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By E. Arokkh. Union University. 2018.

Your Doctor Visit What your doctor will ask you about: headache purchase clindamycin 150mg online, anxiety order 150 mg clindamycin overnight delivery, depres- sion buy cheap clindamycin 150mg on-line, numbness in hands or around mouth cheap clindamycin 150 mg on line, weakness discount clindamycin 150 mg free shipping, muscle wast- ing or tenderness, lack of coordination, change in vision or hearing, change in speech, neck pain, back pain. Your doctor will want to know if you or anyone in your family has had any of these conditions: any nervous system disease, car- diovascular disease, diabetes, high blood pressure, emotional prob- lems, alcoholism, anemia, syphilis, cancer, kidney disease. Your doctor will want to know if you have other feelings besides numbness, if you feel numb constantly or intermittently, and where exactly you feel numb. If you are also having trouble talking, your doctor may ask you questions to ensure you are not having a stroke. For instance, your doctor may ask if you are experiencing a stiff neck, blurred vision, convulsions, or a loss of consciousness. Your doctor will want to know if you have recently been exposed to arsenic or large amounts of lead. Your doctor will do a physical examination including the fol- lowing: blood pressure, pulse, tests of reflexes, balance, coordina- tion, and sensation. Most commonly, numbness results from conditions that can also cause pain in joints, legs, arms, hands, and feet. See chapters on those symptoms for more information, or the table below for less common causes of numbness. WHAT CAN CAUSE NUMBNESS, LOSS OF MOVEMENT, AND TROUBLE TALKING, AND WHAT IS TYPICAL FOR EACH CAUSE? CAUSE WHAT IS IT YPICAL SYMPTOMS Hyper- Breathing rapidly and Numbness in both hands, ventilation deeply over an extended faintness, pins and needles period around lips, trouble breathing Transient A type of stroke in which Numbness on one side of ischemic attack there is a temporary halt the body, clumsiness, trou- in the flow of blood to ble speaking, trouble see- part of the brain, lasts no ing; occurs more commonly longer than 24 hours in the elderly and in people with diabetes, heart disease, or high blood pressure Stroke A failure of blood to get Numbness on one side of to the brain, either the body, clumsiness, trou- because of excessive ble speaking, trouble see- bleeding in the brain ing; occurs more commonly causing a blockage or a in the elderly and in people clot in the blood vessels with diabetes, cardiovascu supplying the brain lar disease, and high blood pressure; lasts longer than a transient ischemic attack 168 NUMBNESS, LOSS OF MOVEMENT, OR TROUBLE TALKING WHAT CAN CAUSE NUMBNESS, LOSS OF MOVEMENT, AND TROUBLE TALKING, AND WHAT IS TYPICAL FOR EACH CAUSE? Overdose or Poisoning What it is: taking too much of a medication or ingesting a toxic substance. If you believe that you or someone you know has ingested too much of a medication or a toxic substance, seek medical attention immedi- ately by calling your local poison control center at 1-800-222-1222, before attempting to treat the problem yourself with syrup of ipecac or any other substance. Your Doctor Visit What your doctor will ask you about: loss of consciousness, hyper- activity, abnormal breathing, fever, low temperature, change in skin color, convulsions, tremors, spasms. Your doctor will want to know if you or anyone in your family has had any of these conditions: previous overdose, poisoning, sui- cide attempts, depression, emotional problems, alcohol or drug abuse, any chronic disease. Your doctor will want to know what you ingested and how much, and if you have been contemplating suicide. Your doctor will do a physical examination including the fol- lowing: blood pressure, pulse, breathing rate, temperature, tests of mental alertness, looking inside the throat, listening to the chest with a stethoscope, pushing on the abdomen, thorough skin exam, check- ing sensation and reflexes. The doctor may ask you to bring in samples of all the potential sources of the poisoning. Depending on what substance was ingested, the doctor may try to get you to regurgitate it or rid the body of it in another way. Do not attempt to do this yourself before calling a poison control center at 1-800-222-1222, as the substances may cause more damage traveling back through your digestive system than they normally would. If you have any questions about specific poisons, contact your local poison control center listed in the phone book. Normal intake for moderately active men ranges from 2200 to 2800 calories per day, and for women ranges from 1800 to 2100 calories. Your