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Corticosteroids are the mainstay of treatment generic 50mg sumatriptan overnight delivery muscle relaxant drug class, with methotrexate and azathioprine used in refractory cases order sumatriptan 50 mg amex spasms going to sleep. Incidence Percutaneous angioplasty or surgical bypass of affected 13 per 1 buy sumatriptan 25 mg low cost muscle relaxant indications,000,000 per year. Polyarteritis nodosa Denition Geography Polyarteritis nodosa is a rare intense necrotising vasculi- Largest number of cases in Asia and Africa. Aetiology/pathophysiology Associated with hepatitis B infection in 1020% be- Age cause of hepatitis B surface antigen immune complexes. Transmural neutrophil inltration of medium-sized arteries occurs, causing degeneration, weakness and microaneurysm Sex formation. Veins are also affected and the condition may M = F result in thrombosis and tissue infarction. Clinical features Aetiology/pathophysiology Polyarteritis nodosa is usually an acute illness charac- It is thought to be an autoimmune disorder. Serumconcentrations of IgA ammatory occlusion of small and medium-sized pe- are raised in approximately half of patients and IgA- ripheral arteries and veins of the upper and lower limbs. Clusters of cases have been noted with no obvious pre- Aetiology/pathophysiology cipitant. It occurs almost exclusively in heavy cigarette smokers and is therefore seen more in countries with high levels Pathophysiology of smoking. There is segmental chronic inammatory The condition results from inammation within the inltration of the vessel walls with resultant obliteration walls of small blood vessels, predominantly capillaries of the lumen and secondary thrombosis. The condition starts with digital ischaemia, ulceration The inammation of the vessels increases permeability preceded by claudication in the feet, or rest pain in the resulting in a leaking of uid and cells from the circula- ngers or toes. IgA deposition within ankle pulses are usually absent but brachial and popliteal the glomeruli of the kidney causes a focal segmental pat- pulses are present. There may be a previous history of tern of glomerulonephritis with a resultant proliferation supercial thrombophlebitis. Investigations Clinical features Arteriography shows narrowing or occlusion of small This multisystem disorder may occur with simultaneous peripheral arteries with healthy main vessels. The rash characteristically affects the lower The condition remits with quitting smoking; nicotine limbs and buttocks, but is not always conned to these replacement therapy cannot be used but bupropion areas. Prostaglandin infusions, thrombolytic puric and then goes through the classic colour changes therapy, surgical sympathectomy and revascularistion of a bruise, lesions of varying ages are present at one procedures have been tried. Oedema of the face, dorsum of the hands and feet, perineum or foreskin may occur especially in young children HenochSchonlein Purpura r Aself-limiting acute arthritis of large distal joints oc- Denition curs without articular damage with the patient com- A syndrome resulting from a vasculitis of small blood plaining of swollen, tender painful joints exacerbated vessels. Clinical features Symptoms are symmetrical with ngers affected more Complications than toes, it usually begins in a single digit and then Gastrointestinal complications include infarction and becomes more generalised. Renal failure may due to vasoconstriction progressing through cyanosis to occur in the acute phase, or may progress over many hyperaemia (white to blue to red). Investigations The diagnosis is clinical; erythrocyte sedimentation rate, Investigations white cell count and eosinophils may be raised. Urine Primary Raynauds phenomenon must be distinguished microscopy should be performed looking for red and fromRaynaudssyndromeoccurringwithconnectivetis- white blood cells, casts and protein. In more pain and rash may be achieved with nonsteroidal anti- severe cases calcium channel blockers such as nifedipine inammatory drugs. In severe cases prostacyclin infusions may be manifestations may be improved with the prompt use of required. Complications such as acute renal failure and intussusception should be managed promptly. Behcets syndrome Prognosis Denition Inmostcasestheoverallprognosisisexcellent,thecourse Achronic,relapsingmultisystemvasculitischaracterised