Betnovate

By T. Kulak. University of Maryland at Baltimore. 2019.

It is common in people older than 40yrs and results from variable combinations of insulin resistance and defects in insulin secretion cheap 20gm betnovate mastercard. In the hypothetical case already mentioned the health officer requested the following laboratory investigations with the results shown below generic betnovate 20gm line. Clinical features The presentation of patients depends on the type of diabetes and the stage of pathologic process. The disease is often present for many years before the diagnosis and chronic hyperglycemia may be responsible for susceptibility to infections (eg. Short term – immediate treatment to relieve the symptoms such as polydipsia, polyuria, or acute infection. Long term – to prevent the development or delay progression of complications of diabetes The treatment of diabetes can be categorized as non-drug therapy and drug therapy. Regular Physical exercise This results in improvements in the sense of well being, cardiovascular fitness, blood pressure, insulin sensitivity, weight reduction and glycemic control. Dietary Control A general dietary recommendation includes consumption of a balanced health diet composed of: - 10 – 20% protein - 30% fat - 50-60% carbohydrate Patients should be advised to avoid dimple sugars like table sugar, honey etc and low saturated fat and cholesterol white high fiber diet is recommended. Insulin is also used in type 2 diabetics when a combination of oral agents fails to achieve glucose targets and temporarily in patients with serious infection or surgery. Standard insulin therapy consists of one to two injections per day using intermediate or long acting insulin with or without regular insulin. Adults of normal weight may be started with 20-25 u/d of intermediate acting insulin and increased to maintain a blood sugar level of 80-120 mg/dl. If this regimen does not lead to adequate blood glucose control, oral antihyperglycemic agents with or without insulin are indicated. On examination, signs include tachycardia, orthostatic hypotension, poor skin turgor, warm or dry skin and mucous membranes, deep and fast breathing (Kussmaul’s respiration), hypothermia or normothermia, acetone breath, and altered mental status or coma. Relate the clinical manifestation of diabetic mellitus to the associated pathophysiologic alteration 5. Learn on the pharmacological calculation of insulin to reach on accurate dose (units to milliliter from a vial containing 40,80 or100 units) 12. Describe the major macrovascular, microvascular and neuropathic complication of diabetic and self care behavior important in the prevention 14. Use the Nursing process as a frame work for care of the patient with diabetes 43 Diabetes Mellitus Definition: - is a chronic multifactorial, systemic metabolic disorder characterized by hyperglycemia and abnormal insulin production and /or action. There are five components of management for diabetes: - - Diet - Exercise - Monitoring blood glucose - Medication (as needed) - Education 45 I. The general recommendation include consumption of a balanced healthy diet composed of the following • 50% to 60% of calories to be derived from carbohydrates • Less than 30% obtained from fat and • The remaining 10% to 20% from protein *Food which diabetic should avoid (rapidly absorbed carbohydrate/simple sugar) 1) Sugar, honey, jam, marmalade and candy 2) Cakes and sweet biscuits 3) Soft drink (Fanta, coca cola, etc) 4) Alcohol (Cognac, tej, araki, whisky) There are types of alcohols which are allowed in moderation, that is less sweat drinks i. Exercise - Is extremely important in the management of diabetes because of its effect on lowering blood glucose and reducing cardiovascular risk factors - Lowers blood glucose level by increasing the uptake of glucose by body muscles and by improving insulin utilization - Pre or post exercise snack may be required to prevent hypoglycemia after exercise - Patients should be taught to do regular, moderate exercise at the same time and in the same amount