Kidney stones (renal lithiasis):
Renal calculi is formation of stone in any part of the urinary tract. urinary tract is divided into four main divisions
- Kidney (renal calculi)
- Ureter (ureteric calculi)
- Urinary bladder(vesical calculi)
Cause of renal calculi depends one many factors,of which the following are important
- Concentrated urine especially in hot climate,decreased fluid intake,chronic diarrhea.
- Urinary stasis-urinary tract obstruction,prolonged recumbency.
- Recurrent urinary tract infections
- Polycystic kidney disease
- Vitamin A deficiency
- Foreign body
- Hypercalcaemia-hyperparathyroidism,vitamin D deficiency,excessive calcium intake eg milk,cheese,eggs.
- Hyperoxaluria-excessive intake oxalate eg tomato,raddish,spinach,strawberry,tea,chocolate,cold drinks.
- Hyperuricemia-gout,excessive purine rich food intake eg red meat,fish.
- Common in males and common or peak incidence 30-50 years.
Clinically, calculi is divided into
- Renal calculus
- Ureteric calculus
- Vesical calculus.
In renal calculus symptoms are pain in flank,dull aching,pain worse on movement,changing position,walking upstairs,haematuria.
In ureteric calculus symptoms are pain which has sudden onset ,sharp,excruciating pain,which radiates tofrom loin to groin,patient draws up his knees and rolls,vomiting,strangury,haematuria.
In vesical calculus,symptoms are frequent unsatisfactory urination,pain at the end of micturation which is worse during exertion,jolting movements;better by lying. interruption of urinary stream(stone blocking internal meatus) better by change of posture,haematuria.
Plenty of fluid intake,diet restriction according to the type of stone,
If stone is uric acid and urates,eliminate-meat and meat products,dals,whole grain cereals,oat,meal,dried peas and beans.
If stone is oxalate eliminate-spinach,sweet potato,almonds,cashewnuts,grapes.
Large stones need to be removed surgically.
Diabetes mellitus is a common problem in India,its root cause is still not known. Diabetes mellitus is multifactorial clinical syndrome of glucose metabolism due to absolute or relative deficiency of insulin secreted by beta cells of pancreas or its diminished biologic effectiveness resulting in impaired carbohydrate tolerance and persistent hyperglycaemia with or without glycosuria,and characterised by polyuria,polydipsia,polyphagia and weight loss.
Cause of diabetes is divided according to clinical types as
- Primary Diabetes mellitus
- Secondary Diabetes mellitus.
Cause for primary Diabetes mellitus
It is of two types
- Type 1 Diabetes mellitus or insulin dependent Diabetes mellitus(IDDM)- onset is usually juvenile age,exact cause is not known. probably its ia auto-immune disorder resulting in destruction of pancreatic islet cells by anti-islet cell antibodies,also associated with HLA-DR3 and HLA-DR4.
- Type 2 Diabetes mellitus or non insulin dependent Diabetes mellitus(NIDDM)-exact cause is not known. predisposing causes are familial predisposition,ageing,obesity,inactivity. physical and mental stress especially in precipitaing latent form of disease.
Cause for secondary Diabetes mellitus
Endocrinal disorders-impaired glucose intolerance and increase insulin resistance. Common conditions like acromegaly,cushing’s syndrome could be the cause for Diabetes mellitus.
chronic pancreatitis-reduction in beta cell mass,80% of islet mass must be destroyed for clinical hyperglycaemia.
Haemochromatosis-pancreatic destruction due to excessive iron accumulation(bronze diabetes),due to dark skin pigmentation due to iron deposition.
Pregnancy(gestational Diabetes mellitus)-state of glucose intolerance occuring in late second trimester.
- Pathogenesis of Diabetes mellitus is still not clear,but factors possibly responsible for development of Diabetes mellitus include deficiency of insulin,presence of antagonists,excessive neoglucogenesis.
Onset of symptoms is insidious. Clinically characterised by symptoms like polyuria(increased frequency micturation),polydipsia,compensatory mechanism to prevent dehydration by excessive thirst,dryness of mouth,throat,polyphagia(excessive hunger),inspite of good appetite,there is lack of energy,weakness,tiredness,weight loss,rapid emaciation due to starvation,neoglucogenesis. Constipation-bowels occurs every 2-3 days once,with hard stools.
