Project 2

Project-2

1. Project: A Detail study of Urinary system Clinical condition and its diagnostic/surgical procedure:

Introduction:

• The kidneys are a pair of bean-shaped organs present in all vertebrates. They remove waste products from the body, maintain balanced electrolyte levels, and regulate blood pressure.
• The kidneys are some of the most important organs in the body. The ancient Egyptians left only the brain and kidneys in position before embalming a body, inferring that they held a higher value than other organs.
• The positioning of the kidneys is just below the rib cage, with one on each side of the spine. The right kidney is generally slightly lower than the left kidney to make space for the liver.
• Each kidney is approximately 3(cm) thick, 6 cm wide, and 12 cm long. In males, the average weightof the kidneys is roughly 129 grams (g) for the right one and 137 g for the left. In females, the average weight of these organs is 108 g for the right kidney and 116 g for the left kidney.
• The kidneys are two bean-shaped organs that are roughly the size of a fist. A tough, fibrous renal capsule surrounds each kidney and provides support for the soft tissue inside. Beyond that, two layers of fat serve as further protection. The adrenal glands lie on top of the kidneys.
• Inside the kidneys are a number of pyramid-shaped lobes. Each consists of an outer renal cortex and an inner renal medulla.
• Nephrons flow between these sections. Each nephron includes a filter, called the glomerulus, and a tubule. The glomerulus filters blood, which enters the kidneys through the renal arteries and leaves through the renal veins.
• The kidneys are relatively small organs, but they receive 20–25%of the heart’s output.
• The tubule returns necessary substances to the blood and removes waste that then becomes urine. The kidneys excrete urine through the ureter, a tube that leads to the bladder.

Function of a kidney:

• The main role of the kidneys is maintaining homeostasis. They manage fluid levels, electrolyte balance, and other factors that keep the internal environment of the body consistent and comfortable.
• These organs carry out a wide range of bodily functions.
• Waste excretion: The kidneys removevarious waste products and get rid of them in the urine. Some major compounds that the kidneys remove are:
• urea, which results from the breakdown of proteins
• uric acid from the breakdown of nucleic acids
• drugs and their metabolite.

• Reabsorption of nutrients: The kidneys reabsorb nutrients from the blood using tubules and transport them to where they will best support health. They also reabsorb other products to help maintain homeostasis. Reabsorbed products include:

• Maintaining pH: n humans, the range of acceptable pH levels is 7.35–7.45. At levels below or above this range, the body enters a state of acidaemia or alkalemia, respectively. In these states, proteins and enzymes break down and can no longer function. In extreme cases, this can be fatal.
• The kidneys and lungs help keep the body’s pH stable. The lungs achieve this by moderating the concentration of carbon dioxide in the blood. The kidneys manage the pH by reabsorbing and producing bicarbonate from urine, which helps neutralize acids.
• The kidneys can retainbicarbonate if the pH is tolerable and release it if acid levels rise. They can produce new bicarbonate by excreting
• Osmolality regulation: Osmolalityis a measure of the body’s electrolyte-water balance, which is the ratio between fluids and minerals in the body. Dehydration is a primary cause of electrolyte imbalance.
• If osmolality rises in the blood plasma, the hypothalamus in the brain responds by passing a message to the pituitary gland. This gland releases antidiuretic hormone (ADH). In response to ADH, the kidney makes several changes, including:

• increasing urine concentration
• increasing water reabsorption
• reopening portions of the collecting duct that water cannot normally enter, allowing water back into the body
• retaining urea in the medulla of the kidney rather than excreting it, as this compound draws in water

Kidney Stones:

• Kidney stones develop when dissolved minerals build up inside the kidneys. A low fluid consumption, dietary factors, and a person’s medical history may contribute to their development.
• Kidney stones may be small and pass unnoticed through the urinary tract, but some grow to the size of a golf ball. Larger stones can cause severe pain as they leave the body.
• Without treatment, kidney stones can lead to urinary problems, infections, and kidney damage.
• Kidney stones are a common problem in the United States, and the incidence appears to be growing. Dietary factors and climate change may contribute to this increase, according to one

