Final ppt shadab

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Final ppt shadab

  1. 1. APPLIED ANATOMY OF DIGESTIVE SYSTEM BY- UNDER THE GUIDANCE OF ASMA MAZGAONKAR DR. SIPPY SIR SHADAB KHAN ASHISH UBALE JITENDRA MOURYA NARENDRA DAUNDKAR VINOD DARADE PREETI TAWDE
  2. 2. Ludwig's Angina • Is a skin infection that occurs on the floor of the mouth, underneath the tongue. • Complications can be life threatening. Causes:- • Ludwig’s angina is a bacterial infection. It is usually caused by the bacterium Streptococcus or Staphylococcus and often follows a mouth injury or infection such as a tooth abscess. • Poor dental hygiene, lacerations in the mouth or a recent tooth extraction.
  3. 3. Symptoms:- Ludwig’s angina often follows a tooth infection or other infection or injury in the mouth. Symptoms include: • pain in the floor of your mouth • problems with speech • neck pain • swelling of the neck • redness on the neck • weakness, fatigue • earache • swollen tongue pushing against your palate • fever, chills
  4. 4. Diagnosis:- • Physical exam:-Head, neck and tongue will appear red and swollen. • Imaging tests:-Contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) images. • Fluid cultures :-Fluid from the affected area may tested to identify the bacterium. Complications:- • Blocked airway. • Sepsis (a severe reaction to bacteria or other germs) • Septic shock(infection that leads to dangerously low blood pressure).
  5. 5. Treatment:- • Blocked airway - Insert a breathing tube through your nose or mouth into your lungs. - Tracheotomy. • Surgery. • Antibiotics. Prevention:- • Practicing good oral hygiene. • Having regular dental checkups. • Seeking prompt treatment for tooth and mouth infections.
  6. 6. Oral Mucositis • Oral Mucositis (OM) refers to an inflammatory, erosive and ulcerative process inside the mouth, which is usually caused by radiation or chemotherapy. Causes:- • Side effect of cancer treatment. Increased risk:- • Smoking. • Drinking alcohol. • Eating spicy foods. • Dehydration. • Dry mouth–is another side effect of radiotherapy and chemotherapy. • Receiving a higher dose of chemotherapy.
  7. 7. Symptoms:-The symptoms of oral Mucositis usually begin five to 10 days after starting chemotherapy or 14 days after starting radiotherapy. • Burnt sensation while eating very hot food. • Develop white patches or ulcers on the lining of mouth, on tongue and around lips. • Red and inflamed oral mucosa. • Ulcerations may cause severe pain. Conditions look like Oral Mucositis:- • Candidiasis (oral thrush); • Herpes simplex virus (HSV); and • Graft-versus-host disease (GVHD).
  8. 8. Diagnosis:- • Examining your mouth. • Diagnosis symptoms of pain. • Checking ability to eat and drink properly. Complications:- • Severe pain and trouble eating . • Dry mouth. • Alterations in taste that can lead to Anorexia. • Weight loss. • Weakness due to poor nutrition. • Severe inflammation and injury to the oral mucosa also increases the chance of other infections in the mouth and body. • Cause a reduction in dose of treatment.
  9. 9. Treatment • Self-care - Avoid tobacco, alcohol and hot & spicy foods. - Drink plenty of fluids. • Palifermin is given by injection which encourages the growth of new cells on the lining of the mucous membrane.
  10. 10. Adenoiditis • Adenoiditis is an inflammation of the adenoids. • Adenoids are masses of lymph tissue that help the body fight infection. • Adenoids are found in the pharynx (throat) just behind the nose and are the first line of defense in your throat. Causes:- • Adenoiditis can be caused by a bacterial infection, such as Streptococcus, or by viruses such as the Epstein-Barr virus.
  11. 11. Risk:- Certain risk factors are: • Recurring infections in the throat, neck, or head. • Infections of the tonsils. • Contact with airborne viruses, germs and bacteria. Symptoms:-. • Difficult to breathe through nose. • Sounding “nasal” when speaking. • Sore or dry throat from breathing through the mouth. • Snoring during the night or any time you sleep. • Signs of infection, such as a runny nose that produces green or discolored mucus.
