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Two hour plasma glucose > 200 mg% during an Hypoparathyroidism oral glucose tolerance test skin care 30 years old order 0.025% tretinoin cream fast delivery. Addison’s disease Addison’s disease In the absence of unequivocal hyperglycaemia and Graves’ disease acute metabolic decompensations these criteria should Thyroiditis Thyroiditis Type 1 diabetes (5%) Type 1 diabetes (50%) be confirmed by repeat testing on a different day acne jeans mens purchase tretinoin cream 0.05% with visa. Vitiligo Vitiligo Principles of the test: Give 150-200 gm of carbohydrate Hepatitis daily for 3 days prior to skin care for swimmers cheap 0.05% tretinoin cream amex the test acne zinc cheap tretinoin cream 0.05% visa. Overnight fast is Malabsorption Coeliac disease Myasthenia gravis advocated the day before the test skin care 40 year old buy tretinoin cream american express. Patient should Pernicious anaemia Pernicious anaemia take 75 g of glucose dissolved in 300 ml of water; Serositis Serum glucose should be measured every half an Parkinson’s disease hour for 2 hours. Islet cell antibodies are positive in about 80% of the patients before administration of insulin. The glucose oxidase sensor, which is located inside a small needle is placed in the subcutaneous tissue and is Immune intervention trials have been carried out in discarded after single use on removal. This trial has proved that the disease process can be effectively halted by preventing further Treatment destruction of cells. However, this intervention must be done in the Goal of therapy is to maintain euglycemia during most prediabetic state, in high risk individuals from birth, by part of the day by aggressive insulin therapy. This is genetic screening and periodically measuring circulating done to rest the damaged islet cells and to induce antibodies with periodic assessment of cell function. Insulin Therapy Clinical Features Goals of Insulin Therapy Patient is usually thin built and wasted. Elimination of primary glycosuric symptoms polydipsia, polyphagia, weight loss, fatigue and 2. Restoration of lost lean body mass diabetic ketosis (air hunger, Kussmaul’s respiration, 4. Improvement in physical performance acetone odour of breath, dehydration, vomiting, 5. Reduction of frequent infections 648 Manual of Practical Medicine Actions of Insulin Anabolic effects (^) Anticatabolic effects (v) Carbohydrate metabolism Increases glucose transport Decreases gluconeogenesis (muscle, adipose tissue) Glycogenolysis Glucose phosphorylation Glycogenesis Glycolysis Pyruvate dehydrogenase activity Pentose phosphate shunt Lipid metabolism Triglyceride synthesis Lipolysis Fatty acid synthesis (liver) Lipoprotein lipase (muscle) Lipoprotein lipase (adipose tissue) Ketogenesis activity Fatty acid oxidation (liver) Protein metabolism Amino acid transport Protein degradation Protein synthesis Electrolytes Cellular potassium uptake Types of insulin A chain B chain 8th amino acid 10th amino acid 30th amino acid Human insulin Threonine Isoleucine Threonine Pork insulin Threonine Isoleucine Alanine Beef insulin Alanine Valine Alanine 7. Delay, arrest or prevention of microvascular and macrovascular complications of diabetes. Short acting (regular/soluble) seems to be related to lipoatrophy at injection sites, 2. Short Acting Insulins Action Profile Lispro Aspart Regular Onset (mts) <15 <15 30-60 Peak 30-90 40-50 2-3 hrs Duration (hrs) 3-5 4-6 3-6 Insulin Glargine Glargine is a “peakless” bioengineered human insulin analog. After a lag time of 4-6 hours, the flat peakless effect lasts for a period of 24 hours. It is given once a day as subcutaneous injection at bed time along with premeal regular insulin or insulin lispro. The amino acid threonine at the B30 position on the human insulin chain is lacking, and a 14-carbon fatty acid (tetradecanoic acid or myristic acid) is attached to lysine at B29. Albumin binding character allows the analogue to remain liquid and soluble following injection Fig. Substitution of amino acid lysine with asparagine at hypoglycaemic drugs or pre-meal short acting position 3 of the human insulin beta chain. Single Dose Regimen in 1-mg and 3-mg blister packs (1-mg is equivalent to Treatment with insulin is usually initiated with a single 2. Patients should use one or two daily injection of intermediate acting insulin given before inhalations for any given dose. Increment should be made by 5 units Hypoglycaemia, cough and bitter taste were every 3 to 4 days. This insulin is not recommended for smokers If control is not achieved, second injection is given and patients with pulmonary disorders (altered insulin before supper. Multiple Daily Injections • Aggressive insulin therapy using four shots of shortType 1 patients may require this kind of therapy with acting or two shots of intermediate-acting insulin is plain insulin 3 times daily before breakfast, lunch and started in order to rest the damaged islet cells. To decrease the excess hepatic overnight glucose • Insulin is given in a dose of 1 unit/kg/day. Insulin should be given in the abdomen, buttock or hip areas where the muscles are less active 4. Commercial premixed after diagnosis and lasts for a few months during which insulin preparations are safe and convenient for use, time, insulin requirement falls drastically to as low as but the dose adjustment of individual components is 0. These can be used easily and there is enhanEndocrine and Metabolic Disorders 651 ced accuracy. Insulin pens: An insulin pen holds a prefilled cartridge diabetes as they lack the normal glucoregulatory of the desired type of insulin and has a disposable needle mechanisms. External insulin pump therapy: Portable insulin on the pre-exercise plasma glucose, circulating insulin infusion pump or continuous subcutaneous insulin level and exercise induced catecholamines. Multiple basal rates (Insulin requirement can be circulating insulins, hypoglycaemia results. This can preprogrammed and the delivery is according to be avoided by taking the meal one to three hours before that). Other measures include, decreasing the insulin set ending in a needle or cannula inserted subcutadose before exercise and injecting insulin into a nonneously and changed every 24-72 hours. Advantages: • Ease of taking multiple boluses if desired • Ability to programme the basal rate of