmo ko unya mokaon dayon diretso” as verbalized by the patient.
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“Nanghupong man ko adtong pagka-admit nako. Dani sa akong nawong og tiil. Naa pa gani sya hantud karun,” as verbalized by the patient.
ObjectiveCurrent Weight:70 kg Height: 5’4”Body Build: Round and plumpSkin Turgor: Good Mucous membranes: Moist, pinkishHernia/Mass: NoneEdema: General: None Dependent: None
Periorbital: None Ascites: NoneThyroid enlarged: Not enlarged Halitosis: NoneCondition of teeth/gums: With 28 adult teeth and four false teeth; smooth yellowish tooth enamel; presence of plaque and cavities in the molars; gums are pink and moist; no bleeding notedAppearance of tongue: Pink and moist with thin whitish coating; slightly rough with raised papillaeOthers/Comments: Patient has Facial and Bipedal edema; BMI= overweight- 26.7
VII – HYGIENE
SubjectiveActivities of Daily Living (Dependent/Independent)
Pls. encircle Mobility: D / I Feeding: D / IHygiene: D / I Dressing: D / IToileting: D / I
Others: NoneEquipment/prosthetic devices required: NoneAssistance provided by: Husband and sonOthers/Comments:
“Galisod jud ko ug lakaw unya mahadlok pud ko musakit ug samot akong tiil mao nang gapatabang ko sa akong bana sa pag.cr” as verbalized by the patient.
ObjectiveGeneral Appearance: Patient is dressed in clean pair of shorts and shirt, has unkempt hair; skin on extremities look dry and clean with wound dressing at left lower leg, face has butterfly rash that has darkened the skin on the bridge of the nose and around patient’s cheeks.Manner of dress: Appropriate for age Personal Habits: Takes a bath once a dayBody odor: None Condition of scalp: Dry, with flakingPresence of vermin: (+) Others/Comments: Patient appears neat except for her unkempt hair. Patient also has pediculosis upon inspection.
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VIII – NEUROSENSORY
SubjectiveFainting Spells/dizziness: NoneHeadache: Location: Temporal areaOnset: Occurs suddenlyFrequency: unpredictableSeizures: None Aura: N/A How controlled: N/AEyes: Vision Loss: R: 120+ L: 120+Last examination: around November of 2008
Glaucoma None Cataract: NoneEars: Hearing Loss R: None L: None Last examination: not examinedSense of smell: No problem reported Epistaxis: NoneOthers/Comments:
“Ang sakit sa akong ulo kay kalit lang mutukar. Mawala ra siya pag akong ipahulay. Dili pud ko gatumar ug tambal kung musakit akong ulo” as verbalized by the patient.
Affect: Appropriate Delusions: None Hallucinations: NoneMemory: Recent: Good: Able to recall last meal intakeRemote: Good: Able to recall onset of signs and symptoms of existing diseaseSpeech pattern: Spontaneous Congruence: CongruentGlasses: None Contacts: None Hearing Aids: NonePupil size/reaction: R: PERRLA – 2mm L: PERRLA – 2mmFacial droop: None Swallowing: Good: No problems with swallowingHandgrip/release: R: Strong L: StrongPosturing: Slouched DTR: normal - +2 Paralysis: NoneOthers/Comments: Patient is active, coherent and cooperative.
IX – PAIN
SubjectiveOnset: Patient started to feel pain in early February of 2009. Since then pain wasn’t relieved Duration: Pain is always presentLocation: at the left lower leg Intensity: Pain score of 6 with 10 as the highestFrequency: Pain is always present Quality: BearableDescription of Pain (check all that apply)
Precipitating Factors: Lesions in lower left leg Aggravating Factors: Exerting pressure on left lower leg such as upon movement and contact with a surface. How relieved: Slowed movement and placing of cold packs around the painful area Associated Symptoms: Headache
Others/Comments:“Tulo mani ka burot, isa ka dako ug duha ka gagmay, sa pagka-admit nako dani nibuto ni ang pinakadako. Sukad sa pagkasamad nako ani nga burot sobra kasakit jud akong gibati unya dili gakawala ang sakit” as verbalized by the patient.
“Dili ko ganahan mag-lihok2x kay musakit ug samot akong tiil. Pagmusakit akong tiil musakit pud akong ulo”, as verbalized by the patient.
“Akong gabutangan ug botelya na naai bugnaw na tubig ang ibabaw sa akong samad aron mahubsan ang ka-sakit,” as verbalized by client.
Objective(Check all that apply)____Grimacing ____ Being Irritable____Moaning ____ Sitting Rigidly(√) Sighing (√) Moving very slowly(√) Limping ____ Clenching Teeth(√) Avoiding Physical Activity ____ Narrowed focus(√) Lying down during the day(√) Requesting help with walking(√) Walking with an abnormal gait(√) Stopping frequently while walking____ Frequently shifting posture or position(√) Moving in a guarded or protective manner ____Holding or supporting the painful body area____ Asking to be relieved from tasks or activities____ Asking such questions as “Why did this happen to me?”____ Using a cane, cervical collar, or other prosthetic
Others/Comments: Patient is able to tolerate pain.
Smoker: No Pack/day: N/A Number of years: N/AUse of respiratory aids: None Oxygen: None
Others/Comments:“Dili ko gapanigarilyo. Wala jud koy problema sa akong pag-ginhawa, Pero sa
among balay gapanigarilyo akong magulang, dugay2x pud ko na-expose adto kay sugod 14 hantod 19 years old man ko adto.” as verbalized by the patient.
ObjectiveRespiratory: Rate: 19 cpm Depth: Deep Symmetry: Symmetrical
Use of accessory muscle: None Nasal Flaring: NoneFremitus: Present Breath sounds: BronchovesicularCyanosis: None Clubbing of fingers: NoneSputum characteristics: N/AMentation/restlessness: NoneOthers/Comments: Patients had no observable signs of respiratory problems.
Respiration rate and rhythm is within normal range.
XI – SAFETY
SubjectiveAllergies/sensitivity: Crabs and shrimpReaction: Facial Redness and warmthHistory of STD (date/type): NoneBlood transfusion/number: None When: N/AHistory of Accidental injuries: NoneFractures/dislocations: NoneArthritis/unstable joints: NoneBack problems: NoneChanges in moles: None Enlarged nodes: NoneProsthesis: None Ambulatory devices: NoneExpression of ideation of violence (self/others): Patient is non violent toOthers/ comments:
“Allergic ko sa alimango ug uwang, kung makakaon ko mamula akong nawong unya manginit” as verbalized by the patient.