  12. 12. Complications :- Complications may chronic or severe inflammation that spread to other locations of the head and neck. • Ear Infections • Glue Ear • Sinusitis • Infections of the Chest Diagnosis:- • Physical examination • Throat examinations • Blood tests • X-rays
  13. 13. Treatment:- • Antibiotics • Surgery Prevention:- • Healthy foods. • Plenty of fluids.
  14. 14. Oesophagus Congenital Anomalies Muscular dysfunctions Haematemesis of oesophageal origin Inflammatory Lesions Tumours of Oesophagus
  15. 15. Congenital Anomalies Oesophageal Atresia and Tracheo-oesophageal Fistula 1 in 4425 live births. Congenital esophageal atresia (EA) represents a failure of the esophagus to develop as a continuous passage. Instead, it ends as a blind pouch. Tracheoesophageal fistula (TEF) represents an abnormal opening between the trachea and esophagus
  16. 16. Clinical Features Hypersalivation Regurgitation of every feed Attacks of cough Cyanosis Death usually results from Asphyxia Aspiration pneumonia Fluid-electrolyte imbalance The most immediate and effective treatment in the majority of cases is a surgical repair to close the fistula/s and reconnect the two ends of the esophagus to each other.
  17. 17. Others Agenesis Duplication of Oesophagus Stenosis
  18. 18. Musular Dysfunction Achalasia Cardia (Cardiospasm) Hiatus Hernia Oesophageal Diverticula Oesophageal Webs and Rings
  19. 19. Achalasia Cardia a neuromuscular dysfunction Cardiac sphincter fails to relax during swallowing Progressive dysphagia Dialatation of the oesophagus
  20. 20. Signs and symptoms Dysphagia (difficulty in swallowing), Regurgitation of undigested food, Chest pain behind the sternum, Weight loss. Coughing when lying in a horizontal position. Cardiospasm. It can be extremely painful in some sufferers. Food and liquid, including saliva, are retained in the esophagus and may be inhaled into the lungs (aspiration). Investigations Barrium swallow Endoscopy
  21. 21. Management Forceful pneumatic dialatation using a 30-35mm diameter endoscopically postioned balloon disrupts the oesophageal sphincter and improves symptoms in 80% of patients Endoscopically directed injection of botulinum toxin into the lower oesophageal sphincter induces clinical remission,but late relapse is common.
  22. 22. Surgical Surgical Myotomy (Heller’s Operation)
  23. 23. Hiatus Hernia  Hiatus hernia or hiatal hernia is the protrusion (or herniation)  of the upper part of the stomach into the thorax through a tear  or weakness in the diaphragm. Classification Sliding (Oesophago-Gastric) Hiatus Hernia- 90% Rolling (Paraoesophageal) Hiatus Hernia-    5% Mixed   (Transitional)          Hiatus Hernia-     5%
  24. 24. Etiology Failure of the muscle fibres of the diaphragm that forms the  margin of the oesophageal hiatus Short oesophagus Degenaration of muscle due to aging Increased intra-abdominal pressure Recurrent Oesophageal regugitation and spasm causing  inflammation and fibrosis Increase in fatty tissue in obease people causing decreased  muscular elasticity of diaphragm
  25. 25. Signs and symptoms Hiatal hernia has often been called the "great mimic"  because its symptoms can resemble many disorders. Dull pains in the chest,shortness of breath (caused by the hernia's effect on the diaphragm), Heart palpitations (due to irritation of the vagus nerve),  Swallowed food "balling up" and causing discomfort in  lower esophagus until it passes on to stomach. Heartburn (retrosternal burning sensation) Regurgitation of gastric juice into the mouth
  26. 26. Management 1.To minimise gastro-oesophageal reflux Elevate bed head by 20cm Avoid posture precipitating reflux,bending  or stooping forwards,sitting in a  low chair Avoid large meal No food or drink for 3-4 hours before bedtime Reduce weight if possible No smoking Avoid all non dteridal anti-inflammatory drugs Avoid food which provoke syptoms eg: pastries, coffee 2.Reduce gastric acidity and pepsin secretion (Renitidine,Cimetidine, Famotidine) 3.Increase tone of lower oesophageal sphincter Metoclopramide 10 mg tds
  27. 27. Surgical Restoration of intra-abdominal segment of oesophagus into  abdomen and anchoring it,repairing the hiatus and enveloping  the lower oesophagus by gastric fundus. ( Nissen fundoplication) )
  28. 28. Oesophageal Diverticula Congenital Diverticula (Upper end of the oesophagus or at the bifurcation of the trachea) Acquired Diverticula Pulsion (Zenker’s) Type (in the region of hypopharynx) Traction Type (Occurs in the lower third of oesophagus from contraction of fibrous  tissue such as from pleural adhesions,scar tissue of  healed  tuberculous lesions in the hilum,silicosis etc.  
