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The skin of a burn victim has been with the circulatory and nervous systems cheap 50mg female viagra visa. Integumentary Explain the variations of this layer in becomes drier female viagra 50mg with mastercard, wrinkled purchase 50mg female viagra fast delivery, and slower to regeneration will be slow with some males and females buy 100 mg female viagra with mastercard. Which vary in thickness in different parts of the structural changes purchase female viagra 50mg visa, how would you advise kind of burn is this? Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Skeletal System: Introduction 6 and the Axial Skeleton Organization of the Skeletal System 132 Functions of the Skeletal System 134 Bone Structure 135 Bone Tissue 138 Bone Growth 140 Developmental Exposition: The Axial Skeleton 141 Skull 144 Vertebral Column 158 Rib Cage 164 CLINICAL CONSIDERATIONS 165 Clinical Case Study Answer 168 Important Clinical Terminology 169 Chapter Summary 170 Review Activities 170 Clinical Case Study A 68-year-old man visited his family doctor for his first physical examination in 30 years. Upon sensing a disgruntled patient, the doctor gently tried to determine the reason. In response to the doctor’s inquiry, the patient blurted out, “The nurse who measured my height is incompe- tent! I know for a fact I used to be six feet even when I was in the Navy, but she tells me I’m 5′10″! He explained to the patient that the spine contains some nonbony tissue, which shrivels up a bit over the years. The patient interrupted, stating indignantly that he knew anatomic terms and principles and would like a detailed explanation. How would you explain the anatomy of the vertebral column and the changes it undergoes during the aging process? Hints: The patient’s normal posture and the fact that he had no complaints of pain indicated good health for his age. FIGURE: Decreased height, postural changes, and loss of bone density are just a few of the age-related alterations that may afflict the skeleton. The patellae (“kneecaps”) are two OF THE SKELETAL SYSTEM sesamoid bones all people have. For convenience of study, the skeleton is divided into axial The axial and appendicular components of the skeletal system of and appendicular portions, as summarized in table 6. The axial skeleton consists of the bones that form strong, flexible body framework. The components of the axial skeleton are axial and appendicular components. The skull consists of two sets of bones: the cranial The adult skeletal system consists of approximately 206 bones. Three auditory ossicles (“ear bones”) curs during infancy, the number increases. During adolescence, are present in the middle-ear chamber of each ear and however, the number of bones decreases, as separate bones grad- serve to transmit sound impulses. The hyoid bone is located above the larynx total functioning of the skeletal system. The vertebral column (“backbone”) the skull called sutural (wormian) bones. Additional bones may consists of 26 individual bones separated by cartilaginous develop in tendons in response to stress as the tendons repeat- intervertebral discs. Bones formed this way are called wormian bone: from Ole Worm, Danish physician, 1588–1654 sesamoid: Gk. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 133 Parietal bone Frontal bone Temporal bone Skull Occipital Zygomatic bone bone Maxilla Mandible Clavicle Pectoral Scapula girdle Costal cartilages Sternum Rib cage Ribs Humerus Vertebral column Ulna Ilium Pelvic girdle Os Pubis Sacrum coxae Coccyx Ischium Radius Carpal bones Metacarpal bones Phalanges Femur Patella Tibia Fibula Calcaneus Tarsal bones Creek Metatarsal bones Phalanges (a) (b) FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 134 Unit 4 Support and Movement are fused to form the sacrum, which is the attachment por- tion of the pelvic girdle. A few terminal vertebrae are fused FUNCTIONS to form the coccyx (“tailbone”). The rib cage forms the bony and cartilaginous The bones of the skeleton perform the mechanical functions of sup- framework of the thorax. It articulates posteriorly with the port, protection, and leverage for body movement and the meta- thoracic vertebrae and includes the 12 pairs of ribs, the bolic functions of hemopoiesis and storage of fat and minerals. Objective 2 Discuss the principal functions of the skeletal system and identify the body systems served by these functions. The com- The strength of bone comes from its inorganic components, of ponents of the appendicular skeleton are as follows: such durability that they resist decomposition even after death. The paired scapulae (“shoulder blades”) mans, has been determined from preserved skeletal remains. In fact, the term skeleton comes from a Greek word meaning is the axial component.