Pruritis-intense itching especially in anus or external genitalia,which is thought to be due to irritant action of sugar on tissues,superimposed fungal or bacterial infection. Other features include burning of feet,impotency in males,tendency to infections,delayed wound healing.
Complications of Diabetes mellitus are diabetic neuropathy,diabetic nephropathy. other complications include-diabetic foot,diabetic ketoacidosis,presenile cataract. complications of gestational diabetes- maternal risks-polyhydramnios,pre-eclamptic toxaemia. fetal risks if left untreated-abortion,foetal growth disturbance,stillbirth,increased in perinatal morbidity and mortality.
measures to correct/modify predisposing causes,adequate physical and mental rest,reduce weight if obese,abstain from smoking and alcohol,regular monitoring of blood pressure,blood sugar,serum cholesterol,serum creatinine.
diet therapy-follow strict diet to be followed in proper proportion of carbohydrates,fats and proteins according to the caloric need.
example for calories of 1300-proteins(60 grams),carbohydrates(180 grams),fats(33 grams) along with lemon tea or nimbu pani early in the morning.
Hypertension is a condition characterised by systemic arterial pressure consistently above 140 mmhg systolic and 90 mmhg diastolic. Normal blood pressure is 120/80 mmhg.
Cause of hypertension is divided into
- Primary(essential) hypertension.
- Secondary hypertension.
Cause for primary hypertension are- idiopathic.
Predisposing causes-smoking,mental stress,hyperlipaemia,excessive intake salts,fats,obesity,lack of physical activity.
Cause for secondary hypertension are:
- Renal cause-chronic renal failure,polycystic kidney disease,hydronephrosis,renal artery stenosis.
- Endocrine cause-thyrotoxicosis,acromegaly,cushing’s syndrome,hyperaldosteronism,phaeochromocytoma.
- Neurological cause-brain tumours,cerebrovascular accident(CVA).
- Other causes are psychogenic,atherosclerosis,polycythaemia,pregnancy.
Clinically hypertension is charcterised by asymptomatic phase during compensatory phase. symptoms like throbbing headache,giddiness,faintness,sleeplessness,epistaxis,angina pectoris,exertional fatigue,decreasing exercise tolerance,oliguria,nocturnal cough.
- Cardiovascular-left ventricular failure(LVF).congestive cardiac failure(CCF),myocardial infarction.
- Cerebral-cerebro-vascular accidents(CVA),hypertension encephalopathy.
- Retinal-hypertension retinopathy.
Treat the cause,stop all the predisposing causes like smoking,mental and physical rest,diet-restrict salt diet,low fat diet,reduce weight if obese,regular moderate exercise.
Diabetes insipidus is a condition which occurs due to deficiency of antidiuretic hormone(ADH) or inability of kidney to respond to normal levels of ADH,resulting in polyuria of very dilute urine,with polydipsia.
Cause of Diabetes insipidus is divided into
- Central(neurogenic) diabetes insipidus(CDI)
- Nephrogenic Diabetes insipidus(NDI).
Causes of central(neurogenic) diabetes insipidus(CDI) are
- Familial manisfested as autosomal dominant.
- Associated with diabetes mellitus,optic atrophy,nerve deafness,bladder atony.
- Acquired-idiopathic,tumour eg craniopharyngioma,inflammatory eg basal meningitis,head trauma,surgery causing disruption of pituitary stalk,irradiation,sheehan’s syndrome.
- Causes of nephrogenic Diabetes insipidus(NDI) are
- Familial-manifested as sex-linked recessive. Acquired-iatrogenic eg methoxyflurane,colchicine;after pyelonephritis,polycystic kidney disease,obstructive uropathy,hypokalaemia,hypercalcaemia,sickle cell anaemia.
PATHOLOGY BEHIND DIABETES INSIPIDUS:
Inappropriate ADH secretion implies persisitent release of ADH as consequences ,there is excess reabsorption of water in kidneys,expansion of extracellular fluid volume,which leads to haemodilution,hyponatramia,inability to excrete dilute urine.
In CDI,complete or partial deficiency results in polyuric statew,in which,in which kidneys is unable to concentrate urine,which results into large amount of dilute urine excretion.
In NDI,ADH production is normal,thre is ineffectual response of ADH on distal tubule or collecting tubule. the defect is in respond to ADH by kidney.