Doctor Visit What your doctor will ask you about: anxiety, depression, eating to relieve stress, changes in weight, excessive urination, excessive thirst, ability to tolerate heat, weakness. Your doctor will want to know if you or anyone in your family has had any of these conditions: diabetes, thyroid disease, emo- tional problems, obesity, recent cessation of smoking. Your doctor will want to know why you think you eat too much, how much food you typically eat every day, and whether you engage in eating “binges. Your doctor will do a physical examination including the fol- lowing: weight, height, eye exam, thorough neck exam. CAUSE WHAT IS IT YPICAL SYMPTOMS Smoking Recently giving up a Overeating cessation smoking habit Hyper- Overactivity of the Weight loss, hot flashes, thyroidism thyroid gland sweating, sometimes a swollen gland in the neck Diabetes An inability to properly Frequent drinking and process sugar urination, fatigue, some- times double vision or weight loss Medication use Overeating as a result of Overeating because of a taking antidepressants, frequent feeling of hunger antipsychotics, or lithium Bulimia Engaging in cycles of Binge eating followed by nervosa “binging” and “purging,” vomiting or taking laxatives in which you overeat and then starve yourself, vomit, or take laxatives Parasitic Infection by tapeworm Overeating because of a infection of the and other parasites frequent feeling of hunger intestines Poor Appetite What it feels like: an inability to eat as much food as your body requires. Your Doctor Visit What your doctor will ask you about: weight loss, nausea, vom- iting, fever, abdominal pain, jaundice (skin taking on a yellowish appearance), joint pains, bowel habits, changes in your emotion- al state, changes in sexual activity or sleep habits, your ability to concentrate. Your doctor will want to know if you or anyone in your family has had any of these conditions: cancer, emotional problems, dis- eases affecting the kidneys or the circulatory or digestive systems.

Most states also permit chiropractors to maintain and use radiological facilities order clindamycin 150mg free shipping. To a large extent this is the result of a long-standing boycott of chiropractors by radiologists who would not perform radiological tests at their request generic 150 mg clindamycin with amex. The more recent co-operation between these professions has led to a decrease in the number of chiropractic offices maintaining their own radiographical facilities discount clindamycin 150mg amex. Chiropractic schools have historically devoted a significant amount of training to the study of radiology buy clindamycin 150mg line, and studies have shown that the ability to interpret X-rays for pathological red flags by chiropractors is at 11 least as good as that of family physicians and orthopedic residents and specialists buy clindamycin 150mg low price. Despite the relative uniformity of chiropractic laws, there remain a few states where chiropractors are permitted to recommend or prescribe medications and perform minor surgical procedures, and other states where they are not even permitted to perform such procedures as a prostrate physical examination. Most of these practice variations fly in the face of education, which has become increasingly uniform as the result of national accreditation. SPECIALTIES The chiropractic profession has several established specialty councils, most of which have a diplomate or certification process. These councils are established under the auspices of the American Chiropractic Association (ACA) and/ or the International Chiropractic Association (ICA) to recognize and encourage greater expertise in particular disciplines. At the present time, recognized programs include radiology, orthopedics, sports medicine, rehabilitation, industrial medicine and nutrition. Complementary therapies in neurology 36 With the exception of the diplomate program in radiology, which has an established 2year residency, most of these programs consist of postgraduate courses of at least 300 h (diplomate programs) or 100 h (certification programs) of study in the field. SCOPE OF PRACTICE State law and the legal interpretations of the law define the scope of chiropractic practice. As described above, there is some variability in the diagnostic and therapeutic interventions that are permitted from state to state, but in most locations these include the diagnostic procedures that are required to determine the appropriateness of patients for chiropractic care. In all states, chiropractors are allowed to see patients without referral from other physicians and to treat them within the scope of the law. Most state laws do not restrict the type of patients