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High-risk individuals should be encouraged to • Maintain a normal body mass index • Engage in regular physical exercise No specific intervention is proven to prevent type 2 diabetes mellitus buy discount trazodone 100 mg line. Braunwald buy cheap trazodone 100 mg, Fauci trazodone 100 mg sale, Kasper, Hauser, Longo, Jameson:Harrison’s Principles of th Internal medicine, 15 Edition 12. Links or references to nonfederal organizations mentioned in this book or in the resource list are provided solely as a service to our users. This book is dedicated to all people living with diabetes, in honor of your struggles and your strength. People with diabetes often have stories to share about their struggles for balance and harmony in their lives. We can honor people by listening to and learning from their stories to fnd meaning and hope for our own lives. An old, well-loved story, told around the world, is about the turtle and a sure-footed animal, like a rabbit. In this story, the turtle tricks the other animal to win a race—simply by not giving up and by staying on its path. It takes determination like that to face diabetes, day after day, reminding yourself that you can do it if you stick to it! There are about 250 kinds of turtles, and almost all have the same pattern on their top shell—13 plates that ft together in harmony and balance to form a strong shell. The turtle and its shell can remind us of the harmony and balance we seek in all parts of our lives—including living with diabetes. The division is part of the National Center for Chronic Disease Prevention and Health Promotion, Department of Health and Human Services. We asked people with diabetes who read the frst book to help us make the second book even more useful. The American Association of Diabetes Educators did a survey among people with diabetes and diabetes educators to learn what people liked and didn’t like about the frst book. Conducted by the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, this important study provided scientifc proof that glucose control can help prevent or delay complications of diabetes. Ann Constance, Claudia Martinez, Hope Woodward, Margaret Fowke, Nancy Haynie- Mooney, Melinda Salmon, Mike Engelgau, and the Chattahoochee Nature Center also helped with the writing. Rick Hull, Diana Toomer, Melissa Stankus, and Kristina Ernst reviewed and edited the fnal version of this guide. You may even want to join a community group in which people share their stories and help others deal with their diabetes. It’s important to work with a primary health care provider, as well as other members of a team who Work with your health care team to take charge of your diabetes. To fnd out about resources in your community, contact one of the groups listed below: ■ Diabetes organizations, listed on pages 127–129 of this book. With the support of your family and friends, your health care team, and your community, you can take charge of your diabetes. See the list beginning on page 127 for phone numbers, addresses, and web sites of organizations where you can get more information. Find out as much as you can about the three most important things for controlling your diabetes: food, physical activity, and diabetes medicine. There’s enough room on these pages to write questions and other points you want to remember when you go to your visits every 4 to 6 months. Harper Telephone number: ________________________________222-222-2222 Your questions: ___________________________________ _________________________________________________What was my last A1C result? The pancreas, an organ near the stomach, makes a hormone called insulin to help glucose get into our body cells. When you have diabetes, your body either doesn’t make enough insulin or can’t use its own insulin very well. Signs and Symptoms of Diabetes You may recall having some of these signs before you found out you had diabetes: ■ Being very thirsty. Scientists are learning more about what causes the body to attack its own beta cells of the pancreas (an autoimmune process) and stop making insulin in people with certain sets of genes. The pancreas of people with type 2 diabetes keeps making insulin for some time, but the body can’t use it very well. Some people with type 2 diabetes may also need to takediabetes may also need to take diabetes pillsdiabetes pills oror insulininsulin