is variable with cases lasting between a few days and a by oral ulceration. Rarely it may continue for up to a year and there may be a course of relapse and remission. Denition An exaggerated vascular response to cold, causing a Sex spasm of the arteries supplying the ngers and toes. M > F Prevalence Geography Five to ten per cent of young women in temperate cli- Much more common in Turkey, Iran, China, Korea and mates. Patients demonstrate pathergy (a gered autoimmune reaction in a genetically susceptible papule or pustule forms at sites of skin puncture) this individual. Clinical features Management Patients have recurrent oral aphthous or herpetiform ul- Corticosteroids and immunosuppressive agents are used cers. Colchicine may be of benet for ery- ular disease (uveitis), skin lesions (erythema nodosum), thema nodosum and arthralgia. A thin section a few mil- limetres around and underneath the resulting defect Nomenclature and description is taken, divided into pieces, and cut as a fresh frozen specimen. If tumour is seen at a particular margin re- The cornerstone of dermatological diagnosis is accu- section is continued at the appropriate margin, and rate observation and description of lesions and rashes. Dermatological procedures Skin grafts r Shaveortangential excision: This procedure slices a Skin grafts are sections of skin that are completely de- surface growth off using a blade, often to remove a tached and transferred to cover large areas of skin defect. The recipient site requires a good blood supply, as the r Punch biopsy: Under local anaesthesia a full thickness graft has no supply of its own. Ifaverylargedefectneeds are scraped off with a special tool and the area is cau- covering, the graft can be meshed. Repeated treatment may be take up a blood supply more easily than full thickness required. The area heals often leaving a small hypopig- grafts, but tend to shrink and have abnormal pigmen- mented mark. Lightfreezingcausesapeeling,moderate dermis, are used mainly in reconstructive surgery. They leave a donor site, which requires closure by su- r Mohs surgery: This is a technique used in the re- tures, limiting the size of the graft. Erythroderma Intense and widespread reddening of the skin due to dilation of blood vessels, often with exfoliation. Excoriation Stripping of the skin usually by scratching as a result of intense itching of the skin. May be a primary lichenoid disease or a secondary lichenication due to repeated excoriation as seen in chronic eczema. Macule Describes a skin lesion that is at, often well circumscribed with alteration of colour.

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They may cause voluminous life threatening diarrheal diseases in patients with acquired immunodeficiency syndrome effective sumatriptan 50 mg muscle relaxant topical cream. Evaluation of a patient with diarrhea Careful interview of patients with diarrhea contributes in etiologic diagnosis purchase 50 mg sumatriptan mastercard spasms in 8 month old, evaluation of severity of illness purchase sumatriptan 25 mg without a prescription muscle relaxant 4211, and in designing treatment and preventive measures. Thus, the history should include Duration of illness: if the diarrhea lasts for 2 - 4 wks, acute diarrheal diseases are said to exist. However, if it lasts for more than 4 wks, consider chronic diarrheal diseases and infectious causes are unlikely. Bloody diarrhea is usually inflammatory or ischemic in origin and caused by invasive organisms, ulcerative colitis, or neoplasms Volume of diarrhea Large volume diarrhea indicates small bowel or proximal colonic diseases Scanty, frequent stools associated with urgency suggest left colon or rectal diseases Any association with specific meal? If diarrhea is associated with intake of Fat it is due to fatty intolerance Sweet diet it is due to osmotic diarrhea Milk and milk products - it is due to lactase deficiency Is there history of drug intake? Laxatives Chemotherapeutic agents 7) Presence of underlying diseases (like diabetes mellitus) or systemic symptoms Physical examination: Assess severity of dehydration, Wight loss and other associated signs in patient with chronic diarrhea. Diagnosis: Laboratory tests: 1) Culture and sensitivity testing to detect a pathogenic bacterial strains. Proctosigmoidoscopy: to exclude of confirm the diagnosis of inflammatory bowel diseases. Rehydration In patients