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As a medical examiner, your fundamental obligation during the musculoskeletal assessment is to establish whether a driver has the musculoskeletal strength, flexibility, dexterity, and balance to maintain control of the vehicle and safely perform nondriving tasks. Key Points for Musculoskeletal Examination During the physical examination, you should ask the same questions as you would for any individual who is being assessed for musculoskeletal concerns. Adapt the observation, inspection, palpation, and screening tests of the general musculoskeletal examination to ensure that the physical demands of commercial driving are assessed. Additional questions should be asked to supplement information requested on the form. Any musculoskeletal or neuromuscular condition should be evaluated for the nature and severity of the condition, the degree of limitation present, the likelihood of progressive limitation, and the potential for gradual or sudden incapacitation. Have mild, moderate, or severe chronic musculoskeletal pain (frequency and intensity)? Sufficient power grasp and prehension of hands and fingers to maintain steering wheel grip? Sufficient mobility and strength of spine and/or torso to drive safely and perform other job tasks? If findings so dictate, radiology and other examinations should be used to diagnose congenital or acquired defects or spondylolisthesis and scoliosis. Examination by a neurologist or physiatrist who understands the functions and demands of commercial driving may be required to assess the status of the disease. However, as a medical examiner, it is your responsibility to determine certification status. Overall requirements for commercial drivers as well as the specific requirements in the job description of the driver should be deciding factors in the certification process. The driver is responsible for ensuring that both certificates are renewed prior to expiration. Musculoskeletal Tests Detection of an undiagnosed musculoskeletal finding during the physical examination may indicate the need for further testing and examination to adequately assess medical fitness for duty. Diagnostic-specific testing may be required to detect the presence and/or severity of the musculoskeletal condition. The additional testing may be ordered by the medical examiner, primary care physician, or musculoskeletal specialist. When requesting additional evaluation, the specialist must understand the role and function of a driver; therefore, it is helpful if you include a description of the role of the driver and a copy of the applicable medical standard(s) and guidelines with the request. Table 7 - Medical Examination Report Form: Laboratory and Other Test Findings Page 171 of 260 Grip Strength Tests the Federal Motor Carrier Safety Administration does not require any specific test for assessing grip power. Sphygmomanometer used as a screening test for grip by having the applicant repeatedly squeeze the inflated cuff while noting the maximum deflection on the gauge. The most common form of diabetes mellitus is Type 2 (adult onset or non-insulin-dependent diabetes mellitus). May preserve blood glucose control counter-regulatory mechanisms for many years with lifestyle changes and oral hypoglycemic medications. May, over time, have insulin production fail and require insulin replacement therapy.

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If there is a pocket of hardened tissue, very gently stretch the skin until the skin feels softer, more flexible, and is less restricting of movements. In order to prevent fluid from returning back into the skin, it is necessary to apply external compression to the swollen area. Depending on the amount of the swelling, either garments or compression bandages are worn to reduce swelling in the limb. Your therapist will discuss recommended garments and arrange a fitting with a garment vendor. All compression garments should be comfortable to wear and should not cause increased swelling, blisters, or redness. They should be cleaned according to manufacturer directions for proper fit, hygiene, and to ensure they last as long as possible. If this is not the case it is best to use rubber gloves to smooth and straighten the fabric so that the lines travel straight up the extremity. Stockings: Stockings should not bunch or cut at the ankles or behind the knees, nor should they roll down or slide down the leg. Open toes should begin just below the toes and should not put any pressure on the foot bones. Bras should not cutoff under the armpit or at the ribs, nor cut in at the shoulders. Bras should come up as high as possible under the armpit for support in that area. Head and Neck Garments: Should feel comfortable and not restrict breathing, swallowing or neck range of motion. The Use of Adhesive Lotion: the use of a water-soluble adhesive lotion can solve rolling or slipping of garments. To apply adhesive lotion, put the garment on and assure the proper fit of it, turn the border over and apply the roll on applicator to the skin just above the edge of the garment, allowing several minutes for the lotion to become tacky, then