shots to help control their diabetes. Some people with diabetes are concerned aboutSome people with diabetes are concerned about their family members getting diabetes. A national study show’s that people may be able to prevent orstudy show’s that people may be able to prevent or delay the onset of type 2 diabetes. Studies show that keeping your blood glucose (also called blood sugar) close to normal helps prevent or delay some diabetes problems. Through careful control, many problems such as eye disease, kidney disease, heart disease, nerve damage, and serious foot problems can be prevented or slowed. People who have type 1 diabetes as well as people who have type 2 diabetes can beneft by keeping their blood glucose levels closer to normal. To keep your glucose at a healthy level, you need to keep a balance between three important things: ■ What you eat and drink. When you eat dairy products (cheese, milk, yogurt, and others), choose those that have little or no fat or cream. Here are some things you can do to eat less sugar: – Eat more high-fber foods, like vegetables, dried beans, fruit, and whole grain breads and cereals. See pages 28–32 for more on ways to prevent problems when your blood glucose levels are too high or too low. If you want to include a drink in your food plan once in a while, ask your health care team how to do so safely. A Few Things About Diabetes Medicine If you take diabetes pills or insulin injections to control your diabetes, ask your health care provider to explain how these work. If you take other medicines that are sold with or without a prescription, ask your doctor how these can affect your diabetes control. If you inject insulin, your health care team should be able to tell you: ■ How to give yourself injections. Keeping your glucose level close to normal helps prevent Keep a daily record of your blood or delay some diabetes glucose levels. You can do this by: ■ Checking your own glucose a number of times each day (self-monitoring blood glucose). These tests can help you and the rest of your diabetes health care team—doctor, diabetes educator, and others—work together to help you control your blood glucose. Using a fnger prick, you place a drop of blood on a special coated strip, which “reads” your blood glucose. Blood glucose testing can help you understand how food, physical activity, and diabetes medicine affect your glucose levels. Ask your health care team to help you set a goal for your glucose range and show you how to record your glucose readings in a logbook or record sheet. Keeping track of your glucose on a day-to-day basis is one of Think of your daily the best ways you can take log sheet as a diary for charge of your diabetes. Getting a Summary Lab Test (AC) By performing an A1C test, health provides can sum up your diabetes control for the past few months. Since each red blood cell is replaced by a new one every 3 to 4 months, this test tells you how high the glucose levels have been during the life of the cells. If most of your recent blood glucose readings have been near normal (70 to 140 milligrams per deciliter or mg/dL, with the higher reading mainly after meals), the A1C test will be near normal (usually about 6%–7%). If you’ve had many readings above normal, the extra glucose sticking to your red blood cells will make your A1C test read higher. If your A1C test results are high, work with your team to adjust your balance of food, physical activity, and diabetes medicine. Having Problems with Low Blood Glucose In general, a blood glucose reading lower than 70 mg/dL is too low. Low blood glucose is usually caused by eating less or later than usual, being more active than usual, or taking too much diabetes medicine. Foods and Liquids for Low Blood Glucose (each item has 15 grams of carbohydrate) Food Item Amount Sugar packets 3 to 4 Fruit juice 1/ cup (4 ounces) 2 Soda pop (not diet) 1/ cup (4 ounces) 2 Hard candy 3 to 5 pieces Sugar or honey 4 teaspoons Glucose tablets 3 to 4 Check your blood glucose again in 15 minutes. Eat another 10 to 15 grams of carbohydrate every 15 minutes until your blood glucose is above 70 mg/dL. Eating or drinking an item from the list on this page will keep your glucose up for only about 30 minutes. So if your next planned meal or snack  is more than 30 minutes away, you should go ahead and eat a small snack, something like crackers and a tablespoon of peanut butter.