that can be seen and treated by chiropractors. On a practical level, however, the vast majority of patients seen by chiropractors are treated for musculoskeletal conditions, with only a very small percentage seen primarily for conditions that would commonly be consid ered to be 6,12 internal disorders. Historically, exaggerated claims of therapeutic efficacy on the part of some chiropractors, particularly regarding treatment of various non-musculoskeletal conditions and diseases, has been a major impediment to good relations between chiropractors and medical physicians. There are many anecdotal descriptions of successful chiropractic treatment of various internal disorders scattered within the chiropractic (and, indeed, osteopathic and medical) literature. The few attempts at systematically evaluating these claims (particularly with regard to the treatment of asthma and colic) have not provided any dramatic support for spinal manipulation in these conditions (see below). Neck pain is the next most common presenting complaint, with headache (cervicogenic and otherwise) following. Many of these patients presenting with these conditions have additional diagnoses and a wide variety of general symptoms. Improvement in these additional symptoms during the course of chiropractic treatment has provided much of the impetus for anecdotal claims of benefit in the treatment of other conditions, including internal disorders. The three most frequently diagnosed non-musculoskeletal complaints treated by chiropractors are asthma, otitis media and migraine headaches. Only a very small percentage (1–10%) of patients seeking chiropractic care do so for non-musculoskeletal symptoms. Given these statistics, it is somewhat ironic that overzealous claims made by some chiropractors concerning the treatment of a tiny fraction of chiropractic patients produce the greatest amount of friction between chiropractors and the medical community. The strongly musculoskeletal bias of the conditions presenting to chiropractic offices probably results from the fact that patients are most likely to view chiropractors as being particularly effective in the treatment of these conditions. This distribution of patients may also result from the fact that conditions such as back and neck pain are often refractory to conventional medical care. It is not surprising, then, that the greatest amount Chiropractic 37 of evidence for a beneficial effect of chiropractic and spinal manipulation is in the treatment of back pain, neck pain and headache (see below and Chapter 15. Historically, most chiropractic patients saw medical physicians first, and only sought chiropractic care when all else failed. Therefore, the quality of chiropractic education in the primary analysis and diagnosis of patients has become of greater importance.

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Each of the approximately 20 amino acids that are used to make human proteins are metabolized by specific biochemical reactions order clindamycin 150 mg otc. Several of these amino acids Genetic profile (isoleucine order 150 mg clindamycin amex, valine purchase clindamycin 150 mg without prescription, threonine buy 150mg clindamycin otc, methionine) generic 150 mg clindamycin, as well as MCM deficiency is a genetic condition and can be cholesterol and some fatty acids, share a common bio- inherited or passed on in a family. The genetic defect for chemical reaction in the pathway to conversion to usable the disorder is inherited as an autosomal recessive trait, energy. Each of these substances is converted to methyl- meaning that two abnormal genes are needed to display malonic acid (also known as methylmalonic CoA), an the disease. A person who carries one abnormal gene intermediate product on the pathway leading to the pro- does not display the disease and is called a carrier. In order for MCM to function properly, At least two forms of MCM deficiency have been it also requires a vitamin B12-derivative called adenosyl- identified. The disease genes are called, mut0, in which cobalamin (when an enzyme requires another substance there is no detectable enzyme activity, and mut-, in which in order to perform its job, the helping substance is there is some, but greatly reduced, enzyme activity pres- known as a coenzyme or cofactor). The gene for MCM is located on chromosome 6 When there is a defect or deficiency of MCM, (locus 6p21), and about 30 different mutations in the methylmalonic acid cannot be converted into succinic gene have been reported. Other mutations in pathways acid and methylmalonic acid accumulates in high levels that produce the cofactor, adenosylcobalamin, exist and in the bloodstream (methylmalonicacidemia) and