turn the garment border back over and adhere. The Use of Rubber Gloves: Wearing household rubber gloves or gardening gloves makes the application of a compression garment much easier. They allow you to smooth out the fabric with minimal effort and grip the material firmly while pulling. They also protect the fabric from runs and pulls caused by fingernails or jewelry. The Use of Slip On Aids: Various aids are available to assist with putting on and taking off garments. The best type of exercise depends upon the severity and cause of the lymphedema and other co-existing medical conditions. Answer: Exercise increases circulation and removal of lymphatic fluid from the skin. Starting at an appropriate fitness level and gradually increasing activities while monitoring effects on swelling of the involved area are important. You may return to high intensity activities such as tennis, golf, bowling, running, and mountain biking provided you did this before the onset of lymphedema and are vigilant in monitoring your swelling. The three main types of exercise are aerobic, strengthening, and flexibility exercises. Additionally, lymphatic drainage exercises are simple movements that are performed in a sequence that pump fluid through lymphatic pathways and are best performed with compression. The goal is 30 minutes of aerobic exercise, 4-5 times a week, with a 60-65% target heart rate. Strength training can be beneficial for you because it will allow you to perform daily activities with less effort, thus possibly preventing injury and subsequent swelling. Flexibility exercises can minimize skin scarring and joint contractions that may lessen lymphatic flow. Pilates, Yoga, Tai Chi, Qigong, aquatic exercises, breathing exercises and relaxation are other types of exercise that have health benefits. Allow adequate rest intervals between sets Avoid constrictive clothing or weights that wrap tightly around an extremity Maintain good hydration Avoid extreme heat or overheating Never exercise to the point of pain For an easy to start exercise program see page 17. If you have difficulty, let your therapist know, so that changes can be made that will allow you to perform these exercises. Abdominal breathing Lie on your bed or floor or sit in a comfortable chair, knees slightly bent, feet on the floor, hands resting on your stomach.

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Small pilot studies have evaluated the impact of supplements, such as ginseng, vitamin D, and others for cancer-related fatigue. Recommendations: Screening for Depressive Symptoms All patients should be screened for depressive symptoms at their initial visit, at appropriate intervals, and as clinically indicated, especially with changes in disease or treatment status (i. Screening suggested at initial diagnosis, start of treatment, regular intervals during treatment, end of treatment, post-treatment or at transition to survivorship, at recurrence or progression, advanced disease, when dying, and during times of personal transition or re-appraisal such as family crisis, during post-treatment survivorship and when approaching death. Screening should be done using a valid and reliable measure that features reportable scores (dimensions) that are clinically meaningful (established cut-offs). For individuals endorsing either item (or both) as occurring for more than half of the time or nearly every day within the last two weeks (i. It is estimated that 25-30% of patients would need to complete the remaining items. For patients completing the latter step it is important to determine the associated sociodemographic, psychiatric or health comorbidities, or social impairments, if any, and the duration that depressive symptoms have been present. Having noted that, it is the frequency and/or specificity of the thoughts that are most important vis-a-vis risk. It should be noted, however, that doing may artificially lower the score, with the risk of some patients appearing to have fewer symptoms than they actually do. Such changes also weaken the predictive validity of the score and the clarity of the cutoff scores. It is important to note that individuals do not typically endorse a self-harm item exclusively or independent of other symptom; rather, it occurs with several other symptom endorsements. These include but are not limited to the following: (a) use culturally sensitive assessments and treatments as is possible, (b) tailor assessment or treatment for those with learning disabilities or cognitive impairments, (c) be aware of the difficulty of detecting depression in the older adult. Assessments should be a shared responsibility of the clinical team, with designation of those who are expected to conduct assessments as per scope of practice. The assessment should identify signs and symptoms of depression, the severity of cancer symptoms. A range of problem checklists is available to guide the assessment of possible stressors. Clinicians can amend checklists to include areas not represented or ones unique to their patient populations. If moderate to severe or severe symptomatology is detected through screening, individuals should have further diagnostic assessment