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Generally order trazodone 100 mg without a prescription, in any patient with thoracic problem cheap trazodone 100mg visa, chest physiotherapy generic trazodone 100mg online, that is incentive spirometry if available or inflating a glove or intravenous fluid bag with deep inspiration and expiration and early movement is of paramount importance for smooth recovery of the patient. It is usually characterized by stridor (noisy breathing); suprasternal retraction; tachycardia and cyanosis develop as obstruction becomes complete. If a foreign body aspiration is suspected, tilt the patient’s head down and slap the patient sharply across the back. Then, explore the pharynx and mouth by finger and if possible, urgent laryngoscopy should be done. If indicated, intubate the airway immediately, otherwise do emergency cricothyroidotomy (insert wide bore needle to the cricothyroid membrane) and give 100% oxygen until intubation or proper tracheostomy is done. It is indicated to by- pass upper airway obstruction, for drainage of the respiratory tract and to provide assisted ventilatory support. Tracheostomy should be performed in operating room under general anaesthesia with intubation, if possible, especially in case of children. But if very urgent situation is encountered, do cricothyroidotomy while preparing for tracheostomy. Make incision over fourth tracheal ring transversely or vertically in case of emergency. Dissect strictly in midline to separate the strap muscles and pre tracheal fascia to expose the trachea. Open the trachea by midline incision through three adjacent tracheal rings, usually rd th th 3 , 4 and 5 , after holding upper end of cricoid cartilage using fine cricoid hook. Hold open cut edge by tracheal dilator and insert a tube which comfortably fits the trachea while the anaesthesiologist withdraws the endotracheal tube. Aspirate tracheal secretion soon after initial incision on the trachea and repeat after the tube in place. Humidify inhaled gas as near to body temperature as can be achieved by frequent application of saline soaked gauze over the tube. Tracheostomy toilet from 10 minutes to as long as two hours as needed and if there is inner tube take it out every four hours and wash it. The terrible death toll related to chest injuries is avoidable by simple measures. It results in hemothorax in more than 80% and pneumothorax 146 in nearly all cases. It should be considered as thoracoabdominal if penetration is below fourth intercostal space. Tightly dress any sucking wound and look for signs of tension pneumothorax (distended neck veins, shift of the trachea, hyper resonance with decreased air entry), cardiac tamponade (hypotension, distended neck vein and distant heart sounds), massive hemothorax and flail chest all of which can compromise ventilation despite patent airway and adequate oxygenation. Control extreme hemorrhage and restore circulation: Insert wide bore cannula for fluid and blood transfusion. B: If one suspects tension pneumothorax, massive hemothorax or cardiac tamponade, the management should be dealt as part of resuscitation and patients should not be sent for confirmatory investigations. Besides, in case of suspected cardiac tamponade, simple insertion of a needle through xiphoid angle pointing towards the left shoulder tip can help enter the pericardium and aspirate accumulated blood. Major chest wall injuries: Flail chest: paradoxical movement of a segment of chest wall as a result of fracture of four or more ribs at two points or bilateral costochondral junction separation. Diagnosis: Usually clinical, by closely observing paradoxical chest motion, chest x-ray shows multiple segmental fractures. Fracture of first, second rib and the sternum: These are considered to be major injuries since a considerable force, which usually causes associated injury to underlying structures like vessels or nerves, is required. Diagnosis: Chest x-ray (parenchymal opacity immediately after injury and increasing in the next 24-48 hours). Injury to mediastinal structure: Injury to trachea, bronchus, major vessel and heart are fortunately rare. But if they occur, they are usually fatal and patient often does not reach health facility. Diaphragmatic rupture: Mostly occurs on the left side and diagnosis needs high index of suspicion. Symptoms and signs are usually due to herniation of intra abdominal organ like stomach or colon in to the chest. Tension: This is a surgical emergency associated with development