insulin Complications of Insulin Therapy delivery is especially useful in dawn phenomenon 1. Hypoglycaemic unawareness due to drugs, tight delivered into the splanchnic system. Defective counter regulatory hormone response to hypoglycaemia Factors Influencing Insulin Absorption k. Insulin Resistance • Physical conditions at the injection site (increase in temperature, blood flow, degree of exercise, massage It is arbitrarily defined as a situation in which the of injection site) will increase rate of absorption. Relative insulin resistance is present in most of the • Relative rate of absorption is different at different patients when carefully looked for, using the glucose sites. Alstrom syndrome (autosomal recessive; phosphorylates the insulin receptor and initiates subsechildhood blindness (retinal degeneration), quent intracellular phosphorylations that mediate nerve deafness, vasopressin resistant diabetes multiple actions of insulin. Binding of insulin to the baldness, hyperuricaemia, hypertriglycerireceptor initiates a rapid mobilisation of intracellular daemia and aminoaciduria). Pineal hyperplasia syndrome (early dentition simultaneously activating those units already in place. Insulin resistance may be at Other conditions of insulin resistance are already 1. Treatment • Prereceptor level resistance is due to the presence of Prednisone should be given in a dose of 80–100 mg/ abnormal insulin or insulin antibodies. If there is no • Receptor level resistance is due to decrease in number response up to 3–4 weeks, steroids should be withdrawn. If there is response, and if insulin requirements begin • Post-receptor level resistance is due to abnormal to fall, prednisone can be gradually decreased to signal transduction resulting in failure to activate the 10–20 mg even in 3–7 days until a maintenance level of tyrosine kinase receptor. It can be continued for many In diabetics with insulin requirements > 200 units/ months. Insulin Allergy Insulin Resistant States Local allergy at injection site: Redness, pruritus, swelling and heat occurs. Prereceptor resistance (mutated insulins, antiweeks of therapy and is self-limiting. Type A syndrome (absent or dysfunctional anaphylaxis can occur but rare, this is related to prior receptor) intermittent use of insulin. Lipodystrophic states (generalised or partial) Patients who have been having poor glycaemic control. Leprechaunism (elfin facies, hirsutism, thick in the past, may develop peripheral oedema when their skin, absence of subcutaneous fat) glucose is rapidly brought down. Ataxia telangiectasia (cerebellar ataxia, telanIt is a self-limiting condition clearing in about one week giectasia, immune system abnormality) unless the patient has a renal or cardiac problem. Rabson-Menderhall syndrome (dental Home monitoring of glycaemic status can be done by dysplasia, dystrophic nails, premature i. He is advised to consume water so less than 10% of glycosylated haemoglobin are that a fresh sample of urine is obtained. Home blood glucose is monitored by using glycaemic control also, so that insulin dose can be various reagent strips. Blood sugar monitoring from ear lobe or finger Glycosylated albumin, or total proteins (fructotip should be done for at least 3 consecutive days samine) can also be estimated to find out the previous in a month, for a minimum of 4 times (prebreakstatus of glycaemic control. Since the half-life of serum fast, prelunch, presupper and at bedtime) and protein is short (20 to 25 days), this estimation gives an maximum of 8 times (postprandial samples in idea about the glycaemic status in the previous 2 to 3 addition) during each 24 hour period. Noncompliance is a major cause of recurrent ketoGoal of therapy is to maintain euglycaemic level at acidosis in children. Any preprandial level should be maintained at 70– Hypoglycaemia 90 mg/dl and postprandial level lower than 160–180 mg/dl. In very young children, and in insulin sensitive Most episodes are predictable and preventable. But individuals, insulin can be diluted using diluent given children are usually unaware of hypoglycaemic symptoms. Abnormal Glycated Haemoglobin counter regulatory response in diabetic patients may account for prolonged hypoglycaemia. Control Hb A1 (%) Hb A1c (%) Good 8–10 6–8 Fasting Hyperglycaemia Fair 10–12 8–10 Somogyi Phenomenon (Rebound effect): this is hypoPoor 12–14 10–12 Very poor > 14 > 12 glycaemia induced hyperglycaemia due to increased secretion of counter regulatory hormones. Hb A1 = Hb A1 (a, b, c) If the insulin dose is increased beyond the amount Hb A1c is preferred since the glycosylation is with glucose and not required for any given portion of the day, there is counter with other sugars. Hb A of 6% corresponds approximately to a mean plasma glucose regulatory hormone response, resulting in hypergly1c level of 120 mg%. Methods used to detect glycated haemoglobin are high pressure liquid chromatography or gel electroIt is the most common type of diabetes accounting for phoresis; the subfraction A1c is separated out. Is not ketosis prone under basal conditions does I phase (euglycaemia with increased insulin levels): Plasma not require exogenous insulin for short-term glucose remains normal despite demonstrable insulin survival resistance because insulin levels are elevated. Rule out diabetes in tuberculous patients above Patients with impaired glucose tolerance need 40 years and also in mothers who have babies born with further evaluation at a later date since they are potential a weight of more than 4 kg (macrosomia). Endocrine and Metabolic Disorders 655 It is treated with diet therapy, exercise, biguanides Potential Diabetics and sulphonylureas like glypizide and gliclazide. Physical exertion should be are known to have given an abnormal result under avoided for 1 day prior to the test. Pregnancy, infection, myocardial infarction, steroid Fasting is advised for at least 10 hours to a maxitherapy. Diet Planning normal saline and infused manually or by a pump in Diet control is an endogenous insulin preserver. Primary therapeutic goal is weight loss in obese Two baseline samples and samples at 1, 3, 5, and individuals; Reduction in weight eliminates the need 10 minutes after the test are taken. It is done for patients for oral hypoglycaemic drugs or insulin, especially who cannot take oral glucose. Consistency in Glucose is present in urine and there is confusion composition and timing of meals is important partiwith the diagnosis of diabetes in the following condicularly for patients using fixed insulin regimens or tions. Renal Glycosuria Total calories should be kept ideally between 1000 the most common cause of glycosuria is a low renal and 1200 kcal/day; threshold for glucose, which commonly occurs tempoFor obese individuals, 20 kcal/kg ideal body weight rarily in pregnancy and is a much more frequent cause For normal adults (sedentary), 30 kcal/kg ideal body of glycosuria than diabetes in young people. Renal weight glycosuria is a benign condition and is not accompanied For normal adults (manual worker) and growing by the classical symptoms of diabetes.