Symptoms of kidney stones:

• Kidney stones do not always cause symptoms. A person may pass very small stones out of the body in the urine without being aware of them.
• When symptoms appear, they commonly include:

• pain in the groin, the side of the abdomen, or both
• blood in the urine
• vomiting and nausea
• a urinary tract infection (UTI)
• fever and chills, if there is an infection
• an increased need to urinate

• If kidney stones block the passage of urine, a kidney infection may result. The symptoms include:

• a fever and chills
• weakness and fatigue
• diarrhea
• cloudy, foul-smelling urine

Diagnosing kidney stone:

• As a first step toward diagnosis of kidney disease, your doctor discusses your personal and family history with you.
• Among other things, your doctor might ask questions about whether you've been diagnosed with high blood pressure, if you've taken a medication that might affect kidney function, if you've noticed changes in your urinary habits and whether you have family members who have kidney disease.
• Next, your doctor performs a physical exam, checking for signs of problems with your heart or blood vessels, and conducts a neurological exam.
• For kidney disease diagnosis, you might also need certain tests and procedures to determine how severe your kidney disease is (stage). Tests might include:
• Glomerular filtration rate (GFR)
• Serum creatinine test
• Extracorporeal shock wave lithotripsy (ESWL)

Glomerular filtration rate (GFR):

• A glomerular filtration rate (GFR) is a blood test that checks how well your kidneys are working.
• Your kidneys have tiny filters called glomeruli. These filters help remove waste and excess fluid from the blood.
• A GFR test estimates how much blood passes through these filters each minute.
• A GFR can be measured directly, but it is a complicated test, requiring specialized providers.
• So GFR is most often estimated using a test called an estimated GFR or eGFR. To get an estimate, your provider will use a method known as a GFR calculator.
• A GFR calculator is a type of mathematical formula that estimates the rate of filtration.
• It does this by comparing the results of a blood test that measures creatinine, a waste product filtered by the kidneys, with other information about you.
• A GFR test is used to help diagnose kidney diseaseat an early stage, when it is most treatable.
• GFR may also be used to monitor people with chronic kidney disease(CKD) or other conditions that cause kidney damage. These include diabetes and high blood pressure.

Procedure:

• A health care professional will take a blood sample from a vein in your arm, using a small needle.
• After the needle is inserted, a small amount of blood will be collected into a test tube or vial.
• GFR tests measure cystatin C, a protein made by most types of cells in the body. Unlike creatinine, the blood level of cystatin C is less influenced by differences in our body, such as muscle mass, physical activity, and diet.
• Therefore, cystatin C-based calculation of eGFR is more accurate in some circumstances.

Serum creatinine test:

• This test measures creatinine levels in blood and/or urine. Creatinine is a waste product made by your muscles as part of regular, everyday activity.
• Normally, your kidneys filter creatinine from your blood and send it out of the body in your urine. If there is a problem with your kidneys, creatinine can build up in the blood and less will be released in urine.
• If blood and/or urine creatinine levels are not normal, it can be a sign of kidney disease.
• A creatinine test is used to see if your kidneys are working normally. It's often ordered along with another kidney test called blood urea nitrogen (BUN)or as part of a comprehensive metabolic panel (CMP).
• A CMP is a group of tests that provide information about different organs and systems in the body. A CMP is frequently included in a routine check-up.

Procedure:

Creatinine can be tested in blood or urine.

For a creatinine blood test:

• A health care professional will take a blood sample from a vein in your arm, using a small needle.
• After the needle is inserted, a small amount of blood will be collected into a test tube or vial.
• You may feel a little sting when the needle goes in or out.

For a creatinine urine test:

• Your health care provider will ask you to collect all urine during a 24-hour period.

