Virtual tour of a beautiful house on sale...Must see!

http://tour.circlepix.com/tour.htm?id=721513

Home Selling Tips:

1) Stage your home: Make it appealing to the buyer.
2) Remove the clutter: Let the buyer have the feeling of openness.
3) Put more plants indoor as well as outdoors: Plants give a fresh look to your house.
4) Replace all bad and old light fixtures: There should be lot of light in the house.
5) Clean the windows and doors: Open them to give a bigger look to your hoom.
6) Clean the carpet: Get all the stains removed.
7) Take off personal pictures: Depersonalization removes all the biases that teh buyer might have.
8) Burn some candles with nice fragrances: Nice smell makes a good impact.
9) Set the closets: Stack up all the clothes and toys. You don't want buyer to open the closet and have things falling on him.
10) Paint the house in neutral colors: You don't want the buyer to remember your house as "that yellow house".

DIABETES

Diabetes type II is one of the most common conditions that is seen in Family practice. Here are some simple tips to manage diabetes.

Diagnosing Criteria:
1) FBS> or equal to 126 on two occasions
2) Random blood sugar > or equal to 200 with symptoms ( Polyuria, polydipsia, polyphagia)
3) 2 hrs PP blood sugar > or equal to 200

Etiology:
Genetic factors, obesity, drug induced (antipsychotics, HIV meds)

Risk Factors:
Family history (1st degree relatives), gestational diabetes, obesity, ethnicity (AA, Latino, native American, Asian American), BP > 140/90, HDL <35mg/dl>250mg/dl, metabolic syndrome, PCOS.

Symptoms:
polyuria, poluydipsia, polyphagia, weight los, weakness, fatigue, frequest infections.

Tests:
1) FBS
2) 2 hr PP if FBS between 100-125
3) HgA1c - though not used for diagnosing

Management:

Pnemonic: GLUCOSEBAD
G: Glycemic control. Goal FBS <130, PP <180, before meals <140. Goal HgA1C <7%
L: Lipids. Goal LDL <100, if CVD present then goal LDL <70. Statins are now considered in
every patient >40 if one or more CVD risk factors are present.
U: Urine microalbumin urea. Goal urine albumin/Serum creatine ratio is < 30ug/mg. If
abnormal, start ACEI'S even if BP is normal.
C: Cigarette smoking. Pts should be counseled to stop smoking.
O: Opthalmology. Pts need dilated eye exam yearly to rule out retinopathy
S: Sexual problems. Pt's sexual problems should be addressed at every visit. If males are
experiencing erectile dysfunction, consider Sildenafil.
E: Comprehensive foot exam needed yearly and monofilament test at evry visit. If abnormal test
or absent pedal pulses, refer to vascular surgery. If neuropathy, consider medications
(Gabapentin).
B: Goal BP <130/80. ACEI's are recommended if no contraindications.
A: ASA use. Every pt >40 yrs of age should be on ASA
D: Dental exam evry 6 monthly.

Medications:
Sulfonylureas: Glyburide Glipizide, Glimeperide
Thiazolidinediones : Rosiglitazone, Pioglitazones
Biguanides: Metformin
Meglitines: Nateglinide (starlix), Repaglinide (prandin)
Alpha glucosidase inhibitors: Acarbose
DDP-4 Inhibitor: Sitagliptin (Januvia)
GLP-1 mimetic: Exanatide (Byetta)
Amylinomimetic: Pramlintide (Symlin)
Insulin: Rapid acting (lispro, aspart), Short acting (Regular), Intermediate acting ( NPH),
Long acting ( Lantus, Detemir)

Start with Metformin, if not controlled add SFU or TZD's or DDP4i. can give upto 3 group of medications. If still not controlled, add insulin. Stop SFU's, dec dose of TZD's.

INSULIN: Starting dose in outpatient is 0.2 units/kg/day. If patient already on insulin then start with 0.5 units/kg/day. Keep increasing 3 units every 3 rd day till blood sugars at at goal.

Method: Start with either 1)Basal insulin (long acting) plus bolus (rapid acting) OR
2) NPH + Regular in 70/30 mixture or 50/50 mixture.

1) Divide total daily dose (TDD) of insulin into half. Give half as long acting at night and half as rapid acting given with each meal (this half is divided into 3)

2) For 70/30, give 2/3rd in am and 1/3rd in pm. For am give 2/3rd of NPH and 1/3rd regular. For pm give 1/2 of NPH, 1/2 regular. OR 60% of 70/30 in am and 40% in pm.
Am dose: TDD x 0.4 NPH and TDD x 0.2 regular
PM dose: TDD x 0.2 NPH, TDD x 0.2 regular

Actions of medications:
SFU's, TZD's, Metformin, insulin: Peak is 2,4,8, none hrs
Duration of action is 4,8,12,24 hrs

Tip: For every 30 mg increase in blood sugar, HgA1C inc by 1%.