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Of these cheap prednisone 10 mg on line allergy symptoms itchy throat, the iliofemoral is by far the strongest and resists hyperexten- sion strains on the hip prednisone 5 mg otc allergy testing wiki. If the hip is forced into posterior dislocation while adducted (a) prednisone 20 mg overnight delivery allergy report nj, there is no associated fracture of the posterior acetabular lip (b). Dislocation in the abducted position (c) can only occur with a concomitant acetabular fracture (d). The palatine tonsil lies in the between the anterior and poste- rior pillars of the fauces. The anterior pillar, or, forms the boundary between the buccal cavity and the oropharynx; it fuses with the lateral wall of the tongue and contains the palatoglossus muscle. The poste- rior pillar, or, blends with the wall of the pharynx and contains the palatopharyngeus (Fig. The floor of the tonsillar fossa is formed by the superior constrictor of the pharynx separated from the tonsil by the, which is a thick condensation of the pharyngeal submucosa (the pharyngobasilar fascia). This capsule is itself separated from the superior constrictor by a film of loose areolar tissue. This epithelium is pitted by, up to twenty in number, and often bears a deep in its upper part. The lymphoid material may extend up to the soft palate, down to the tongue or into the anterior faucial pillar. On either side of the larynx the pharynx forms a recess, the, in which swallowed foreign bodies tend to lodge. The muscles of the larynx function to open the glottis in inspiration, close the vestibule and glottis in deglutition and alter the tone of the true vocal cords in phonation. The remaining muscles constitute a single encircling sheet whose various attachments are denoted by the names of its separate parts: the Relations Fig. Lesions of the retina or optic nerve result in in the affected segment, but lesions of the optic tract and central parts of visual pathway result in contralateral. The lesion responsible for the is thought to be in the vicinity of the pretectal area. The pupil is constricted, does not respond to light but responds to accommodation, but there is no satisfac- tory explanation why the pupillary reaction to light should be abolished while the convergence–accommodation reflex is preserved. In addition to supplying most of the extrinsic eye muscles, the oculomotor nerve conveys the preganglionic parasympathetic fibres for the sphincter of the pupil via the ciliary ganglion. Its nucleus of origin lies in the floor of the cerebral aqueduct at the level of the superior colliculus (Fig. From these nuclei, fibres pass vertically through the midbrain tegmen- Fig. The is the delicate mucous membrane lining the inner surface of the lids from which it is reflected over the anterior part of the sclera to the cornea. Over the lids it is thick and highly vascular, but over the sclera it is much thinner and over the cornea it is reduced to a single layer of epithelium. The line of reflection from the lid to the sclera is known as the conjunctival fornix; the superior fornix receives the openings of the lacrimal glands. Movements of the eyelids are brought about by the contraction of the orbicularis oculi and levator palpebrae superioris muscles. The width of the palpebral fissure at any one time depends on the tone of these muscles and the degree of protrusion of the eyeball. The main part of the gland is about the size and shape of an almond, but it is connected to a small terminal process which extends into the posterior part of the upper lid. The gland is drained by a series of 8–12 small ducts which open into the lateral part of the supe- rior conjunctival fornix whence its secretion is spread over the surface of the eye by the action of the lids. In the early nineties, under the aegis of the United States Na- tional Information Infrastructure, the Internet facilitated the creation of an “informa- tion-for-all” environment. Despite the unstructured nature of its existence, the Internet has seen an unprecedented global growth in its role as a promoter of information solutions to the citizens of the world. In contrast to the developments we witnessed in the past decade, the features of the next generation Internet have shifted emphasis from the “information-for-all” environment to a “knowledge-for all” paradigm. Healthcare is undoubtedly one of the major areas in which we are beginning to see revolutionary changes that are attributable to the emer- gence of the knowledge engineering concepts. Ad- vances in the field of medical informatics are a clear testimony of newer technology developments facilitating the storage, retrieval, sharing, and optimal use of biomedical information, data, and knowledge for problem solving. These are reflected in the design and implementation of comprehensive knowledge-based networks of interoperable health record systems. They provide information and knowledge for making sound decisions about health, when and where needed. There are three major and somewhat overlapping areas of knowledge engineering appli- cations, which have dominated the healthcare sector: education, patient care, and re- search. Knowledge stimulates creation of new knowledge