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This vicious circle of thoughts purchase sarafem 10mg fast delivery womens health group, physical symptoms and changes in behaviour maintain Georges anxiety and depression order sarafem amex breast cancer 2b. Thoughts Physical symptoms Behaviour Look at your thoughts, physical symptoms and behaviour. Linking thoughts, physical symptoms and behaviour. For example rather than say I feel depressed, identify what it is about being depressed that is a problem to you. These are examples of the common problems people say they have: It takes me 2 hours to get off to sleep at night. Using the above questions and the information you have on your thoughts, physical symptoms and behaviour define your problems and write them in the box on the next page. Helpful hints Keep a diary monitoring your feelings, thoughts and behaviour for 1 week to see if it helps you to identify the problem. After you have written your problem, use the scale below to rate each problem in the box titled Time 1. After you have worked on your problem for a few weeks rate the problem again at time 2 using the scale below to see what progress you have made. In a few months rate your problem again at time 3 to ensure that you have maintained your progress. This problem upsets me and or interferes with my life 0----------------2-------------------4------------------6-----------------8 not at slightly sometimes much all the all time Problem 1. Time 1 Time 2 Time 3 Problem 2. Time 1 Time 2 Time 3 9 Now you have defined your problems, you can decide what you want out of your programme. Goals will help you to: keep focussed on the problem; be clear about what you want to achieve; and get feedback on your progress. You may want to feel better or to feel less anxious but ask yourself what feeling better means you will be able to do. Examples of goals might be: to go and play badminton once a week and enjoy it; to get to sleep in 30 minutes on 6 occasions weekly; and to be able to concentrate and enjoy reading a book regularly. Working with too many goals can be confusing so we would suggest that you work with between 1 and 3 goals. After you have worked on your problem re rate the goal at time 2 to see what progress you have made. In a few months re rate the goals to ensure that you are maintaining your progress. My progress towards achieving each goal regularly without difficulty is: 0----------------2-------------------4------------------6-----------------8 complete 75% 50% 25% 0% success success success success success Goal 1. Time 1 Time 2 Time 3 Goal 2. Time 1 Time 2 Time 3 Goal 3. The strategies aim to change thoughts, physical symptoms or behaviour, and because they each affect one another, a change in one area will lead to changes in the other areas. All the strategies have been studied in research trials and have been shown to help people with anxiety and depression. It is suggested that you read through the following interventions and choose the one that you think is best for you. If you are depressed and finding it difficult to motivate yourself it is often helpful to begin with behavioural activation and then using cognitive restructuring. If you have a specific fear or phobia exposure will probably be the best way of overcoming your problem. If you were suffering from more general anxiety and stress we would suggest that you use problem solving and some relaxation techniques. This will lead to more helpful thoughts such as I have achieved something today and found it pleasurable. Changing your thoughts and behaviour will also lead to positive changes in your physical symptoms. This is to make sure that you can do what you set out to do and that you do not become physically exhausted. Ask yourself if it was because something happened that was outside your control or if it was because you set yourself an unrealistic schedule. Many studies have shown behavioural activation to be helpful when it is used with other treatments such as cognitive therapy. However there is also evidence that this treatment alone is successful in reducing mild and moderate depression. On completing each activity score your feeling of achievement and pleasure using the following scales: Achievement (the sense of achievement you felt) 0----------------2-------------------4------------------6-----------------8 None moderate complete Pleasure (the amount of pleasure you gained) 0----------------2-------------------4------------------6-----------------8 None moderate complete 15 Example of using behavioural activation Anne is 35 and works as a receptionist 3 days a week in a dental surgery. A year ago a long-term relationship had broken down and since then has felt depressed. As result of the death of her mother and loss of relationship, and subsequent depression she has lost contact with many friends and rarely meets other people or socialises other than at work. Consequently she no longer engages in any of her previously enjoyed activities such as going to the cinema, days out at the weekends and going for a drink in the local pub. Anne said that in the evenings and at weekends she does very little except watch television, she used to enjoy gardening but says I just do not seem to be able to get going. Anne also did not do many other things she had stopped reading the daily paper and did not have it delivered any more. She used to go to the local library at least once a week and read 2-3 books weekly. Anne defined her problems and goals as: Problem 1 Feeling depressed and miserable for the last year and I have not been able to motivate myself to do the things I used to enjoy doing. Ringing her friend was the task that she achieved most pleasure as her friend had asked to meet up with her the following week. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9-10 Work Work Work Read paper Read paper Read paper Read paper for 30 for 30 mins for 30 mins for 30 mins minutes A = 5 A = 5 A = 5 A = 5 P = 3 P = 4 P = 4 P = 3 10-11 Work Work Work Library A = 5 P = 5 11-12 Work Work Work 12-1 Work Work Work 1-2 Work Work Work 2-3 Work Work Work 3-4 Work Work Work 4-5 Work Work Work 5-6 Ring a friend A = 6 P = 6 6-7 7-8 8-9 17 Anne slowly increased her levels of activity and looking at her diary 6 weeks later shows the amount of progress that Anne made. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9-10 Work Work Work Read paper Read paper Read paper Coach outing for 30 mins for 30 mins for 30 mins with friend A = 4 A =4 A = 5 all day P = 4 P = 4 P = 4 10-11 Work Work Work As above 11-12 Work Work Work Shopping As above A= 3 P= 2 12-1 Work Work Work As above 1-2 Work Work Work As above 2-3 Work Work Work Library Inquired re As above A= 6 nightschool P= 5 A= 8 P= 8 3-4 Work Work Work Gardening As above 4-5 Work Work Work Gardening As above 5-6 Read paper Read paper Read paper Read novel Gardening As above A = 4 A = 4 A = 4 A= 6 A= 6 A = 7 P = 4 P = 4 P = 4 P= 5 P= 7 P = 7 6-7 Cinema Read novel A= 6 P= 5 7-8 Cinema 8-9 Cinema A= 7 P = 7 By about week 12 Anne was beginning to feel like her normal self. She felt it had been difficult to do some of the tasks she set herself, particularly in the first 4 weeks but very much worthwhile the effort. We are not very good at taking time out for ourselves, but we always feel better when we do. There are a number of ways of relaxing and you need to choose a way that works for you. Progressive relaxation Use the rating scale on page 17 to rate the level of relaxation you feel before you begin a relaxation exercise. You need to become aware of the feelings you get in your body when you tense and release muscles.

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When no specific existing code is available cheap 10 mg sarafem with mastercard breast cancer 9gag, an independent lab can seek (and is typically assigned) a miscellaneous code to identify a new laboratory-developed test for billing purposes 20mg sarafem sale women's health center bar harbor. The lab can seek from its local Medical contractor a payment rate for the new test using that miscellaneous code because all claims for the test will be submitted to that contractor. This approach is not available for a manufacturer of a comparable test who plans to sell the test to multiple labs around the country. These stacked codeseach with a separate payment ratecan sometimes combine to provide a fair payment to the lab performing the test. However, these generic method codes do not identify for the insurer what specific test was performed. In addition, this approach provides disincentives for a lab to develop or to make use of a test which has fewer steps, even if it is a 45 better test. With the development of new molecularespecially genetictests, the current coding system faces challenges in assigning codes that have the necessary specificity to identify new tests. In a Congressionally-mandated study examining this payment system that was completed in 2000, the Institute of Medicine 46 concluded that this system was not only outdated, but also irrational. The payment system lacks openness and adequate procedures for stakeholder involvement; clear and consistent information on how the system works and opportunities for the public and stakeholders to have input into decision processes are limited. The fee schedules administrative operations are unnecessarily complex and inefficient; particularly in the way the system incorporates new technologies and determines whether or not a laboratorys claim 47 should be paid. Though some progress has been made in recent years by Medicare to seek stakeholder views 48 during the process of setting rates for new tests, the underlying problems with the Clinical Laboratory Fee Schedule (e. The current rate-setting approach for new tests does not support the return on investment that would support the generation of the evidence needed to fully evaluate clinical performance prior to 49 marketing, and, by focusing on matching new tests to existing tests (and their payment rates), 50 it provides little reward for creating additional value. Local variations in payment rates force laboratories to cross-subsidize tests for which payment rates are too low, and they distort laboratory incentives for efficiency, threatening patient access. Because private health insurers use Medicare payment rates as a reference point in setting their own payments, these deficiencies in the Clinical Laboratory Fee Schedule are further magnified. This leaves the prudent use of antimicrobial medicines, along with infection control, as the major strategies to counter this emerging threat. A safe and efective