• Your health care provider or a laboratory professional will give you a container to collect your urine and instructions on how to collect and store your samples.

• A 24-hour urine sample test generally includes the following steps:

• Empty your bladder in the morning and flush that urine away. Record the time.
• For the next 24 hours, save all your urine passed in the container provided.
• Store your urine container in the refrigerator or a cooler with ice.
• Return the sample container to your health provider's office or the laboratory as instructed.

Extracorporeal shock wave lithotripsy (ESWL):

• Extracorporeal shock wave lithotripsy is a procedure to break up stones inside the urinary tract, bile ducts or pancreatic duct with a series of shock waves generated by a machine called a lithotripter.
• The shock waves enter the body and are targeted using an X-ray. The goal of the procedure is to break the stones into smaller pieces that can pass through the body or become easier to extract.
• For stones in the kidneys and ureter, fragments will exit with urine. For stones in the bile ducts or pancreatic duct, large fragments may need to be removed by using an endoscope (a flexible tube inserted through the mouth).
• ESWL works differently in various people, and is not always the best choice for someone who has a stone. The following are some of the factors that can affect the procedure’s success.

• Stone composition: Stones composed of cystine and certain types of calcium do not break up well with shock waves.
• Stone location: Stones in very narrow ducts may have trouble passing through or being extracted even after they are broken up.
• Stone size: large stones may create big fragments that can be difficult to pass or extract.

Procedure:

• The ESWL procedure takes about an hour, and sometimes longer depending on the size and number of the stones. During the procedure:

• You lie on a table in a specialized treatment room that has the shock wave machine and imaging equipment.
• After you receive anaesthesia, the doctor will use a computerized X-ray machine, sometimes in combination with ultrasound, to pinpoint the stone’s location.
• The doctor will place you in the best position to aim the shock waves at the stone.
• A series of shock waves (several hundred to several thousand) is released at the stone. The doctor will adjust the power and the intervals of the shock waves as needed to break up the stone.

• Pancreatic duct or bile duct stones broken up by ESWL may need to be extracted with an endoscope, which is done right after the ESWL procedure.

Surgical procedure to treat Kidney stone:

Ureteroscope:

• It is an endoscope designed to visualize and work within the ureter.
• Other scopes commonly used by urologists and endourologists include the cystoscope (used in the bladder) and the nephoscope (used in the kidney)
• There are two types of ureteroscopes, rigid and flexible.
• Rigid ureteroscopes, as their name implies, are firm and preferred for treatment of stones lodged in the lower ureter which can usually be accessed in a straight path.
• Flexible ureteroscopes: when stones are located in the upper ureter and/or kidney, they often require flexible ureteroscopes that accommodate to the shape of the ureter and renal collecting system (Fig-1).
• Though more difficult to manoeuvre, flexible scopes allow the urologist to inspect nearly the entirety of the inner kidney to find stones, treat them, and remove them using a variety of techniques. Innovation this area is brisk and modern digital ureteroscopes offer increasingly superior image quality, lighting and wide fields of view.

(Fig-1)

Instruments used in Ureteroscopy:

Irrigation and Access Sheaths:

• In order visualize anything at all, fluid must run continuously through the scope and into the kidney to wash away blood, debris, and crystals that impair visualization.
• To accomplish this, the fluid (most commonly saline) is hung from a bag and run through tubing directly into the body of the scope where it comes out the tip and into the kidney.
• This inflow is harmless, but excess filling of the kidney because of high pressure inflow or an inability of the fluid to freely exit around the scope can overstretch the kidney and cause fluid absorption, leakage, bleeding, and small tears within the kidney itself, a term we call extravasation.
• To prevent this, many urologists use a device called a ureteral access sheath (Fig-2). This can be thought of as a temporary tunnel from the bladder to the kidney which allows any fluid that is irrigated into the kidney to quickly wash out around the scope, optimizing visualization and decreasing the likelihood of extravasation.
• The scope can be passed back and forth without rubbing against and potentially damaging the lining of the ureter, which is generally around the same small diameter as the scope itself.
• When used appropriately, temporary sheaths are safe and decrease postoperative infections and sepsis. While the majority of urologists routinely use themduring ureteroscopy, debate does exist within the community as to whether or not they are required in every case.

