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-It presents with nervousness, palpitations, tremor, heat intolerance, weight loss, mental changes, fatigue, insomnia, increased appetite,

-Diagnosis: TSH, Free T4,T3, Radioactive Uptake Scan, CBC, ESR, Ultrasound, Thyroid antibodies.

-Graves Disease: Most common cause of hyperthyroidism.

-Other causes: Hashimoto’s, amiodarone, iodine, postpartum thyroiditis, metastatic thyroid cancer.

-Graves Disease Treatment: Radioactive Iodine, PTU or methimazole, beta blockers.

-Methimazole safer than PTU.

-With PTU, there is risk of serious liver injury.

-In pregnancy, use PTU.


Mayo Clinic Diet

In our clinic, one of the diets I strongly recommend is Mayo Clinic Diet. I do not receive any financial or other incentives in recommending this program. I found it more scientific than many other diet plans popular in our society. In this diet plan, you eat by serving size. There is no calorie-counting and there are no complicated formulas to use with the Mayo Clinic Diet. You become an expert in estimating serving sizes and how much you’re eating of certain foods.

The Mayo Clinic Diet is a practical and enjoyable program that will help you not only lose weight, but also improve your health and feel better.


The Mayo Clinic Diet consists of two phases: Lose It!, a two-week jump-start phase in which you can lose weight relatively quickly by changing a number of habits, and Live It!, in which you take the habits that you changed in Lose It! and turn them into long-term lifestyle changes that will help you continue to lose weight and manage your weight loss over time.

LOSE IT: In the Mayo Clinic Diet pilot program, people lost on average about 6 to 10 pounds in the two weeks of the Lose It! phase. When people started changing their habits, they reported that it seemed challenging at first, but once they got into it, it wasn’t that bad. And they felt empowered; they reported that they did much better than they thought they could.

LIVE IT: Live It! is an indefinitely long lifestyle-change phase where you take the habits that you learned in Lose It! and build on them. And you know that you can do it because of the results you achieved in the Lose It! phase. You’ve lost some weight, and the goal is to continue to lose weight at a rate of about one to two pounds a week until you reach your goal weight.


In preparation for starting the Mayo Clinic Diet, motivation to lose weight is important to consider, both now and in the future. What is your inner burning desire that will help you keep weight off in the long term? There may be several reasons, such as having better health, having more energy, and looking better and feeling better. All of these reasons are valid, but what matters is what is important to you.

‹‹Spend a few minutes thinking about what motivates you to lose weight and write down all of your motivators. Post them where you will see them often; this will help you when you’re having a temporary challenge or need a pick-me-up. Add new ones to your list as you go through your weight-loss program.


Choosing a start date is helpful because you’ll need to do a little preparation before then. You’ll want to be as ready and prepared as possible so that you don’t have to take time later to make adjustments while you’re focusing on your plan.


Then get your kitchen ready, including your cupboard, pantry, and fridge. The idea is to get rid of high-calorie, processed foods and stock up on lower-calorie, unprocessed foods, especially frozen or shelf-stable basics that you can keep on hand. That way, when you need a meal in a hurry, you’ll be ready to go and you won’t be tempted to grab a less healthy option.


The next step is exercise. Line up the gear you’ll need for physical activity. Make sure that you have a good pair of walking shoes, comfortable clothes, and whatever else you need to be physically active. Consider buying a bicycle if you like bicycling. Before exercise, plan to meet Dr.Paul to examine whether your body is ready for exercise.


This chart helps you to log your habits and dietary habits.




This food pyramid is divided into different food groups. At the bottom of the pyramid are fruits and vegetables. Above that are whole-grain carbohydrates. Above that are lean proteins and dairy, followed by healthy fats and, at the top of the pyramid, a small amount of sweets. At the center of the pyramid is daily physical activity—both because of its effect on weight loss and on improving health.

Eat more foods from the food groups at the base of the pyramid and less food from those at the top—and start moving more.




Vegetables and fruits should make up the largest portion of your meal. Vegetables should make up half of your plate, and fruits have their own bowl— you can eat them with the meal, as a snack, or both. An easy way to include more vegetables in your diet is to have a green salad with your meal, which is why there is a separate salad plate.