  29. 29. Killiance Dehiscence is a triangular area in the wall of the pharynx between the  thyropharyngeus part of the inferior constrictor of the pharynx  and the cricopharyngeus muscle, also of the inferior constrictor  muscle of the pharnyx It represents a potentially weak spot where a pharyngoesophageal diverticulum (Zenker's diverticulum) is more likely to occur.
  30. 30. Oesophageal Webs and Rings Esophageal webs are thin (2-3mm) membranes of normal  esophageal tissue consisting of mucosa and submucosa that  can partially protrude/obstruct the esophagus.   A Schatzki ring or Schatzki-Gary ring is a narrowing of the lower part of the esophagus that can causedifficulty  swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue  (which lines the esophagus) or muscular tissue.
  31. 31. Heamatemesis Of Oesophageal Origin Vomiting Of Blood 1.Oesophageal Varices 2.Mallory- Weiss Syndrome 3.Rupture Of The Oesophagus 4. Other Causes Bursting of aortic aneurysm into  the lumen of oesophagus Oesophageal Cancer Purpuras Heamophilia Zollinger-EllisonDisease
  32. 32. Inflammatory Lesions Oesophagitis Reflux of the gastric juice is the commonest cause of oesophagitis
  33. 33. Barrett’s Oesophagus Infective Oesophagitis Other Causes of oesophagitis Intake of certain drugs Ingestion of hot, irritating fluids Radiation Crohn’s disease
  34. 34. PEPTIC ULCER • Peptic ulcer disease refers to painful sores or ulcers in the lining  of the stomach or first part of the small intestine, called the  duodenum. CAUSES OF PEPTIC ULCER • ulcer is the end result of an imbalance between digestive fluids  in the stomach and duodenum. Ulcers can be caused by: • Infection with a type of bacteria called Helicobacter pylori (H.  pylori) • Use of painkillers called no steroidal anti-inflammatory drugs  (NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn,  and others), ibuprofen (Motrin, Advil, Midol, and others), and  many others available by prescription. Even safety-coated  aspirin and aspirin in powered form can frequently cause  ulcers. • Excess acid production from gastrinomas, tumors of the acid  producing cells of the stomach that increases acid output 
  35. 35. Symptoms of peptic ulcer • Bloating • Heart Burn • Vomiting blood (that can look like "coffee-grounds") • Severe pain in the mid to upper abdomen
  36. 36. TREATMENT AND DIAGNOSIS DIAGNOSIS: The diagnosis of an ulcer is made by either a barium upper  gastrointestinal X-ray (Upper GI series) or an Upper GI  endoscopy  Treatment: • The goal of ulcer treatment is to relieve pain, heal the ulcer,  and prevent complications. . • The first step in treatment involves the reduction of risk  factors (NSAIDs and cigarettes).and second is medications: • Antacids • Proton-pump inhibitors (PPIs)  
  37. 37. Gastric ulcer • A gastric ulcer is a sore in the lining of your stomach.      CAUSES: • Upsets in the balance of stomach acid and digestive juices can  lead to an ulcer. This can be caused by: • Helicobacter pylori (H. pylori) infection • NSAIDs Risk Factors: • Taking NSAIDs for a long time       and at higher doses • Cigarette smoking • Alcohol abuse
  38. 38. Symptoms: • Gnawing pain • Bloating • Burping • Weight loss Diagnosis:  Physical examination Treatment: Talk to your doctor about the best treatment plan for you.  Treatment options may include one or more of the following: • Medication • Lifestyle Changes • Surgery and Endoscopy
  39. 39. Gastritis • Gastritis occurs when the lining of the stomach becomes  inflamed or swollen. • Gastritis can last for only a short time (acute gastritis), or  linger for months to years (chronic gastritis). Causes: • Alcohol abuse • Eating or drinking caustic or corrosive substances (such as  poisons) • Extreme stress • Certain medications, such as aspirin