for at least 30 minutes each day. Exercise recommendations must be altered as necessary for patients with diabetic complications - Blood glucose level should be measured before any exercise activity is initiated. Medications Insulin therapy • In type 1 diabetes, the body loses the ability to produce insulin, thus, exogenous insulin must be administered indefinitely. A standard insulin treatment consists of one or two injection/day, using intermediate or long acting insulin with or with out regular insulin. In addition, some patients whose type 2 diabetes is usually controlled by diet alone or diet and an oral agent may require insulin temporarily during illness, infection, pregnancy, surgery or some other stressful events. Actually there is no significant difference in the biologic activity between insulin put in the refrigerator and in the temperature (25- 34oc). It would seem safe to conclude that unless insulin in Africa is stored for a long period at very high temperature, there is no potential problem (5). Rotation - Rotation of injection site is required to prevent lipodystrophy, localized changes in fatty tissue, The patient is instructed as: 1. Systemic allergic reaction-are rare - Can be life threatening - Local skin reaction that gradually spreads in to generalized urticaria which can include laryngeal edema with respiratory distress 51 Treatment involves: - desensitization, gradually increasing the amount of insulin under cautious observation. Insulin lipodystrophy - Refers to a localized disturbance of fat metabolism in the form of lipoatrophy (loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat) or lipohyperthrophy (is the development of fibro fatty masses at the injection site and is caused by the repeated use of injection site) - If insulin is injected in to scarred areas the absorption may be delayed Treatment: Patient should avoid injection on the areas and prevent by rotating injection sites 3. Metformin Dosage, 500 – 2000 mg Po daily in divided doses Side effects: anorexia, nausea, vomiting, abdominal discomfort and diarrhea. This bolus is followed by the continuous infusion of 5 to 10 % of glucose at a rate sufficient to keep the plasma glucose level> 100mg/dl Patient education: - prevented by following a regular pattern for eating, administering insulin, and exercising - Because unexpected hypoglycemia may occur all patients treated with insulin should wear an identification bracelet or tag indicating that they have diabetes and should keep sugar or candy in their pocket - Patient and family members should be aware of signs of hypoglycemia 2. Paradoxically potassium appear elevated as a response to acidosis, though this is a temporary shift of potassium from intra to extra cellular space Sign and symptoms: - anorexia, nausea, and vomiting & abdominal pain - Acetone breathe - Kussmaul respiration (very deep& and fast respiration) -Lab. See the core module for the details Clinical manifestations * Symptoms of hypotension - Profound dehydration - Tachycardia and - Neurologic signs (e. Long term Complications of diabetes - Affect almost all organ systems of the body - Generally categorized as Macro vascular and Micro vascular 1. Macro vascular Complications This complication are cardiovascular& cerbrovascular disease including hypertension myocardial infarction ischemia, stroke& peripheral vascular disease - Prevention and treatments of modifiable risk factors is recommended (Smoking, obesity & initiation of safe exercise. Micro vascular Complications involve retina, kidney and nerves - Are unique to diabetes - Is characterized by capillary basement membrane thickening - 3 places where impaired capillary function may have devastating effects are the microcirculation of the retina of the eye (Retinopathy - twenty five times greater risk of blindness) & the kidney (Nephropathy - seventeen 57 times more likely to experience kidney failure) and blood supply to peripheral nerves (Neuropathy). If callus formation is present, rub areas with a pumice stone when the feet are wet then rub with a towel.