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However acne quick treatment order tretinoin cream 0.05% amex, the broiler chickens did not 35 seem to acne 5 year old buy generic tretinoin cream be affected for any long period afterwards (personal observation) acne xl order tretinoin cream australia. The birds had always free access to skin care yg bagus discount tretinoin cream 0.025% fast delivery feed acne scars purchase 0.05% tretinoin cream with mastercard, and more than enough space at the feeders per bird (one feeder with a diameter of approximately 30 cm, per group of 20 birds) which leads to good animal welfare. If they do not have free access to feed they need 20 mm (12 mm at the age of 0-7 weeks) per bird, if the feeder is round. At the end of the study, they were very heavy, in average 2 694 g for the experimental group and 2 586 g for the control group which is considerably more than what is usual in Zambia. Perhaps the study should have been completed earlier, given the fact that it is hard for fully grown broiler chickens to cope with a hot climate (Daghir, 1995) and that the ventilation was poor. Profitability Is it profitable to use solar lamps in broiler chicken production in Zambia The use of solar lamps in the present study resulted in a more rapid growth of the experimental broiler chickens. Broiler chickens to be sold at a particular weight instead of a certain age can be ready for sale earlier by using light. However, it is important that they have free access to feed; otherwise the extra light has no effect on the production. If the broiler chickens should be sold at the weight of 2 kg, calculated on the basis of the average growth rate and weights of the two groups, the broiler chickens in the experimental group would be ready for sale 34 days old and broiler chickens of the control group at the age of 35 days. Shorter rearing period give more batches of broilers per year and thus greater profit is possible. For the rural population in a developing country it may be very difficult to invest so much money or find financial support. Larger groups would need to have many more lamps and the cost to purchase the lamps would be high. Using the lamps for broiler production would be viable, if we put aside the cost for the lamps. Deaths and mortality During the study, up to 42 days of age, the mortality was 5 %. If the period after completion of the study, up to 44 days of age is included, the mortality was 10 %. A mortality < 5 % is normal, but when it becomes higher, something could be wrong. The birds that died at the end of the study and shortly afterwards were not autopsied. The heavy bodies and the warm 36 weather may have been the cause of death, since these broiler chickens were very big at the end. If the feed had been changed from Broiler Grower to Broiler Finisher some days or one week earlier, maybe the broiler chickens had coped better with the heat, since Broiler Finisher contains more fat, which is beneficial at heat stress (Daghir, 1995), if it was heat stress the last ones died from. If high mortality is a problem in hot climates it may be a good idea to hold back the feed during midday, the hottest days, and allow free access again in the evening, when light. No cause of death was determined for the broiler chicken in the control group who died 22 days old. I suspect that the broiler chicken died from heatstroke as it was very hot the day before it died, though it does not provide any obvious traces at autopsy. The green diarrhoea outbreak the day before the study ended was not found to be linked to the deaths. As the feed was changed from Broiler Grower to Broiler Finisher two days before the green faeces appeared, and all the broiler chickens (both groups) were affected, any substance in the Broiler Finisher is suspected to have caused the green diarrhoea, but without causing any disease or major injury. Smallholder broiler farmers in Batoka and Choma area It has been difficult to get an overall picture and draw general conclusions from the smallscale broiler farmers, as only three of them were interviewed and since there are several differences also between these three. Disease and knowledge the knowledge about diseases, treatments and generally about broiler chicken management seemed to be limited. The farmers do what they think is right, what they can afford and what they are able to manage by themselves. Farmer 1 says that she had “outbreaks” of coccidiosis among her broiler chickens and that the symptoms were swollen eyes, soft faeces and that the birds could not move. However, it is more a matter of definition and may not have a significant impact for the small-scale broiler farmer. However, a good knowledge about diseases can increase the chance that the treatment is correct. Inability to move could be because they died (due to severe coccidiosis) or a very poor general health, but it appears more like they were lame for any other reason. Among the interviewed only one farmer gave medicine when the birds were sick and he did not know what it was. Proper knowledge about diseases and how to treat them, and 37 also some biosecurity, would be beneficial and save money for both the individual farmer and on society level (diseases would be treated and spread of infection would be prevented better). Increased knowledge could also be beneficial for the prevention of antibiotic resistance, as at the moment anyone in Zambia can walk in to a drug store and buy broad-spectrum antibiotics when they think it is necessary. Many people may not know what antibiotic resistance is and that it is a threat to the public health. Even