and the management and dissemination of such new knowledge is the key to the building of modern educational infrastructure in medicine and healthcare. Whether it is the utility of the electronic cadaver in anatomy education, or the capturing of evidence-based medical content, or the design of a rule-based expert system in disease diagnosis, technology develop- ments have stayed focused on creating the knowledge discovery tools, with insights mainly borrowed from the Artificial Intelligence methodologies. These include machine learning, case-based reasoning, genetic algorithms, neural nets, intelligent agents, and stochastic models of natural language understanding, as well as the emerging compu- tation and artificial life. The central dogma in healthcare research is to ensure the patient to be the principle focus, from diagnosis and early intervention to treatment and care. Especially with the advent of the Internet, clinical knowledge management is a topic of paramount importance. Bali and his authors present in the book a number of discussions of the available technolo- gies to stimulate the future expansion. Knowledge repositories are increasingly getting larger in size and complex in structure, as seen for example, in the hospital information systems. Such massive data explosions require efficient knowledge management strat- egies, including the critical need to develop knowledge retrieval and data mining tools. The latter mostly consist of appropriate software-based techniques to find difficult-to- see patterns in large groups of data. The effective analysis and interpretation of such large amounts of data collected are being enhanced by applying machine vision tech- niques while at the same time we are looking at machine learning mechanisms to pro- vide self-learning instructions between processes. These are all some of the modern day innovations that are providing the capabilities to extract new knowledge from the existing knowledge. Healthcare is benefitting immensely from these applications, mak- ing it possible for healthcare professionals to access medical expert knowledge where and when needed. The design principles for the management of knowledge sharing and its global impact are a complex mix of issues characterized by varying cultural, legal, regulatory, and sociological determinants. What is especially important is to improve the overall health of the population by improving the quality of healthcare services, as well as by controlling the cost-effectiveness of medical examinations and treatment (Golemati et al.

Iyengar in Light on Yoga mentions a variety of yoga poses that may be useful in the treatment of migraines buy cheap prednisone 20 mg on line allergy symptoms numbness. These include headstand cheap prednisone 5mg overnight delivery allergy shots better than pills, shoulderstand buy cheap prednisone 10mg online allergy testing kalamazoo mi, seated and standing forward bends, a seated pose with the soles 19 of the feet together (Baddha Konasana), lotus, breathing exercises and relaxation. Using some of the poses assumes an ability to perform the asanas of Hatha yoga that many people may find challenging. Desikachar has developed a way to prescribe individualized yoga series for patients based on their capabilities and their ayurvedic medical diagnosis. In ayurveda there are three basic universal qualities (satva, raja and tamasic), from which five basic elements are derived: earth, water, fire, air and space. In ayurveda health is in large part determined by the balance of the three doshas; disease is a state that results from external or internal conditions adversely affecting the balance of the doshas. MEDITATION Meditation is most commonly used in the USA in a medical setting as a stress-reduction 20 technique. The focused awareness while practicing the postures, on both the alignment of the body and the movement of the breath, are a meditation within the system of Hatha yoga. In addition most yoga classes begin and/or end with a short meditation and relaxation exercise. Regular meditation appears to reduce stress and increase relaxation, and like the postures of Hatha yoga it may also improve medical conditions ranging from hypertension to chronic pain through some of the same neurological mechanisms (Table 21–27 28 2). Even though there are many of styles of meditation, a common denominator is that breathing is frequently used as a technique for increasing concentration. Another point of focus other than the breath is a series of words or phrases known as a mantra. For most patients, it is often helpful to begin with a class or instructions that can be augmented with an audiotape for home use. Consistency of practice, even if it is only for a brief period every day, seems to be an important factor in obtaining benefits from meditation. MINDFULNESS-BASED STRESS REDUCTION Jon Kabat-Zinnt introduced mindfulness-based stress reduction in 1979 as a tool integrating meditation techniques with Hatha yoga at the Stress Reduction Clinic at the University of Massachusetts Medical School. Since 1979, the 8-week program has treated thousands of patients with a variety of medical conditions, from psoriasis to cancer. There are clinical research studies using mindfulness-based 