Puede mejorarse el flujo de las colaterales por medio de la simpatectomía order betnovate 20 gm visa, mientras que el flujo troncular se mejora desobstruyendo la arteria enferma o derivándola mediante el procedimiento denominado by pass o puente order betnovate 20gm with visa. Más recientemente el desarrollo de endoprótesis ha permitido realizar revascularizaciones, especialmente en las zonas de aorta e ilíacas, por la vía endovascular, con mucho menos tiempo y riesgos, aunque con costos aún muy elevados. Definir las formas anatomopatológicas mas frecuentes y las manifestaciones clínicas específicas de cada uno de los territorios afectados: carotídeo y vertebral. Determinar las diferentes formas de tratamiento así como destacar la importancia del tratamiento preventivo. Enfatizar la necesidad absoluta de auscultar las arterias carótidas en todo examen físico en busca de soplos patológicos. Ellas tienen su origen dentro o fuera del cráneo, de ahí que se clasifiquen en intracraneales y extracraneales. Actualmente se conoce, que esta localización extracraneal es la causa de más de 50 % de los episodios cerebrovasculares. Estos cuadros pueden variar desde ser fugaces, sin dejar secuelas, hasta ser permanentes cuando determinan invalidez del enfermo, incluso su muerte. Causas ¾ Desde el punto de vista anatómico 69 La estenosis de las arterias carótidas, casi siempre por ateromas. Estenosis La trombosis es otra de las causas, pero su cuadro es agudo y se instala en una arteria previamente estenosada por aterosclerosis, cuando el ateroma se desestabiliza. Por ejemplo una deshidratación o hipotensión, concentran la sangre o hacen más lento su movimiento y por lo tanto la inestabilidad del ateroma produce la oclusión súbita de la arteria que asciende al cráneo, cuya evolución y pronóstico son muy graves. Una carótida enferma con placas de ateromas puede ocasionar émbolos, debido a ulceraciones de estas placas en las que puede ocurrir un desprendimiento del material ateromatoso, es la ateroembolia. De hecho, muchas de las isquemias transitorias no son solamente producto de serios trastornos hemodinámicos, sino también de microembolias desprendidas del ateroma carotídeo que se impactan en las pequeñas arterias del interior del encéfalo. De igual manera, un corazón enfermo puede ser causa de embolias tal como se precisa en el capítulo 12. La acodadura y el enrollamiento, se producen cuando la arteria se alarga debido a una hipertensión arterial severa de muchos años de evolución. El alargamiento termina acodándose y en el grado extremo, enrollándose y se evidencia como una tumoración visible delante del músculo esternocleidomastoideo, que late, se expande y hasta puede tener un soplo sistólico, por lo que semeja un aneurisma, que es infrecuente en la arteria carótida. Cuadro clínico Es diferente según se afecte el territorio de la arteria carótida o vertebral. La derecha nace por detrás de la articulación esternocostoclavicular de ese lado como rama ascendente de la bifurcación del tronco arterial braquiocefálico, que también emite de forma casi horizontal y hacia afuera, la arteria subclavia. Del lado izquierdo la arteria carótida primitiva nace como segunda rama del arco aórtico, tiene una porción intratorácica y es unos centímetros más larga que la derecha. Ambas ascienden por delante del músculo esternocleidomastoideo y forman parte del paquete vasculonervioso del cuello, junto con la vena yugular interna y el nervio neumogástrico, vago, o (X) par. Un centímetro por encima de los cartílagos de la laringe se divide en dos ramas: interna y externa, que es el sitio preferente para su obligada auscultación. La externa busca hacia fuera y arriba, la glándula parótida y en su intimidad se divide en temporal superficial y maxilar interna para irrigar el cuero cabelludo, músculos masticadores y cara. La carótida interna se introduce por la base del cráneo y ya en su interior, contribuye con sus ramas terminales a conformar el polígono de Willis, con frecuencia un heptágono, que en general anastomosa ambas carótidas internas entre sí, así como con las vertebrales. La carótida interna es responsable de la irrigación de los dos tercios anteriores de los hemisferios cerebrales, con sus áreas motoras y sensitivas, los ojos y los oídos, lo que explica el cuadro clínico. Sensitivos: Calambres o adormecimiento, entumecimiento del hemicuerpo contralateral. Visuales: Amaurosis fugaz, del mismo lado que se encuentra la carótida afectada, o sea ipsilateral. Signos Examen neurológico: - Fuerza muscular disminuida en el hemicuerpo contralateral, hasta la hemiplejia. Examen del cuello: - Inspección: Cara anterolateral del cuello, puede ser normal o estar presente una tumoración que late por acodadura o enrollamiento y más raramente aneurismas. Es muy difícil diferenciar, por la palpación, si es una acodadura- enrollamiento o un aneurisma, lo que se hará por ultrasonografía. En su recorrido hacia la región posterior del cuello busca el agujero de la apófisis transversa de la 6ta vértebra cervical, para así ascender a través de ellos y penetrar al cráneo uniéndose a la del lado opuesto y formar un tronco único y medio, el tronco basilar. Es responsable de la irrigación del tercio posterior de los hemisferios cerebrales con la cisura calcarina, donde se integra la visión, así como el cerebelo y el tallo encefálico. Trastornos binoculares: Diplopía - Disfagia - Vértigos, mareos, trastornos del equilibrio. Signos Examen neurológico: - Ataxia - Fuerza muscular disminuida en ambos miembros inferiores. Paraparesia Examen del cuello: - Inspección: Prácticamente es negativo, excepto cuando se presenta una tumoración que late y expande hacia la región lateral y algo posterior del cuello y generalmente existe el antecedente de un trauma.