Vegetables and fruits have a lot of water and a lot of fiber, which adds bulk and volume but not calories. You can eat more of these foods, and the weight and volume will fill you up, but you won’t consume a lot of calories. If you’re eating more fruits and vegetables, you’re actually eating more food but getting in fewer calories—and that’s a good thing.

If you’re eating more fruits and vegetables, you’re not eating something else that is higher in calories. You’ll consume fewer calories so that you can lose weight but still achieve satiety.

BE AWARE OF WHAT YOU PUT ON YOUR VEGETABLES: Often, the sauces and other things that you add to vegetables contain more calories than the vegetables, so you will need to be careful about what you put on them.

Carbohydrates, Proteins and Fats: Limit carbohydrates to a quarter of your plate. The same goes for protein and dairy. Fats and sweets should be eaten sparingly, and they may not be a part of every meal.


Water: For your fluids, include beverages that are low in calories or calorie-free. Water is best.Water contained in food has a greater effect on increasing satiety than consuming water separately, probably because the water is absorbed more quickly if it’s consumed separately. So, choosing foods that are high in water content will lower the energy density of a meal and increase your satiety.




You’re not going to overdose on green beans or broccoli!


Weight Loss: Interesting Facts

Losing and maintaining weight will help treat and even prevent the conditions associated with increased weight. Weight loss is one of the most effective ways to lower blood pressure.

Losing weight also improves joint pains.

Genes do play a role: About 30 to 50 percent of weight is related to genetics; the rest is environment. Then, there are individual factors, such as diet and physical activity habits, that are separate from the environment.

Weight and Diabetes: When compared to someone with a normal BMI, people who are overweight are three times more likely to have diabetes, and people who are obese are seven times more likely to have diabetes.

Physical Activity: While changes in both diet and activity factors are related to the increasing prevalence of obesity, there is more evidence that the major factor responsible is a decrease in daily physical activity, separate from exercise. One study reported that Americans burned 130 calories per day less at work in 2010 than they did in 1960.

Sleep and Weight: The energy balance equation states that the calories we eat minus the calories that we burn will determine our weight. There are things you can do that influence the equation. For example, if you get too little or too much sleep, you tend to burn fewer calories and weigh more.

For more information,  please discuss your weight issues with Dr.Paul Kattupalli MD.

Child Abuse: Look for it and Report it

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Physical child abuse may be broadly defined as injury inflicted upon a child by a parent or caretaker. Specific definitions can vary widely among countries, as well as among different ethnic and religious groups.

Abused children who are returned to an abusive environment without intervention are highly likely to be maltreated again and are at an increased risk for death.

Careful history and physical examination and awareness of “red flags” for child physical abuse can prevent additional injury and may be life-saving.

Young age, a prior history of abuse in the household, and social factors (eg, domestic violence, caregiver substance abuse or psychiatric illness, presence of family stressors, or family isolation) can also raise the level of concern for child physical abuse in equivocal cases. We recommend not using race or socioeconomic status to determine the need for further abuse evaluation.

Actively maintaining child abuse in the differential diagnosis of trauma and puzzling medical presentations

Careful evaluation for findings of abuse on history and physical examination.

Utilization of multidisciplinary child abuse teams as consultants

Prompt reporting of suspected child physical abuse to the appropriate governmental agency

Evidence is lacking to support universal screening for abuse. Until better formal methods are developed which have acceptable accuracy and can be easily implemented, we favor the broad distribution and use of current guidelines among all pediatric health care providers to enhance general awareness and to support timely recognition of child physical abuse.

How to Decide on Tetanus Shot?

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Administration of the diphtheria-tetanus-acellular pertussis (DTaP) vaccine is routinely recommended in children, with a single booster dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) recommended for 11- to 12-year-olds, followed by tetanus toxoid and the reduced diphtheria toxoid in the form of Td recommended at 10-year intervals throughout life. Despite these recommendations, immunity to tetanus and diphtheria continues to wane among adults in the United States.

The United States Advisory Committee on Immunization Practices (ACIP) recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) 0.5 mL intramuscularly [IM] in place of Td for all adults aged 19 years and older who have not received Tdap previously to address waning immunity against pertussis. The ACIP recommends that all pregnant women receive vaccination against pertussis with Tdap during each pregnancy.