25 stress reduction that have shown that it may be useful in patients with anxiety, pain, 30 psoriasis and prostate cancer. VIPASANA MEDITATION Vipasana meditation, or mindfulness meditation, comes from the Buddhist meditation tradition and uses breath awareness as the primary point of focus, particularly while beginning. The idea is not to concentrate on any one thing, but impartially to note sensations and thoughts as they arise in the present moment. One then lets them go rather than continuing to dwell on any particular sensation or thought. Complementary therapies in neurology 196 TRANSCENDENTAL MEDITATION Maharishi Mahesh Yogi introduced this form of meditation to the West. It incorporates the use of a mantra or repeated word or phrase to help focus the mind and increase concentration. Its medical applications have been studied extensively in Iowa at Maharishi University with grant support of the National Center for Complementary and 21,22,26,31–33 Alternative Medicine at the National Institutes of Health. The role of transcendental meditation continues to be evaluated in a variety of clinical research projects and has been used successfully as an adjunctive therapy in the treatment of hypertension, coronary artery disease and stress reduction. SIDDHA YOGA MEDITATION This popular meditation tradition was introduced to the West by Swami Muktananda more than 30 years ago when he moved from India to the USA. In Siddha yoga, the field of awareness during meditation may vary but commonly may begin with the breath and then expand into a more general field of awareness. YOGA, PRANAYAMA, MEDITATION AND HEALTH CARE Hatha yoga, pranayama and meditation can be adapted for almost any patient. Most group Hatha yoga classes incorporate postures, breathing exercises and relaxation or meditation into a 1–2-h yoga class. It may be a challenge to locate a yoga teacher with the experience and patience to apply yoga therapeutically to a patient, particularly when the teacher may not have a medical background. It is important to remember that few yoga instructors are licensed health-care providers. Many yoga teachers are certified but the certification varies from correspondence courses to weekend training programs to a multi-year process with requirements for anatomy and physiology courses as with Iyengar yoga. It is important to ask teachers about their training and select one who has at least several years of teaching experience and continues to attend yoga teacher workshops. Certified yoga therapists who are experience in teaching Hatha yoga and comfortable working with patients are increasingly common, as Hatha yoga becomes more widely available and integrated with other medical therapies, from the Ornish 33 program for cardiac rehabilitation to postpolio syndrome. It may be useful to recognize that Hatha yoga can be viewed as an exercise system that provides a whole-body work-out or be used restoratively to alleviate fatigue. Medical studies have documented that there are many physical and mental benefits to exercise— improved fat metabolism, weight loss, increased circulation, decreased risk of cancer, to name but a few. Commonly, at any given moment, many of our small blood vessels are constricted, reducing blood flow and supply. During the practice of Hatha yoga the blood supply to these areas and the abdominal organs opens up through compression and expansion. This increased circulation supplies these areas with oxygen and other nutrients as well as improving waste removal. Bone density also increases when periosteal stresses Hatha yoga and meditation for neurological conditions 197 are placed on the bone, using isometric exercises over a period of time, as occurs with Hatha yoga. It appears to improve co-ordination which will result in fewer injuries, particularly in the elderly. This, of course, may limit the usefulness of yoga, given the lack of medical qualifications of yoga teachers combined with the lack of awareness of physicians of how Hatha yoga could be applied in a given illness or condition or what styles of Hatha yoga might be most appropriate for a given patient. CONCLUSION Hatha yoga and meditation appear to be safe and can be used to guide a therapeutic response. This may be of reassurance to some patients, who may have worried that these activities could put them in conflict with their religion. It is important when recommending Hatha yoga and/or meditation for a patient that it be a joint decision based on a variety of factors including the availability of qualified instructors. Some styles of Hatha yoga are quite physically demanding and involve complex series of movements where a trained instructor (and a patient/student with a high level of body awareness) is critical. Meditation, while it does not appear to be as physically demanding, can be challenging, and finding a system of meditation that works for a patient can be problematic. There are many self-instructional materials available—books, videos, CDs—some of which are excellent, particularly for a motivated patient. Hatha yoga and meditation are tools that patients can use to manage their own health and wellness. Anxiety, drug consumption, and personality correlates of yoga and progressive muscle relaxation.