Objective:Temperature: 37 C Diaphoresis: NoneSkin integrity: Dry but not intact at left lower leg; wound dressing presentScars: Light scars present in both legs and arms
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Rashes: Presence of butterfly rash in the face (across the bridge of the nose and the cheeks)Lacerations: NoneUlcerations: None Ecchymosis: None Blisters: NoneBurns, degree/percent: NoneDrainage (note location): NoneGeneral Strength: Patient is able to do daily activities but with some limitations in movement due to pain felt at left lower leg; weakness is only noted when patient experiences fever Muscle tone: goodGait: Abnormal-Limping Paresthesia/Paralysis: NoneOthers/Comments: Patient has an abnormal gait due to pain in the left lower leg.
XII – SEXUALITY
Sexually active: Not at the momentSexual concerns/difficulties: Unsatisfactory coitus due to pain felt in the lower
extremityRecent change in frequency/interest: minimal sexual interaction
SubjectiveAge of menarche: 14 y.o.Length of cycle: irregular (ranging from 28 -60 days) Duration: 5 daysLast menstrual period: Jan. 15, 2009 Menopause: N/AVaginal discharge: LeukorrheaBleeding between periods: NoneDeliveries/Pregnancies: G 1 P 1 T 1 P 0 A 0 L 1Episiotomy: mediolateral (towards right side) Lochia: NoneComplications of pregnancy: None Surgeries: NoneHormonal therapy/calcium use: Use of Calcium supplement for almost a month (Jan 15- Feb 5 2009) as prescribed by Dr. GabatanPractices self-breast examination: No Discharges: NoneLast Pap smear: Never Method of birth control: NoneOthers/Comments:
“Adtong mi-aging tuig ka lima ko wala nag mens. Tagsa ka bulan ang biya, natingala jud ko.” as verbalized by the patient.“Wala pa jud ko sukad naka pa pap smear”, as verbalized by the patient.
ObjectiveExamination:Genitals: Not assessed due to patient’s refusal and lack of privacy. Patient verbalized that her genitals are normal.Breasts: Breasts are saggy, slightly unequal in size; skin smooth and intact; no tenderness, masses or nodulesVaginal warts/lesions: None
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Others/Comments: No discharges from the breast were noted.
XIII - SOCIAL INTERACTIONS
SubjectiveMarital status: Married Years in relationship: 6 yearsLiving with: Husband and sonConcerns/stresses: Financial concerns for needs and wantsExtended family: NoneOther Support Persons: None Role within family structure: Full time housewife and motherReport of problems related to illness/condition: Painful left lower leg and presence of butterfly rash on the face hinders social interaction thus, patient wants to be alone.Others/Comments:
“Dili nako ganahan na mag.gawas2x sa balay kai pangit na kaau ko ” as verbalized by the patient.
“Gusto ko ako ra isa dili ko ganahan makit-an sa uban na inani akong nawong Sakit pud akong tiil maypag magpuyo, arang2x pa kung ako nalang isa.” as verbalized by the patient.
ObjectiveSpeech: (√) Clear ____Slurred
____Unintelligible ____ AphasicOthers/Comments: Patient is very accommodating and cooperative.
XIV - TEACHING/LEARNING
SubjectiveDominant Language (specify): Visayan Literate: (√)Educational Level: 3 rd year High School Health beliefs/practices: Seeks herbal meds rather than medical advice; does not report all felt signs and symptoms to the doctor; does not take the existing condition seriously due to lack of knowledge regarding the disease. Familial risk factors (check all that apply & indicate relationship):
(√) Diabetes Paternal____Tuberculosis ___________ Heart Disease _______ Stroke _______ (√) High BP Paternal____ Epilepsy ___________ Kidney Disease _______ Cancer ___________ Mental Illness _______
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Use of Alcohol (amount/frequency): No Others/Comments:
“Mas ganahan jud ko ug herbal2x sa kaysa sa tambal jud” as verbalized by the patient. “Wala na sad ko nag ingon sa doctor atong nangalarot akong buhok kai ok ra man pud to nako. Wala ra kayo ko nahadlok ato.”, as verbalized by the patient “Akong papa kay diabetic man to unya high blood pa jud” as verbalized by the patient.
XV - Body Map: (Illustrate in the body map how your patient looks like, e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, affected areas. Mark with a small “X” where it is located or draw it on the body map and then label it in the space provided.)
Date: February 15,2009
xx General Appearance: x Headache: Temporal area
Yellowish Sclera Butterfly Rash
Vission loss: +120 OU
Dry lips
Pale nailbeds Use of Diaper
IVF#6- D5 0.3%NaCl @KVO rate
Wound dressing Skin is reddened,swollen &
warm Pain score=6(10as
highest) Cracked heels
Moving slowly while supporting Painful area
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X
X
XX X
Date: February 17, 2009 xx General Appearance: x Headache: Temporal area
Yellowish Sclera Butterfly Rash
Vission loss: +120 OU
Dry lipsIVF#8- D5 0.3%NaCl @KVO rate
Pale nailbeds
Venipuncture with dry cottonball
Use of diaper
Wound dressing Skin is reddened,swollen &
warm Pain score=6(10as
highest) Moving slowly while supporting Painful area
Cracked heels
Date: February 19, 2009
xx General Appearance: x Headache: Temporal area
Yellowish Sclera Butterfly Rash
Vission loss: +120 OU
Dry lipsIVF#9- D5 0.3%NaCl @KVO rate
Pale nailbeds
Venipuncture with dry cottonball
Use of Diaper
Wound dressing
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X
X
X
X X
X
X
X X
Skin with reduced redness & swelling
warm;Pain score=5(with10 as
highest) Cracked heels
Moving slowly while supporting Painful area
Date: February 20, 2009
xx General Appearance: x Headache: Temporal area
Yellowish Sclera Butterfly Rash
Vission loss: +120 OU
Dry lips IVF#10- D5 0.3%NaCl KVO
Pale nailbeds
Venipuncture with dry cottonball
Wound dressing Skin with reduced redness &
swellingwarm; Pain=4(with10as highest) Moving slowly while supporting Painful areaCracked heels
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X
X
X X
X
B. DIAGNOSTICS AND LAB RESULTS
I. LATEST LAB RESULTS
URINALYSIS (February 20, 2009)
Color Yellow NormalTransparency Slightly Hazy NormalProtein ++++ Proteinuria due to patient’s
lupus nephritis.pH 6.0 NormalSpecific Gravity 1.030 NormalPus Cells >50/hpf May reveal some
destructive or healing process in the urinary tract anywhere from the kidney to the bladder.