of pressure which compromise breathing as well as circulation. B: In most cases of traumatic pneumothorax, there will be associated bleeding which may not be apparent. Look for decreased chest expansion, tracheal shift, hyper resonant percussion note and decreased air entry. In case of tension pneumothorax, insertion of needle at second intercostal space over the mid clavicular line of the same side relives the tension until chest tube insertion. Massive Hemothorax is a bleeding of more than 1500ml in to pleural cavity and rarely occurs in blunt trauma. Signs of fluid collection in the pleural cavity (decreased air entry, dull percussion note) are found on physical examination. Chest x-ray: Erect chest film reveals costophrenic angle obliteration if more than 500 ml blood exists. The purpose is to maintain the negative intrapleural pressure and allow complete re-expansion of underlying lung. This is achieved by connecting the tube to underwater seal drainage bottle with or without suction. B: Remove the chest tube while patient is in full inspiration and tightly close the insertion site by gauze soaked with a lubricant. Staphylococcus aureus, Streptococcus pneumonia and Streptococcus pyogens most common causes in healthy adult. Immunocompromised patients are prone to Aerobic gram negative bacilli and fungal infection. Children: less than 6 month of age: Staphylococcus aureus most common pathogen 6 month-2 years of age: Staphylococcus aureus, Streptococci pneumonia and H. Signs of pleural effusion and signs of chronicity (chachexia, finger clubbing and discharging sinus) can be detected. The principle of treatment includes control of infection by appropriate antimicrobials and drainage of pus to achieve full lung expansion. Thoracentesis: This is aspiration of fluid from the pleural cavity by a surgical puncture. If fluid analysis shows non loculated fluid without organism and serial x-ray demonstrates lung expansion, this procedure is adequate with appropriate antibiotics for 10% of patients. Closed tube thoracostomy: A procedure of inserting tube into the pleural cavity and connecting it to underwater seal bottle with or without suction. Open tube drainage: Drainage procedure by cutting the tube from under water seal to convert it to open one and follow the progressive obliteration of cavity. Rib resection and open drainage: Is a drainage procedure by resecting the rib and break all loculation. Thoracotomy and decortication: A procedure of removing fibrous peel, which entraps the lung. B: Tuberculous empyema needs drainage only if super infected, a bronchopleural fistula occurs or the patient is distressed. On examination, patients appear chronically sick, febrile with coexisting effusive finding. Conservative: Includes use of antibiotics, penicillin and metronidazole for up to six weeks in most case, periodic sputum bacteriology, and internal drainage (postural, percussion, coughing). Operative: Surgical treatment is indicated in case of failure of conservative approach, massive hemoptysis, thick or large cavity which is unlikely to collapse and in case of suspected malignancy. However, when complicated with some other systemic illness, the mortality rate reaches 75-90%. A 45-year old male patient involved in a motor vehicle accident presents with severe respiratory distress. On examination, he is found to have tachypnea, hypotension and distended neck veins. A 30-year old lady who was on antibiotic therapy for severe pneumonia started to shoot fever on the third day. She was found to be in respiratory distress and examination revealed evidence of fluid in left hemi thorax.

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Society in general disapproves order trazodone 100 mg without prescription, because in most cases there is a social cost cheap trazodone 100 mg amex; for certain drugs discount trazodone 100 mg free shipping, this is judged to out-weigh the individual benefit and their use is banned in many countries. The ester containing compounds are usually inactivated in the plasma and tissues by non-specific esterases. Local anesthetics block the initiation of action + potentials by preventing the voltage-dependant increase in Na conductance. Local anesthetics are used in minor surgery, dentistry, abdominal surgery and painless childbirth. Methods of administration Uses Drugs Surface anaesthesia Nose, mouth, urinary tract Lidocaine Infiltration anaesthesia Direct injection into tissues to reach nerve Most braches and terminals. Write about mechanism