with massive diarrhea and vomiting with hypotension intravenous fluids like Ringers lactate or Normal saline should be given in adequate amount. Antimicrobial therapy Antibiotics: Most acute infectious diarrheal diseases do not require antibiotic therapy because majority of them are self limited and viral in nature. In immunocompromized patients continue maintenance dose of the same drug three times a week. Anemia Learning objectives: At the end of this topic the student we be able to:- 1. Evaluate cases of anemia with appropriate history, physical examination and proper laboratory studies 4. Anemia: General approach a) Definition Functional definition: A significant reduction in red cell mass and a corresponding decrease in the 02 carrying capacity of the blood. For instance; 389 Internal Medicine Hgb or Hematocrite could be falsely elevated ( plasma volume) e. Clinical approach to the Patients with anemia Anemia is a manifestation of an underlying pathological condition. Multifactorial : a combination of these History: Accurate history provides information crucial to the diagnosis of the underlying cause. Cardiovascular adjustment Increased in cardiac output occurs at Hgb level of 7-8 gm% : the increased in cardiac output coupled with modest tachycardia creates a hyperdynamic state and hence systolic ejection murmur Peripheral vascular resistance decreases there by facilitating tissue perfusion; clinically is evidenced by wide pulse pressure. Local changes in tissue perfusion: Redistribution of blood flow to vital organs at the expense of reduced blood flow to less vital organs. Reduction of mixed venous O2 tension to increases the arteriovenous O2 difference O2 extraction at peripheral tissues 393 Internal Medicine Individuals tend to survive at extremely low hemoglobin levels (even as low as 3 gm %) due to these compensatory mechanisms. Therapeutic considerations and indications In the management of anemic patients carefully remember the following points Identify and correct the cause of anemia Administration of Hematinines such as Iron, Vit B12 or folate without correct diagnosis of the cause of anemia is an unacceptable practice in the treatment of anemia Therapeutic modalities include: Iron, folate, Vit. Identify possible reasons for inadequate response to therapy and indications for parenteral iron administration 8. Iron deficiency anemia Hypo chromic microcytic cells Etiologies of Iron deficnecy Anemia 1. Increased demands Prematurity in newborns Rapid growth ( as in adolescent ) growth spurt Pregnancy 3. Poor diet Contributory factor in many countries but rarely sole cause Clinical manifestation: Is insidious in onset and progressive in course Patients often present with nonspecific symptoms mentioned above with/without some specific symptoms. Inadequate response may imply Continuing hemorrhage non compliance to therapy Wrong diagnosis Mixed deficiency associated folate or vit. Inability or unwillingness to take orally Iron-dextran complex or iron sorbitol citrate can be used Intra-muscularly or intra-venous route. Correction of reversible contributors (iron, folate, cobalamine supplements if necessary) C) Sideroblastic anemia: Refractory anemia with hypochromia with marrow iron Many pathological ring sideroblasts are found in the bone marrow Is caused by defect in hem synthesis Classification: Hereditary (sex linked recessive trait) Acquired 399 Internal Medicine o Primary :Myelodysplasia o Secondary : - Malignant diseases of the marrow - Drugs e. Macrocytic Anemia Learning objectives: at the end of the student will be able to:- 1. Understand the management of Megaloblastic anemia and asses response to therapy properly Megaloblastic Anemia and other Macrocytic Anemia Pathogenesis: Its a descriptive morphologic term in which maturation of the nucleus is delayed relative to that of cytoplasm. Abnormalities of vitamin B12 or folate metabolism, transcobalamine deficiency, antifolate-drugs 4. B12 deficiency 1) Nutritional: especially in vegans 2) Malabsorption a) Gastric causes i) Adult (addisonian) pernicious anemia ii) Congenital lack or abnormality of intrinsic factor iii) Total or partial gastrectomy b) Intestinal causes i) Intestinal stagnant loop syndrome, jejunal diverticulosis, blind loop, stricture etc. Vit B12 Deficiency: is treated with Hydroxocobalamine which is given parentraly Dose: Initial dose: 6 x 1000 g over 2-3 weeks and Maintenance : 1000 g