RBC 13-15/hpf Can be due to infection, trauma or any kidney disease that alters its permeability.
Squamous Moderate NormalBacteria Few NormalMucus thread Few Normal
FBS 98.0 NormalCreatinine in Serum 0.6 NormalSodium 133.9 Hyponatremia which can be
manifested through nausea, vomiting, headache and malaise.
Potassium 3.7 Normal
HEMATOLOGY (February 11, 2009)
Hematocrit 38.0% NormalHemaglobin 12.7% NormalFBS 98.0 NormalCreatinine in Serum 0.6 NormalSodium 133.9 Hyponatremia which can be
manifested through nausea,vomiting, headache and malaise.
Potassium 3.7 Normal
HEMATOLOGY (February 10, 2009)
Hematocrit 38.0% NormalHemoglobin 12.7% NormalWBC Count 17,000 Leukocytosis due to
inflammation, bacterial infection, trauma and stress.
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Differential Count:Segmenters 86% NormalLymphocytes 14% NormalPlatelet Count 350,000 NormalESR 110.0 mm/hr A very high ESR usually
has an obvious cause, such as a marked increase in globulins that can be due to a severe infection. A rising ESR can mean an increase in the inflammation or a poor response to a therapy.
ECG RESULT (February 10, 2009)
NAME: Patient X ID NUM.: 219406AGE: 25 years old SPEED: 25mm/secSEX: Female DATE: Feb. 10, 2009REQUESTING PHYSICIAN: Dr. Gabatan PERFORMED BY: Therese Beth Akut
(Refer to appendix D-Figure 1)
II. PREVIOUS LAB RESULTS:
URINALYSIS (January 26, 2009)
Color Dark Yellow Concentrated urine can be due to dehydration.
Transparency Cloudy Indicative of infection and stasis of urine.
Protein ++++ Proteinuria may be due to patient’s lupus nephritis or any other disease involving the kidneys.
Sugar Negative NormalpH 6.5 NormalSpecific Gravity 1.020 NormalPus Cells 50 > TNTC Infection present.RBC 3-8/hpf Can be due to infection,
trauma or any kidney disease that alters its permeability.
Squamous Abundant Acute tubular necrosis may be present with the
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infection.Bacteria Abundant Infection is present in the
urinary tract.
HEMATOLOGY (January 25, 2009)
Hematocrit 42.5% NormalHemoglobin 14.2 gm/dL NormalWBC Count 13,700 Leukocytosis due to
inflammation, bacterial infection, trauma and stress.
Differential Count:Segmenters 90% Infection presentLymphocytes 10% Indicative of immune
deficiency that decreases T-lymphocytes.
Platelet Count 346,600 NormalESR 99.0 mm/hr A very high ESR usually
has an obvious cause, such as a marked increase in globulins that can be due to a severe infection.
Segmenters 72% NormalLymphocytes 27% NormalPlatelet Count 240,000 NormalESR 74 mm/hr A very high ESR usually
has an obvious cause, such as a marked increase in globulins that can be due to a severe infection.
URINALYSIS (November 19, 2008)
Color Yellow NormalTransparency Hazy Indicative of infection and
stasis.Protein +++ Proteinuria may be due to
patient’s lupus nephritis or any other disease involving the kidneys.
Sugar Negative NormalpH 6.0 NormalSpecific Gravity 1.030 NormalPus Cells 6-10/hpf Infection present.RBC 3-5/hpf Can be due to infection,
trauma or any kidney disease that alters its permeability.
Squamous Abundant Acute tubular necrosis may be present with the infection.
Bacteria Few Infection is present in the urinary tract.
Mucus Thread Few Normal
CRP RESULT (September 25, 2008)
NAME: Patient X ID NUM.: 214906AGE: 24 years old DATE: Sept. 25, 2008SEX: Female: RESULT: Negative
25
INTERPRETATION:
ECG RESULT (September 25, 2008)
NAME: Patient X ID NUM.: 219406AGE: 24 years old SPEED: 25mm/secSEX: Female DATE: Sept. 25, 2009REQUESTING PHYSICIAN: Dr. Gabatan PERFORMED BY: Chona Giputa
(Refer to Appendix D- Figure 2)
URINALYSIS (September 25, 2008)
Color Yellow NormalTransparency Turbid Bacterial infection present.Protein ++++ Proteinuria due to patient’s
lupus nephritis.Sugar Negative NormalpH 6.0 NormalSpecific Gravity 1.020 NormalPus Cells >50 TNTC May reveal some
destructive or healing process in the urinary tract anywhere from the kidney to the bladder.
RBC 1-3/hpf NormalSquamous Moderate NormalBacteria Few Infection is present.
BLOOD CHEMISTRY (September 25, 2008)
FBS 80.1 NormalCreatinine in Serum 0.8 NormalBlood Uric Acid 4.1 NormalAlbumin 2.2 Low albumin level can
suggest conditions in which the body does not absorb or digest protein or in which large amount of proteins
26
are lost from the intestines.Alkaline Phosphatase 144.7 NormalSGOT 60.9 SGOT increase can be due
to liver damage due to medications, trauma and diseases.
Platelet Count 215,000 NormalESR 93 mm/hr A very high ESR usually
has an obvious cause, such as a marked increase in globulins that can be due to a severe infection.
ANA DETERMINATION (April 21, 2008)
RESULT: Positive (++++) TITER: 1:80PATTERN: Homogenous Pattern PredominatingINTERPRETATION: Result indicates that the person is positive with SLE (Systemic Lupus Erythromatosus
27
). A titer of 1:80 is considered a low-positive and the homogenous pattern is most often seen in patients with SLE.
ANATOMY AND PHYSIOLOGY
SKIN
The skin is the outer covering of the body, also known as the epidermis. It is the largest organ of the integumentary system made up of multiple layers of epithelial tissues, and guards the underlying muscles, bones, ligaments and organs. The adjective cutaneous literally means "of the skin".
Because it interfaces with the environment, skin plays a very important role in protecting (the body) against pathogens. Its other functions are insulation, temperature regulation, sensation, synthesis of vitamin D, and the protection of vitamin B folates. Severely damaged skin will try to heal by forming scar tissue. This is often discolored and depigmented.