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Hereditary sideroblastic anemia is most commonly Since the gene is defective and in the XY state there is no inherited as an X-linked recessive trait best 40 mg prednisone allergy shots tiredness. Typical X-linked genetics Genetics of X-linked sideroblastic anemia The following concepts are important to understand- The genetic abnormality that causes X-linked sider- ing the inheritance of an X-linked disorder discount 40mg prednisone with mastercard allergy medicine yeast infections. All humans oblastic anemia is a mutation in the erythroid (red blood have two chromosomes that determine their gender: cell) specific form of delta-aminolevulinate synthase females have XX order 5 mg prednisone amex allergy report, males have XY. ALAS2 is the first enzyme in the heme biosyn- also called sex-linked, inheritance affects the genes thetic pathway and the mutation, when present, results in located on the X chromosome. It occurs when an unaf- the inability to transport the heme (iron) into the hemo- fected mother carries a disease-causing gene on at least globin, making it ineffective. Because females have two X The ability to test for this genetic disorder has chromosomes, they are usually unaffected carriers. X chromosome that does not have the disease-causing gene compensates for the X chromosome that does. For a Demographics woman to show symptoms of the disorder, both X chro- mosomes would need to have the disease-causing gene. That is why women are less likely to show such symp- It may be seen in maternal uncles and male cousins of toms than males. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 87 Autosomal transmitted forms of the disease may cirrhosis, and heart failure from iron overload occur in both men and women. Hereditary sideroblastic anemia generally occurs X-linked sideroblastic anemia often improves with during the first three decades of life especially during pyridoxine (vitamin B6) therapy. Dosage is 50–200 mg, adolescence, but it has been diagnosed in patients over 70 however, pregnant or nursing mothers may wish to limit years old. In cases of extreme anemia, whole red blood cell Signs and symptoms transfusion may be required. Repeated whole red blood General weakness, fatigue, dizziness, and difficulty cell transfusion, however, will contribute significantly to breathing are associated with the disorder. The mucous membranes and skin of hands and arms Desferrioxamine binds excess body iron and promotes may be pale, possibly with a lemon-yellow cast. It is administered by Subcutaneous bleeding may occur, causing a brownish- intravenous infusion from a small portable pump. Side effects vary and include pain and matosis, accumulates over years in the bone marrow, swelling at injection site. This progressive deposition Certain drugs are sometimes associated with of toxic iron may result in an enlarged spleen or liver, liver disease, diabetes, impotence, arthritic signs, and acquired sideroblastic anemia: progesterone (found in heart disease, particularly cardiac arrhythmia. In other Using Prussian blue staining, sideroblasts are visible cases, acquired sideroblastic anemia may be secondary to under microscopic examination of bone marrow. In these cases, it is • Low levels for total iron binding capacity and trans- important to treat the primary disease or disorder in order ferrin. Development of leukemia is associated with the Additionally, other signs of sideroblastic anemia acquired form of the disease, often first showing up in the include: form of a myeloproliferative disorder. Prognosis • Ringed sideroblasts are visible with Prussian blue stain- The disorder can often be kept in check with regular ing and observable under microscopic examination of medical supervision. Treatment and management Death can result from hemochromatosis (iron-over- The main objective in treatment of X-linked siderob- load) if the disease is untreated or if blood transfusions lastic anemia is to prevent the development of diabetes, are inadequate to account for the iron overload. Stamford, CT: Appleton & Lange, Alpha-fetoprotein (AFP)—A chemical substance 1998. AFP is also found in abnormally high con- PERIODICALS centrations in most patients with primary liver Sheth, Sujit, and Gary M. As an isolated defect, anencephaly appears to be National Heart, Lung, and Blood Institute. PO Box 30105, caused by a combination of genetic factors and environ- Bethesda, MD 20824-0105. The recurrence may be anencephaly or another neural tube defect, such as Jennifer F. The prevalence rates range from less than one in 10,000 IAnencephaly births (European countries) to more than 10 per 10,000 Definition births (Mexico, China). Anencephaly is a lethal birth defect characterized by the absence of all or part of the skull and scalp and mal- Signs and symptoms formation of the brain. Anencephaly is readily apparent at birth because of exposure of all or part of the brain. Not only is the brain Description malformed, but it is also damaged because of the Anencephaly is one of a group of malformations of absence of the overlying protective encasement. In about the central nervous system collectively called neural 10% of cases of anencephaly, other malformations are tube defects. The condition is also Diagnosis called acrania (absence of the skull) and acephaly (absence of the head). In most instances, anencephaly nosis of anencephaly can also be detected through occurs as an isolated birth defect with the other organs maternal serum alpha-fetoprotein screening. In approxi- of alpha-fetoprotein in the maternal blood is elevated mately 10% of cases, other malformations coexist with because of the leakage of this fetal protein into the anencephaly. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 89 Diagram of Anencephaly NORMAL INFANT ANENCEPHALIC INFANT Brain Brain Stem Brain Stem Infants born with anencephaly have either a severly underdeveloped brain or total brain absence. A portion of the brain stem usually protrudes through the skull, which also fails to develop properly. Affected infants are stillborn or die within the first few ORGANIZATIONS days of life. Stevenson, MD all enriched cereal grain flours have been fortified with folic acid. Prognosis Anencephaly is uniformly fatal at birth or soon IAngelman syndrome thereafter. Definition Resources Angelman syndrome (AS) is a genetic condition that PERIODICALS causes severe mental retardation, severe speech impair- Czeizel, A. Individuals with AS show evidence of delayed “Prevention of neural tube defects: results of the Medical development by 6–12 months of age. However, receptive language skills (listen- designated 15q11-13 (bands 11 through 13 on the long ing to and understanding the speech of others) and non- arm of chromosome 15). Imprinting is a chemical gait ataxia (a slow, unbalanced way of walking) and modification of DNA which acts as an “identification tag” tremulous movements of the limbs. Imprinted genes or chromosome regions are expressed or AS is also associated with a unique “happy” behav- not expressed depending on which parent transmitted the ior, which may be the best-known feature of the condi- chromosome. This may include frequent laughter or smiling, often 15q11-13 region (from the father) cause a different with no apparent stimulus. These characteristic behaviors led to the origi- nal name of this condition, the “Happy Puppet” The most common cause of AS is a small deletion syndrome. However, this name is no longer used as it (missing piece) in the maternally inherited chromosome is considered insensitive to AS individuals and their 15. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 91 UBE3A mutation Signs and symptoms In approximately 11% of AS cases, there is a muta- The first abnormalities noted in an infant with AS are tion within the maternally inherited UBE3A gene. All often delays in motor milestones (those related to physi- the genetic mechanisms leading to AS appear to compro- cal skills, such as sitting up or walking), muscular hypo- mise expression of this gene, which is located within the tonia (poor muscle tone), and speech impairment. This gene is considered to be the “crit- infants seem unaccountably happy and may exhibit fits of ical gene” responsible for AS, although its specific func- laughter.

List only those that you are seriously considering generic 40mg prednisone mastercard allergy zone map, and include in your plan what you intend to do to exclude each one order 10mg prednisone with amex allergy medicine to dry up sinuses. Save the exhaustive list for the time your attending asks for all the causes of a symptom order prednisone 20mg on line allergy forecast appleton wi, syndrome, or abnormal laboratory value. Unlike the write-up, which contains all the data you obtained, the presentation may include only the pertinent positive and negative evidence of a disease and its course in the patient. It is hard to get a feel for what is pertinent until you have seen and done a few presentations yourself. Try never to read from your write-up, as this often produces dull and lengthy presentations. Most attendings will allow you to carry note cards, but this method can also lead to trouble unless content is carefully edited. Presentations are given in the same order as a write-up: identification, chief complaint, history of the present illness, past medical history, family history, psychosocial history, review of systems, physical exam- ination, laboratory and x-ray data, clinical impression, and plan. Only pertinent positives and negatives from the review of systems should be given. These and truly relevant items from other parts of the interview often can be added to the history of the present illness. Fi- nally, the length and content of the presentation vary greatly according to the wishes of the attending and the resident, but you will learn quickly what they do and do not want. RESPONSIBILITY Your responsibilities as a student should be clearly defined on the first day of a rotation by either the attending or the resident. Ideally, this enumeration of your duties should also in- clude a list of what you might expect concerning teaching, floor skills, presentations, and all the other things you are paying many thousand dollars a year to learn. You will frequently be expected to call for a certain piece of laboratory data or to go re- view an x-ray with the radiologist. The same basic rules and skill set necessary for inpatient care can be easily transferred to the outpa- tient setting. The whole service relies to a great extent on a well-informed presentation by the student. The better informed you are, the more time left for education and the better your evaluation will be. These may include the frequency of vital signs, medications, respiratory care, laboratory and x-ray