By K. Sibur-Narad. Williams Baptist College. 2018.

We have found that existing systems do not handle the richness of time-related concepts during the diagnosis stage and the variety of temporal refer- ences required buy zithromax 500mg lowest price bacteria zapper for acne. For example generic 250 mg zithromax fast delivery antimicrobial activity of plant extract, some symptoms are described as occurring on a particular day, like “The symptoms started last Monday”. Some of them are identified precisely once the duration is known, for example, “He had fever for three days”. Sometimes the duration is not precisely identifiable and there is some degree of uncertainty the system should be able to handle, for example, “Started yesterday evening and stopped at some point during the night”. It is important to recognize repetitive processes, for example, “He has headaches each time that he goes to music class” and frequencies of occurrence, for example, “He has been taking this medicine three times each day”. Rich calendric references should be handled, like seasons, in order to discover potential causes of disease, for example allergies. Here we consider why, where and when these issues are important in the context of Internet-based medical assistance. Interaction Shifts with Internet-Based Diagnosis The use of the Internet as an intermediate level between health centers and patients brings a shift in the interaction and the usual tasks involved. The interaction is no longer a physical meeting but instead there is a media that may restrict, sometimes significantly, what each person involved in the communication perceives from each other. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Here the interaction between (i) a rich interface that allows extraction of information from the patient in terms of the symptoms and (ii) suitable algorithms that can relate a, most possibly, incomplete description of symptoms to a meaningful subset of possible scenarios, will be crucial for the effectiveness of such systems. In a routine visit to a clinician, natural language, body language and other usual means of communications between humans are available. With Internet-based consultations we can consider some substitutes like video and sound but some of them may or may not be available. There may be occasions when these media would not be usable, for example, due to privacy issues. Until image, video and sound are widely available at the level of quality required to replace a face to face clinical examination we focus on the more basic and less sophisticated ways of collecting information via dynamically generated web based forms that can be used as the base for interaction either in synchronous or asynchronous communication between patient and health professional. Other areas of computer science become relevant like Natural Language processing and appropriate interfaces that are friendly enough for the patient while gathering as much information for the clinicians as possible. At the diagnosis level different subtleties will help to identify between a possible dangerous situation and a non-dangerous one or between two diseases that may require very different treatment even when they share similar symptoms, for example, flu and hepatitis. Being able to successfully detect the described symptoms with pre-known patterns of disease will require mechanisms like: a) disambiguating relative orders between events and descriptions, b) inferring possible durations for them when they are not given explicitly, c) dealing with degrees of uncertainty in terms of the temporal scope of a given set of events and conditions, d) using the partial list obtained at any time during the interaction to assess which is the most likely scenario which in turn will help to select which questions to ask next or which information to gather in order to maximize efficiency during the diagnosis process. There are quite a few hypotheses that must be taken into account to supply the system with extra information that is available or gathered by other means. One basic point is that patients should have a history, the normal approach for storing time-related information being temporal databases (Tansel, Clifford, Gadia, Jajodia, Segev, & Snodgrass, 1993; Etzioni, Jajodia, & Sripada, 1998). Also, the system should be time sensitive in the sense that each subsequent visit should provide a different context. For example, if the purpose of the later visit is to incorporate further information about a previous description of symptoms, the system should react accordingly and should present information differ- ently and/or different information. Once all the symptoms have been entered and those that are relevant to the hypothetical syndrome are identified, the system may advise on how to monitor for their evolution in time. The rules for diagnosis should be “time-aware” and the interface with the patient should allow some way to clearly indicate key time-based references, for example, the frequency, Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Management and Analysis of Time-Related Data in Internet-Based Healthcare 43 duration and proximity of symptoms. The inference engine should instantiate internally these temporal references with patterns and use the time of occurrence as a reference during the reasoning. A specific device can be used for daily monitoring so as to reduce errors, but more sophisticated users or applications will demand a more sophisticated interaction and description of events and conditions. For example, if a patient is trying to describe symptoms to ascertain if they have a medical condition, the temporal distance between their occurrence and the relative order of their occurrence can make a difference in the final diagnosis. In an asynchronous context, patients may be monitored and the system, based on the trends of the input data in time, may decide to take a cautionary step of contacting a health professional. Exemplar Scenarios of TR in Healthcare To detail further of how TR in Internet-based healthcare may be employed, the following sections provide an overview of three potential candidates.