Skin has pigmentation, or melanin, provided by melanocytes, which absorb some of the potentially dangerous ultraviolet radiation (UV) in sunlight. It also contains DNA-repair enzymes that help reverse UV damage, and people who lack the genes for these enzymes suffer high rates of skin cancer. One form predominantly produced by UV light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can
often be deadly. Human skin pigmentation varies among populations in a striking manner. This has led to the classification of people(s) on the basis of skin color.
The skin serves as a protection, an anatomical barrier from pathogens and damage between the internal and external environment in bodily defense; sensation, contains a variety of nerve endings that react to heat and cold, touch, pressure, vibration, and tissue injury; heat regulation, the skin contains a blood supply far greater than its requirements which allows precise control of energy loss by radiation, convection and conduction. Dilated blood vessels increase perfusion and heat loss while constricted vessels greatly reduce cutaneous blood flow and conserve heat; control of evaporation, the skin provides a relatively dry and impermeable barrier to fluid loss. Loss of this function contributes to the massive fluid loss in burns; aesthetics and communication, others see our skin and can assess our mood, physical state and attractiveness; storage and synthesis, acts as a storage center for lipids and water, as well as a means of synthesis of vitamin D by action of UV on certain parts of the skin.; excretion, sweat contains urea, however its concentration is 1/130th that of urine, hence excretion by sweating is at most a secondary function to temperature regulation; absorption, oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in small amounts, some animals using their skin for their sole respiration organ. In addition, medicine can be administered through the skin, by ointments or by means of adhesive patch, such as the nicotine patch or iontophoresis. The skin is an important site of transport in many other organisms; water resistance, the skin acts as a water resistant barrier so essential nutrients aren't washed out of the body.
LYMPH NODE
A Lymph node is an organ consisting of many types of cells, and is a part of the lymphatic system. Lymph nodes are found all through the body, and act as filters or traps for foreign particles. They contain white blood cells. Thus they are important in the proper functioning of the immune system.
Lymph nodes also have clinical significance. They become inflamed or enlarged in various conditions, which may range from trivial, such as a throat infection, to life-threatening such as cancers. In the latter, the condition of lymph nodes is so significant that it is used for cancer staging, which decides the treatment modalities to be employed, and for determining the prognosis.
Lymph nodes can also be diagnosed by biopsy whenever they are inflamed. Certain diseases affect lymph nodes with characteristic consistency and location.
Pathogens can set up infections anywhere in the body. However, lymphocytes will meet the antigens in the peripheral lymphoid organs, which include lymph nodes. The antigens are displayed by specialized cells in the lymph nodes. Naive lymphocytes (meaning the cells have not encountered an antigen yet) enter the node from the bloodstream through specialized capillary venules. After the lymphocytes specialize they will exit the lymph node through the efferent lymphatic vessel with the rest of the lymph. The lymphocytes continuously recirculate the peripheral lymphoid organs and the state of the lymph nodes depends on infection. During an infection, the lymph nodes can expand due to intense B-cell proliferation in the germinal centers, a condition commonly referred to as "swollen glands".
WHITE BLOOD CELL
White blood cells, or leukocytes, are cells of the immune system defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found throughout the body, including the blood and lymphatic system
The number of leukocytes in the blood is often an indicator of disease. There are normally between 4×109 and 11×109 white blood cells in a litre of blood, making up approximately 1% of blood in a healthy adult. In conditions such as leukemia, the number of leukocytes is higher than normal, and in leukopenia, this number is much lower. The physical properties of leukocytes, such as volume, conductivity, and granularity, may change due to activation, the presence of immature cells, or the presence of malignant leukocytes in leukemia.
KIDNEYSThe kidneys are organs that have numerous biological roles. Their primary role is
to maintain the homeostatic balance of bodily fluids by filtering and secreting metabolites (such as urea) and minerals from the blood and excreting them, along with water, as urine. Because the kidneys are poised to sense plasma concentrations of ions such as sodium, potassium, hydrogen, oxygen, and compounds such as amino acids, creatinine, bicarbonate, and glucose, they are important regulators of blood pressure, glucose metabolism, and erythropoiesis (the process by which red blood cells (erythrocytes) are produced). The medical field that studies the kidneys and diseases of the kidney is called nephrology.
In humans, the kidneys are located in the posterior part of the abdominal cavity. There are two, one on each side of the spine; the right kidney sits just below the diaphragm and posterior to the liver, the left below the diaphragm and posterior to the spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right kidney being slightly lower than the left one while the left kidney is located slightly more medial. The bulk of water re-absorption in the vertebrate kidney takes place in the loop of Henle.
The kidneys are retroperitoneal and range from 9 to 13 cm in diameter; the left slightly larger than the right. They are approximately at the vertebral level T12 to L3. The upper parts of the kidneys are partially protected by the eleventh and twelfth ribs, and each whole kidney and adrenal gland are surrounded by two layers of fat (the perirenal and pararenal fat) and the renal fascia which help to cushion it. Congenital absence of one or both kidneys, known as unilateral (on one side) or bilateral (on both the sides) renal agenesis, can occur. Renal agenesis is also the base for the renal anal gland which helps the large intestine absorb water.
The kidneys receive unfiltered blood directly from the heart through the abdominal aorta which then branches to the left and right renal arteries. Filtered blood then returns by the left and right renal veins to the inferior vena cava and then the heart. Renal blood flow accounts for 20-25% of the cardiac output.
Blood Filtering
The renal corpuscle is the site of the nephron, where blood is "filtered".
The blood enters the kidney through the renal artery in the renal sinus. It branches into segmental arteries, which further divide into interlobar arteries penetrating the renal capsule and extending through the renal columns between the renal pyramids. The interlobar arteries then supply blood to the arcuate arteries that run through the boundary of the cortex and the medulla. Each arcuate artery supplies a variety of additional interlobar arteries that feed into the afferent arterioles to be filtered through the nephrons. After filtration occurs the blood moves through a small network of venules that converge into interlobar veins. As with the arteriole distribution the veins follow the same pattern, the interlobar provide blood to the arcuate veins then back to the interlobar veins which come to form the renal vein exiting the kidney for transfusion for blood.
Blood filtering takes place in the (nephron), which is found in the kidney.
Excretion of waste products
The kidneys excrete a variety of waste products produced by metabolism, including the nitrogenous wastes: urea (from protein catabolism) and uric acid (from nucleic acid metabolism) and water.