strategy for antibiotic use involves prescribing an antibiotic only when it is needed and selecting an appropriate and efective medicine at the recommended dose, with the narrowest spectrum of antimicrobial activity, fewest adverse efects and lowest cost. Only prescribe antibiotics for bacterial infections if: Symptoms are signifcant or severe There is a high risk of complications The infection is not resolving or is unlikely to resolve 2. Reserve broad spectrum antibiotics for indicated conditions only The following information is a consensus guide. It is intended to aid selection of an appropriate antibiotic for typical patients with infections commonly seen in general practice. Individual patient circumstances and local resistance patterns may alter treatment choices. Subsidy information for medicines has not been included in the guide as this is subject to change. Fully-subsidised medicines should be prescribed as frst-line choices, where possible. Antibiotic treatment is unlikely to alter the clinical course of the illness unless given early (in the catarrhal stage). Women who are in their third trimester of pregnancy should also receive antibiotic treatment, regardless of the duration of cough. The patient should be advised to avoid contact with others, especially infants and children, until at least fve days of antibiotic treatment has been taken. Erythromycin ethyl succinate is currently the only fully subsidised form of oral erythromycin available in New Zealand. Treatment and prophylaxis is recommended for 14 days with erythromycin ethyl succinate. There is evidence that seven days of treatment with erythromycin estolate (which has superior tissue and serum concentrations compared with the other erythromycin salts), is as efective as 14 days treatment. Ciprofoxacin should not be used as it does not reliably treat infections due to S. In addition, if there is no response to treatment in 24 48 hours, review diagnosis and consider referral to hospital. Can be frst-line in school-aged children where the likelihood of atypical pathogens is higher. Only available in tablet form, therefore only if the child can swallow tablets; whole or half tablets may be crushed. Most topical antibacterials are contraindicated in the presence of a perforated drum or grommets, however, they may need to be used if other treatment options have been unsuccessful. Flucloxacillin if there is spreading cellulitis or the patient is systemically unwell; also consider referral to hospital. Consider antibiotics for children at high risk such as those with systemic symptoms, aged less than six months, aged less than two years with severe or bilateral disease, or with perforation and/ or otorrhoea. Also consider antibiotics in children who have had more than three episodes of otitis media. Co-trimoxazole should be avoided in infants aged under six weeks, due to the risk of hyperbilirubinaemia. The major beneft of treating Streptococcus pyogenes pharyngitis is to prevent rheumatic fever, therefore antibiotic treatment is recommended for those at increased risk of rheumatic fever, i. Sinusitis acute Management Most patients with sinusitis will not have a bacterial infection. Even for those that do, antibiotics only ofer a marginal beneft and symptoms will resolve in most patients in 14 days, without antibiotics. Most bacterial conjunctivitis is self-limiting and the majority of people improve without treatment, in two to fve days. In newborn infants, consider Chlamydia trachomatis or Neisseria gonorrhoeae, in which case, do not use topical treatment. Common pathogens Viruses, Streptococcus pneumoniae, Haemophilus infuenzae, Staphylococcus aureus Less commonly: Chlamydia trachomatis or Neisseria gonorrhoeae Antibiotic treatment Conjunctivitis First choice Chloramphenicol 0. Give benzylpenicillin before transport to hospital, as long as this does not delay the transfer. Almost any parenterally administered antibiotic in an appropriate dosage will inhibit the growth of meningococci, so if benzylpenicillin or ceftriaxone are not available, give any other penicillin or cephalosporin antibiotic. Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e. Adult and child >12 years: 160+800 mg (two tablets), twice daily, for fve to seven days 10 Cellulitis Management Keep afected area elevated (if applicable) for comfort and to relieve oedema. Common pathogens Streptococcus pyogenes, Staphylococcus aureus, Group C or Group G streptococci Antibiotic treatment Cellulitis First choice Flucloxacillin Child: 12. Adult and child aged over 12 years: 160+800 mg (two tablets), twice daily, for fve to seven days 11 Skin (continued) Diabetic foot infections Management Antibiotics (and culture) are not necessary unless there are signs of infection in the wound. However, in people with diabetes and other conditions where perfusion and immune response are diminished, classical clinical signs of infection are not always present, so the threshold for suspecting infection and testing a wound should be lower. Referral to hospital should be considered if it is suspected that the infection involves the bones of the feet, if there is no sign of healing after four weeks of treatment, or if other complications develop. Common pathogens Early infection is usually due to Staphylococcus aureus and/or streptococci.