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Degenerative muscle carrier and if they are homozygous then they will show weakness and floppiness may occur due to a decline in the trait generic zithromax 500 mg without a prescription antimicrobial medicines. This is caused by the disorder will passed onto the child (ren) if both par- increased accumulation of sphingomyelin in the nerv- ents are heterozygous for the trait and a 100% chance if ous system cheap 500 mg zithromax with visa antibiotic prescribing guidelines. Pigmentation in the tissue of the eyes may has been located on the short arm (p) of chromosome 11. Formation of cherry-red spots may be seen in The gene for types C and D has been located on chromo- approximately 50% of patients diagnosed with NPD some 18. Type E is similar to type C fever, and gastrointestinal (GI) problems such as vomit- and may be a variant form. Demographics Symptoms progress slowly and begin during infancy or Niemann-Pick disease affects males and females early childhood. Like type A, type B occurs due to a defi- equally and has been identified in all races. Neurological most common form of the disease and is responsible for involvement is minimal and usually absent. Abnormal enlargement of the Type E liver and spleen occur due to the accumulation of sphin- As of 2000, many researchers consider this to be a gomyelin. The formation of cherry-red spots on the eyes begin until adulthood and neurological impairment is may be seen in some affected individuals. Enlargement of the liver and rate and increased incidence of respiratory infections. This is characterized by confusion, disori- entation, deterioration of intellectual capacity and func- This type of Niemann-Pick disease occurs due to the tion, and impairment of the memory. NPD type C can occur at any- inability to control the muscle movement of the eyes. Symptoms are as follows: This type of Niemann-Pick disease is characterized • Hepatosplenomegaly. The liver and spleen may be by a finding of sea-colored blue cells in the blood and/or moderately enlarged due to the inability to breakdown bone marrow of individuals and therefore may be called cholesterol. Symptoms tremors, and spasticity of the muscles result due to may include: excessive accumulation of cholesterol in the brain. Abnormal enlargement of the individual with NPD type C may also exhibit extreme liver and spleen may occur in individuals with NPD muscle weakness due to emotional excitement and type F. This is may suffer from a decrease in the number of platelets an impaired function of the muscles of the eyes and found in the blood. Platelets are necessary for coagula- may cause the eyes to become stuck or fixed in an tion of the blood. Individuals may have an absence of hair in the skin, eyes, and possibly the mucous membranes. Type D Diagnosis This is the Nova Scotia variant of Niemann-Pick As of 2000, there is no objective diagnostic test for disease. Like NPD type C, individuals with type D are Niemann-Pick disease types D, E, and F. The symptoms of type D are very similar low levels of the enzyme sphingomyelinase in white blood to type C but vary from case to case. GALE ENCYCLOPEDIA OF GENETIC DISORDERS 815 Type C can be diagnosed by prenatal testing of fibroclas- In individuals with types C and D, death usually results tic cells to determine their ability to process and store cho- in adolescence or early adulthood. This is done by testing the amniotic fluid (liquid B have a prolonged survival due to the decrease of neu- which bathes and cushions the fetus). As of 2000 the prognosis for types cells occurs in all types of NPD and can be determined E and F has not been adequately researched. Diagnosis of all Affected individuals and their families may want to types is made possible by taking a detailed family history seek genetic counseling. Pregnant women that are Symptoms of Niemann-Pick disease may be similar carriers and have a partner that is a carrier should receive to those of Refsum syndrome (disorder of fat metabolism genetic counseling regarding the 25 percent chance of the associated with abnormal accumulation of phytanic acid child having Niemann-Pick disease. Due to advances in (disorder found in Eastern European Jewish descendents medicine an early diagnosis may increase life that results in deterioration of the central nervous sys- expectancy. As of 2000, there is no specific treatment available “Sphingomylin Lipidoses (Niemann-Pick disease). Individuals are Principle and Practice of Medical Genetics, Volume 2, treated on a symptomatic basis. Gulli, MD lowering drugs and low cholesterol diets are often used Tanya Bivins, BS for individuals with NPD types C and D.

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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 purchase 100 mg zithromax antibiotic resistance wiki answers. For example order 100mg zithromax overnight delivery antibiotics for uti how long, 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. This category de- pends on the age and sex of the patient but could include last Pap smear and pelvic exam, breast exam, whether the patient does self breast examination, date of last mammogram, diphtheria/tetanus immunization, pneumococcal and flu vaccine, stool samples for hemoc- cult, sigmoidoscopy, cholesterol, HDL cholesterol, and use of seat belts. Pediatric patients: Include prenatal and birth history, feedings, food intolerance, and immunization history. Family History: Age, status (alive, dead) of blood relatives and medical problems for any blood relatives (inquiry about cancer, especially breast, colon, and prostate; TB, asthma; MI; HTN; thyroid disease; kidney disease; peptic ulcer disease; diabetes mellitus; bleeding disorders; glaucoma, and macular degeneration). Psychosocial (Social) History: Stressors (financial, significant relationships, work or school, health) and support (family, friends, significant other, clergy); life-style risk factors, (alcohol, drugs, tobacco, and caffeine use; diet; and exposure to environmental agents; and sexual practices); patient profile (may include marital status and children; present and past employment; financial support and insurance; education; religion; hobbies; beliefs; living conditions); for veterans, include military service history. Weight loss, weight gain, fatigue, weakness, appetite, fever, chills, night sweats Skin. Vision, changes in the visual field, glasses, last prescription change, photophobia, blurring, diplopia, spots or floaters, inflammation, discharge, dry eyes, excessive tear- ing, history of cataracts or glaucoma Ears. Hearing changes, tinnitus, pain, discharge, vertigo, history of ear infections Nose. Sinus problems, epistaxis, obstruction, polyps, changes in or loss of sense of smell Throat. Bleeding gums; dental history (last checkup, etc); ulcerations or other lesions on tongue, gums, buccal mucosa Respiratory.

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