  40. 40. SYMPTOMS: • Loss of appetite • Nausea and vomiting • Black stools DIAGNOSIS: • CBC • H. pylori tests • Stool test to check for small amounts of blood in the stools,  which may be a sign of bleeding in the stomach TREATMENT: MEDICATIONS • Antacids may be used to treat chronic gastritis caused by  infection with Helicobacter pylori bacteria. • H2 antagonists: famotidine (Pepsid), cimetidine
  41. 41. SMALL INTESTINE
  42. 42. Problems with the small intestine can include: 1.Bleeding 2.Celiac disease 3.Crohn's disease 4.Infections 5.Intestinal cancer 6.Intestinal obstruction 7.Irritable bowel syndrome 8.Ulcers, such as peptic ulcer
  43. 43. Crohn's disease It causes inflammation of the digestive system. It is one of a group of diseases called inflammatory bowel disease. It most commonly starts between the ages of 13 and 30. Location-   Crohn's can affect any area from the mouth to the anus. It often affects the ileum.
  44. 44. Causes- The exact cause of Crohn’s disease is unknown. Most researchers think that it is caused by a combination of factors. 1.Genetics 2.The immune system 3.Smoking 4.Previous infection 5.Environmental factors
  45. 45. The five types of Crohn's disease- 1. Ileocolitis: Most common type of chron’s disease. Affects the mouth and colon 2. Ileitis: affects the ileum 3. Gastroduodenal Crohn's disease: Affects the stomach and duodenum 4. Jejunoileitis: affects the jejunum 5. Crohn's colitis: Affects only the colon
  46. 46. Symptoms 1.Pain in the abdomen 2.Diarrhea 3.Bleeding from the rectum 4.Weight loss 5.Fever Diagnosis- • Barium enema • Colonoscopy • CT scan of the abdomen • Endoscopy • MRI of the abdomen
  47. 47. Complications of Crohn's disease- 1.Intestinal blockages 2.Ulcers in the intestine 3.Problems getting enough nutrients 4.Joint pain and skin problems 5.Growth problems (in children) Treatment-There is no cure for Crohn's. Treatment to control symptoms 1.Medicines 2.Nutrition supplements 3.Surgery
  48. 48. Medicines: 1. Anti-inflammatory drugs • Sulfasalazine • Mesalamine • Corticosteroids 2. Immune system suppressors • Azathioprine • Remicade • Adalimumab 3. Antibiotics • Metronidazole • Ciprofloxacin
  49. 49.  Other medications: 1. Anti-diarrheals 2. Laxatives 3. Pain relievers 4. Iron supplements 5. Nutrition (special diet given via a feeding tube) 6. Vitamin B-12 shots  Surgery: Removes a damaged portion of your digestive tract Limitations of surgery- 1. temporary benefits 2. Recurrence of chron’s 3. Post surgery medication’s required
  50. 50. Ulcerative colitis
  51. 51. Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. The main symptom of active disease is usually constant diarrhea mixed with blood, of gradual onset. It is a form of inflammatory bowel disease (IBD). Ulcerative colitis is a form of colitis, a disease of the intestine, specifically the large intestine or colon, that includes characteristic ulcers, or open sores, in the colon INTRODUCTION
  52. 52. SYMPTOMS :- • The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience. • Anemia • Fatigue. • Weight loss • Loss of appetite • Rectal bleeding • Loss of body fluids and nutrients • Skin lesions • Joint pain • Growth failure (specifically in children)
  53. 53. DIAGNOSIS • Many tests are used to diagnose ulcerative colitis. A physical exam and medical history are usually the first step. • Blood tests may be done to check for anemia, which could indicate bleeding in the colon or rectum . • In addition, a stool sample allows the doctor to detect bleeding or infection in the colon or rectum caused by bacteria, a virus, or parasites.