Regardless of prior tetanus and diphtheria immunization, Td immunization should be reviewed when anyone presents with an acute injury or wound and prophylaxis administered as indicated. In addition to tetanus immunization, human tetanus immune globulin is indicated in individuals who have sustained a wound that is more severe than a clean and minor wound (eg, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite) and who have either received fewer than three doses of tetanus toxoid previously or in whom the number of previous doses is unknown.

If there is any doubt about whether or not an adult received the primary series, three doses of Td should be administered; the first dose and second dose should be separated by four weeks and the third dose should be given 6 to 12 months later. Tdap should be used in place of Td in adults who have an indication.

Cellulitis and Insect Bites

-Caused by Staph and Strep infections.

-caused by MRSA is more serious.

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-infected with Pasteurella multocida.

Watch for bone and joint infection.


-Irrigate copiously. Treat with Amoxicillin Clavunate.


Most common on extremities.

Only 5 percent develop infection.


-Regional lymphadenopathy; Don’t incise; Self-Limiting Disease


Erythema migrans: Rash with classic bull’s eye. Treat with Doxycycline.

Caused by Borrelia burgdorferi

Transmitted by Deer tick.

Cranial neuropathy: 7th nerve. Lymphocytic meningitis.

Cardiac disease: think A-V block.

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Common Skin Problems

Psoriasis: Oval, plaque-like lesions, involves extensor surfaces. Treat with calcipotriene, tazarotene, topical corticosteroids, Anthralin, Tacrolimus, Pimecrolimus, Localized UVB phototherapy, Phototherapy.

Shingles: Bullous lesions. Varicella-zoster virus; causes vesicles; crusts lasts 2-3 weeks; Post-herpetic neuralgia; Treat with analgesics, wet compresses, Acyclovir. Can use Steroids to decrease pain.

Post Herpetic Neuralgia: use narcotics, and other analgesics.

Bullous Pemphigoid: Bullae expands lateralally.

Scabies: caused by Sarcoptes scabiei, causes burrows, might affect finger webs and other places, can cause crusted lesions in HIV, treat with launder all bedding and clothes, use 5% permethrin cream,

Poison Ivy Dermatitis: Causes linear lesions, vesicles, itches, treat with wet compresses, topical corticosteroids and systemic corticosteroids.

Folliculitis: can be due to hot tub baths, caused by Staph. In most cases, treatment is not necessary. in severe cases, treat with ciprofloxacin.

Impetigo: usually due to Staph bacteria; treat with Mupirocin, Retapamulin, Dicloxacillin, Cephalexin, Clindamycin, TMP-SMX.

Acne: face, upper back, chest; treat with benzoyl peroxide, doxycycline, erythromycin, clindamycin. oral contraceptives, spiranolactone, Isotretinoin, Icision and Drainage, Topical Tea Tree oil.

Rosacea: more common in women, papules and pustules, telangiectasia, Rhinophyma. Triggered by sunlight, spicy foods, alcohol, exercise, medications. Treat with metronidazole, benzoyl peroxide, brimonidine, carvedilol.

Seborrheic Dermatitis: treat with corticosteroids, ketoconazole shampoo.

SLE: Butterfly rash.

Tinea Versicolor: caused by Pityrosporum species; lesions begin as circular macules that enlarge, treat with ketoconazole, selenium.

Erythrasma: Under the breasts, coral pink orange red fluorescence, use antibacterials.

Tinea Capitis: treat with Griseofluvin, Terbinafine, Itraconazole, Fluconazole.

Molluscum Contagiosum: Umbelicated lesions; may spontaneously resolve, Cryosurgery, Curettage, Cantharidin, Imiquimod, Podofilox, KOH 5 percent, topical retinoids, salicylic acid, laser

Warts: Due to HPV virus; treat with Podofilox, Imiquimod

Basal cell Carcinoma: Mohs Surgery

Malignant Melanoma: mostly in Caucasians, metastasize quickly.

If you have a skin lesion that needs to be taken care of, please talk to Dr.Paul Kattupalli