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On the one hand female viagra 50 mg with mastercard, the obstetrician has responsibility for both the mother and the fetus purchase 50 mg female viagra visa. However 100 mg female viagra otc, the mother has the right and authority of ascribing patient status to her unborn under the doctrine of autonomy buy 50mg female viagra overnight delivery. Assuming a competent parent female viagra 100 mg line, the physician may only take those actions for the baby consented to by the mother/parent. All aspects of informed refusal should be thoroughly documented in the medical record, particularly the potential risks imparted to the unborn by the decision of the parent. It is best to avoid making the mother feel accused of potentially harm- ing her baby. The majority of malpractice claims in gynecology arise from the issues surrounding reproductive function. Both medical and surgical management of pelvic diseases may impair fertility and reproduction. When assisted reproduction is at issue, the learned Ob/Gyn specialist defers and refers to experts in the subspecialty of reproductive biology and endocrinology. For those physicians specializing in infertility, the majority of suits evolve from failure to meet implied outcome expec- tations. The patient has the right to receive informed consent, which includes outcome statistics comparing potential results from other infertility centers available to the patient. The more common Ob/Gyn clinical issues leading to litigation include those inherent in all specialties, such as the following: • Failure to provide informed consent. There are a number of issues specific to obstetrics and gynecology that are frequently the subject of litigation. Antibiotic prophylaxis is recommended to prevent vaginal cuff infection in all hysterectomies (3) and to prevent group B streptococcus (GBS) sepsis in the newborn (4,5). The drug of choice for patients who have hysterectomies is a cephalosporin administered intravenously approx 30 minutes before Chapter 11 / Obstetrics and Gynecology 143 transvaginal incision. For GBS prophylaxis, intravenous penicillin G is preferred over ampicillin for two reasons. A single loading dose of penicillin is likely as effective as two doses of ampicillin given 4 hours apart. In addition, the second most frequent cause of neonatal meningitis after GBS is Escherichia coli, which is often resistant to ampicillin. Delayed diagnosis of cancer is another major issue for this spe- cialty. The Ob/Gyn has a responsibility to inform, educate, and thus empower his or her patients about the importance of appropriate screen- ing evaluations including mammography and Pap smears. The patient’s history, including family history, is an important part of the assess- ment of risk. Trust the patient when she notes a change in status and listen to the history she relates. The responsible physician best serves the patient when he or she obtains the history in the patient’s “own words” rather than the secondhand interpretation of staff’s documen- tation. A family history of breast cancer, particularly under age 45 years, imparts increased risk to the patient. All suspicious masses should be biopsied, regardless of the mammogram interpretation. The diagnosis of cervical cancer is an important consideration in the evaluation of intravaginal bleeding. Pelvic sonography in the postmeno- pausal patient may be done to assess the thickness of the endometrium. Again, the patient’s history is often telling and may lead to a diagnosis of cancer when the appropriate evaluations are performed. The other major area of liability for this specialty is prenatal care and delivery. Prenatal diagnostic ultrasonographic evaluation of the fetus is an increasing area of litigation. It is essential that the respon- sible Ob/Gyn clarify for the patient what fetal anatomy can or cannot be seen and what diagnoses can or cannot be made. Limitations of equipment, the impact of fetal position and number, and maternal size should be emphasized. For example, only one-third of major fetal anatomic abnormalities are defined at second-trimester scans. Even when a consultant provides the interpretation of the study, the primary Ob/Gyn should review the implications of the findings with the patient and family.