in the produce a condition similar to MCM deficiency. There are 20 types of About half of the reported patients with methylmaloni- amino acids (eight are “essential amino acids” cacidemia have a deficiency of MCM mut0 or mut-), as which the body cannot make and must therefore opposed to problems with the cofactor. The geographical distribution Autosomal recessive—A pattern of genetic inheri- of methylmalonicacidemia is not uniform and may be tance where two abnormal genes are needed to higher in certain ethnic groups. MCM defi- Carrier—A person who possesses a gene for an ciency is seen in equal amounts in males and females. Signs and symptoms Cofactor—A substance that is required by an The symptoms experienced by an infant with MCM enzyme to perform its function. Infants Enzyme—A protein that catalyzes a biochemical born with the mut0 type MCM deficiency will typically reaction or change without changing its own show more severe symptoms that manifest in the first 1- structure or function. Both sets of infants may show poor feeding, vomit- Methylmalonic CoA mutase (MCM)—The enzyme ing, lethargy, and low muscle tone, as well as a failure to responsible for converting methylmalonic acid to grow at the normal rate. The disorder may first come to succinic acid, in the pathway to convert certain medical attention as it escalates into a full scale over- substances to usable energy. If the condition has not yet levels of methylmalonic acid in the bloodstream been diagnosed, treatment is often poor, and patients may due to an inborn defect in an enzyme. More els of methylmalonic acid in the urine due to an severe attacks can lead to seizures, coma, and eventually, inborn defect in an enzyme. As a result, newborns and infants with MCM defi- Mutation—A permanent change in the genetic ciency may die early, even before a diagnosis can be material that may alter a trait or characteristic of reached. Between episodes the patient may composed of amino acids, involved in the forma- appear normal, but often, mild to moderate mental retar- tion of body structures and controlling the basic dation will develop. Other symptoms of the disorder include fre- A small percentage of people with the MCM defi- quent infections (especially yeast infections of the skin ciency apparently experience no symptoms or complica- and mouth), enlarged liver, and low amounts of red blood tions of the disease. Often a family history is present for affected sib- patients can tolerate a normal protein intake and accumu- lings or siblings that died very early in life for unclear late high levels of methylmalonic acid in their body flu- reasons. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 739 Diagnosis that a trial of vitamin B12 may be reasonable to determine if it will result in improved MCM function. Finally, When symptoms such as those described above are bicarbonate can be used to counteract low levels of acid encountered in a young infant or newborn, a diagnostic that persist in the bloodstream. A rou- tine blood test performed on almost all people who come All of the above medications can be used to aid in to the hospital with severe illness will show high levels of treatment of a severe attack of methylmalonicacidemia. Other clues to possible MCM In addition, a patient in crisis should be given excessive deficiency include high levels of other substances in the amounts of intravenous fluids, to help clear methyl- bloodstream that appear with methylmalonicacidemia malonic acid from the circulation. Special blood filtering such as ketones and ammonia, or the presence of abnor- machines can be used when levels of methylmalonic acid mally low amounts of glucose or red blood cells. Stressful situa- After high levels of acid in the bloodstream are tions that may trigger attacks (such as infection) should noted, and if methylmalonicacidemia is suspected, sam- be treated promptly. Abnormally high lev- larly by a team of health care specialists including a pri- els of methylmalonic acid suggest that MCM deficiency mary care provider, a dietician, and a biochemical may be present. Genetic studies can then be performed to geneticist who is familiar with the management of the determine if any mutation in the MCM gene is present. Parents should be educated in the signs and When the disease is diagnosed in a child, research symptoms of impending attacks and how to respond laboratories can test unaffected siblings to determine if appropriately. The same urinary content of methylmalonic acid, and growth technology can be used to diagnose MCM deficiency progress is necessary to ensure proper balance in the diet before the birth of a child, by analyzing fluid or tissue and the success of therapy.