  54. 54. TREATMENT • Drug Therapy:- • AMINO SALICYLATES • CORTICOSTEROIDS • IMMUNO SUPRESSIVE DRUGS • BIOLOGIC TREATMENT • SURGERY • OTHER SURGICAL ALTERNATIVES • DIET • BACTERIAL RE COLONIGATION
  55. 55. Appendicitis McBurney’s point Site of maximum tenderness in appendicitis
  56. 56. HEMORRHOIDS • Hemorrhoids are swollen and inflamed veins in the anus and lower rectum. Internal and External Hemorrhoids • Internal hemorrhoids located inside the rectum; • External hemorrhoids develop under the skin around the anus.
  57. 57. CAUSES • Too much pressure on the veins in the pelvic and rectal area causes hemorrhoids. Factors that might cause increased pressure include: • Overweight • Pregnancy • Diarrhea or constipation • Sitting for long periods of time on the toilet • Diet low in fiber or fluids
  58. 58. SIGNS AND SYMPTOMS • Extreme itching around the anus • Irritation and pain around the anus • Itchy lump located near your anus • Fecal leakage • Painful bowel movement • Blood on your tissue after having a bowel movement
  59. 59. Diagnosis • Digital rectal exam • Sigmoidoscopy Treatment • Rubber band ligation • Sclerotherapy • Surgery : Hemorrhoidectomy
  60. 60. MEDICATION • Ointments: as zinc oxide or petroleum jelly • Ointment that contains 1% hydrocortisone • Acetaminophen can help with pain. • Aspirin and other nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) and naproxen (Aleve) can help with pain and swelling.
  61. 61. COMPLICATIONS • Blood clots within the swollen vein • Bleeding • Iron-deficiency anemia (caused by blood loss)
  62. 62. PREVENTION • Avoid straining during a bowel movement. • Increase your water intake. Drinking adequate water can keep your stool from hardening.
  63. 63. Disorders of Tongue • Glossodynia (burning mouth syndrome)- spontaneous burning, discomfort, pain, irritation, or rawness of the tongue, has no identifiable etiology most of the time • Etiology- – Idiopathic, Infection, Allergic/contact hypersensitivity, Mechanical trauma – Xerostomia, Geographic tongue/ Fissured tongue – Vesiculobullous disease, temporomandibular dysfunction – Referred pain from teeth or tonsils – Drugs- Antibiotics, psychiatric medications, chemotherapy
  64. 64. Glossodynia Treatment Treatment for burning mouth syndrome varies greatly between cases based on the severity of the symptoms, the underlying cause and the diagnosis of the physician. In many cases the symptoms will be associated with a psychological disorder such as depression and the burning mouth and the underlying cause will be treated together with anti- depressants. In other cases patients can try altering their medication, using different toothpastes, checking their dentures and increasing their consumption of vitamin B12.
