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By T. Vak. Regis College.

The other option for patient diagnosed before developing acute complications Start with 20- 25 units of Humulin insulin (equivalent to daily insulin production by islets) S cheap 250 mg keppra visa. It helps to achieve near normal blood glucose level and thus delays the development of chronic complications order generic keppra on-line. Oral hypoglycemic agents These groups of drugs are widely used in type 2 patients whose hyperglycemia has failed to be controlled with conservative measures buy keppra 250 mg cheap. The dose can be increased by 5 U every 3 to 7 days until adequate control is achieved. Follow up of patients:-Since this is a lifelong disease regular follow up of patient is crucial. Points to give emphasis during follow up Symptoms of hyper or hypoglycemia Wight Blood pressure Visual acuity Examine the oral cavity Examination of the feet Examine Injection site Laboratory tests: blood or urine sugar and urine albumin or protein. Hyperosmolar Comma 1) Hypoglycemia in the diabetic patient is caused by Overdose of insulin or hypoglycemic agents Missing of meal Strenuous exercise 446 Internal Medicine Clinical manifestations Early: one may feel the effects of sympathetic stimulation such as cold sweat, tremor, hunger or palpitations. This biochemical changes bring about: Increased production of glucose by the liver and increased glycogen degradation to glucose Decreased glucose uptake and utilization by muscles Lipolysis: enhanced break down of free fatty acids and subsequent ketogenesis. This increases blood levels of keton bodies such as acetoacetic acid, -hydroxybutyric acid, and acetone, resulting in metabolic acidosis. Signs and symptoms: Volume depletion : dehydration- dry tongue and bucal mucosa, poor skin turgor and hypotension Kussmaul respiration : deep and fast breathing resulting from metabolic acidosis Acetone ("fruity") odour of breath: due too acetone Nausea and vomiting and frequent complaint of abdominal pain. Supportive therapy: Airway maintenance, supplemental oxygen as needed, and treatment of shock. Fluid replacement: Fluid replacement corrects dehydration caused by glucose induced osmotic diuresis. Insulin: Insulin is administered to increase glucose use in the tissues, to inhibit ketogenesis, and to counter balance the effect of counter regulatory hormones. Then 5-10 /hr units or regular insulin is given per hour till the blood glucose level drops to 250-300mg/dl 449 Internal Medicine Blood glucose determination is done every hour. Close follow-up of patients Monitor serum glucose and potassium as well as urine output hourly. Oral intake may resume when mental status of the patient improves and nausea and vomiting are controlled. Initial diet should consist of fluids, and solid diet is may not be resumed until ketoacidosis is corrected. Symptoms: Such patients present with several weeks history of polyuria, weight loss, and diminished oral fluid intake that is followed by mental confusion, lethargy or comma. Physical examination: Patients have extreme dehydration, hypotension, tachycardia and altered state of consciousness or comma. The dehydration is caused by a hyperglycemia induced osmotic diuresis, when it is not matched by adequate fluid intake. Retinopathy : Is one of the commonest chronic complications and one of the leading causes of blindness in developed countries. Diabetic Foot Ulcer The following are underlying mechanism for diabetic foot ulcers Neuropathy o Loss of pain sensation exposes to injury o Loss of sweating results dry skin that is susceptible to injury Vascular: poor blood supply to the foot causes decreased healing of wound poor recovery from secondary infections. Since the foot is not in a normal anatomic position it is exposed to abnormal load and pressure sores develop. Thyroid disorder Learning objectives: at the end of this lesson the student will be able to: 1. Identify the clinical manifestation of diseases of the