These correspond to different parts of the lifespan best 20gm betnovate, namely (a) pregnancy and lactation purchase betnovate 20 gm with visa, (b) infancy and childhood (c) adolescence and adulthood, and (d) old age. Therefore, a mother needs to gain weight during pregnancy to help nourish her growing baby. Women who do not gain enough weight often have babies that weigh too little (low birth weight). It may also suffer more from infection and malnutrition compared with babies of normal weight. The increased requirement of nutrients during pregnancy and lactation is shown in Box 3. If the mother gains less than this, the baby’s chances of survival and health declines. If she has already gained 11 kg after six–seven months, she should continue to gain moderately until delivery. This is because the unborn baby puts on most of its weight during the last months of pregnancy. Therefore the following are essential nutrition actions related to maternal nutrition:. A pregnant or breastfeeding woman needs extra foods, especially those that are good sources of iron. Pregnant women need at least one additional meal (200 Kcal) per day during the pregnancy. She should reduce her involvement in strenuous household tasks that lead to higher energy expenditure. Pregnant women should take vitamin A rich foods (such as papaya, mango, tomato, carrot, and green leafy vegetable) and animal foods (such as fish and liver). In the malarious areas, pregnant women should sleep under an insecticide- treated bed net. Pregnant women during the third trimester of pregnancy should be de- wormed using mebendazole or albendazole (you will learn about the doses for this in Study Session 7 of this Module). This should include as far as possible food from the different food groups (animal products, fruits, vegetables, cereals and legumes). A pregnant or lactating woman can get extra foods by eating a little more of ordinary meals. She should increase the amount of nourishment at one or two meals, not every meal. They may be anaemic, which in turn means that they may have difficulty in pregnancy and childbirth. A pregnant or breastfeeding mother should have enough iron to keep herself and her baby healthy. She should eat plenty of iron-rich foods every day such as dried beans, legumes, dark green leafy vegetables, liver, kidney and heart. A pregnant mother should go for her first antenatal care visit at the latest by the fourth month of her pregnancy. At the clinic, check her urine for excess sugar and proteins, and her blood for malaria (if she is showing signs of infection). You diagnose anaemia in the following way: Examine the lower eyelids, the inside of the lips and the palms which should be bright pink; if there is anaemia, all of these will be pale whitish. Give the mother iron tablets or tablets with iron and folate to build strong blood 27. If the iron tablets upset the mother or cause side effects, she should not stop taking iron, but eat more leafy vegetables. As a Health Extension Practitioner it is important that you identify the women who may need extra help and support. Encourage them to eat as good mixture of foods as they can afford (fruits, vegetables, animal source foods). Encourage other members of the household to do some of the work and lessen the work burden on the woman. The baby of an anaemic mother will not develop well and will have low birth weight. If there is anaemia, they will be pale whitish; if there is no anaemia they will be pinkish. When a baby sucks at the nipple, this causes the milk to come into the breast and continue to flow. Breastmilk is food produced by the mother’s body especially for the baby, and it contains all the nutrients (nourishment) a healthy baby needs. A lactating woman needs at least two extra meals (550 Kcal) of whatever is available at home. This will enable the baby to get an adequate supply of vitamin A for the first six months. During the first six months the best way of feeding the baby is for the mother to breastfeed exclusively.