to identify the nature and extent of the depressive symptoms and the presence or absence of a mood disorder. As a shared responsibility, the clinical team must decide when referral to a psychiatrist, psychologist, or equivalently trained professional is needed. Such would be determined using measures with established reliability, validity, and utility. For optimal management of depressive symptoms or diagnosed mood disorder use pharmacological and/or non-pharmacological interventions. These guidelines make no recommendations about specific antidepressant pharmacological regimens being better than another. The choice of an antidepressant should be informed by the side effect profiles of the medications, tolerability of treatment, including the potential for interaction with other current medications, response to prior treatment, and patient preference. Offer support and provide education and information about depression and its management to all patients and their families, including what specific symptoms and what degree of symptom worsening warrants a call to the physician or nurse. If an individual has comorbid anxiety symptoms or disorder(s), the route is usually to treat the depression first. Some people have depression that does not respond to an initial course of treatment. Use of outcome measures should be routine (minimally pre and post treatment) to a) gauge the efficacy of treatment for the individual patient; b) monitor treatment adherence; and, c) evaluate practitioner competence. Recommendations: Treatment and Care Options for Depressive Symptoms It is common for persons with depressive symptoms to lack the motivation necessary to follow through on referrals and/or to comply with treatment recommendations. If compliance is poor, assess and construct a plan to circumvent obstacles to compliance, or discuss alternative interventions that present fewer obstacles.

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Know the effects of thyroid hormone replacement on therapeutic replacement requirements for cortisol and vasopressin 4. Know the relative roles of pituitary and placental gonadotropins in sexual differentiation b. Know sex differences in fetal maturational patterns of hypothalamicpituitary gonadal axes c. Understand the biphasic nature of the maturational pattern of the reproductive system d. Understand the effects of the inhibins/activins on gonadotropin synthesis and secretion 3. Know the developmental pattern of circadian rhythms of gonadotropins in early puberty h. Know that serum prolactin concentrations may increase moderately with pituitary stalk interruption b. Recognize hyperprolactinemia as a possible cause of primary or secondary amenorrhea 3. Know the differences between prolactin-secreting tumors and increased prolactin from other causes 9. Know the relative roles of blood volume and osmolality in the regulation of vasopressin secretion b. Know the location and function of the carotid pressure and atrial volume sensors in vasopressin physiology c. Know the differences between the structure and effects of synthetic analogues and vasopressin 4. Know the clinical usefulness of "water deprivation testing" and hypertonic saline administration in the evaluation of vasopressin secretion 2. Know inheritance patterns of vasopressin deficiency and vasopressin unresponsiveness 4. Know characteristic phases of posterior pituitary dysfunction after surgical manipulation of or trauma to the median eminence area or pituitary stalk 5. Understand appropriate diagnostic approach to patients with "idiopathic" acquired diabetes insipidus 6. Understand that the diagnosis of diabetes insipidus can often be made based on serum and urine osmolality without the need for a water deprivation test 9. Understand the treatment of vasopressin deficiency and vasopressin unresponsiveness 10. Understand that vasopressin deficiency can be associated with absent thirst mechanism 2. Know how to distinguish diabetes insipidus, nephrogenic diabetes insipidus, and compulsive water drinking 3. Know the origin of commonly used World Health Organization growth charts and their limitations and differences b. Know the techniques of assessing body composition and the differences and limitations c. Know how to distinguish physiological from pathologic tall stature in childhood c. Know the normal growth rates during fetal life, infancy, childhood, and adolescence d. Know how factors such as twinning and maternal/paternal size influence fetal growth. Know how to utilize longitudinal growth data to distinguish between physiological and pathological patterns of growth g. Know the criteria used to distinguish normal variants of short stature from pathologic short stature in childhood h. Understand the concept of skeletal age and the nutritional, hormonal and genetic factors that influence it b. Know linear and weight growth patterns that are suggestive of hypothyroidism or hyperthyroidism c. Know the hormonal factors controlling pubertal growth and the relationship between peak growth velocity and the stages of pubertal development 2. Know the effects of sex steroids on linear growth, body composition, and bone maturation d.