Clinically diabetes insipidus is characterised by two very important symptoms that is polyuria(increased frequency of micturation) and polydipsia.
polydipsia is consequence of polyuria that is to say polydipsia is compensatory mechanism to prevent dehydration by excessive incessant thirst,craving for ice cold water,disturbs sleep,patient may consume in excess of 10 litres of water per day,attempts to limit fluid intake my cause severe dehydration.
other features of diabetes insipidus are weakness,fatigue,irritability,muscular pains,constipation.
Look of diabetes insipidus patient-sunken eyes,drowsiness,dry skin,dry tongue,emaciation in prolonged cases.
- Severe dehydration,shock,coma,with or without convulsions.
Maintain fluid,electrolyte balance,eat well balanced,nutritious diet,consult a physician as early as possible.
Sciatica is pain along the course of the sciatic nerve. The nerve distribution of The sciatic nerve is nearly the whole of the skin of the leg, the muscles of the back of the thigh, and those of the leg and foot. sciatic nerve is longest single nerve in human body.
Cause of sciatica are:
- Infective cause-leprosy,post herpetic neuralgia.
- Iatrogenic causes-nerve injury due to injection.
- Mechanical cause-compression due to tumour of cauda equina,arachnoiditis,lumbar disc prolapse.
Clinically symptoms of sciatica start suddenly,with pain which is vague aching to severe unbearable neuralgic pain with parasthesia. Location of pain is from lumbar region radiates to gluteal and upto great toe of foot. pain is worse on stretching the limb,coughing. pain better by rest,weakness of affected limb,numbness of affected limb. patient presents with history of trauma,exposure cold,damp weather.
In acute stage-complete bed rest on hard bed for 2 weeks,local application of heat,avoid stress over the spine.
In chronic stage-complete bed rest for 6 weeks,supine posture.
Bronchial Asthma is respiratory disease which usually has genetic tendency with positive family history,Bronchial asthma is lower respiratory tract infection(LRTI).
Bronchial asthma is a syndrome of variable airflow obstruction.
Bronchial tube hypersensitivity disorder characterised by reversible airway obstruction as result of mucosal oedema,bronchial constriction and excessive secretion of viscid mucus.
pathologically bronchial asthma is characterised by bronchial inflammation,physiologically,bronchial asthma is characterised by bronchial hypersensitivity.
Clinically characterised by -Variable cough
- Chest tightness
Generally asthma is classified into
- Extrinsic asthma- also called atopic asthma where in there is increase production of IgE(immunoglobulins) in response to allergens(dusts,pollens).
- Intrinsic asthma-also called non atopic asthma where in IgE cannot be demonstrated.
- Inducers of asthma
- Inhalants like house dust,pollens,fumes,smoke
- Ingestants like few food products to which the patient is hypersensitive to like egg,milk..etc.
Precipitating causes are the once that bring about an attack of asthma
- Emotional stress
- Physical exertion
- Change in temperature
- Exposure to cold
- Cigarette smoking
- Lowered immunity.
- The onset of an attack of Bronchial asthma is sudden,starts in late night or early morning(key note symptom of Bronchial asthma)
- Sensation of tightness in chest
- Dyspnoea(difficulty in breathing)
- Want of air,gasping type .
- Paroxysmal cough(sudden outbursts of cough).
- Expectoration is difficult ,scanty,mucoid.
- Attack subsides within few hours.
- Complete bed rest.
- Physical anmd mental rest.
- Avoid all the above mentioned precipitating factors.
- Take extra puff of aerosol inhaler.
- Take some hot tea or keep sipping warm water.
Urinary tract infection (UTI):
UTI is a common genitourinary disease commonly caused due to bacteria called E.coli and condition is characterised by hectic rise in temperature,rigor,loin pain,painful and frequent micturition (acute attack). Recurrent episodes of infection after acute attack associated with frequency of urination,dysuria,loin pain and unexplained fever.
UTI causes are divided into acute cause and chronic cause
Acute cause are:
- Few of causative organisms of UTI are E.coli,staphylococcus,klebsiella,candida,proteus,enterococci predisposing factors of UTI.
- Common in females compared to male,enlarged prostrate,neuropathic bladder,urinary tract calculi,polycystic kidney disease,diabetes mellitus,vesico-ureteric reflex,bladder catheterisation.