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This helps care givers and the patient to access and follow the efficiency of their glycemic control plan buy 10mg sarafem fast delivery pregnancy pillows. Every three months buy discount sarafem 20 mg womens health jacksonville, examinations of blood pressure, eyes as well as skin and bones on feet and legs are done in order to prevent diabetes related complications. It allows patient to determine if they have reached the glycemic target by evaluating their response to therapy. The outcome may be useful in the prevention of hypoglycemia and ad- justing medications (especially dosage of prandial insulin). It helps to achieve gly- caemic goals for clients, using irregular insulin injections, medical nutritional thera- py and non-insulin therapy. It should be done periodically for patient that are not achieving glycemic goals or changed therapy. The point-of-care testing in A1C grants proper decision when needed on therapy changes. Healthy meal means eating food from all the food groups, low calories and taking the same amount of carbohydrate at each meal (Medlineplus 2015a. Patient with diabetes type 2 should eat carbohydrate from fruit, vegetables, low fat milk and whole grains. Also should monitor their carbohydrate level by counting the amount of carbohydrate in their food content. Insulin secretion by beta- cells is glucose sensitive and a high intake of carbohydrate in relation to energy intake produces higher post-prandial insulin levels. It is possible that repeated stimulation of a high insulin output by a high carbohydrate diet could speed up an age-related decline in insulin secretion and lead to an earlier onset of type 2 diabe- tes. However, the quality and quantity of carbohydrate can urge this response (Mann 2006). The most important source of carbohydrate is from vegetables, leg- umes, whole-grain cereals and fruits and a person total energy intake should con- tain about 45-60% of this while free sugars such as fruit juice and sugary drink should be no more than 5%. Additionally, carbohydrate needs to be monitored in other to obtain glycemic con- trol like counting carbohydrate in meal, exchanges and experience-based estima- tion. Meal containing sucrose can be replaced by other carbohydrate food or if taken insulin or lowering glucose medication should be used after the meal. The recommended dietary allowance for carbohydrate is 130g/day (American diabetes association 2008a. Fish (particularly fatty fish) should be eaten at least two times (two servings) each week. The amount of dietary saturated fat, cholesterol, and trans-fat recommended for people with diabetes is the same as that recom- mended for the general population. This type of diet does not only improve glycemic control but also produce an increase in high density lipoprotein choles- terol level and reduces the low density lipoprotein cholesterol level. It is also stated that a meta- analysis within diabetes subject shows the percentage of hemoglobin A1c of aver- age 0. Limited amount of alco- hol can be taken, but blood sugar level can be affect if alcohol is taken with an empty stomach. If alcohol is taken with carbohydrate substance it may raise the blood glu- cose but may not have affect alone when consumed moderately. In type 2 diabetes, important risk factors include central obesity, age and decreased physical activity among adultS. These drug(s) are introduced when the control of blood glucose level remains and / or becomes insufficient, or if the patient does not tolerate the first line drug therapies. The final stage is the initiation of insulin therapies or/ and combining insulin with an oral agent when the oral therapies fail. The major classes of oral anti-diabetics agents for the treatment of type 2 diabetes have different modes of action, safety profiles and tolerability. These classes include agents that spur insulin secretion, increase insu- lin action, minimize hepatic glucose production and delay digestion and absorption of intestinal carbohydrates. Oral anti-diabetic agents should be started with a low dose, then after the measurement of glycosylated hemoglobin (HbA1c) which is 19(55) done by self-monitoring of capillary blood glucose by some patients, the dose may then be titrated up conforming to the glycemic response. The major classes of oral anti-diabetic agents have usually had a comparable average glucose-lowering ef- fect, thus about an average of 12% reduction in HbA1c. It is an essential doctrine to modify treatments according to individual patients and doses must be titrated up steadily according to response. Sulphonylurea has been largely used for half a century for type 2 diabetes treat- ment. These agents stimulate the secretion of insulin from the -cell of the pan- creatic islet, thereby lowering blood glucose levels. They are very effective when used early after type 2 diabetes diagnosis and are also regarded as good first line oral drugs for patients who, despite using non pharmacological measures (e. Excluding other insulin secretagodues, they can also be used as combi- nation therapy with other anti-diabetic agents. However, they can cause hypogly- caemia due to their ability to inhibit glucose production and stimulate insulin re- lease at a low glucose level. They also have a side effect of increased appetite, unwanted weight gain and provoke long term cardiovascular disease risk. They improve fasting hyperglycaemia as well as low- er postprandial glucose levels. They can be used as mono-therapy or as a combi- nation therapy with other class of oral anti diabetic agents. Meglitimides can be helpful drugs for mild to moderate renal impairment patients but a small increase in weight could be expected. They are quite more expensive and have a lower risk of hypoglycaemia than sulphonylureas. They have no risk of hypoglycaemia when used as mono-therapy, hence it can be used as a re- placement drug if a patient has contraindication for, or is intolerant to metformin. They are also used as a combination therapy with other oral agents for obese or non- obese type 2 diabetes patients. The major possible risks to take into consid- eration when using thiazolidinediones are oedema, weight gain, bone fracture and anaemia. Patients with evidence of congestive heart disease or heart failure are contraindi- cated to the use of thiazolidinediones. Most type 2 diabetes patients widely regard metformin as a foundation of oral therapy or as an add- on to some patients on other treatments, such as sulphonylureas. Minimizing the production of an enormous amount of he- patic glucose is the dominant action of metformin. It increases hepatic sensitivity, coordinates cellular energy as well as glucose and lipid metabolism.