thyroid, with special emphasis on hyperthyroidism and hypothyroidism. Introduction: The thyroid gland normally weighs 20gm and is visible in thin women. The basic unit of thyroid structure is a follicle which is spherical in shape, filled with colloid, and encompassed by single epithelial cell layer. The hormones produced by the thyroid gland are referred to as tri- iodothyronine (T3) and thyroxin (T4). Thyroid disorders: Manifest with qualitative or quantitative alteration of thyroid hormone secretion, enlargement of thyroid, or both. The advantages of carrier proteins are: They are reservoirs to replenish free hormone level They buffer any fluctuation in gland secretion They protect against hepatic degradation and renal excretion of the hormone Standard lab tests measure protein bound hormone level so that results depend on the concentration of these proteins. Serum T3 and T4 level: measures the total bound (99 %) and free (1 %) hormone level in the circulation. This gives some clue about serum level of thyroid hormone, but has limitation since serum level of the hormone is influenced by conditions affecting the level of carrier proteins. It is a very sensitive test and, because it usually becomes elevated even before thyroid hormone (T3 and T4) level decline below normal. Thyroid stimulating antibodies, circulating antibody against T3 and T4 is an evidence for autoimmune disease of thyroid glands. Thyroid carcinoma Epidemiology of Thyroid Diseases is Ethiopia Simple nodular goiter is very common in areas where there is serious iodine deficiency. Of these 44% were thyrotoxic, 24% has solitary nodules, 29% simple toxic goiter, while thyroiditis and hypothyroidism were rare. Patients however remain asymptomatic probably due to decreased impact on peripheral tissue. Hyperthyroidism Definition: Hyperthyroidism is a hypermetabloic state, resulting from excessive thyroid hormone function. Etiology: Common causes of hyperthyroidism include: Gravesdiseases Toxic multinodular goiter Toxic adenomas 458 Internal Medicine Graves disease: Is the most common cause of hyperthyroidism in the third and fourth decades. Toxic multinodular goiter: It usually develops insidiously in a patient who has had a nontoxic nodular goiter for years. When they do, they are usually less toxic than those with Graves disease, and they do not develop ophthalmopathy or pretibial myxedema. Autoimmune thyroiditis/ Hashimotos thyroiditis: Normal-sized or enlarged nontender thyroid gland. Excess exogenous thyroid hormone administration: May occur because of dosage errors or occasionally in individuals taking large doses of thyroid hormones to lose weight or increase their energy. Antithyriod drugs: Inhibit the oxidation of iodine and coupling of iodotyrosines, thus decrease the synthesis of thyroid hormone. Side effects /drug toxicity Skin rash or joint pain Agranulocytosis Advantages of Atithyroid drugs: Hospitalization, surgery and anesthesia are avoided The occurrence of post treatment hypothyroidism is less likely Disadvantages: Permanent remission occurs in fewer than 50 % of patients Treatment success depends on patient compliance to treatment 2. Radioactive iodine 131 131 Iodine, 5 to 15 mCi, a single dose of I, causes a decrease in function and size of the thyroid gland in 6- 12 weeks. Advantages: Hospitalization, surgery and anesthesia are avoided The rate of cure is almost 100% Little patient compliance is required Disadvantages: There is a risk of treatment induced hypothyroidism 131 Pregnancy is an absolute contraindication to I therapy. Inorganic iodine rapidly controls hyperthyroidism by inhibiting hormone synthesis and release from the gland. Surgery: Subtotal thyriodectomy - usually reserved for those who are unable to take antithyroid drugs Preparation for surgery: Operation on thyrotoxic patient produces the risk of thyroid storm; therefore, treatment should be initiated with atntithyriod drugs, long enough in advance for patients to return to a euthyriod state before surgery.