The kidney is one of the major organs involved in whole-body homeostasis. Among its homeostatic functions are acid-base balance, regulation of electrolyte concentrations, control of blood volume, and regulation of blood pressure. The kidneys accomplish these homeostatic functions independently and through coordination with other organs, particularly those of the endocrine system. The kidney communicates with these organs through hormones secreted into the bloodstream.
Acid-base balance
The kidneys regulate the pH of blood by adjusting H+ ion levels, referred as augmentation of mineral ion concentration, as well as water composition of the blood.
Blood pressure
Sodium ions are controlled in a homeostatic process involving aldosterone which increases sodium ion reabsorption in the distal convoluted tubules.
Plasma volume
Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. A rise in osmolality causes the gland to secrete antidiuretic hormone, resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels.
ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane allowing water to leave the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the body.
There are two systems that create a hyperosmotic medulla and thus increase the body plasma volume: Urea recycling and the 'single effect.'
Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not.
The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not permeable to water but is permeable to NaCl. This means that a countercurrent system is created whereby the medulla becomes increasingly concentrated setting up a osmotic gradient for water to follow should the aquaporins of the collecting duct be opened by ADH.
Hormone secretionThe kidneys secrete a variety of hormones. Erythropoietin is released in
response to low levels of O2 in the renal circulation. It stimulates erythrocyte production in red bone marrow. Renin is involved in the regulation of aldosterone secretion by the renin-angiotensin-aldosterone system. Calcitriol, the activated form of vitamin D, promotes the absorption of Ca2+ from the blood and the excretion of PO32-. They both help to increase Ca2+ levels.
NEPHRON
Nephron is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.In humans, a normal kidney contains 800,000 to one million nephrons.
Two general classes of nephrons are cortical nephrons and juxtamedullary nephrons, both of which are classified according to the location of their associated renal corpuscle. Cortical nephrons have their renal corpuscle in the superficial renal cortex, while the renal corpuscles of juxtamedullary nephrons are located near the renal medulla. The nomenclature for cortical nephrons varies, with some sources distinguishing between superficial cortical nephrons and midcortical nephrons;
Each nephron is composed of an initial filtering component (the "renal corpuscle") and a tubule specialized for reabsorption and secretion (the "renal tubule"). The renal corpuscle filters out large solutes from the blood, delivering water and small solutes to the renal tubule for modification.Renal corpuscle
Composed of a glomerulus and Bowman's capsule, the renal corpuscle (or Malpighian corpuscle) is the beginning of the nephron. It is the nephron's initial filtering component.
The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. The glomerular blood pressure provides the driving force for water and solutes to be filtered out of the blood and into the space made by Bowman's capsule. The remainder of the blood (only approximately 1/5 of all plasma passing through the kidney is filtered through the glomerular wall into Bowman's capsule) passes into the narrower efferent arteriole. It then moves into the vasa recta, which are collecting capillaries intertwined with the convoluted tubules through the interstitial space, in which the reabsorbed substances will also enter. This then combines with efferent venules from other nephrons into the renal vein, and rejoins the main bloodstream.
The Bowman capsule, also called the glomerular capsule, surrounds the glomerulus. It is composed of a visceral inner layer formed by specialized cells called podocytes, and a parietal outer layer composed of a single layer of flat cells called simple squamous epithelium. Fluids from blood in the glomerulus are filtered through the visceral layer of podocytes, and the resulting glomerular filtrate is further processed along the nephron to form urine.
Renal tubule
The renal tubule is the portion of the nephron containing the tubular fluid filtered through the glomerulus. After passing through the renal tubule, the filtrate continues to the collecting duct system, which is not part of the nephron.
The components of the renal tubule are: proximal tubule, loop of Henle (descending limb of loop of Henle and ascending limb of loop of Henle), and distal convoluted tubule.
The nephron carries out nearly all of the kidney's functions. Most of these functions concern the reabsorption and secretion of various solutes such as ions (eg, sodium), carbohydrates (eg, glucose), and amino acids (eg, glutamate). Properties of the cells that line the nephron change dramatically along its length; consequently, each segment of the nephron has highly specialized functions.
The proximal tubule as a part of the nephron can be divided into an initial convoluted portion and a following straight (descending) portion. Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily glucose and amino acids).
The loop of Henle, also called the nephron loop, is a U-shaped tube that extends from the proximal tubule. It consists of a descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal straight tubule, extends into the medulla as the descending limb, and then returns to the cortex as the ascending limb to empty into the distal convoluted tubule. The primary role of the loop of Henle is to concentrate the salt in the interstitium, the tissue surrounding the loop.
Considerable differences distinguish the descending and ascending limbs of the loop of Henle. The descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs.
Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic filtrate is passed to the distal convoluted tubule in the renal cortex.
The distal convoluted tubule has a different structure and function to that of the proximal convoluted tubule. Cells lining the tubule have numerous mitochondria to produce enough energy (ATP) for active transport to take place. Much of the ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the tubule also secernates hydrogen and ammonium to regulate the pH.
After traveling the length of the distal convoluted tubule, only about 1% of water remains, and the remaining salt content is negligible.
Each distal convoluted tubule delivers its filtrate to a system of collecting ducts, the first segment of which is the collecting tubule. The collecting duct system begins in the renal cortex and extends deep into the medulla. As the urine travels down the collecting duct system, it passes by the medullary interstitium which has a high sodium concentration as a result of the loop of Henle's countercurrent multiplier system.
Though the collecting duct is normally impermeable to water, it becomes permeable in the presence of antidiuretic hormone (ADH). ADH affects the function of aquaporins, resulting in the reabsorption of water molecules as it passes through the collecting duct. Aquaporins are membrane proteins that selectively conduct water molecules while preventing the passage of ions and other solutes. As much as three-fourths of the water from urine can be reabsorbed as it leaves the collecting duct by osmosis. Thus the levels of ADH determine whether urine will be concentrated or diluted. An increase in ADH is an indication of dehydration, while water sufficiency results in low ADH allowing for diluted urine.
Lower portions of the collecting duct are also permeable to urea, allowing some of it to enter the medulla of the kidney, thus maintaining its high concentration (which is very important for the nephron).
Urine leaves the medullary collecting ducts through the renal papillae, emptying into the renal calyces, the renal pelvis, and finally into the urinary bladder via the ureter.
Because it has a different origin during the development of the urinary and reproductive organs than the rest of the nephron, the collecting duct is sometimes not considered a part of the nephron. Instead of originating from the metanephrogenic blastema, the collecting duct originates from the ureteric bud.