the well-educated people in Zambia seem to have the attitude that some antibiotics cannot hurt (personal observation). Animal welfare the animal welfare at the different broiler farms was similar to that of western broiler production. One of the few things that differed was mainly the slaughter when the birds were killed by cutting the throats without stunning. In a western slaughter house the birds are stunned before killing with either electrical water bath or carbon dioxide, and the animals are checked (random samples) before killing, that they are sufficiently stunned. Production Two of the small-scale broiler farms provided free access to feed, the third one did not answer on that aspect, and all of them used Choma Millings Broiler feed. Inadequate vaccination coverage, lack of treatment for sick broiler chickens and insufficient cleaning routines are probably factors with major negative impacts on their production. By starting up in small-scale and having the right priorities, a small business can grow and eventually the extra profitable things can be affordable. If the farmers get paid according to the weight or sell the chickens at a specific weight they may earn more money by improving growth by help of solar light provided that they have free access to feed. Large-scale broiler farmer outside Lusaka In the large-scale broiler farm that was visited, there was a good awareness on hygiene, diseases and how to take care of broiler chickens in the best way. It is obvious that they have a very controlled production skilled eye, but maybe they have to when it is such a large-scale production and much money invested. If anything goes wrong, it can have tremendous consequences and the company will lose a lot of money. This is probably why they leave nothing to coincidence and has control over every step in the production process. As described earlier, strict hygiene is one of the most important factors in the prevention of the most common diseases. The density at the smallscale broiler farms is unknown, but based on personal observations it was quite high. Broiler slaughter house outside Lusaka the management and routines of the slaughter house was impressing. The broiler chickens are slaughtered without stunning and no one checked if the birds were dead before they were blanched. It was very important that the slaughter was done according to halal and they had a religious person to control and approve the slaughter, even though only a minority of the inhabitants in Zambia is Muslims. The transport of the broilers that came to the slaughter house may also have been deficient, but the low mortality, if it is true, indicated acceptable conditions. The slaughter house had come a long way but they were just not there yet, from a Swedish and animal welfare viewpoint. They did not see the animals as living creatures and how to treat them with respect. They will hopefully soon realize the importance of humane treatment of animals, as part of the development of the country. It may be understandable that a country that has so many other problems, people who are starving and are sick, do not think of the animals first. Only when people have a decent life themselves they have the energy to start caring about the animals and their welfare. In Zambia almost everybody lifts both broiler chickens and village chickens in the wings (personal observations). In a country where many people do not have so much money there is a risk that animals are kept alive for a little too long and suffer unnecessary, because of its economic or social value. However, there are many things that can be changed, that do not take such a big effort. Some examples could be to avoid lifting the birds in the wings, do not bring chickens on the bus for three hours in 30° C heat and hit the hen’s head in a stone before cutting the throat at slaughter. A few small things or actions can result in considerable differences but changing people’s habits is usually not easy and therefore information and education are needed in order to influence traditions and attitudes. The welfare of the broiler chickens were not apparently affected by increasing the light period of 2. More studies are needed, involving more broiler chickens, more replicates and the studies need to follow the whole rearing period from hatchery to slaughter day, for conclusions to be scientifically based. It could be profitable to use solar lamps in the broiler chicken production, if it is possible to bring down the cost of the solar lamps in any way, for example by charity, loans or any other means. The lamps can also be used for other things like charging of cell phones, fans, radios etc. In conclusion there is a wide variation in how broiler chicken production is performed in Zambia. Heat stress is a problem, at least during the warmest periods of the year, and the knowledge about diseases among the small-scale farmers interviewed was very low. Thanks to Mr Sakala for helping us with contacts and interpreting during interviews with local farmers. Thanks to the company Zambia’s finest chickens because they received us and made it possible to visit their largest broiler farm, with very short notice. Thanks also to Country Choice Chicken farm and their slaughter house for giving us a tour of their broiler breeding, answered all our questions and without prior notice quickly arranged a tour of their broiler slaughter house with a knowledgeable guide. Thanks to the broiler feed company Choma Milling Ltd who gave us a tour in their lab with their chemist, also on very short notice. Also thanks to Veterinarmedicinska fakultetens stipendiesamfond and Gulli Stralfeldts fond for the scholarships, which were used for buying solar lamps. Thanks to Mrs Simango, who came up with the idea of using solar lamps to enhance the productivity of poultry, for receiving us and helping with the projects. Thanks to my supervisor researcher Lotta Jonsson and assistant supervisor Elisabeth Persson for all the support during my stay in Zambia, but also for all the help with this essay. Pandey for helping us with the study, post mortems and much more during our stay in Zambia. Last but not least thanks to my friend and travel and project companion in Zambia, Johanna Lindell. Heat stress in Poultry and the beneficial effects of ascorbic acid (vitamin C) supplementation during periods of heat stress.