every 3 months Prophylactic therapy is indicated in patients with Total gastrectomy and Ileal resection 2. Folate deficiency: is treated with Folic acid preparation which is given orally Dose: 5 mg Po daily Prophylactic therapy is indicated in pregnancy, sever hemolytic anemia, in patients with dialysis, and premature newborns 3. Additional measures: Correct underlying cause Antibiotics for bacterial over growth and treatment of fish tapeworm Response to therapy Feeling of general well being is restored in 48 hrs Reticulocytosis begins in 3-4 days and peaks in 7-10 days. Leukemias Learning Objective: At the end of this unit the student will be able to 1) Define leukemia 2) Classify the different types of leukemias 3) Describe the possible etiologies and epidemiology of leukemia. Cell of origin : there are two types of leukemias Lymphoid leukemias Myeloid leukemias 2. But studies have demonstrated that both genetics and environmental factors are important in the causation of these diseases. Genetics There is a greatly increased incidence of leukemia in the identical twin of patients with leukemia. Environmental factors like Ionizing radiation: The relation between acute leukemia and ionizing radiation, has been established in those having occupational radiation exposure, patients receiving radiotherapy and Japanese survivors of atomic bomb explosions. Epidemiology Globally the incidence of all leukemias is 13/100,000/ year usually affecting men more than women. Acute Leukemias Acute leukemias are characterized by the presence of immature white blood cells in the marrow and peripheral blood. Pathophysiology Acute leukemias are characterized by clonal proliferation of immature hematopoietic cells. In the majority of cases the initial symptoms are present for less than 3 months and are the consequence of bone marrow failure, i.

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Studies insulin was licensed for use in 2006 but has been withdrawn from examining data trends within Africa point to evidence of a the market because of low patronage purchase sumatriptan 50mg overnight delivery spasms just below sternum. Olokoba decades and much of the increase will occur in developing countries Department of Ophthalmology discount 25mg sumatriptan with amex spasms meaning, University of Ilorin Teaching Hospital order sumatriptan 50 mg amex spasms below left rib cage, where the majority of patients are aged between 45 and 64 years. However, practicing As a result of this dysfunction, glucagon and hepatic glucose physicians frequently employ other measures in addition to those levels that rise during fasting are not suppressed with a meal. In July 2009, the International Expert Committee Oman Medical Specialty Board Oman Medical Journal (2012) Vol. Pre- emphasizes specifcity, commenting that this balanced the stigma prandial administration allows fexibility in case a meal is missed and cost of mistakenly identifying individuals as diabetic against without increased risk of hypoglycemia. Pioglitazone nutrition evaluation; lifestyle recommendations should be tailored use is not associated with hypoglycemia and can be used in cases according to physical and functional ability. Due to the concern of development T eir use is usually limited due to high rates of side-efects such of lactic acidosis, metformin should be used with caution in elderly as diarrhoea and fatulence. It has a low incidence 39 drugs, has been shown in a study to signifcantly improve glucose of hypoglycemia compared to sulfonylureas. T ey dehydrogenase 1, which reduce the glucocorticoid efects in liver are efective as monotherapy in patients inadequately controlled and fat. Insulin-releasing glucokinase activators and pancreatic- with diet and exercise and as add-on therapy in combination with G-protein-coupled fatty-acid-receptor agonists, glucagon-receptor metformin, thiazolidinediones, and insulin. Education of the populace is still key to the control of this some beta cell function remains. Novel drugs are being developed, yet no cure insulin is necessary if beta cell exhaustion occurs. Rescue therapy is available in sight for the disease, despite new insight into the using replacement is necessary in cases of glucose toxicity which pathophysiology of the disease. T e long acting forms are less likely to cause hypoglycemia compared to the short acting 1. T e worldwide epidemiology of the new insulin