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Carriers ing tissues in children with BS is not recommended as a cannot be identified by SCE analysis because they do not part of the cancer surveillance generic 150 mg clindamycin. Additionally discount clindamycin 150 mg line, individuals with this disorder are instructed to avoid x rays order 150mg clindamycin otc, chemotherapeutic drugs and Carrier testing is available for the Ashkenazi Jewish other environmental exposures that may damage their population generic clindamycin 150mg visa. Due to the immunodefi- mutation in the BLM gene that is responsible for most ciencies often associated with BS clindamycin 150mg low price, it is important to treat cases of BS. Almost all Ashkenazi Jewish carri- ers of the BS gene can be identified in this manner. The great majority of carriers of the mutation causing BS are Prognosis of Ashkenazi Jewish descent and, thus, this test is The mean age at death is 23 years with a range from designed for that high-risk population. Cancer is the most common cause of fatali- accurate for people from other ethnic populations in ties in individuals with BS and is thought to be responsi- whom the specific changes of the BLM gene are not so ble for approximately 80% of deaths. Prenatal diagnosis is available for carrier couples Resources with previously identified mutations in the BLM gene. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 165 Rong, Suo-Bao, Jouni, Valiaho, and Mauno Vihinen. An “Structural Basis of Bloom Syndrome (BS) Causing affected parent has a 50% chance of passing the disorder Mutations in the BLM Helicase Domain. Ranging in size from mil- limeters to several centimeters, the nevi can number from a few to hundreds. In rare cases, large lesions can cause nevus syndrome skeletal deformities that may lead to amputation. Blue rubber bleb nevus syndrome (BRBNS) is a rare Patients with BRBNS develop an extreme paleness disorder characterized by hemangiomas of the skin and or pallor of the skin. Hemangiomas are benign or mia, a low blood count, decreases the amount of oxygen noncancerous tumors of newly formed blood vessels and available to the surface skin. This syndrome derives its name from these distinc- fatigue that results from low iron stores and the anemia. Chronic or acute bleeding in the GI tract may be detected when blood is present in the stool. Chronic Description bleeding causes anemia, pallor, fatigue, and low iron In 1860 G. Iron supplements will help to increase the blood of cutaneous or skin nevi and intestinal lesions with GI count. William Bean in 1958 first used the term can rapidly decrease a normal blood count. Because of blood transfusion or surgery to remove the bleeding his description, BRBNS is sometimes called Bean syn- nevus can correct this condition. Besides the skin and GI tract, nevi are found on all internal organs and even the brain. Nevi are birth- Diagnosis marks of the skin that are probably hereditary because they are not caused by external factors. If they do not have the dis- tinct rubbery texture, blue color, and refill after they have Genetic profile been compressed, another diagnosis should be consid- To date, the gene that causes BRBNS has not been ered. Some cases of BRBNS However, lack of nevi in the GI tract does not completely are familial and support an autosomal dominant form of rule out BRBNS, since they may not develop until inheritance, meaning that only one copy of the non- adolescence. The doctor can then examine the GI tract for Anemia—A blood condition in which the level of nevi. Common symptoms include and iron deficiency as well as a stool test for the presence paleness, fatigue, and shortness of breath. Although nevi may be found on the brain, few Cutaneous—Of, pertaining to, or affecting the patients have neurological signs such as seizures or par- skin. Endoscopy—A slender, tubular optical instrument used as a viewing system for examining an inner Treatment and management part of the body and, with an attached instrument, for biopsy or surgery. Treatment of BRBNS will depend upon the severity, number, size, and location of the nevi. Skin lesions that Nevus—Any anomaly of the skin present at birth, are life-threatening can be safely removed by surgery, or including moles and various types of birthmarks. Surgery can remove single lesions; however, the number may be too great to Nevus Outreach, Inc. WEBSITES Patients who have neurological signs should have a “Blue Rubber Bleb Nevus Syndrome.

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