of action and adverse effects of Phenytoin and carbamazepine. The etiologies include Obesity (because chronic calorie intake and prolonged stimulation of β cell causes a decrease in insulin receptor and also adipose tissue and muscle are less sensitive),hereditary,damage of pancreatic tissue, diabetogenic hormones(like growth hormone, thyroid, epinephrine), diabetogenic drugs like Thiazide diuretics, epinephrine, phenothiazines ,Other factors like Pregnancy. The common Signs and symptoms include polydipsia, polyphagia, polyuria, dehydration due to glucosuria. It is severe metabolic disturbance due to insulin deficiency, which results in hyperglycemia, ketonimia and later acidosis. It is characterized by headache, nausea, vomiting, rapid pulse, dry skin, deep breathing, and change in mentation. Hypoglycemic Coma is more serious complication which usually occurs due to excess dose of insulin which produces severe lowering of blood glucose that may leads to coma. The Sign /Symptom are mental confusion, in coordination, paresthesia, convulsion, coma and Signs of sympathetic over activity. Effects of insulin Carbohydrate metabolism Liver: it increases glycogen synthesis from glucose and glucose utilization while decreases gluconeogenesis and glycogenolysis Muscle: it increases glucose uptake, glucose utilization and glycogen synthesis. Adipose tissue: it increases glucose uptake and glycerol synthesis (esterifies fatty acid) Fat metabolism Liver: it increases lipogenesis Adipose tissue: it increases synthesis of triglycerides and synthesis of fatty acid 130 Protein metabolism Liver: it increases protein catabolism Muscle: it increases aminoacid uptake and protein synthesis Other metabolic effect: + ++ It increases uptake of K and Ca into cells and synthesis of nucleic acids There are some factors that increase insulin demand: like Infection, surgery, pregnancy and drugs (those that antagonize actions of insulin glucocorticoids, thyroid hormone, adrenaline) Type of insulin preparation: A. They are also used in the treatment of hyper kalmia due to renal failure Adverse Reaction: can be categorized as Local: Atrophy or hypertrophy at site of injection, local hypersensitivity and secondary infections. First generation: Tolbutamide, Chlorpropamide Second generation: Glibenclamide, Glipizide Mechanism: hypoglycemic action is due to Stimulation of insulin release from β cell, Depression of glucagon secretion, Increase number of insulin receptor, Reduce insulin output from liver (Decrease hepatic gluconeogenesis and glycogenolysis) Pharmacokinetics: They are rapidly absorbed from the gastrointestinal tract. They are also extensively plasma protein bound and are mainly metabolized in the liver. The important toxic effects include: hypoglycemia, allergic skin rash and bone marrow depression, cholestatic jaundice (esp. Alcohol produces “Disulfirum” like action (flushing of the face, severe headache, vomiting etc. Biguinides They potentiate the hypoglycemic action of insulin and sulphonyl ureas but they don’t produce clinical hypoglycemia in diabetics. Biguanides include drugs like metformin and phenformin Mechanism: They do not stimulate the release of insulin. They increase glucose uptake in skeletal muscle, and have effects on glucose absorption and hepatic glucose production. Metformin is largely excreted unchanged in the urine and has a longer duration of action. Side effects: Nausea, vomiting, anorexia, diarrhea, abdominal cramp, lactic acidosis (esp. It also causes ejection of milk through contraction of the myo-epithelial cells around the alveoli of the mammary gland. Pharmacokinetics: It is inactivated orally and absorbed rapidly after intramuscular administration. Use: Induction of labor in women with uterine inertia, Relief of breast engorgement during lactation (few minutes before breast feeding) as nasal spray, Postpartum hemorrhage. Side effect: Oxytocin may cause over stimulation and leads to rupture of the uterus in the presence of cephalo-pelvic disproportion. Prostaglandins They induce labor at anytime during pregnancy but most effective at the third trimester. In female reproductive system prostaglandin E & F are found in ovaries, endometrium and menstrual fluid which is responsible for initiating and maintaining normal birth process. They are contraindicated in the presence of cardiac, renal, pulmonary or hepatic disease Ergometrine It is one of the ergot alkaloids with the ability to cause contraction of the uterine smooth muscle. Use: after delivery of placenta