Juxtaglomerular apparatus
The juxtaglomerular apparatus is a specialized region of the nephron responsible for production and secretion of the hormone renin, involved in the renin-angiotensin system. This apparatus occurs near the site of contact between the thick ascending limb and the afferent arteriole. It contains three components: the macula densa, juxtaglomerular cells, and extraglomerular mesangial cells.
Because of its importance in body fluid regulation, the nephron is a common target of drugs that treat high blood pressure and edema. These drugs, called diuretics, inhibit the ability of the nephron to retain water, thereby increasing the amount of urine produced.
The heart is a muscular organ in all vertebrates responsible for pumping blood through the blood vessels by repeated, rhythmic contractions, or a similar structure annelids, mollusks, and arthropods.
The heart of a vertebrate is composed of cardiac muscle, an involuntary muscle tissue which is found only within this organ. The average human heart, beating at 72 beats per minute, will beat approximately 2.5 billion times during a lifetime (about 66 years). It weighs on average 250 g to 300 g in females and 300 g to 350 g in males.
In animals, the function of the right side of the heart is to collect de-oxygenated blood, in the right atrium, from the body (via superior and inferior vena cavae) and pump it, via the right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas exchange). This happens through the passive process of diffusion. The left side collects oxygenated blood from the lungs into the left atrium. From the left atrium the blood moves to the left ventricle which pumps it out to the body (via the aorta). On both sides, the lower ventricles are thicker and stronger than the upper atria. The muscle wall surrounding the left ventricle is thicker than the wall surrounding the right ventricle due to the higher force needed to pump the blood through the systemic circulation.
Starting in the right atrium, the blood flows through the tricuspid valve to the right ventricle. Here it is pumped out the pulmonary semilunar valve and travels through the pulmonary artery to the lungs. From there, blood flows back through the pulmonary vein to the left atrium. It then travels through the mitral valve to the left ventricle, from where it is pumped through the aortic semilunar valve to the aorta. The aorta forks and the blood are divided between major arteries which supply the upper and lower body. The blood travels in the arteries to the smaller arterioles, then finally to the tiny capillaries which feed each cell. The (relatively) deoxygenated blood then travels to the venules, which coalesce into veins, then to the inferior and superior venae cavae and finally back to the right atrium where the process began.
The heart is effectively a syncytium, a meshwork of cardiac muscle cells interconnected by contiguous cytoplasmic bridges. This relates to electrical stimulation of one cell spreading to neighboring cells.
MUCOUS MEMBRANE
The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line various body cavities that are exposed to the external environment and internal organs. It is at several places continuous with skin: at the nostrils, the lips, the ears, the genital area, and the anus. The sticky, thick fluid secreted by the mucous membranes and gland is termed mucus. The term mucous membrane refers to where they are found in the body and not every mucous membrane secretes mucus.
The oral mucosa is the mucous membrane epithelium of the mouth. It can be divided into three categories. Masticatory mucosa is a keratinized stratified squamous epithelium, found on the dorsum of the tongue, hard palate and attached gingiva. Lining mucosa is non-keratinized stratified squamous epithelium, found almost everywhere else in the oral cavity. Specialized mucosa is found specifically the regions of the taste buds on the dorsum of the tongue.
ESOPHAGUS
The esophagus or oesophagus, sometimes known as the gullet, is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. In humans the esophagus is continuous with the laryngeal part of the pharynx at the level of the C6 vertebra. The esophagus passes through a hole in the thoracic diaphragm called the esophageal hiatus. It is usually 25-30 cm long which connects the mouth to the stomach. It is divided into cervical, thoracic, and abdominal parts.
Food is passed through the esophagus by using the process of peristalsis. Specifically, it connects the pharynx, which is the body cavity that is common to the digestive factory and respiratory system with the stomach, where the second stage of digestion is initiated.
The esophagus is deeply lined with muscle that acts with peristaltic action to move swallowed food down to the stomach. Due to the fact that the esophagus lacks the mucus lining like that of the stomach, it can get irritated by stomach acid that passes the cardiac sphincter.
STOMACH
The stomach is a hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication. The stomach lies between the esophagus and the duodenum (the first part of the small intestine). It is on the left side of the abdominal cavity. The top of the stomach lies against the diaphragm. Lying beneath the stomach is the pancreas, and the greater omentum which hangs from the greater curvature.
Two smooth muscle valves, or sphincters, keep the contents of the stomach contained. They are the esophageal sphincter (found in the cardiac region) dividing the tract above, and the Pyloric sphincter dividing the stomach from the small intestine.
The stomach is surrounded by parasympathetic (stimulant) and orthosympathetic (inhibitor) plexuses (anterior gastric, posterior, superior and inferior, celiac and myenteric), which regulate both the secretory activity and the motor activity of the muscles.
In humans, the stomach has a relaxed volume of about 45 ml; it generally expands to hold about 1 litre of food, but can hold as much as 1.5 liters.
Sections
The stomach is divided into four sections, each of which has different cells and functions. The sections are: Cardia, it is where the contents of the oesophagus empty into the stomach. Fundus is formed by the upper curvature of the organ. Body or corpus is the main, central region. Pylorus or antrum is the lower section of the organ that facilitates emptying the contents into the small intestine.
Blood supply
The lesser curvature of the stomach is supplied by the right gastric artery inferiorly, and the left gastric artery superiorly, which also supplies the cardiac region. The greater curvature is supplied by the right gastroepiploic artery inferiorly and the left gastroepiploic artery superiorly. The fundus of the stomach, and also the upper portion of the greater curvature, is supplied by the short gastric artery.
Like the other parts of the gastrointestinal tract, the stomach walls are made of the following layers, from inside to outside: mucosa is the first main layer. This consists of an epithelium, the lamina propria composed of loose connective tissue and which has
gastric glands in it underneath, and a thin layer of smooth muscle called the muscularis mucosae. submucosa is the layer that lies under the mucosa and consists of fibrous connective tissue, separating the mucosa from the next layer. The Meissner's plexus is in this layer. muscularis externa is found under the submucosa, the muscularis externa in the stomach differs from that of other GI organs in that it has three layers of smooth muscle instead of two. serosa is the layer under the muscularis externa, consisting of layers of connective tissue continuous with the peritoneum.