(Fig-2)

Lasers and Baskets:

• Many instruments, all are extremely thin, can be passed through the small working channel that runs from the back of the ureteroscope outside of the body, to the tip of the scope in the kidney. They are used to fragment and remove stones.
• Stone retrieval baskets, pictured below (Fig-2), (Cook Medical, Bloomington, IN) are opened and closed by an assistant to ensnare stones and remove them from the kidney. They come in various shapes, sizes and configurations. When stones are roughly 2-4 mm the basket is able to remove them intact. When stones are larger, they must be fragmented into smaller pieces in order to be removed or pass.

(Fig-2)

• The most commonly utilized method to fragment stones during ureteroscopy is laser lithotripsy. Several lasers exist for the purpose but the most popular one by far is the Holmium laser.
• The Holmium laser (Fig-3) can safely fragment any type of stone.The laser delivers short bursts of light energy through water that destroys the stone’s structure by creating a micro explosion of intense heat, pressure, and cavitation bubbles. Because the laser energy penetrates less than half of a millimetre deep it causes minimal damage to surrounding tissues.

(Fig-3)

Ureteroscopy Stone Treatment Techniques:

• As ureteroscopy technology and familiarity with this approach to treat stones continues to grow, the relative number of stones being treated in this fashion has been growing rapidly as well.
• The latest estimates of surgical practice from the past decade show that ureteroscopy has replaced shock wave lithotripsy as the most commonly performed treatment of kidney stones, accounting for 54% of upper urinary tract stone procedures.
• Along with the widespread adoption of this procedure, two main techniques have evolved into practice, the optimal one of which remains unclear.

Active Extraction

• Active extraction means to remove every piece of stone from the kidney so that at the end of the procedure there are no remaining stones and patients do not pass any stones postoperatively.
• Critics raise concerns that this technique requires a ureteral access sheath, an assistant to operate the basket, and potentially increases the operating time.

Stone Dusting

• Stone dusting is conceptually different from active extraction because the goal of the procedure is not to remove all stones directly but rather fragment them into minute pieces (dust) that can then be passed after the procedure, painlessly and without consequence.
• Because his technique needs no access sheath, being performed with single pass of the ureteroscope, it benefits patients with narrow ureters.
• The surgeon can dust with only a laser and avoid a basket with its cost of disposable equipment and need for a skilled assistant.

YouTube video link:

https://youtu.be/oU_GUAWz52w

1. Project: A Detail study of Cardiac system Clinical condition and its diagnostic/surgical procedure:

Introduction:

• The evaluation of the cardiovascular system includes a thorough medical history, a detailed examination of the heart and the peripheral arterial and venous circulations, and appropriate laboratory studies.
• In addition to the electrocardiogram and chest x-ray, the availability of sophisticated non-invasive techniques (e.g., echocardiography and nuclear cardiology) and the continued improvement of cardiac catheterization and angiography have significantly enhanced the clinical work-up of the patient with a cardiovascular problem.
• A careful assessment will enable the clinician to identify the etiologic, anatomic, and physiologic components of a specific cardiovascular disorder, as well as to determine overall cardiac function.