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The fourth approach looks to informed con- sumers to enter into voluntary contractual arrangements with health care providers that modify various aspects of the tort system cheap 100 mg female viagra with mastercard. However cheap female viagra 50 mg overnight delivery, the assumptions that underlie each vary buy female viagra 50 mg amex, as do their objectives buy female viagra 100 mg without prescription. Some aspects of each remain unresolved buy 100mg female viagra with amex, which means that specific proposals that fall within the same approach may be in tension with one another. Finally, some approaches may be based on unstated rationales or have unanticipated consequences. Expert Resolution Reforms designed to confer expertise on the malpractice dispute reso- lution system continue to attract substantial support from physicians, who blame the problems with malpractice litigation on unscrupulous lawyers, naive and impressionable juries, unfocused judges, and decep- tive expert witnesses. Proposals to enhance clinical authority in litiga- tion dovetail with theories of patient safety based on voluntary, confidential reporting of medical errors in a “safe,” professional envi- ronment walled off from the medical malpractice system. Holding experts accountable to nonexperts is a longstanding prob- lem in society (34), and it is only natural for professionals to resist external review when the public expects it. No form of public account- ability is perfect: the legislative process is democratic but erratic; regulatory agencies are expert but bureaucratic, budget-obsessed, and prone to capture; and the civil justice system suffers from a range of familiar infirmities. Market accountability through incentive-based payment systems has greater potential than has generally been appre- ciated but is incapable of governing all of medicine (35). As a result, modern medicine still enjoys substantial self-regulatory privileges, including aspects of malpractice liability such as a standard of care determined by customary practice. Physicians nonetheless feel that the malpractice system is beyond their control, which compounds the uncertainties they experience from managed care, fraud and abuse oversight, demanding patients, and changing technology. Two expertise-related reforms that have been widely enacted are certificates of merit and medical screening panels (36). Certificates of merit exist in about one-third of states and require plaintiff attorneys to obtain expert assessments that claims are warranted before filing them. These provisions may be effective in reducing claims filed by inexperienced lawyers, who are less likely than malpractice special- ists to weed out meritless cases despite the financial incentive to do so created by contingent fee payment. On the other hand, medical screen- ing panels do not seem to perform well. Panel systems vary in their details, but most involve a hearing before a group consisting at least Chapter 17 / New Directions in Liability Reform 265 in part of physicians, with the results of that hearing admissible into evidence should the case proceed to trial. Of the 20 states that enacted screening panel requirements, 11 chose to repeal or invalidate them rather than revise them, often because difficulty finding members created long delays without demonstrably improving the quality of legal claims. Since trials remain rare, and screening panel findings are seldom factually definitive, they also seem to be an inefficient way to improve the quality of evidence at trial in comparison with better use of court-appointed experts, modification of trial presentations, jury learning aids, and the like. Specialized medical courts have attracted recent attention from phy- sicians and general tort reformers, and bills establishing them have been introduced in Congress and some state legislatures (37). Most proposals contemplate dividing a state into a handful of judicial dis- tricts with dedicated, expert trial judges. Proponents argue that these courts would do better than the current decentralized system at man- aging caseloads, ensuring high-quality evidence, and reaching consis- tent decisions about liability and damages. On the other hand, specialized courts run risks of becoming politicized, especially in states where judges are elected rather than appointed and in areas where well-financed groups have clearly defined, unvarying interests in a court’s outcomes. As Struve observes, one reason the court of appeals for the federal circuit functions well when hearing patent law disputes is that powerful corporations appear as both plaintiffs and defendants. In contrast, in malpractice cases, medical providers and malpractice insurers will always want a specialized court to constrain liability, not expand it. Another caution is that some expertise-based arguments are merely subterfuges for changing the composition of juries. For example, in Pennsylvania the principal effect of the medi- cal courts proposal currently under consideration would be to redis- trict the eastern part of the state so that jurors from Philadelphia—who historically favor plaintiffs with respect to both liability and dam- ages—would be mixed with jurors from surrounding counties. Wide variation in jury behavior is an important issue, but it should be addressed openly. In sum, the malpractice system could benefit from enhanced exper- tise, but the source of the problem and best reform approach may differ from those commonly cited. Some malpractice claims, especially larger ones, turn on delicate clinical judgments; however, many do not. The mismatch between legal claims and actual negligence has major public policy significance, but claims, findings of liability, and assessments 266 Sage of damages are not random (25). Health care providers are far more likely to be held liable when they provide negligent care than when they provide competent care (38).