Control of secretion and motility
The movement and the flow of chemicals into the stomach are controlled by both the autonomic nervous system and by the various digestive system hormones: Gastrin is a hormone which causes an increase in the secretion of HCl, pepsinogen and intrinsic factor from parietal cells in the stomach. It also causes increased motility in the stomach. Gastrin is released by G-cells in the stomach to distenstion of the antrum, and digestive products. It is inhibited by a pH normally less than 4 (high acid), as well as the hormone somatostatin. Cholecystokinin (CCK) has most effect on the gall bladder, but it also decreases gastric emptying and increases release of pancreatic juice which is alkaline and neutralizes the chyme. In a different and rare manner, secretin, produced in the small intestine, has most effects on the pancreas, but will also diminish acid secretion in the stomach. Gastric inhibitory peptide (GIP) decreases both gastric acid and motility. Enteroglucagon decreases both gastric acid and motility. Glycogen, produced in the brain and stomach, affects the liver and level of glucose in the stomach.Other than gastrin, these hormones all act to turn off the stomach action. This is in response to food products in the liver and gall bladder, which have not yet been absorbed. The stomach needs only to push food into the small intestine when the intestine is not busy. While the intestine is full and still digesting food, the stomach acts as storage for food.
The three basic/main functions of the stomach are to kill any bacteria ingested, break down the food into smaller pieces to create a larger surface area for easier digestion, and to hold food and release it at a constant rate. The stomach is a highly acidic environment due to hydrochloric acid production and secretion which produces a luminal pH range usually between 1 and 2 depending on the species, food intake, time of the day, drug use, and other factors. Combined with digestive enzymes, such an environment is able to break down large molecules (such as from food) to smaller ones so that they can eventually be absorbed from the small intestine. A zymogen called pepsinogen is secreted by chief cells and turns into pepsin under low pH conditions and is a necessity in protein digestion.
The human stomach can produce and secrete about 2.2 to 3 liters of gastric acid per day with basal secretion levels being typically highest in the evening. The stomach can expand to hold between 1-1.5 liters of food. It is a temporary food storage area, and in the process of digestion, the food goes into the stomach first.
Absorption of vitamin B12 from the small intestine is dependent on conjugation to a glycoprotein called intrinsic factor which is produced by parietal cells of the stomach.
Other functions include absorbing some ions, water, and some lipid soluble compounds such as alcohol, aspirin, and caffeine.
Menstruation is the shedding of the uterine lining (endometrium). It occurs on a regular basis in reproductive-age females of certain mammal species. Overt menstruation (where there is bleeding from the vagina) is found primarily in humans and chimpanzees. The females of other placental mammal species have estrous cycles, in which the endometrium is reabsorbed by the animal (covert menstruation) at the end of its reproductive cycle. Many zoologists regard this as different from a "true" menstrual cycle.
Eumenorrhea denotes normal, regular menstruation that lasts for a few days (usually 3 to 5 days, but anywhere from 2 to 7 days is considered normal).The average blood loss during menstruation is 35 millilitres with 10-80 mL considered normal; many females also notice shedding of the endometrium lining that appears as tissue mixed with the blood. (Sometimes this is erroneously thought to indicate an early-term miscarriage of an embryo.) An enzyme called plasmin — contained in the endometrium — tends to inhibit the blood from clotting. Because of this blood loss, premenopausal women have higher dietary requirements for iron to prevent iron deficiency. Many women experience uterine cramps, also referred to as dysmenorrhea, during this time, caused largely by the contractions of the uterine muscle as it expels the endometrial blood from the woman's body. A vast industry has grown to provide drugs to aid in these cramps, as well as sanitary products to help manage menses.
Menstruation is the most visible phase of the menstrual cycle. Menstrual cycles are counted from the first day of menstrual bleeding, because the onset of menstruation corresponds closely with the hormonal cycle.
During pregnancy and for some time after childbirth, menstruation is normally suspended; this state is known as amenorrhoea, i.e. absence of the menstrual cycle. If menstruation has not resumed, fertility is low during lactation. The average length of postpartum amenorrhoea is longer when certain breastfeeding practices are followed; this may be done intentionally as birth control (lactational amenorrhea method).
FlowThe normal menstrual flow follows a "crescendo-decrescendo" pattern; that is, it
starts at a moderate level, increases somewhat, and then slowly tapers. Sudden heavy flows or amounts in excess of 80 mL (hypermenorrhea or menorrhagia) may stem from hormonal disturbance, uterine abnormalities, including uterine leiomyoma or cancer, and other causes. Doctors call the opposite phenomenon, of bleeding very little, hypomenorrhea.
The typical woman bleeds for two to seven days at the beginning of each menstrual cycle. Prolonged bleeding (metrorrhagia, also meno-metrorrhagia) no longer shows a clear interval pattern. Dysfunctional uterine bleeding is hormonally caused bleeding abnormalities, typically anovulation. All these bleeding abnormalities need medical attention; they may indicate hormone imbalances, uterine fibroids, or other problems. As pregnant patients may bleed, a pregnancy test forms part of the evaluation of abnormal bleeding.
RED BLOOD CELLS
Red blood cells are the most common type of blood cell and the vertebrate body's principal means of delivering oxygen to the body tissues via the blood. The cells are filled with hemoglobin, a biomolecule that can bind to oxygen. They take up oxygen in the lungs or gills and release it while squeezing through the body's capillaries. The blood's red color is due to the color of hemoglobin. In humans, red blood cells develop in the bone marrow, take the form of flexible biconcave disks, lack a cell nucleus, subcellular organelles and the ability to synthesize protein, and live for about 120 days.
Red blood cells are also known as RBCs, red blood corpuscles (an archaic term), haematids or erythrocytes. The capitalized term Red Blood Cells is the proper name in the US for erythrocytes in storage solution used in transfusion medicine.
When erythrocytes undergo shear stress in constricted vessels, they release ATP which causes the vessel walls to relax and dilate.
When their hemoglobin molecules are deoxygenated, erythrocytes release S-nitrosothiols which also acts to dilate vessels, thus directing more blood to areas of the body depleted of oxygen.
Erythrocytes also play a part in the body's immune response: when lysed by pathogens such as bacteria, their hemoglobin releases free radicals that break down the pathogen's cell wall and membrane, killing it.