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Pneumonias Ischaemic heart disease Cardiovascular System 79 Aortic valve disease Characteristics of Anginal Pain Hypertension Site Substernal Cardiomyopathy Nature Pressing acne zones and meaning tretinoin cream 0.05% for sale, squeezing skin care shiseido order tretinoin cream visa, strangling acne extractor purchase genuine tretinoin cream line, consAtrial fibrillation tricting skin care guru order genuine tretinoin cream on line, ‘a band across the chest’ acne kids buy discount tretinoin cream on line, ‘a Rarely in mitral disease or atrial tumours. Anginal pain can Dyspnoea occurs only in the left or right lateral decuradiate in all directions, as mentioned bitus position, most often in patients with heart disease. Platypnoea is dyspnoea which occurs only in the upright Duration 5 to 15 minutes position. Aggravating Exertion, emotion, after a heavy meal, factors or exposure to cold Causes Relieving factors Rest, nitrates. Angina Pectoris Anginal Equivalent Anginal equivalents are symptoms of myocardial A discomfort in the chest and adjacent area due to ischaemia other than angina such as dyspnoea, faintness, myocardial ischaemia. Nocturnal Angina Angina occurs during sleep at night due to coronary Differentiation between Cardiac Asthma and ostial stenosis, as seen in cardiovascular syphilis. Chronic Pulmonary Disease Features Left sided failure Chronic pulmonary Unstable Angina (cardiac asthma) disease the following three patient groups may be said to have Age Old age Young and middle age History Heart disease Lung disease unstable angina pectoris. Patients with new onset (< 2 months) angina that is Symptoms Dyspnoea precedes Cough with severe and/or frequent (>) 3 episodes/d cough and expectoration 2. Patients with accelerating angina, that is, those with expectoration precedes dyspnoea Pulse Pulsus alternans Pulsus paradoxus chronic stable angina who develop angina that is Percussion Dull note due to Normal or distinctly more frequent, severe, prolonged or pulmonary oedema hyper-resonant note precipitated by less exertion than previously. Idiopathic It occurs on initial exertion, but then subsides without the patient resting only to sometimes recur with continuing exertion. Syncope may be defined as a transient loss of consciousness due to inadequate cerebral blood flow Causes of Angina Pectoris secondary to abrupt decrease in cardiac output. Coronary artery disease: Due to narrowing or spasm Depending on the duration of syncope, the of coronary artery. Aortic stenosis: Due to decreased stroke volume, If syncope lasts for reducing coronary perfusion and compression of 5 seconds, patient experiences dizziness coronaries by hypertrophied myocardium, decreas10 seconds, patient may become unconscious ing O2 supply and increased O2 demand by the 15 seconds, patient may throw convulsions. The maximum duration of syncope, with or without Decreased capillary density and co-existent convulsion, may be 30 minutes. Supra-ventricular or ventricular tachyarrhythnary perfusion as a result of left ventricular mias. Vasodepressor (vasovagal) syncope is a very comHypoglycaemia mon cause of dizziness or syncope that charac4. High output states Anaemia, pyrexia, teristically occurs in response to fear, sudden Aortic regurgitation, emotional stress, anxiety, physical or mental Patent ductus arteriosus exhaustion, pregnancy or anaemia. Drugs Atropine, adrenaline, always preceded by warning symptoms such as aminophylline, thyroxine, nausea, weakness, sweating, epigastric discomcoffee, tea, alcohol fort, blurred vision, headache, tinnitus, difficulty Cardiovascular System 81 in concentrating, sighing and dizziness. Disorders resembling syncope: rate falls, and the patient appears pale and ill at i. The syncope is transient, lasting a few carbon dioxide due to hyperventilation seconds to a few minutes, and may be prevented ii. Orthostatic hypotension produces dizziness on arising or after prolonged standing and can be Cyanosis related to reduced effective blood volume, autoCyanosis is a bluish discolouration of the skin and nomic nervous system dysfunction, or, rarely, to mucous membrane due to an increased quantity of circulating vasodilator substances. Diabetic autonomic neuropathy There are two types of cyanosis – Iron-replete and Anaemia iron-deplete. Low blood volume Iron-replete compensated erythrocytosis establish Large varicose veins equilibrium with haematocrits and rarely result in Pregnancy symptoms of hyper-viscosity because iron-replete cells Addison’s disease (rare cause) are deformable. Hypersensitive carotid sinus is suspected when the compensated erythrocytosis fails to establish equilibrium patient describes dizziness or syncope after with unstable, rising haematocrits, resulting in recurrent hyperextension of the neck, turning of the head, hyper-viscosity symptoms. The syncope is is not due to dehydration or iron deficiency is a simple evanescent, with rapid and complete recovery. Types the victims are almost exclusively middle-aged, overweight men with lung disease. Micturition syncopeis diagnosed when syncope Peripheral cyanosis occurs during or after urination. Onset is abrupt with Causes little or no warning; duration is brief and followed by full recovery. Decreased arterial oxygen saturation stimulate esophageal sensory receptors that 1. Haemoglobin abnormalities A pulse wave is a waveform that is felt by the finger, 1. Carotid 30 milliseconds the diagnosis of methemoglobinaemia can be susBrachial 60 milliseconds pected, if on exposing the patient’s blood to air, it Femoral 75 milliseconds remains brown whereas in cyanosis due to decreased Radial 80 milliseconds arterial oxygen saturation, it turns bright red. Arterial pulse is assessed in the following way: In Case of Peripheral Cyanosis 1. Cyanosis is seen only in the upper limbs—Patent Reduced ± ductus arteriosus with pulmonary hypertension, Absent – with right to left shunt and transposition of great Aneurysmal++ vessels. Rarely, in addition to the lower limbs, the left upper Pulse Rate limb may also be cyanosed when the patent ductus Pulse rate should be counted for one full minute by opens proximal to the origin of left subclavian artery. Normal pulse rate is 60-100 per minute Intermittent Cyanosis is seen in Ebstein’s anomaly. Sinus bradycardia—pulse rate < 60 per minute Sinus tachycardia—pulse rate > 100 per minute. Differentiating Features Between Central and Peripheral Cyanosis Features Central cyanosis Peripheral cyanosis Mechanism Right to left shunts Peripheral stasis or lung disorders Site Whole body Nail bed, nose tip, earlobe, extremities Associations Clubbing – Polycythaemia – Extremities Warm Cold On warming No change Disappears the extremities O2 inhalation Slight improvement No change Arterial blood Low < 85% Normal 85–100% Fig. Sleep Pathological Severe hypoxia Regularly Irregular Rhythm Hypothermia Seen in Sick sinus syndrome i. Acute inferior wall infarction Raised intraocular pressure Irregularly Irregular Rhythm Raised intracranial tension Seen in Heart blocks i. Causes of Sinus Tachycardia Physiological Infants Pulse Volume Children Pulse volume is best assessed by palpating the carotid Emotion artery. When pulse pressure is between 30 and 60 mm Hg, High output states: anaemia, pyrexia, beriberi, thyropulse volume is normal. When pulse pressure is less than 30 mm Hg, it is a Acute anterior wall myocardial infarction. Drugs (atropine, nifedipine, beta agonists— salbutaPulse volume depends on stroke volume and arterial mol, thyroxine, catecholamines, nicotine, caffeine). Pulse Deficit (Apex-Pulse Deficit) Pulse Character It is the difference between the heart rate and the pulse rate, when counted simultaneously for one full minute. The rapid downstroke is because of diastolic run-off into the left ventricle, and decreased peripheral Fig. Causes Causes Patent ductus arteriosus High output states—Anaemia, pyrexia, beriberi Aortic regurgitation 86 Manual of Practical Medicine Fig. Alternating small and large volume pulse in regular this is best felt in brachial and femoral artery. It is best appreciated by palpating radial or due to ejection of rapid jet of blood through the aortic femoral pulses, rather than the carotids. During the peak of flow, Bernouli’ s effect on the walls of ascending aorta causes a sudden decrease in lateral pressure on the inner aspect of the wall. It may occur for several beats, following a pre-mature Aortic stenosis and aortic regurgitation beat, in an otherwise normal heart. It is a single pulse wave with one peak in systole and one peak in diastole due to a very low stroke volume Pulsus Bigeminus with decreased peripheral resistance. A pulse wave with a normal beat followed by a premature beat and a compensatory pause, occurring in rapid succession, resulting in alternation of the strength of the pulse. In pulsus alternans, compensatory pause is absent, whereas in pulsus bigeminus, compensatory pause is present. Cardiovascular System 87 Korotkoff Sounds Korotkoff sounds should be examined preferably with bell of the stethoscope. The air bag within the cuff should extend for at least Hypertrophic obstructive cardiomyopathy 2/3rd of the arm length and circumference. Intermittent positive pressure ventilation the midportion of the rubber bag within the cuff Atrioventricular dissociation. Delay of the femoral compared with the right radial Auscultatory Gap pulse is found in coarctation of the aorta. Occasionally, after the initial appearance of the Korotkoff sounds, indicating the systolic pressure, the sounds disappear for sometime, to re-appear again and finally disappear at the diastolic pressure. Auscultatory gap occurs when there is venous distension or reduced velocity of arterial flow in the arm. It is the tissue perfusion should not have consumed coffee or tea for the preceding pressure. He Mean arterial pressure = Diastolic blood pressure should not be on adrenergic stimulants and there should + 1/3 of pulse pressure. When there is a fall in systolic pressure of > 20 mm below 140 mm Hg indicates normal blood pressure. Hg after standing for 3 minutes, from the lying posture, between 140-149 mm Hg indicates borderline isothe patient is said to have postural hypotension. Hypovolaemia (blood or fluid loss) > 30 mm Hg and a diastolic pressure of > 20 mm Hg 2. Autonomic neuropathy (diabetes mellitus, old age) from the basal original level, it indicates presence of 3. Pulse pressure is the difference between systolic and Isolated Systolic Hypertension diastolic blood pressure. Cardiovascular System 89 Accelerated Hypertension Labile Hypertension A significant recent increase in blood pressure over Patients who sometimes, but not always have arterial previous hypertensive levels, associated with evidence pressure within the hypertensive range, are classified of vascular damage on fundoscopic examination, but as having labile hypertension. The cuff is It is systemic hypertension seen for a transient phase then deflated even more slowly, and the pressure is of time when the patient is under stress or when he is again noted when Korotkoff sound becomes audible having a disorder with a transient hypertensive phase, throughout the respiratory cycle. If it is more than Episodic or Paroxysmal Hypertension 10 mm Hg, pulsus paradoxus is said to be present. However, a patient Paradox: Heart sounds are still heard over the prewith pheochromocytoma may be normotensive, hypocordium at a time when no pulse is palpable at the radial tensive or hypertensive. Pulsus alternans is present if there is an alteration in the intensity of Korotkoff sound. The overall height of the pulsating column is an indicator the right internal jugular vein is selected because it of mean right atrial pressure, which can be estimated is larger, straighter and has no valves. It is situated based on a