  65. 65. Disorders of Tongue… • Macroglossia- congenital or acquired process, tongue is disproportionately large relative to the patient’s jaw size • Difficulty with mastication and speech and accidental tongue biting are common • Differential- Down syndrome, hypothyroidism, Beckwith- Wiedemann syndrome, neurofibromatosis, infection by mycobacteria, filamentous bacteria or fungus, amyloidosis
  66. 66. Macroglossia treatment Tongue Reduction Surgery Speech Therapy
  67. 67. DISEASES OF LIVER
  68. 68. • Most common chronic blood-borne infection  accounts for 50% of all patients with chronic liver disease in the US • Flaviviridae family, genus Hepacivirus • HCV RNA polymerase with poor fidelity  inherently unstable  (+) genomic instability & antigenic variability within one individual  evade IFN-mediated anti-viral response  repeated bouts of hepatic damage Hepatitis C
  69. 69. • Persistent infection and chronic hepatitis are the hallmarks of HCV infection • MOT: 1. inoculations 2. blood transfusions 3. hemodialysis 4. sexual transmission 5. perinatal Hepatitis C
  70. 70. Hepatitis C Therapy • Interferon Alone < 15% • Interferon/Ribavirin – 12 months Genotype 1 – 6 months Genotype 2 and 3 • Sustained response (Hep C PCR- 6 mos post therapy) – 5-15% monotherapy – 35-40% combo therapy – 45-70% PEG combo therapy • Must use birth control--teratogenic
  71. 71. What is cirrhosis? • Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver
  72. 72. What causes cirrhosis? • heavy alcohol consumption • chronic hepatitis C (the most common) • Obesity • Autoimmune inflammation of the liver • Metabolic disorders
  73. 73. What are the symptoms of cirrhosis? Symptoms are hard to catch in the early stages of the disease. However, as the disease progresses, a person may experience the following symptoms: • weakness • fatigue • loss of appetite • nausea • vomiting • weight loss • abdominal pain and bloating • itching • spiderlike blood vessels on the skin
  74. 74. Treatment and Prevention Prevention •Stop drinking alcohol (or don’t start at all) •Limit salt in the diet •Eat a nutritious diet •Get vaccinated for influenza, hepatitis A and B. •Practice safe sex Treatment •Liver transplant •Antibiotics
  75. 75. DESEASES OF GALL BLADDER
  76. 76. Gallstones Gallstones develop when cholesterol and other substances in the bile form crystals that become hard stones in the gallbladder. The gallbladder is a small sac located just under the liver. Gallstones can form when too much cholesterol is in the bile or when the gallbladder does not empty properly.
  77. 77. Symptoms • Pain in the RUQ – Most common and typical symptom – May last for a few minutes to several hours – Mostly felt after eating a heavy and high-fat meal • Pain under right shoulder when lifting up arms • Fever, nausea and vomiting • Jaundice (obstruction of the bile duct passage) • Acute pancreatitis (gallstone enters the duct leading to pancreas and blocks it)
  78. 78. Diagnosis • Ultrasound – Most sensitive and specific test for gallstones • Computerized tomography (CT) scan – May show gallstones or complications, such as infection and rupture of GB or bile ducts • Cholescintigraphy (HIDA scan) – Used to diagnose abnormal contraction of gallbladder or obstruction of bile ducts • Endoscopic retrograde cholangiopancreatography (ERCP) – Used to locate and remove stones in bile ducts • Blood tests – Performed to look for signs of infection, obstruction, pancreatitis, or jaundice
  79. 79. Treatment • Surgery: Cholecystectomy (gallbladder removal) – 5 - 40% of patients develop postcholecystectomy syndrome (gastrointestinal distress and persistent pain in the RUQ) – 20% of patients develop chronic diarrhea • Two surgical options – Open cholecystectomy – Laparoscopic cholecystectomy
  80. 80. • Nonsurgical treatment: – Only in special situations • When a patient has a serious medical condition preventing surgery • Only for cholesterol stones – Oral dissolution therapy • Ursodeoxycholic acid - to dissolve cholesterol gallstones • Months or years of treatment may be necessary before all stones dissolve – Contact dissolution therapy • Experimental procedure • Involves injecting a drug directly into the gallbladder to dissolve cholesterol stones
  81. 81. DIABETES MELLITUS • DM is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced. • Types : 1. Type 1 DM results from the body's failure to produce insulin. 2. Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. 3. Gestational diabetes
  82. 82. SYMPTOMS • Polyuria • Polydypsia • Nocturia • Hyperphagia • Weight loss • Pruritis • Blurred vision • Giddiness • Numbness
  83. 83. Diagnosis • Random blood sugar test • Fasting blood sugar test Treatment • Metformin - type 2 diabetes • Insulin and other medications e.g. regular insulin ,insulin isophane.
  84. 84. COMPLICATIONS • Heart Disease • Stroke • Retinopathy • Chronic renal failure • Difficulty in passing urine in adults • Dehydration • Ketosis • Acidosis • Coma • Death
  85. 85. PREVENTION • Avoid obesity • Quit Smoking • Elevated Cholesterol Level • Lifestyle changes • Appropriate Diet • Regular Exercise • In case of Diabetic patient wear diabetic sock, avoid higher risk of serious diseases, weight loss, proper medication.
  86. 86. THANK YOU

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