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History and Physical Examination Proctalgia fugax occurs in about 14% of adults and is somewhat more common in females than males purchase keppra now. The pain may be excruciating buy keppra with american express, but since it is so short-lived patients seldom report it to their physician buy generic keppra 250mg. In 90% of instances it lasts less than five minutes and in many cases less than a minute. Differential Diagnosis Perianal disease may cause pain but it usually accompanies, rather than follows, defecation. One should be particularly careful to exclude the presence of an anal fissure, which may be difficult to see on anal inspection. Pain originating from the coccyx may be accompanied by coccygeal tenderness both externally and from within the rectum. An acute attack of anal pain lasting several hours may indicate a thrombosed hemorrhoid. Saloojee Examination of the abdomen is an important component of the clinical assessment of anyone presenting with suspected disease of the gastrointestinal tract. As in all other parts of the examination, care must be taken to show respect and concern for the patient while ensuring an appropriate and thorough examination. While performing the examination it is useful to keep in mind the concepts of sensitivity and specificity. How confident can we be that a suspected physical finding is in fact present and has clinical significance? For example, how sensitive and specific is our bedside examination for hepatomegaly? What is the clinical significance of an epigastric bruit heard in a thin 20-year-old female versus a 55-year-old hypertensive, obese male? In the following sections we will describe an appropriate sequential examination of the abdomen and highlight some of the potential pitfalls of this process. When describing the location of an abnormality it is useful to divide the abdomen into four quadrants. Imagine a perpendicular line through the umbilicus from the xiphoid process to the symphysis pubis. The overall appearance of the abdomen can be described as scaphoid (markedly concave), protruberant, or obese. One should examine the skin for cutaneous lesions, vascular markings, dilated veins and striae. Division of the abdomen into nine quadrants: the left upper quadrant, right regions. Auscultation It is useful to auscultate the abdomen for bowel sounds and bruits prior to palpation or percussion. Bruits are vascular sounds created by turbulent flow and may indicate partial arterial occlusion. Arterial bruits are usually heard only during systole and best heard with the diaphragm of the stethoscope, as they are high pitched. Renal bruits may be heard midway between the xiphoid process and the umbilicus, 2 cm away from the midline. About 20% of normal persons will have a vascular bruit, so that the auscultation of an abdominal bruit has to be placed within the clinical context. This is found an area approximated by an ellipse between the umbilicus and the midclavicular line where it crosses the right subcostal margin. There are, however, no studies to suggest this is a helpful finding in routine examination. Friction rubs are a rare sound indicating inflammation of the peritoneal surface of an organ. However, even with careful auscultation of patients with known liver tumours, fewer than 10% are found to have a rub. Bowel Sounds Bowel sounds should be listened for prior to palpation or percussion, but the yield of this examination is low. Listening in one spot, such as the right lower quadrant, is generally sufficient since bowel sounds are transmitted widely through the abdomen. Rushes of very high pitched bowel sounds First Principles of Gastroenterology and Hepatology A. Shaffer 32 coinciding with crampy pain may indicate hyperperistalsis and acute small bowel obstruction. Palpation Palpation of the abdomen should be done in an orderly sequence with the patient in the supine position. Light palpation should be done in all four quadrants, assessing for areas of potential tenderness. With one hand, using the pads of the fingertips, palpate in a gentle, circular motion. It is thought that using one hand for deep palpation may increase the risk of missing a mass. Involuntary guarding and rebound tenderness are signs of peritoneal inflammation (peritonitis). Guarding refers to contraction of abdominal wall muscles when the abdomen is palpated. Involuntary guarding occurs as a protective mechanism when peritonitis is present. It is useful in defining organomegaly and the presence of free intra-abdominal fluid (ascites), as discussed below. The patient is asked to breathe deeply and slowly, in order to bring the liver edge down to the examining fingertips of the right hand. The examiner moves the right hand in a cephalad direction about 2 cm with each expiration. When the liver edge is palpable, trace the edge First Principles of Gastroenterology and Hepatology A. Percuss in a cephalad direction in the right midclavicular line until an area of dullness is encountered. Percuss for the upper border starting in the right midclavicular line in the third intercostal space. Move down one interspace at a time until the percussion note changes from resonant to dull. To confirm the change of percussion note strike the third and fourth fingers laid in adjacent interspaces. Measure the distance between the upper and lower percussion edges in the mid-clavicular line. The diaphragm of the stethoscope is placed at the right costal margin in the midclavicular line.

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