simple anatomic fact, that in most indivibetween two heads of sternomastoid. Thus, the vertical height of the column Since right atrial pressure is often very low, optimal of blood in the neck can be estimated from the sternal positioning of the patient to visualise the column of angle, to which 5 cm is added to obtain an estimate of venous blood above the level of the clavicle is critical. This the examiner must position the patient’s upper thorax amount can be converted to millimetres of mercury by so that the column of blood in the internal jugular vein multiplying by 0. This estimation may be patient, the lower the pressure in the venous system, erroneous in patients with deformed chest walls or the more supine the patient’s position should be; the malpositioning of the heart (Fig. Cardiac Cardiac failure Tricuspid stenosis Tricuspid regurgitation Constrictive pericarditis Cardiac tamponade b. Erythema marginatum Friedreich’s sign is the rapid fall (steep ‘y’ descent) and rise of Subcutaneous nodules. Anaemia, jaundice Clubbing, splinter haemorrhages Osler’s nodes Causes of Kussmaul’s sign Janeway lesions Arthritis. Markers of Coronary Heart Disease Abdominal Jugular Reflux Arcus senilis Firm compression is given in the periumbilical area for Xanthelasma, xanthomas 30 seconds. Arcus senilis—Starts superiorly and no iris is Abdominal jugular reflux is positive in right or left visible between limbus and arcus heart failure and/or tricuspid regurgitation. In the Corneal arcus—Starts inferiorly and iris is visible absence of these conditions, a positive abdominal jugular between limbus and arcus.

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Label a diagram of the accessory organs skin care myths purchase discount tretinoin cream, and explain the role of each in digestion acne scar treatment order cheap tretinoin cream on line. Nutrients must be broken down by mechanical and chemical means into molecules that are small enough Tto be absorbed into the circulation acne before and after discount tretinoin cream express. Within cells acne quick treatment buy tretinoin cream with a mastercard, the nutrients are used for energy and for rebuilding vital cell components skin care 1 buy 0.05% tretinoin cream otc. Also contributing to the digestive process are several accessory organs that release secretions into the small intestine. Food is moved through the digestive tract by peristalsis, wavelike contractions of the organ walls. In the process of chewing, or mastication, the tongue and the palate, the roof of the mouth, help to break up the food and mix it with saliva, a secretion that moistens the food and begins the digestion of starch. The moistened food is then passed into the pharynx (throat) and through the esophagus into the stomach. The partially digested food passes through the lower portion of the stomach, the pylorus, into the flrst part of the small intestine, the duodenum. As the food continues through the jejunum and ileum, the remaining sections of the small intestine, digestion is completed. The substances active in digestion in the small intestine include enzymes from the intestine itself and secretions from the accessory organs of digestion. The digested nutrients, as well as water, minerals, and vitamins, are absorbed into the circulation, aided by small projections in the lining of the small intestine called villi. The Accessory Organs the accessory organs of digestion are illustrated in Figure 12-4. A major part of its activity is to process blood brought to it by a special circulatory pathway called the hepatic portal system. The common hepatic duct from the liver and the cystic duct from the gallbladder merge to form the common bile duct, which empties into the duodenum. The pancreas produces a mixture of digestive enzymes that is delivered into the duodenum through the pancreatic duct. The Large Intestine Undigested food, water, and digestive juices pass into the large intestine. This part of the digestive tract begins in the lower right region of the abdomen with a small pouch, the cecum, to which the appendix is attached. The large intestine continues as the colon, a name that is often used to mean the large intestine because the colon constitutes such a large portion of that organ. The colon travels upward along the right side of the abdomen as the ascending colon, crosses below the stomach as the transverse colon, then continues down the left side of the abdomen as the descending colon. As food is pushed through the colon, water is reabsorbed and stool or feces is formed. This waste material passes into the S-shaped sigmoid colon and is stored in the rectum until eliminated through the anus. The large bone of the upper arm is in which they are used to tell what meaning is the humerus, but this bone is often written as meant. The vagus nerve (cranial nerve X) is tion of the pelvis, but the ileum is the last pornamed with a root that means “wander,” as in tion of the small intestine. Different adjectives the words vague and vagabond, because this are preferred for each, iliac for the flrst and ileal nerve branches to many of the internal organs. Students often write the name as if it had some the word meiosis refers to the type of cell direlation to the famous gambling city in Nevada. Both words come from the that clinicians confuse them, leading to some Greek word that means a decrease. It is produced by three pairs of glands: the parotid, submandibular, and sublingual glands (see Fig. The oropharynx is the part of the pharynx that is located behind the . Exercise 12-2 Use the adjective sufflx -ic to write a word that means each of the following: 1. Use two roots plus the sufflx -stomy to write a word that has the same meaning as each of the following deflnitions: 24. A word that means inflammation of the liver is . Some produce short-lived upsets with gastroenteritis, nausea, diarrhea, and emesis (vomiting). The origins of such ulcers