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Other of memory and perception can severely medications have side effects buy 100mg female viagra with amex, such as limit independent function 50 mg female viagra. Individuals drowsiness and sedation buy female viagra 50mg free shipping, that also affect may fail to carry out age-appropriate role daily function discount 100mg female viagra with mastercard. Indi- Symptoms of the psychiatric disability viduals with a depressive disorder may lose may cause psychic stress and anxiety cheap female viagra 50 mg line, fur- interest in sexual activity, whereas individ- ther compounding the disabling compo- uals with a bipolar depression may have ex- nent of the condition. The side effects of anguish over their impoverished life can some medications can alter sexual function be devastating. In addition, subjective manifesta- impaired function and the impact of their tions of lowered self-esteem and self-con- condition both on others and on their fidence may make it more difficult for future may cause considerable pain and individuals to form intimate relationships. In some instances, individu- als with psychiatric disability may be re- Social Issues luctant to seek appropriate help because of their fear of the stigma associated with The impact of a psychiatric disability on psychiatric conditions that require profes- social function also depends on the nature sional help. Individuals who experi- als may not be aware of their symptoms ence mania as a part of their disability may and the effect of their symptoms on func- enjoy the euphoria and feel that it con- tion, which also hinders them from using tributes to their social well-being. Even though attitudes of society have become more accepting of individuals Lifestyle Issues with mental illness, family members may continue to be resistant to recognizing the The degree to which psychiatric disabil- problem and pursuing appropriate treat- ity affects individuals’ lifestyle depends to ment (Hall & Purdy, 2000). If, however, a great extent on the nature of the condi- individuals manifest bizarre, abusive, or tion. Some psychiatric disabilities so severe- socially offensive behavior, family members ly impair individuals’ ability to carry on the or others within a social group may avoid activities of daily living that constant the individual altogether, leaving him or supervision or hospitalization is necessary. In other instances, individuals are able to Other psychiatric disabilities may lead carry on these activities, but in an altered to social withdrawal. These stresses may be rearrange their schedules so that they can caused by their objective problems in deal- attend therapy sessions. Some medications ing with the individuals and their condi- used in the treatment of psychiatric dis- tion, as well as by more subjective psycho- ability may require special lifestyle consid- logical distress (Hall & Purdy, 2000). Psychosocial and Vocational Issues in Psychiatric Disability 199 Psychiatric disabilities, especially those psychiatric disability (Tschopp, Bishop, & in which individuals need close supervi- Mulvihill, 2001). The skills, aptitude, sion or long-term care and treatment, may motivation, and objective symptoms of place financial hardships on their family individuals with psychiatric disability are because of medical bills, the individual’s important, and their ability to endure and economic dependency, and special needs cope with stress and to engage in active related to household functioning. In some problem solving also determines their abil- instances, the demands of caregiving may ity to work. Job restrictions may be relat- require family members to curtail their ed to job pressure or the ability to work social activities or alter their relationships with others, regardless of the individual’s with friends and acquaintances. The time level of skill or physical and cognitive abil- commitments of caregiving may lead to ity to perform work-related tasks. It may be necessary to Social barriers are frequently erected arrange scheduled absences so that indi- against individuals with a mental disorder viduals can attend therapy sessions. Social stigma may medications used in treatment may pro- be the result of fear of individuals’ behav- duce side effects, such as drowsiness or ior, ignorance about psychiatric disabili- sedation, that could adversely affect work ty, or feelings of inadequacy in interacting performances. In addition, individuals’ with those who have psychiatric disabili- level of adherence to the therapeutic reg- ty. Regardless of the cause, the results can imen is especially important if failure to be a source of continuing stress for individ- do so means possible relapse and recur- uals and their families, as well as a barri- rence of symptoms. Social Individuals’ reaction to the work en- stigma and stereotypes can also have an vironment, including noise and distrac- effect on the extent of the deficits individ- tions, should be taken into account, as uals experience. Deficits sometimes occur should their level of personal responsibil- not only because of the psychiatric condi- ity and ability for self-direction and deci- tion, but also because of the public’s reac- sion making. Individuals’ flexibility to take advantage of chance occurrences and Individuals with psychiatric disability their degree of flexibility in the workplace have a condition that limits their capaci- must also be taken into consideration ty to perform certain tasks and functions (Szymanski, 2000). Some individuals may and their ability to perform certain roles need a more structured work environ- (Farkas & Anthony, 2001). The ability to ment; in some instances, a workshop envi- work depends on the type of disability, the ronment may be preferable. Some individ- type of work in which they are involved, uals’ expectations of work or of their own and the attitudes of those within the work capabilities may be unrealistic. Although work is important to these unrealistic notions are identified and increase self-esteem for those with a num- dealt with before they enter or reenter the ber of disabilities, it can be an especially work setting, discouragement, disappoint- strong therapeutic tool for those with a ment, or even relapse may occur. Continued advocacy that tardation may need specialized training includes educating not only employers and other assistance in job placement, job but also individuals with psychiatric dis- site training, and long-term support. A job ability is necessary in the ongoing process coach may be utilized to provide individ- of reducing employment discrimination. The job coach provides specific assistance CASE STUDIES by helping individuals fill out an applica- tion, going with them for the job inter- Case I view, and participating in travel training and skill training at the job site. Supported employment may be successful He has never been employed and lived with for a number of individuals with psychia- his widowed mother until several months tric disability.