analogues are distinct from those of the regular type 2 diabetes mellitus: present and future perspectives. Diabetic atlas in 2006,55 after it was approved by both the European Medicines ffth edition 2011, Brussels. National diabetes fact sheet: national estimates obesity and type 2 diabetes in Asia. Rates of hypoglycemia in users of United States, 1988-1994 and 1999-2000"Centers for Disease Control and sulfonylureas. Drug interactions of clinical importance with antihyperglycaemic and adolescent overweight and obesity: Summary report. Association of urinary bisphenol A concentration with medical disorders common and distinct processes. Genetics of obesity and the prediction tolbutamide-plus-acarbose in non-insulin-dependent diabetes mellitus. Voglibose for prevention of type 2 diabetes insulin resistance on resting and glucose-induced thermogenesis in man. Int J mellitus: a randomised, double-blind trial in Japanese individuals with Obes Relat Metab Disord 1999 Dec;23(12):1307-1313. Cost-efectiveness of insulin analogues for science, and the multiplier hypothesis. Prandial inhaled insulin plus basal insulin glargine versus twice daily hormones and beta-cell dysfunction. Clin and cost-efectiveness of inhaled insulin in diabetes mellitus: a systematic Diabetes 2009;4(27):132-138. Management of type the risk of type 2 diabetes: a systematic review and meta-analysis. One of the Practical experiences of living with diabetes: functions of insulin is to move glucose from the blood into the cells From diagnosis onwards. Useful numbers: By not producing enough insulin you may start to have these symptoms caused by high blood glucose levels: Diabetes clinic Extreme tiredness Diabetes Specialist Nurse Going to the toilet to pass urine more than usual especially at night Increasedthirst Podiatrist Genital itching or regularepisodes of thrush Blurredvision Dietitian Weight loss. There are also an estimated one million people understand how some of the treatments work. Over three- Blood glucose levels increase when sugar and starchy foods have quarters of people with diabetes have type 2 diabetes. This causes the Type 1 diabetes liver to make more glucose than usual, but the body still cannot use Type 1 diabetes develops if the body is unable to produce any the glucose as fuel. Type 1 diabetes develops usually over a Thisis why people with uncontrolled diabetes have these symptoms: few weeks because the insulin-producing cells in the pancreas have been destroyed. Nobody knows for sure why these cells have been Extreme tiredness you cannot move glucose from the blood damaged but the most likely cause is an abnormal reaction of the into your cells to make fuel body to the cells. This type of lot of glucose is the perfect environment for fungal infections and diabetes usually appears in people over the age of 40 however it is germstothrive. It is more common in people of South Asian urine, your eyes have less fluid in them so it gives you blurred and African-Caribbean origin. This is not permanent damage and its important not to treating diabetes although medication taken as tablets or by get new spectacles or contact lenses as your vision should return injection may also be necessary to control blood glucose levels. Type 2 diabetes develops slowly and high blood glucose symptoms Weight loss when your body cannot move glucose from your are usually less severe. Some people may not notice any symptoms blood into your cells it tries to find glucose from somewhere else at all and diabetes may be picked up in a routine medical check-up. It will next break down fat cells which contain Also, some people may put the symptoms down to getting older stored glucose to use for fuel. Unfortunately this doesnt solve the or overwork which may delay them seeking medical attention. It is problem as there is still not enough insulin to move the fat glucose possible for type 2 diabetes to go undiagnosed for several years. Some patients take a combination of different medication to control their blood glucose levels. The need for changes in medication can Those who are overweight alter over time and therefore it is important to attend regular Those who have a blood relative with diabetes check-ups for your diabetes. This is because the pancreas will gradually Those who are of SouthAsian or African-Caribbeanorigin stop producing insulin andyou mayrequire differenttreatments.

E. Raid. Emmaus Bible College.