studies, and nearly anything else that you can imagine. There are many formats for writing concise admission, transfer, and postoperative or- ders. Some rotations may have a precisely fixed set of routine orders, but others will leave you and the intern to your own devices. It is important in each case to avoid omitting in- structions critical to the care of the patient. Although you will be confronted with a variety of lists and mnemonics, ultimately it is helpful to devise your own system and commit it to memory. Because when you are an intern and it is 3:30 AM, you may over- look something if you try to think it out. The word stat is the abbreviation for the Latin word statim, which means “immedi- ately. Ideally, this order is reserved for the truly urgent situation, but in prac- tice it is often inappropriately used. Most of the blame for this situation rests with physi- cians who either fail to plan ahead or order stat lab results when routine studies would do. Student orders usually require a co-signature from a physician, although at some institu- tions students are allowed to order routine laboratory studies. Do not ask a nurse or pharma- cist to act on an unsigned student order; it is illegal for them to do so. The amount of interest shown by the resident and the attending varies greatly, but ideally you will review the orders on routinely admitted patients with the intern. Have the intern show you how to write some orders on a few patients, then take the initiative and write the orders yourself and review them with the intern. THE DAY The events of the day and the effective use of time are two of the most distressing enigmas encountered in making the transition from preclinical to clinical education. For example, there are no typical days on surgical services, as the operating room schedule prohibits mak- ing rounds at a regularly scheduled time every day. Often, they can see your pa- tient on the same day or at least early the next day. Try to take care of all your business in the radiology department in one trip unless a given problem requires viewing a film promptly. Make a point of knowing when certain services become unavailable, for example, elec- trocardiograms, contrast-study scheduling, and blood drawing. Make a daily work or “scut”* list, and write down laboratory results as soon as you ob- tain them. If you have patients to see on four different floors, try to take care of all their needs, such as, drawing blood, remov- ing sutures, writing progress notes, and calling for consultations, in one trip. If you do not try to get work done early, you never will (this is not to say that you will succeed even if you do try). There is no sin in leaving at 5:00 PM or earlier if your obligations are completed and the supervising resi- dent has dismissed you. A PARTING SHOT The clinical years are when all the years of premed study in college and the first two years of medical school suddenly come together. Trying to tell you adequately about being a clini- cal clerk is similar to trying to make someone into a swimmer on dry land. The terms to describe new clinical clerks may vary at different medical centers (“scut monkey,” “scut boy,” “scut dog,” “torpedoes”). These euphemistic expressions describing the new clinical clerk acknowledge that the transition, a sort of rite of passage, into the next phase of physician training has occurred. It is hoped that this “So You Want to Be a Scut Monkey” introduction and the information contained in this book will give you a good start as you enter the “hands on” phase of becoming a successful and respected physician. The details provided and length of the written H&P can vary with the particular problem and with the service to which the patient is admitted. History of the Present Illness (HPI): Defines the present illness by quality; quan- tity; setting; anatomic location and radiation; time course, including when it began; whether the complaint is progressing, regressing, or steady; of constant or intermittent frequency; and aggravating, alleviating, and associated factors. The information should be in chrono- logic order, including diagnostic tests done prior to admission. Related history, including previous treatment for the problem, risk factors, and pertinent negatives should be included. Any other significant ongoing problems should be included in the HPI in a separate section or paragraph. For instance, if a patient with poorly controlled diabetes mellitus comes to the emergency room because of chest pain, the HPI would first include information regarding the chest pain followed by a detailed history of the diabetes mellitus. If the diabetes mellitus was well controlled or diet-controlled, the history of the diabetes mellitus is placed in the past medical history. Past Medical History (PMH): Current medications, including OTC medications, vit- amins, and herbals; allergies (drugs and other—include how allergies are manifested); surg- eries; hospitalizations; blood transfusions, include when and how many units and the type of blood product; trauma; stable current and past medical problems unrelated to the HPI. Spe- cific illnesses to inquire about include diabetes mellitus, hypertension, MI, stroke, peptic ulcer disease, asthma, emphysema, thyroid and kidney disease, bleeding disorders, cancer, 9 Copyright 2002 The McGraw-Hill Companies, Inc.

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