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Cell bodies of these neurons are located at the mid- and postures of rage and aggression characteristic of fight- line of the brainstem (the raphe system) and in more later- ing behavior quality female viagra 100mg, can be elicited by electrical stimulation of ally placed nuclei generic female viagra 50 mg on-line, extending from the caudal medulla to the sites in the hypothalamus and amygdala cheap 50mg female viagra otc. Serotonin plays a major role in the de- tical connections to the limbic system are severed proven 100 mg female viagra, rage fect underlying affective disorders (discussed later) discount female viagra 50mg online. Drugs postures and aggressiveness become permanent, illustrating the importance of the higher centers in restraining aggres- sion and, presumably, in invoking it at appropriate times. Cingulate gyrus By contrast, bilateral removal of the amygdala results in a Basal ganglia placid animal that cannot be provoked. The biological basis of human sexual ac- tivity is poorly understood because of its complexity and be- cause findings derived from nonhuman animal studies can- not be extrapolated. The major reason for this limitation is that the cerebral cortex, uniquely developed in the human brain, plays a more important role in governing human sex- Hypothalamus ual activity than the instinctive or olfactory-driven behav- Midbrain iors in nonhuman primates and lower mammalian species. Nevertheless, several parallels in human and nonhuman sex- Pons ual activities exist, indicating that the limbic system, in gen- Medulla eral, coordinates sex drive and mating behavior, with higher To spinal cord centers exerting more or less overriding influences. The depicted groups originate in the caudal medulla, pons, ulation reflexes and engorgement of female erectile tissues, and midbrain and send projections to most regions of the brain. Copulatory behaviors and postures can be elicited in ani- New York: Springer-Verlag, 1983. Ablation studies have shown that sexual and serotonergic neurons serving the limbic system. A ther- behavior also requires an intact connection of the limbic apeutic response to these treatments ensues only after treat- system with the frontal cortex. Similarly, when treatment stops, Olfactory cues are important in initiating mating activity symptoms may not reappear for several weeks. Driven by the hypothalamus’ endoge- in treatment response is presumably due to alterations in the nous seasonal clock, the anterior and preoptic areas of the long-term regulation of receptor and second messenger sys- hypothalamus initiate hormonal control of the gonads. Hormonal release leads to the secretion of odorants The most effective long-term treatment for mania is (pheromones) by the female reproductive tract, signaling lithium, although antipsychotic (neuroleptic) drugs, which the onset of estrus and sexual receptivity to the male. The block dopamine receptors, are effective in the acute treat- odorant cues are powerful stimulants, acting at extremely ment of mania. The therapeutic actions of lithium remain low concentrations to initiate mating behavior in males. The unknown, but the drug has an important action on a recep- olfactory system, by virtue of its direct connections with the tor-mediated second messenger system. Lithium interferes limbic system, facilitates the coordination of behavioral, en- with regeneration of phosphatidylinositol in neuronal docrine, and autonomic responses involved in mating. Depletion of phosphatidylinositol in the membrane sonal breeders (mating can occur on a continual basis), ves- renders it incapable of responding to receptors that use this tiges of this pattern remain. Schizophrenia is the collective name for and the continuous regulation of male testicular function. The features most commonly ob- the higher cortical functions of learning and memory, served are thought disorder, inappropriate emotional re- which serve to either reinforce or suppress the signals that sponse, and auditory hallucinations. While the biochemical initiate sexual responding, including the sexual reflexes co- imbalance resulting in schizophrenia is poorly understood, ordinated by the sacral spinal cord. Psychiatric Disorders Involve the Limbic System Current research is focused on finding the subtype of The major psychiatric disorders, including affective disor- dopamine receptor that mediates mesocortical/mesolimbic ders and schizophrenia, are disabling diseases with a ge- dopaminergic transmission but does not affect the nigrostri- netic predisposition and no known cure. So basis for these disorders remains obscure, particularly the far, neuroleptic drugs that block one pathway almost always role of environmental influences on individuals with a ge- block the other as well, leading to unwanted neurological netic predisposition to developing a disorder. Altered side effects, including abnormal involuntary movements (tar- states of the brain’s monoaminergic systems have been a dive dyskinesia) after long-term treatment or parkinsonism major focus as possible underlying factors, based on ex- in the short term. Similarly, some patients with Parkinson’s tensive human studies in which neurochemical imbalances disease who receive L-DOPA to augment dopaminergic in catecholamines, acetylcholine, and serotonin have been transmission in the nigrostriatal pathway must be taken off observed. Another reason for focusing on the monoamin- the medication because they develop psychosis. The affective disorders include ma- Memory and learning are inextricably linked because part jor depression, which can be so profound as to provoke sui- of the learning process involves the assimilation of new in- cide, and bipolar disorder (or manic-depressive disorder), formation and its commitment to memory. The most likely in which periods of profound depression are followed by sites of learning in the human brain are the large association periods of mania, in a cyclic pattern.

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