if bleeding is severe (Prevent postpartum bleeding) Adverse effect: Nausa, vomiting but serious toxic effects are rare. Female Sex Hormones and Hormonal Contraception Oestrogens These drugs can be classified into three groups. Synthetic: Diethylstibosterol Natural Estradiol: Estradiol is most potent, major secretory product of ovary. It is oxidized into esterone by liver; estrone is hydrated to estriol and synthesized by ovarian follicle, adrenal cortex, fetoplacental unit, and testis. Cervix: it makes cervical mucus thin and alkaline Vagina: Stratification, cornification and glycogen deposit is affected by estrogen. It is less effective orally due to complete metabolism by liver so it’s given through intramuscular route. Metabolic actions: (a) Thermogenic action (b) Competes with aldosterone at renal tubule so inhibits sodium reabsorption. They can also be classified as fixed dose combination (monophasic), biphasic and triphasic pills. Fixed dose combination: the commonest procedure is to administer one pill containing both an estrogen and progestin daily at bed time for 21 days. In biphasic and triphasic pills: these are combined oral contraceptive pills containing varying proportion of an estrogen and a progesterone designed to stimulate the normal pattern of menustral cycle. Medroxyprogestrone acetate (Depoprovera ) iii) Subcutanous implant L – norgestril (Norplant®) Mechanism: It makes cervical mucus thick, though & hostile and also alter endometrial wall B. Post coital “morning after” pill Oestrogen like Diethyl stilbosterol used within 72 hrs Combined oral contraceptive pills can also be used. Side effects of oral contraceptive: Thromboembolic complication, Weight gain & fluid retention, Menstrual disorder, Breast tenderness & fullness, Skin changes, Nausea & vomiting, Depressed mood, Reduced lactation Beneficial effects of estrogen /progesterone oral contraceptive 1) Reduced risk of endometrial Carcinoma, ovarian cyst 2) regular Menses, No excessive blood loss 3) Less premenustrual tension and dysmennorrhea 4) Relief of endometriosis Contraindication: In patients withcardiovascular diseases (hypertension, coronary heart disease) Thromboemolic disease, breast Cancer, diabetes mellitus, liver disease, women > 35 years (esp. Effect reduced when taken with enzyme inducers like Rifampicin, Phenytoin, Phenobarbitone etc. Oral contraceptive antagonize the effect of Coumarin anticoagulant and some antihypertensives Ovulation inducing drug These are drugs used in the treatment of infertility due to ovulatory failure. Therapeutic activity in inflammatory disorder is proportional to the glucocorticoid activity. They are not widely used in therapeutics rather its antagonists are of value in cases of edema. Thyroid and Antithyroid Drugs They inhibit the function of the thyroid gland and used in hyperthyroidism. Radioactive iodine ( I) Thiourea Compounds Inhibit the formation of throid hormone through inhibiting the oxidation of iodide to iodine by peroxidase enzyme and blocking the coupling of iodothryosines to form iodothyronines. Toxicities include drug fever, skin rashes, increased size and vascularity of the thyroid gland, and agranulocytosis. Ionic Inhibitors Potassium percholate prevents the synthesis of thyroid hormones through inhibition of uptake and concentration of iodide by the gland. It has the risk of aplastic anemia, therefore no longer used in the treatment of hyperthyroidism. Iodides: Improve manifestations of hyperthyroidism by decreasing the size and vascularity of the gland so they are required for preoperative preparation of the patient for partial thyroidectomy. Iodides act through inhibition of the “protease” enzyme which releases T3 and T4 from thyroglobulin, and organification. It is trapped and concentrated as ordinary iodine, which emits beta rays that act on parenchymal cells of the gland. It is contraindicated in pregnancy and lactation as it affects thyroid gland in the fetus and the infant. Propranolol This is an important drug which controls the peripheral manifestations of hyperthyroidism (tachycardia, tremor). Manifestations include hyperpyrexia, gastrointestinal symptoms, dehydration, tachycardia, arrhythmia, restlessness, etc. Management: It consists of infusion of intravenous fluids, supportive management, and also administration of propylthiouracil, sodium iodide, hydrocortisone, and propranolol. Discuss the mechanism and beneficial effects of combined oral contraceptive pills.

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