are not completely known, although infection with a bacterium, Helicobacter pylori, has been identifled as a major cause. Together these colorectal cancers rank among the most frequent causes of cancer deaths in the United States in both men and women. A diet low in flber and calcium and high in fat is a major risk factor in colorectal cancer. One sign of colorectal cancer is bleeding into the intestine, which can be detected by testing the stool for blood. Because this blood may be present in very small amounts, it is described as occult (“hidden”) blood. Colorectal cancers are staged according to Dukes classiflcation, ranging from A to C according to severity. The interior of the intestine can be observed with various endoscopes named for the speciflc area in which they are used, such as proctoscope (rectum), sigmoidoscope (sigmoid colon) (Fig. When a connection (anastomosis) is formed between two organs of the tract, both organs are included in naming, such as gastroduodenostomy (stomach and duodenum) or coloproctostomy (colon and rectum). The flexible flberoptic endoscope is advanced past the proximal sigmoid colon and then into the descending colon. The shaded portions represent the sections of the bowel that have been removed or are inactive. In a hiatal hernia, part of the stomach moves upward into the chest cavity through the space (hiatus) in the diaphragm where the esophagus passes through (see Fig. Often this condition produces no symptoms, but it may result in chest pain, dysphagia (difflculty in swallowing), or reflux of stomach contents into the esophagus. Hemorrhoids are varicose veins in the rectum associated with pain, bleeding, and, in some cases, prolapse of the rectum. Surgery is necessary to avoid rupture and peritonitis, infection of the peritoneal cavity. If these pouches are present in large number the condition is termed diverticulosis, which has been attributed to a diet low in flber. Collection of waste and bacteria in these sacs leads to diverticulitis, which is accompanied by pain and sometimes bleeding. Although there is no cure, diverticulitis is treated with diet, stool softeners, and drugs to reduce motility (antispasmodics). Lower gastrointestinal series (barium enema) showing lesions of enteritis (straight arrows) and thickened mucosa (curved arrows). Crohn disease is a chronic inflammation of segments of the intestinal wall, usually in the ileum, causing pain, diarrhea, abscess, and often formation of an abnormal passageway, or flstula. Ulcerative colitis involves a continuous inflammation of the lining of the colon and usually the rectum. It may be transmitted sexually, by sharing needles used for injection, and by close interpersonal contact. Most patients recover, but the disease may be serious, even fatal, and may lead to liver cancer. Hepatitis C is spread through blood and blood products or by close contact with an infected person. Hepatitis D, the delta virus, is highly pathogenic but only infects those already infected with hepatitis B. Hepatitis G is believed to be spread through contact with blood of an infected person. The name hepatitis simply means “inflammation of the liver,” but this disease also causes necrosis (death) of liver cells. It appears as yellowness of the skin, whites of the eyes, and mucous membranes caused by the presence of bile pigments, mainly bilirubin, in the blood. As the disease progresses there is splenomegaly, internal bleeding, and brain damage caused by changes in the composition of the blood. A complication of cirrhosis is increased pressure in the portal system that brings blood from the abdominal organs to the liver, a condition called portal hypertension. Gallstones form more commonly in women than in men, especially in women on oral contraceptives and in those who have had several pregnancies. Drugs may be used to dissolve gallstones, but often the cure is removal of the gallbladder in a cholecystectomy. This procedure was originally performed through a major abdominal incision, but now the gallbladder is almost always removed laparoscopically through a small incision in the abdomen. Contrast medium is injected into the biliary system from the duodenum and radiographs are taken. A contrast medium is injected into the pancreatic Duodenal papilla Pancreatic and bile ducts in preparation for radiography. Blood tests in acute pancreatitis show increased levels of the enzymes amylase and lipase. Typically occurs in digestive upset, motion sickness, and sometimes early pregnancy. May result from perforation of an ulcer, rupture of the appendix, or infection of the reproductive tract, among other causes. Can show obstruction, tumors, ulcers, hiatal hernia, and motility disorders, among others. Contrast medium is injected into the biliary system from the duodenum and radiographs are taken (see Fig. May be used for emptying the stomach, administering medication, giving liquids, or sampling stomach contents. Anus Appendix Ascending colon Cecum 1 4 Common bile duct 2 Descending colon 3 Diaphragm 5 Duodenum 6 Esophagus Gallbladder 7 Liver Oral cavity 9 Pancreas 8 Parotid gland 11 Pharynx 10 12 Rectum 15 Sigmoid colon 13 20 Small intestine 14 Spleen 16 Stomach 19 21 Sublingual gland Submandibular gland 17 22 18 Trachea 23 Transverse colon 24 1. The palatine tonsils are located on either side of the . From its name you might guess that the buccinator muscle is in the . A wave of contractions in an organ wall, such as the contractions that move material through the digestive tract, is called . The blind pouch at the beginning of the colon is the . The anticoagulant heparin is found throughout the body, but it is named for its presence in the . The substance cholesterol is named for its chemical composition (sterol) and for its presence in . Her skin, nails, and conjunctivae were yellowish, and she complained of frequent clay-colored stools.

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