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Discuss the safety implications of effects and/or side effects of prescription and over-the-counter medications, supplements, and herbs. By signing the form, the driver certifies that the information and history are "complete and true. Document the significant findings of the health history in the comments section below the signature of the driver. Medical Examination Report Form - Page 2 the results of the four required tests: vision, hearing, blood pressure/pulse, and urinalysis are recorded on the second page of the Medical Examination Report form. Abnormal test results may disqualify a driver or indicate that additional evaluation and/or testing are needed. Drug and alcohol testing are not required for the driver physical examination unless findings indicate they are needed to determine medical fitness for duty. Vision the medical examiner or a licensed ophthalmologist or optometrist can examine and certify vision test results. Color vision must be sufficient to recognize and distinguish traffic signals and devices showing the standard red, amber, and green colors. A driver with monocular vision, who is otherwise medically qualified, may apply for a Federal vision exemption. You may certify the driver who meets vision qualification requirements, with or without the use of corrective lenses, for up to 2 years. Hearing To qualify, the driver must meet the hearing requirement of either the forced whisper test or the audiometric test in one ear. Audiometric test is to have an average hearing loss, in one ear, less than or equal to 40 decibels (dB). The driver who wears a hearing aid to meet the hearing qualification requirement must wear a hearing aid while driving. Blood Pressure/Pulse Record pulse rate and rhythm on the Medical Examination Report Form. The driver with stage 1 or stage 2 hypertension may be certified in accordance with the cardiovascular recommendations, which take into consideration known hypertension history. The dipstick urinalysis must measure specific Page 214 of 260 gravity and test for protein, blood, and glucose in the urine. Attach copies of additional test results and interpretation reports to the Medical Examination Report form. Medical Examination Report Form - Page 3 Record the physical examination and certification status on the third page of the Medical Examination Report form. Physical Examination the physical examination should be as thorough as described in the Medical Examination Report form, at a minimum. Note any abnormal finding, including the safety implication, even if not disqualifying. Inform the driver of any abnormal findings and as needed advise the driver to obtain follow-up evaluation. Physical examination may indicate the need for additional evaluation and/or tests. Specialists, such as cardiologists and endocrinologists, may perform additional medical evaluation, but it is the medical examiner who decides if the driver is medically qualified to drive. Document the certification decision, including the rationale for any decision that does not concur with the recommendations. Certification and Documentation Certification Status Document the certification decision in the space provided for certification status. The driver who must wear corrective lenses, a hearing aid, or have a Skill Performance Evaluation certificate may be certified for up to 2 years when there are no other conditions that require periodic monitoring. Federal exemptions and some Federal Motor Carrier Safety Administration guidelines specify annual medical examinations. Certification and recertification occur only when the medical examiner determines that the driver is medically fit for duty in accordance with Federal qualification requirements for commercial drivers.