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In most patients cheap sarafem 10 mg menstruation 6 weeks after giving birth, serial or previous spected order sarafem online pregnancy guide, and breoptic ureteroscopes can be passed up, measurements of creatinine are useful to monitor the to look for ureteric lesions such as stones or carcinoma. Clearance is dened as the virtual volume of blood cleared (by the kidney) of solute per unit time. When nephrons are lost or are not func- where U = urinary concentration, V = urine ow rate tioning properly, there is compensation by the remain- and P = plasma creatinine. It is 24-hour urinary collections are inconvenient and in- higher following protein intake, in a catabolic state, af- accurate. The best known of these is the creatinine because it is avidly reabsorbed at the proximal Cockcroft and Gault formula: tubules in a uid-depleted state. If the creatinine is also proportionally raised (creatinine is normally Forwomen multiply by 1. The biopsy can be performed percutaneously, or at open surgery (unusual unless the other method is not possible, or contraindicated, e. Ultrasound guidance is used, and usually two cores are obtained using a spring-loaded biopsy needle. These are examined under light microscopy, electron microscopy andimmunouoresenceorimmunoperoxidasestaining. In up to 3% renal failure (creatinine clearance becomes inaccurate), of individuals, blood transfusion is required for bleed- for kidney donors and patients receiving chemotherapy. Contraindications to percutaneous renal biopsy: Anion gap calculation is useful in metabolic acidosis, to r Clotting abnormality or low platelets (unless cor- differentiate causes. The r Small kidneys (<9 cm), as this indicates chronic irre- formula used to calculate the anion gap varies from versible kidney damage. In metabolic acidosis, a normal anion gap indicates that there is failure to excrete acid or loss of base: Dialysis r Failure to excrete acid occurs in renal tubular disease When the kidneys fail to a degree that causes symptoms and Addisons disease. Despite advances in technology, these are still Renal biopsy is indicated when glomerular disease is sus- unable to completely mimic renal function, and none pected,andinunexplainedacuterenalfailure. The dialyser consists of an array of semi-permeable plications include hypotension, line infections, dialysis membranes. The blood ows past the membrane on one amyloid and increased cardiovascular mortality. Smallsoluteswithalarge and solutes across a highly permeable membrane and concentration gradient diffuse rapidly, e. Before the blood is returned to the body, atinine,whereasdiffusionisslowerwithlargermolecules uid is replaced using a lactate or bicarbonate-based so- or if the concentration gradient is low. Proteins are too large to cross the mem- of uid and changes in electrolyte concentration take brane. Underdialysis (lack changedacrosstheperitonealmembranebyputtingdial- of adequate dialysis) is associated with an increase in ysis solution into the abdominal cavity. Dialysateisrunundergravityintotheperi- toneal cavity and the uid is left there for several hours. Blood from Blood to Small solutes diffuse down their concentration gradients patient patient between capillary blood vessels in the peritoneal lining and the dialysate. Patients often develop some consti- Dialysate out Dialysate in pation which can limit the ow of dialysate, they are treated with laxatives. There is a large degree of bacterial peritonitis are the most common serious com- redundancy in the kidney, so many nephrons may be lost plications. This can be treated by adding antibiotics to the It is useful when considering the causes of renal failure peritoneal dialysate. The kidneys have three important functions: 1 Fluid and electrolyte balance, including acidbase bal- ance. High phosphates cause pruritus (itching), chronic r In prerenal failure, the kidney is not damaged but renal failure leads to renal osteodystrophy. Recovery may be possible, though if the disease is severe and scarring results, full Acute renal failure functional recovery is unlikely. The