1. Echocardiogram:

• An echocardiogram is an ultrasound test that checks the structure and function of your heart. An echo can diagnose a range of conditions including cardiomyopathy and valve disease.
• During an echo test, your healthcare provider uses ultrasound (high-frequency sound waves) from a hand-held wand placed on your chest to take pictures of your heart’s valves and chambers.
• There are several types of echo tests: an
• Transthoracic
• Transoesophageal

Transthoracic:

• A transthoracic echo is the type most people think of when they hear “heart echo.” It’s also the type most often used. It’s performed outside your body.
• A sonographer places a hand-held wand (called a transducer) on the outside of your chest to send sound waves to your heart. These sound waves bounce off the different parts of your heart.
• These “echoes” then appear as pictures on the sonographer’s computer screen. These pictures can also be saved for your cardiologist and physician to review later.

Transoesophageal:

• A transoesophageal echo takes pictures from inside your chest, rather than from the outside. It can show your heart and valves in greater detail than a transthoracic echo. That’s because your body’s bones and tissues aren’t in between the transducer and your heart.
• For this test, the sonographer guides a small transducer down your throat and oesophagus (food tube) using a long, flexible tube. This minimally invasive procedure may cause mild, temporary discomfort
• But it has a low risk of serious problems.

2. Exercise tests or stress tests:

• An exercise stress echo, sometimes simply called a stress echo, shows how your heart works when it’s taxed.
• The test resembles a traditional exercise stress test. A technician will monitor your heart rate and rhythm as well as your blood pressure (this is standard during a stress test). But they’ll also use echo imaging (which isn’t normally used during a stress test).
• This test shows how well your heart can withstand activity. Your sonographer takes pictures before you start exercising and then right after you’re done.
• In some cases, you won’t exercise. Instead, your provider will give you medication to make your heart work harder as if you were exercising. The goal is to force your heart to need more oxygen.
• When your heart is under stress, your sonographer can see details they might not be able to see if you were lying on the exam table. These include problems with your coronary arteries or the lining of your heart.

Procedure:

• The exercise stress echo will include the following steps:

• Your sonographer will place electrodes (small stickers) on your chest. These stickers are hooked up to an EKG monitor to check your heart rate and rhythm during the test.
• Your provider will measure your heart rate, heart rhythm and blood pressure before you start moving.
• You’ll lie on an exam table so your sonographer can take pictures of your heart. They’ll place a hand-held wand (the kind usually used for echo tests) on the outside of your chest in various spots.
• Then, it’s time to start moving. You’ll walk on a treadmill or pedal on a stationary bike. The intensity will gradually increase. You’ll keep going until you’re exhausted. This usually takes seven to 12 minutes.
• As you’re exercising, a technician will ask how you’re feeling. Tell them any and all symptoms you notice. They’ll also watch your heart on the EKG monitor.
• You’ll stop moving, and you’ll have another echo test done.
• You’ll then do a short cool-down (slow walking or cycling), and your provider will monitor your vitals until they’re back to normal.

3. Cardiac catheterization:

• Cardiac catheterization is a procedure in which a thin, flexible tube (catheter) is guided through a blood vessel to the heart to diagnose or treat certain heart conditions, such as clogged arteries or irregular heartbeats. Cardiac catheterization gives doctors important information about the heart muscle, heart valves and blood vessels in the heart.
• During cardiac catheterization, doctors can do different heart tests, deliver treatments, or remove a piece of heart tissue for examination. Some heart disease treatments — such as coronary angioplasty and coronary stenting — are done using cardiac catheterization.
• These are some of the other procedures that may be done during or after a cardiac catheterization:

• Angioplasty. In this procedure, your doctor can inflate a tiny balloon at the tip of the catheter. This presses any plaque build-up against the artery wall and improves blood flow through the artery.
• Stent placement. In this procedure, your doctor expands a tiny metal mesh coil or tube at the end of the catheter inside an artery to keep it open.
• Fractional flow reserve. This is a pressure management technique that’s used in catheterization to see how much blockage is in an artery
• Intravascular ultrasound (IVUS). This test uses a computer and a transducer to send out ultrasonic sound waves to create images of the blood vessels. By using IVUS, the doctor can see and measure the inside of the blood vessels.