Chronic cause are:
- Mal-treated acute urinary tract infection,urinary obstruction(enlarged prostrate,stricture,stone),stasis in bladder(cystocele,neurogenic bladder,vesico-ureteric reflux),polycystic kidney disease,diabetes mellitus.
Symptoms of acute UTI are fever,with rigors,malaise,nausea,vomiting,pain in loins,flanks,frequent,burning urination,dysuria,haematuria Symptoms of chronic UTI are Tiredness,Lassitude,Recurrent fever,Pain in loins,Frequent urination,Dysuria. In chronic UTI there may be rise in blood pressure,mild anaemia.
- Renal calculi,Hypertension,Chronic renal failure.
- Plenty of fluids,Regular voiding of urine,Maintain alkalinity of urine,Local hygiene,Salt restriction,if blood pressure is high,Protein restriction,if blood urea is high.
Tension Headaches a common problem seen in India. Tension Headaches is diffuse pain characterised by pain over the head and approximately 80 % of headaches are Tension Headaches.
PATHOLOGY– Sustained muscular contraction causing stretching of muscle nerve endings,compression and traction of scalp blood vessels. Tension headache for example due to work disappears one’s you are done with the work.
- The exact cause is not known.
- Predisposing causes are stress,anxiety states,depression.
- Tension headche is common in adolescents and middle aged.
The onset of symptoms are insidious and Clinically,Tension headache is characterised by pain over the head which is bilateral,diffuse type of pain and pain starts from back of head and neck,spreads to fronto-temporal area in a band like pattern. pain is described by patient in several points with a single finger. character of pain is dull aching,sensation of tightness and pressure as if head surrounded by a tight band,as if head squeezed,as if needle or knives driven in. intensity of pain is mild to moderate. pain worse from fatigue,lack of sleep,noise,emotional stress,sustained physical strain eg driving,typing,overstudy.headache is associated with anxiety,tension,depression.
Reassurance to the patient,explanation to the patient about the nature of the headache ,correct the predisposing cause,daily muscle relaxation exercises,adequate physical and mental rest,adequate sleep,maintain general health,avoid coffee,alcohol,tea.
Migraine is recurrent,paroxysmal,severe,incapacitating,unilateral,throbbing headache,with vomiting and preceded by visual or sensory disturbances.
The pathology of migraine is thought to be due vasoconstriction of branches of internal carotid artery,which causes visual disturbances and sensory-motor symptoms. subsequent throbbing headache is due vasodilatation of the external carotid artery. Migraine is thought to be due to release of certain neuropeptides especially 5-HT histamine and serotonin.
The exact cause of migraine is not known,however few of the predisposing causes are-familial predisposition,psychological disturbances.
precipitating factors-anxiety,fatigue,change in sleep patterns,emotional stress,hormonal imbalance(puberty,menopause,premenstraul tension),fasting or missing meals,bright light,loud noises,aleergic(chemical)-cheese,chocolate,coffee,alcohol,smoking.
Migraine is common in young adults and females are more prone to migraine.
TYPES OF MIGRAINE
- Classical migraine(migraine with aura).
- Common migraine(migraine without aura).
- Systemic migraine(migraine aura without headache).
- Complicated migraine.
- Status migrainous.
- Acephalgic migraine.
- Clinically migraine symptoms start suddenly,and are manifest as prodrome,aura and headache.
- Prodrome(duration of 15-30 minutes)-weakness,lethargy,euphoria or depression,yawning.
- Visual disturbances-blurring of vision,photophobia,hemianopia,lachrymation.
- Sensory disturbances-numbness and tingling in face,extremities,lips,tongue,sernsation of crawling of insects on skin.
- Motor disturbances-weakness,giddiness,dysphagia.
- Headache- onset of headache is morning time after waking,commonly unilateral headache located over frontal,supraorbital,temporal region. character of pain is paroxysmal,sharp,severe,throbbingpulsating,reaches peak within hours.
- Duration of headache is 24-48 hours,bouts of headaceh a\occur at intervals of days,weeks or months.
- Headache worse by light and noise. headache better by rest,dark room,pressure,vomiting. headaceh is associated with irritability,nausea,vomiting,sweating,diarrhea. after attack-profuse urination and sleepiness.
Reassurance to the patient,assess about patients habits,work place personality etc,correct the predisposing causes psychotherapy is psychological disturbance is the cause,avoid all the precipitating factors,improve general health,avoid all the allergy causing food,during attack take rest,remain in dark room.