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Headaches may also be caused by cystic (water filled cavities) changes in the tumor or by interruption of spinal fluid circulation in brain resulting in a condition called hydrocephalus. During normal electrical activity, the nerve cells in the brain communicate with each other through carefully controlled electric signals. During a seizure, abnormal electrical activity occurs, that may stay in a small area or spread to other areas of brain. Disturbance in the way one thinks and processes thoughts (cognition) is another common symptom of a metastatic brain tumor. Cognitive challenges might include difficulty with memory (especially short term memory) or personality and behavior changes. Motor problems, such as weakness on one side of the body or an unbalanced walk, can be related to a tumor located in the part of the brain that controls these functions. Metastatic tumors in the spine may cause back pain, weakness or changes in sensation in an arm or leg, or loss of bladder/bowel control. Both cognitive and motor problems may also be caused by edema, or swelling, around the tumor. Metastatic tumors are diagnosed using a combination of neurological examination and imaging (also called scanning) techniques. The tissue sample may be obtained during surgery to remove the tumor, or during a biopsy. If a metastatic tumor is diagnosed before the primary cancer site is found, tests to locate the primary site will follow. The neurosurgeon will look at your scans to determine if the tumor(s) can be surgically removed, or if other treatment options would be more reasonable for you. When planning your treatment, your doctor will take several factors into consideration. Reducing the swelling in the brain can reduce the raised brain pressure, and thus temporarily reduce the symptoms of a metastatic brain tumor. Research shows that the number of metastases is not the sole predictor of how well you might do following treatment. Your neurological function (how you are affected by your brain metastases) and the status of the primary cancer site (i. Treatment decisions will take into account not only long term survival possibilities, but your quality of life during and after treatment, as well as cognition concerns. That radiation may be whole-brain radiation therapy, whole-brain radiation plus stereotactic radiosurgery or stereotactic radiosurgery alone. This is generally followed by medical therapy (chemotherapy, radiation therapy or immune-based therapy) that may impact not only the primary cancer but also metastatic brain tumor. However in more recent times there is an increase in the use of radiosurgery or medical therapy (chemotherapy, targeted therapy or immune-based therapy) for these patients. If there is a question about the scan results or the diagnosis, a biopsy or surgery to remove the brain tumors may be done. This will allow your physicians to confirm that the brain tumors are related to your cancer. If you do not have a history of cancer, your physicians will order tests to try to determine the primary site. If no other cancer site is found, surgery to obtain a tissue sample may be performed. In general, the primary treatment for multiple metastatic brain tumors (or multiple tumors that are not close to each other) is whole-brain radiation. The goal of this therapy is to treat the tumors seen on scan plus those that are too small to be visible. A neuro-oncologist or a medical oncologist specializing in the treatment of brain tumors can help determine if this additional therapy would be of help to you.

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Understand that stimulatory antibodies may persist for years after treatment in a subset of women with Graves disease, and be unrecognizable if thyroid ablation has occurred, increasing the risk for neonatal hyperthyroidism in their offspring c. Be aware of the occurrence but rarity of the "hot nodule" as a cause of thyrotoxicity b. Be aware of the occurrence of thyrotoxicosis following ingestion of ground beef with a high thyroxine content due to inclusion of neck strap muscles c. Be aware of subacute thyroiditis (silent thyroiditis) as a cause of hyperthyroidism and of its clinical cause d. Be aware of the impact of nonthyroidal illnesses, which alter protein concentrations, on thyroid hormone binding by proteins such as in nephrosis. Know that certain drugs and hormones will alter the concentration of thyroid binding proteins with subsequent impact on laboratory measurements of total thyroid hormones 2. Know the clinical significance of dysalbuminemia and the characteristic laboratory findings b. Be aware of the clinical and laboratory findings in acute suppurative thyroiditis b. Recognize the relationship of subacute (de Quervain) thyroiditis to viral diseases such as mumps 2. Be aware that subacute (lymphocytic) thyroiditis may be a cause of transient hyperthyroidism followed by transient hypothyroidism and then by euthyroidism b. Be aware of the propensity for transient abnormalities caused by subacute (lymphocytic) thyroiditis to recur in affected individuals 4. Be aware of the variable clinical course of chronic thyroiditis including the effects of pregnancy and the postpartum period c. Know the predisposing factors to the development of thyroid carcinoma such as irradiation and the increased risk in children less than 10 years of age b. Recognize the clinical manifestations of thyroid carcinoma involving sites other than the thyroid 3. Be familiar with the clinical and laboratory manifestations of medullary carcinoma 4. Recognize that natural history of medullary carcinoma of the thyroid varies, depending on the specific mutation 6. Know that C cell hyperplasia is a precursor of medullary carcinoma of the thyroid c. Know the indications for biopsy, including fine needle aspiration biopsy, of a single thyroid nodule 4. Recognize that basal calcitonin levels may not be elevated in patients with medullary carcinoma of the thyroid or C-cell hyperplasia d. Know the protocol for medical management following surgery for thyroid carcinoma 3. Understand that metastases of follicular and papillary thyroid cancer may be curable with radioiodine 3. Understand that distant metastases of medullary thyroid carcinoma are not currently curable but that long-term survival is still possible f. Understand the importance of genetic testing at an early age and prophylactic thyroidectomy in individuals with a family history of medullary carcinoma d. Know that diffuse enlargement of the thyroid is most commonly due to chronic lymphocytic thyroiditis b. Be aware of causes of diffuse thyroid enlargement other than chronic lymphocytic thyroiditis d. Know that Hodgkin disease and other infiltrative hematologic diseases (eg, histiocytosis) and their treatment may involve the thyroid gland 2. Be familiar with the clinical methods for diagnosis of diffuse enlargement of the thyroid b. Be familiar with the laboratory tests used to evaluate diffuse enlargement of the thyroid c. Understand effects of maternal glucocorticoids cortisol on fetal adrenal function 4.