Reason for Cardiac catheterization:

• Atherosclerosis. This is a gradual clogging of the arteries by fatty materials and other substances in the blood stream.
• Cardiomyopathy. This is an enlargement of the heart due to thickening or weakening of the heart muscle
• Congenital heart disease. Defects in one or more heart structures that occur during fatal development, such as a ventricular septal defect (hole in the wall between the two lower chambers of the heart) are called congenital heart defects. This may lead to abnormal blood flow within the heart.
• Heart failure. This condition, in which the heart muscle has become too weak to pump blood well, causes fluid build-up (congestion) in the blood vessels and lungs, and edema (swelling) in the feet, ankles, and other parts of the body.
• Heart valve disease. Malfunction of one or more of the heart valves that can affect blood flow within the heart.

Procedure:

• A healthcare professional may shave the area where the catheter will be put in. The catheter is most often put in at the groin area, but other places used are the wrist, inside the elbow, or the neck.
• A healthcare professional will start an intravenous (IV) line in your hand or arm before the procedure to inject the dye and to give you IV fluids, if needed.
• You will lie on your back on the procedure table.
• You will be connected to an ECG monitor that records the electrical activity of your heart and monitors your heart during the procedure using small electrodes that stick to your skin. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) will be monitored during the procedure.
• Several monitor screens in the room will show your vital signs, the images of the catheter being moved through your body into your heart, and the structures of your heart as the dye is injected.
• You will get a sedative in your IV before the procedure to help you relax. But you will likely be awake during the procedure.
• Your pulses below the catheter insertion site will be checked and marked so that the circulation to the limb can be checked after the procedure.
• Your doctor will inject a local anaesthetic (numbing medicine) into the skin where the catheter will be put in. You may feel some stinging at the site for a few seconds after the local anaesthetic is injected.
• Once the local anaesthetic has taken effect, your doctor inserts a sheath, or introducer into the blood vessel. This is a plastic tube through which the catheter is thread into the blood vessel and advanced into the heart. If the arm is used, your doctor may make a small incision (cut) to expose the blood vessel and put in the sheath.
• Your doctor will advance the catheter through the aorta to the left side of the heart. He or she may ask you to hold your breath, cough, or move your head a bit to get clear views and advance the catheter. You may be able to watch this process on a computer screen.
• Once the catheter is in place, your doctor will inject contrast dye to visualize the heart and the coronary arteries. You may feel some effects when the contrast dye is injected into the catheter. These effects may include a flushing sensation, a salty or metallic taste in the mouth, nausea, or a brief headache. These effects usually last for only a few moments.
• Tell the doctor if you feel any breathing difficulties, sweating, numbness, nausea or vomiting, chills, itching, or heart palpitations.
• After the contrast dye is injected, a series of rapid X-ray images of the heart and coronary arteries will be made. You may be asked to take a deep breath and hold it for a few seconds during this time. It’s important to be very still as the X-rays are taken.
• Once the procedure is done, your doctor will remove the catheter and close the insertion site. He or she may close it using either collagen to seal the opening in the artery, sutures, a clip to bind the artery together, or by holding pressure over the area to keep the blood vessel from bleeding. Your doctor will decide which method is best for you.
• If a closure device is used, a sterile dressing will be out over the site. If manual pressure is used, the doctor (or an assistant) will hold pressure on the site so that a clot will form. Once the bleeding has stopped, a very tight bandage will be placed on the site.
• The staff will help you slide from the table onto a stretcher so that you can be taken to the recovery area.
• NOTE: If the catheter was placed in your groin, you will not be allowed to bend your leg for several hours. If the insertion site was in your arm, your arm will be elevated on pillows and kept straight by placing it in an arm guard (a plastic arm board designed to immobilize the elbow joint). In addition, a tight plastic band may be put around your arm near the insertion site. The band will be loosened over time and removed before you go home.

You Tube video link:

https://youtu.be/kY5gKdFWT3k