Non metro Hospital a) clinical diagnosis – nothing specific b)Investigation –X-ray c)Referral criteria: If facilities and know-how are not available for curettage and bone grafting Situation 2: a)clinical Diagnisis is difficult generic betnovate 20gm with amex. Introduction: Benign bone tumour arising from chondroblasts buy discount betnovate 20 gm on-line; usually present in the small bones of hands and feet and asymptomatic for long time; patient presents usually with a pathological fracture or sometimes pain. Differential Diagnosis: Aneurysmal bone cyst, Tubercular dactylitis, Giant cell tumour, clear cell chondrosarcoma & acrometastases. Introduction: Benign cartilaginous tumours; the former is also called “Codman’s Tumour”. Usually seen in the metaphyseal region of immature skeleton and most of the times it is asymptomatic. It may be an incidental finding in a x-ray taken for some other purpose or bigger lesions may present as pathological fractures. They have a characteristic radiological appearance of serpigenous margins which have pencil lined sclerotic borders. Big lesions are curetted prophylactically to prevent pathological fractures and bone grafted. Once they present with a pathological fracture – either they are immobilized in plaster cast till the fracture unites and then curetted and bone grafted or the fracture is openly reduced and internally fixed and at the same time the lesion is curetted and bone grafted. Introduction: A benign very slow growth of in the subcutaneous tissue or intermuscular connective tissue – does not metastasise but recurrence rate after excision is very high. Differential Diagnosis: Other malignant soft tissue tumours like synovial sarcoma or fibrosarcoma. Introduction: Freak outgrowths from the growth plates – multiple osteochondromatosis- which is familial and producing remodeling and growth abnormalities and ten times more potent for malignancy than its solitary counterpart. Freak inclusions of cartilaginous masses from growth plates into the metaphysic producing streaks of lucency is Ollier’s disease – usually present in one side of the body and produces marked growth anomalies. Proliferation of cartilage in the medullary substance of small bones of hands and feet producing globular swellings is multiple enchondromatosis. Differential Diagnosis: usually none; One has to be vizilant to look for a malignant transformation in one of the lesions - the more proximal the lesion is to the axial skeleton more are the chances of malignancy. Mechanical restriction of motion of a neighbouring joint or compression of a nearby nerve are to be looked into b) Investigation – Only plain x-ray is possible d) referral criteria – all cases to be referred to higher centres. Lesions very proximal to the axial skeleton should be excised prophylactically 11) Name of condition: Benign Aggressive tumour – Giant Cell Tumour (Osteoclastoma) I, Introduction:. A benign bone tumour arising from undifferentiated connective tissue cells of bone marrow. It is an aggressive tumour and the chances of recurrence following curettage are very high. Incidence: much more common in India, especially South India (4 to 6 times), than the western world. Differential Diagnosis: Aneurysmal bone cyst, Benign Fibrous histiocytoma and aggressive chondromyxoid fibroma. Excision in toto is ideal if the bone involved is expendable (like lower ulna, proximal fibula). In instances like lower radius, excision and reconstruction using proximal fibula is practiced. In weight bearing bones like distal femur or proximal tibia, when the the bone is totally destroyed, resection arthrodesis (Enneking procedure) is ideal if the patient belongs lower socioeconomic group. But if the patient belongs to higher strata where the load demands are less, excision and custom mega prosthesis may be practiced. In fungating cases or after repeated recurrences, an amputation may be the last resort. Differential Diagnosis: Early lesions are difficult to diagnose unless one has high index of suspicion. Any pain in the metaphyseal region following a minor injury and disproportionate to the injury or if the pain is slowly increasing day by day after minor injury and especially without fever should lead the clinician to suspect this sinister disease. Prevention: Genetic engineering is under trial to prevent the lesion in children who are genetically prone to suffer. In late cases pain preceding a spindle shaped swelling in the metaphysic of long bone must give suspicion of osteosarcoma. In cases of late presentation where tumour excision is not feasible a course of chemotherapy is followed by amputation of the limb – chemotherapy is continued. Introduction: Chondrosarcoma is a malignant bone tumor arising from chondroblasts. The lesion may arise de novo (primary chondrosarcoma) or there may be malignant transformation of an existing benign cartilaginous lesion - osteochondroma / enchondroma (secondary chondrosarcoma).