Human erythrocytesA typical human erythrocyte disk has a diameter of 6–8 µm and a thickness of 2
µm, much smaller than most other human cells. A normal erythrocyte has a volume of about 90 fL. About a third of that volume is hemoglobin, a total of 270 million hemoglobin molecules, with each carrying four heme groups.Adult humans have roughly 2–3 × 10 13 red blood cells at any given time (women have about 4 to 5 million erythrocytes per microliter (cubic millimeter) of blood and men about 5 to 6 million; people living at high altitudes with low oxygen tension will have more). Red blood cells are thus much more common than the other blood particles: there are about 4,000–11,000 white blood cells and about 150,000–400,000 platelets in each microliter of human blood.
In humans, hemoglobin in the red blood cells is responsible for the transport of more than 98% of the oxygen; the remaining oxygen is carried dissolved in the blood plasma.
The red blood cells of an average adult human male store collectively about 2.5 grams of iron, representing about 65% of the total iron contained in the body.
Life cycleThe process by which red blood cells are produced is called erythropoiesis.
Erythrocytes are continuously produced in the red bone marrow of large bones, at a rate of about 2 million per second. (In the embryo, the liver is the main site of red blood cell production.) The production can be stimulated by the hormone erythropoietin (EPO), synthesised by the kidney; this is used for doping in sports. Just before and after leaving the bone marrow, the developing cells are known as reticulocytes; these comprise about 1% of circulating red blood cells.
Erythrocytes develop from committed stem cells through reticulocytes to mature erythrocytes in about 7 days and live a total of about 100-120 days.
The aging erythrocyte undergoes changes in its plasma membrane, making it susceptible to recognition by phagocytes and subsequent phagocytosis in the spleen, liver and bone marrow. Much of the important breakdown products are recirculated in the body. The heme constituent of hemoglobin is broken down into Fe3+ and biliverdin. The biliverdin is reduced to bilirubin, which is released into the plasma and recirculated to the liver bound to albumin. The iron is released into the plasma to be recirculated by a carrier protein called transferrin. Almost all erythrocytes are removed in this manner from the circulation before they are old enough to hemolyze. Hemolyzed hemoglobin is bound to a protein in plasma called haptoglobin which is not excreted by the kidney.
Membranes and surface proteinsThe membranes of red blood cells play many roles that aid in regulating immune
recognition and deformability.There are two main types of proteins on the surface:Band 3, Glycophorins such as glycophorin C
The blood types of humans are due to variations in surface glycoproteins of erythrocytes.
Disorders of the proteins in these membranes are associated with many disorders, such as hereditary spherocytosis, hereditary elliptocytosis, hereditary stomatocytosis, and paroxysmal nocturnal hemoglobinuria.
HAIR FOLLICLE
A hair follicle is part of the skin that grows hair by packing old cells together. Attached to the follicle is a sebaceous gland, a tiny sebum-producing gland found
everywhere except on the palms, lips and soles of the feet. The thicker density of hair, the more sebaceous glands are found.
Also attached to the follicle is a tiny bundle of muscle fiber called the arrector pili that are responsible for causing the follicle lissis to become more perpendicular to the surface of the skin, and causing the follicle to protrude slightly above the surrounding skin (piloerection). This process results in goose bumps (or goose flesh). Stem cells are located at the junction of the arrector and the follicle, and are principally responsible for the ongoing hair production during a process known as the Anagen stage.
The average growth rate of healthy hair follicles on the scalp is 400 µm per day.
Certain species of Demodex mites live in the hair follicles of mammals (including those of humans) where they feed on sebum.
PapillaAt the base of the follicle is a large structure that is called the papilla. The papilla
is made up mainly of connective tissue and a capillary loop. Cell division in the papilla is either rare or non-existent.
MatrixAround the papilla is the hair matrix, a collection of epithelial cells often
interspersed with the pigment producing cells, melanocytes. Cell division in the hair matrix is responsible for the cells that will form the major structures of the hair fiber and the inner root sheath. The hair matrix epithelium is one of the fastest growing cell populations in the human body, which is why some forms of chemotherapy that kill dividing cells or radiotherapy may lead to temporary hair loss. The papilla is usually ovoid or pear shaped with the matrix wrapped completely around it except for a short stalk-like connection to the surrounding connective tissue that provides access for the capillary.
Root SheathThe root sheath is composed of an external root sheath (Henle's layer), a middle
layer (Huxley's layer), and an internal cuticle that is continuous with the outermost layer of the hair fiber.
Hair FiberThe hair fiber is composed of a cuticle that is continuous with the root sheath, an
intermediate cortex, and an inner medulla.
Other StructuresOther structures associated with the hair follicle include arrector pili muscles,
sebaceous glands and apocrine sweat glands. Hair follicle receptors sense the position of the hairs.
MorphogenesisIn utero, the epithelium and underlying mesenchyma interact to form hair follicles.
Hair-follicle cyclingHair grows in cycles of various phases. anagen is the growth phase; catagen is
the involuting or regressing phase; and telogen, the resting or quiescent phase. Each phase has several morphologically and histologically distinguishable sub-phases. Prior to the start of cycling is a phase of follicular morphogenesis (formation of the follicle). There is also a shedding phase, or exogen, that is independent of anagen and telogen in which one of several hairs that might arise from a single follicle exits. Normally up to 90% of the hair follicles are in anagen phase while, 10–14% are in telogen and 1–2% in catagen. The cycle's length varies on different parts of the body. For eyebrows, the cycle is completed in around 4 months, while it takes the scalp 3–4 years to finish; this is the reason eyebrow hairs have a much shorter length limit compared to hairs on the head. Growth cycles are controlled by a chemical signal like epidermal growth factor.
Anagen PhaseAnagen is the active growth phase of hair follicles. The cells in the root of the hair
are dividing rapidly, adding to the hair shaft. During this phase the hair grows about 1 cm every 28 days. Scalp hair stays in this active phase of growth for 2-7 years. The amount of time the hair follicle stays in the anagen phase is genetically determined. At the end of the anagen phase an unknown signal causes the follicle to go into the catagen phase.
Catagen PhaseThe catagen phase is a short transition stage that occurs at the end of the
anagen phase. It signals the end of the active growth of a hair. This phase lasts for about 2–3 weeks while a club hair is formed.
The telogen phase is the resting phase of the hair follicle. The club hair is the final product of a hair follicle in the telogen stage, and is a dead, fully keratinized hair. Fifty to one-hundred club hairs are shed daily from a normal scalp.
Hair growth cycle timesScalp: The time these phases last vary from person to person. Different hair
colour and follicle shape affects the timings of these phases. Anagen phase, 2–3 years (occasionally much longer). Catagen phase, 2–3 weeks. Telogen phase, around 3 months.