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If not exercising regularly, start slowly and gradually increase physical activity intensity and duration. Ask your healthcare team about having a cancer rehabilitation assessment (many insurers now cover a certain amount of rehabilitation for individuals with cancer). The American Cancer Society in Their 2012 Nutrition and Physical Activity Guidelines for Cancer Survivors Recommends People Diagnosed With Cancer: Check with your healthcare provider regarding the right physical activity for you. Start very slowly-a few minutes of a recommended activity such as walking or riding a stationary bike each day is a good way to get started. If you need encouragement, find an exercise class with a certified fitness instructor, personal trainer, or physical therapist who can help you get started. Do what is best for you as an individual, even if it is light exercise that seems like very little. Start by lifting half-pound weights three times Suggestions for Creating an Exercise Program That Is Right for You 1. A cancer rehabilitation assessment before you begin physical activity can help define the best exercise program for you. Do very easy movements for short periods of time each day, even if just a few minutes. If you can, get started under the guidance of a physical therapist or certified fitness trainer. Using these four letters, you can remember the key components of a physical activity program: frequency, intensity, time, and type. F I T T Frequency: refers to how often you are physically active and is usually measured in days per week. Intensity: describes how hard your Resources to Help You with Your Physical Activity body is working during physical activity, and it is often described as light, moderate or vigorous. Specially trained oncology rehabilitation experts are available to help cancer survivors with concerns about lingering cancer and cancer treatment-related side effects. These healthcare professionals include physiatrists (doctors that specialize in rehabilitation medicine), physical therapists, occupational therapists, and speech-language pathologists. They can help to treat and manage medical conditions such as arm or neck pain, lymphedema, post-surgery concerns, and difficulty with swallowing. You can seek help with physical activity planning from a specially trained fitness expert. Time: measures how long you spend you choose such as walking, gardening, hiking, biking, weight training, household chores or playing golf. Yet results from recent population studies show health benefits for cancer survivors who maintain a healthy weight, follow a healthy diet, and engage in physical activity on a regular basis. Body Weight 5 Research conducted over the last few years has established the central importance for cancer survivors to maintain a healthy weight-and to be as lean as possible without being underweight. Having a healthy weight seems to establish a biochemical status or "anti-cancer" environment that discourages cancer growth. The research clearly shows that carrying extra body fat-particularly excess abdominal body fat-means a higher risk for certain cancers. A practical way to do this is to make a habit of filling at least 2/3 of your plate Many cancer survivors find that they feel better if they incorporate healthy behaviors into their daily routine. Eating right for your health needs and including some exercise that relates to your recovery needs may improve how you feel. Ask your healthcare team about your particular risk factors so you know what things you should avoid. Be Physically Active as Part of Everyday Life foods with added fat and sugar, with weight gain, overweight, and obesity. Energy-dense foods are defined as: High-fat, high calorie snack foods "Fast foods"-or prepared baked goods, desserts, and sweets Convenience foods or "on the go foods" not requiring cutlery (spoons, forks, or knives) such as hotdogs, hamburgers, French fries, corn chips, or potato chips. Be moderately physically active for at least 30 minutes every day, and as you become more fit, work toward 60 minutes. A sedentary way of life is a cause of weight gain, overweight, and obesity that increases risk for several types of cancer.


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