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Maria is a 46-year-old woman who presents for her yearly physical examination. Her review of systems is significant for fatigue, constipation and hair loss. Her previous medical history is notable only for obesity. She reports her understanding that she should be on a low calorie, low fat diet with moderate aerobic exercise 4-5 times per week but also notes that having a full-time job and four children makes this difficult to achieve.
She has NKDA and takes a multi-vitamin daily. Maria reports a family history of diabetes (mother) and hypertension (brother). She is a nonsmoker. Her diet largely consists of fast food meals. She drinks sweet tea with every meal and an additional 3-4 cups of coffee per day. Previous labs and exam last year are unremarkable.
Vitals today: BP 120/70 mm Hg, pulse 76, temperature 98.7, respirations 18, height 5’9”, weight 225 pounds. Urine dip + glucose, fasting plasma glucose 179 mg/dl, HgbA1C is 7.4%, TSH 8.5mU/L and Free T4 0.1 ng/dl. The physical exam is notable for acanthosis nigricans at the neck but otherwise is normal.
What are your treatment goals for Maria?What is your pharmacologic plan and rationale? (cite with appropriate clinical practice guidelines or scholarly, peer-reviewed journals)What is the mechanism of action for each drug?Please give five teaching points for each drug prescribed.How would you change the plan if her initial HbgA1C was 10.2mg/dL and her fasting blood glucose was 305mg/dL? Provide a detailed alternative plan with the rationale.
The Western Wall of Jerusalem Guides1orSubmit my paper for investigation Jerusalem is regularly alluded to as the city of three religions. All through the a large number of years that it has existed, this city had been vanquished, demolished, reconstructed, and vanquished again on many occasions—Islamic, Christian, and Jewish powers battled to oversee Jerusalem. There were likewise times when the city was calmly occupied by the delegates of each of the three religions; those were the hours of broad development, advancement, social trade, and exchange. During these periods, a great deal of noteworthy and these days well known spots were raised, which presently fill in as objects of journey for a huge number of individuals everywhere throughout the world. Nonetheless, there is one spot in Jerusalem that isn’t just the most antiquated among all the blessed spots of this city, yet presumably the holiest one: the leftovers of the Second sanctuary, the Western Wall. This is for sure an extraordinary and one of a kind spot; worked in a Jewish city, being a sacred spot for endless Jewish individuals, the Western Wall is, simultaneously, a spot for everybody’s petition. There is no religion whose adepts would be disallowed to ask close to the divider. As the Bible says, when King Solomon manufactured the main Temple, he requested that God hear and answer the supplications of Jewish individuals, yet of others also (1-Kings 8:41-43). In the prophet Isaiah’s disclosures, the Western Wall is classified “a place of supplication for all countries,” and as indicated by the Kabbalah, petitions said close to the divider will climb legitimately to paradise, paying little mind to whom they were said by. As a proof of these accounts, any day when you come the divider, you will see a various group, many ethnicities and several individuals, imploring and crying close to it. Why crying? At the point when the principal Temple was obliterated, the Gates of Heaven, practically every one of them, were closed; the main Gate staying open was known as the Gate of Tears—this is the thing that the legend says; this is the reason individuals, when going to the divider, spill out their tears, and this is the reason the Western Wall is additionally regularly called the Wailing Wall (Jerusalem Insiders Guide). There is a fascinating legend encompassing the pulverization of the Temple. As the development of the Temple began, the work on its various segments was partitioned between different social gatherings. The part presently known as the Western Wall was alloted to needy individuals, who had no cash to procure somebody to carry out their responsibility rather than themselves, and in this manner they needed to function as hard as possible. At the point when Romans decimated the Temple, it was just the Western Wall that endured the pulverization; it is said that the blessed messengers slid from paradise, spreading their wings to secure the Wall, asserting: “This Wall, crafted by poor people, will never be devastated” (Aish.com). This is the reason the Western Wall is the main part of the antiquated Temple that remained practically unblemished. The demolition of the subsequent Temple and the blessed fate of the Western Wall that made Talmudic sages accept: “This is the Western Wall of the Temple, which is never annihilated for the shekhinah [the Divine presence] is in the west” (Bamidbar Rabah 11:63) (GoIsrael). The main Temple, worked by Solomon, was demolished in 586 BC by the Babylonians; the Western Wall and the subsequent Temple was manufactured later by King Herod the Great, wishing to reestablish the Temple to its previous magnificence. The Western Wall was one of four dividers King Herod worked to help the colossal court on which the Temple stood. Its length was very nearly 1,500 feet in length, and the stature arrived at 90 feet; around 60 feet of the Wall went under the ground. The subsequent Temple, in any case, couldn’t dodge the decimation either: in 70 CE, it was torched by the Romans, with the exception of legend says, for the Western Wall. During the division of Jerusalem, somewhere in the range of 1948 and 1967, Jewish individuals were totally isolated from the Wall, as it had happened on many occasions before, when they needed to conquer a wide range of impediments and subject themselves to perils, just to submit a journey to this heavenly place. After the Six Day War in 1967, Jerusalem was brought together, and the Western Wall indeed turned into a position of love, solidarity with the perfect, and the image of adoration and dedication of the Jewish individuals for their Holy City (GoIsrael). The Western Wall is one of the most inexplicable and sacrosanct places on earth. It is said that the supplications verbally expressed close to the Wall are rarely left unanswered. Being a definite representation of the hardships Jewish individuals had experienced for a considerable length of time, the Wall is, simultaneously, an image of confidence and dedication, a blessed spot of journey for individuals all things considered, and a genuine strict marvel that has suffered for a large number of years until present days.>
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