rate at which these rise depends on a number of factors, including how Clinical features catabolic the patient is, i. Complete anuria is only seen with bladder out- Oliguria (urine output <15 mL/hour or <400 mL/ ow obstruction, bilateral (or unilateral in a single 24hour) is common, but does not occur with all causes functioning kidney) ureteric obstruction. Water retention can lead to r Hyperventilationmaybeduetohypoxiaorrespiratory hyponatraemia. Acute glomeru- Primary and secondary causes r Bloods lonephritis of glomerular disease Acute interstitial Pyelonephritis, drugs 1 Anaemia (normochromic, normocytic if underly- nephritis ing disease or in chronic renal failure). Management Acute renal failure is an emergency, with possible life- threatening complications. Complications Reversiblecausesshouldbetreatedassoonaspossible; Hyperkalaemia may cause cardiac arrhythmias and sud- withdraw any potentially nephrotoxic drugs, treat sepsis, den death. Fluid overload may cause cardiac failure, malignant hypertension, and relieve any obstruction. Central venous r Persistent hyperkalaemia >6 mmol/L despite medical pressure measurement may be helpful, but should therapy not be relied upon over clinical assessment espe- r Severe acidosis cially in the presence of cardiac or pulmonary disease. If blood pressure remains low Prognosis despite lling (such as due to cardiac insufciency, Depends on underlying cause and concomitant medical sepsis), then additional treatment, usually inotropic conditions. Denition r In uid overload, or in oliguric renal failure high doses Necrosis of renal tubular epithelium as caused by hypop- of furosemide may be effective in causing a diuresis. However, there is no good evidence that furosemide speeds the recovery from renal failure, and it should Aetiology be avoided in those thought to have pre-renal failure. In addi- tion, in shock renal blood ow is particularly likely to Hyperkalaemia suffer because of constriction of renal vessels due to r Treatseverehyperkalaemia(K>6. Toxin induced r Endogenous Haemoglobinuria, myoglobinuria, Review all medication for dosages in renal failure. Glomerulonephritis 12% Toxinsmayhaveavarietyofmechanismssuchascaus- Pyelonephritis/reux nephropathy 10% ing vasoconstriction, a direct toxic effect on tubular cells Renovascular disease 7% Hypertension 6% causing their dysfunction, and they may also cause the Adult polycystic kidney disease 6% death of tubular epithelial cells which block the tubules. Blockageoftherenaltubulescauses renal function requiring any form of chronic renal re- asecondary reduction in glomerular blood ow. The ep- Incidence ithelial cells take time to differentiate and develop their The exact number of people with chronic renal failure is concentrating function. This phase renal disease such as amyloid, myeloma, systemic lupus may last many weeks, depending on the initial severity erythematosus and gout. Initially there may be a phase of large Prognosis volumes of dilute urine production due to reduction In acute tubular necrosis the mortality is high but if in tubular reabsorption. The kidneys are usually small and shrivelled, with 3 The hormone functions of the kidney are also affected: scarring of glomeruli, interstitial brosis and tubular at- reduction of vitamin D activation causes hypocal- rophy. The onset of uraemia is insidious, but by the time vious historical urea and creatinine measurements are serum urea is >40 mmol/L, creatinine >1000 mol/L, very useful. Late symptoms include r U&E to assess progress of the renal failure, ensure Na+ pruritis, anorexia, nausea and vomiting very late and K+ are normal. It is important to assess the r Urinalysis is performed to look for proteinuria and uid status by looking at the jugular venous pressure, skin turgor, lying and standing blood pressure, and haematuria (if new or increasing these may need fur- for evidence of pulmonary or peripheral oedema (see ther investigation) and urinary tract infections. Management r Cardiovascular: Treat even mild hypertension and The aim is to delay the onset of end-stage renal failure consider treating hyperlipidaemia.