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Anticoagulation (blood-thinning) therapy is then continued or instituted atorlip-10 10mg free shipping xarelto cholesterol. What is the dark line noted within the room with complaints of stabbing chest pain contrast-filled aorta? Which portions of the aorta are exam order atorlip-10 10 mg cholesterol test vitamin c, the patient’s lungs are clear, and heart involved? An electrocardiogram is also nor- difference in blood pressure between mal. Because of his symptoms, you suspect the left and right arm, with the left arm an aortic dissection and order a CT scan. Her blood you request an angiogram of her abdominal pressure is markedly elevated today, and in arteries. How can the renal artery stenosis stethoscope, which corresponds to her heart- (narrowing) seen in the adjacent beat. Lab work shows very low serum potas- angiogram cause high blood pressure? Discuss the impact that this condition low potassium, so you start her on potassium may have on the opposite renal artery supplementation. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 16 Circulatory System 599 Chapter Summary Functions and Major Components of the (c) The heart contains right and left (b) Veins have venous valves that direct Circulatory System (pp. The circulatory system transports oxygen and bicuspid valves, respectively); a compressed by the skeletal muscle and nutritive molecules to the tissue cells pulmonary semilunar valve; and an pumps. Capillaries are composed of endothelial from tissue cells; it also carries hormones 2. They are the basic functional and other regulatory molecules to their are the pulmonary and the systemic; in units of the circulatory system. Principal Arteries of the Body protect the body from infection, and (a) The pulmonary circulation includes (pp. The components of the circulatory system right ventricle through the lungs, and the brachiocephalic trunk, the left are the heart, blood vessels, and blood, from there to the left atrium. The brachiocephalic system, and the lymphatic vessels and other arteries, capillaries, and veins trunk divides into the right common lymphoid tissue and organs of the in the body. These vessels carry blood carotid artery and the right subclavian lymphatic system. Blood, a highly specialized connective (c) The myocardium of the heart is external carotid arteries and the vertebral tissue, consists of formed elements served by right and left coronary arteries. Erythrocytes are disc-shaped cells that coronary sinus collects and empties the paired vertebral arteries, which lack nuclei but contain hemoglobin. Contraction of the atria and ventricles is surrounding the pituitary gland. Leukocytes have nuclei and are classified the atria and then enter the 3. The upper extremity is served by the as granular (eosinophils, basophils, and atrioventricular (AV) node. Leukocytes defend the conducted by the atrioventricular the axillary artery and then the body against infections by bundle and conduction myofibers brachial artery as it enters the arm. During contraction of the ventricles, the the radial and ulnar arteries, which cytoplasmic fragments that assist in the intraventricular pressure rises and causes supply blood to the forearm and formation of clots to prevent blood loss. Erythrocytes are formed through a process the pulmonary and aortic valves close 4. The abdominal portion of the aorta has called erythropoiesis; leukocytes are because the pressure is greater in the the following branches: the inferior formed through leukopoiesis. Closing of the AV valves causes the first renal, suprarenal, testicular (or ovarian), sac, liver, and spleen. In the adult, red sound (lub); closing of the pulmonary and and inferior mesenteric arteries. Heart murmurs are commonly internal and external iliac arteries, which caused by abnormal valves or by septal supply branches to the pelvis and lower Heart (pp.

A patient’s facial expressions and frequent nods indicate how effectively you are getting your message across atorlip-10 10 mg free shipping cholesterol levels recommended uk. The anxieties of sick or injured people often act as a lens that greatly magnifies the physician’s body language buy atorlip-10 10mg free shipping cholesterol levels kidney disease. In some cases, an inno- 70 Gorney cent sigh, a raised eyebrow, or a look of skepticism when evaluating a colleague’s results has triggered a patient’s visit to an attorney. Likewise, remember that a reassuring smile, a comforting touch, and a confident and caring attitude are indispensable ingredients for the development of solid doctor–patient relationships. PROBLEMS OF NURSE–PHYSICIAN COMMUNICATION Case 1 A 39-year-old man was brought to the emergency room (ER) of a large hospital shortly after being struck in the head with a baseball bat. Eleven days later, he returned to the ER because of increasing lethargy. He was hospitalized, and a computed tomography (CT) scan raised the question of a subdural hematoma. It was late in the evening when the CT scan was interpreted, and the patient was alert, so his physician decided to wait until morning to perform further studies. When the patient’s doctor left the hospital at 10 PM, he wrote orders for the nurses to check the patient’s vital signs hourly. However, the doctor did not give specific direction to note the state of the patient’s pupils or his state of consciousness or to call the doctor if any alteration occurred. He later said he felt it was unnecessary to leave such detailed directions because the nurses should have understood their duty in this regard. However, the nurses were not alert to a progressive deterioration that occurred during the night. It was not until the patient was comatose at 4 AM that a neurosurgeon was called. At trial, several negligence issues arose, but the plaintiff’s attorney mainly concentrated on failed communications—failure of the neuro- surgeon to give the nurses sufficiently clear instructions and failure of the nurses to call the physician when the patient obviously was deterio- rating. The jury returned a verdict of $700,000 against the hospital and the neurosurgeon. She was taken to the postoperative recovery room at 9:45 AM,where her blood pressure was noted to be 80/50. A few minutes later, the patient’s blood pressure was Chapter 6 / Communication and Patient Safety 71 70/40. The nurse telephoned the doctor, who said she told him the pulse was strong and that the patient seemed in good condition. Therefore, the doctor said he did not feel it was neces- sary to go to the hospital to evaluate the situation. A few minutes later, the patient was taken to the intensive care unit, where her pressure was found to be 50/30. Therefore, instead of going to the hospital, which was only 5 minutes away, he told the nurse to call his associate, who was 30 minutes away. The defendant then came to the hospital and performed emer- gency surgery. The patient had experienced a massive hemorrhage into the broad ligament resulting from a perforated uterus with injury to the uterine artery. The patient’s residual damage included hemiparesis with recep- tive and expressive aphasia. At trial, the physician testified that the nurse failed to characterize adequately the seriousness of the problem during each of her two calls. If the doctor does not respond appropriately, then the nurse must either persuade the doctor to act or obtain immediate assistance from another source. It is equally incumbent on physicians to ask the right questions to ensure that they have a full understanding of the situation. THE TELEPHONE Despite the sophisticated technology that is now integral to the practice of medicine, the humble telephone can be a dangerous instru- ment of professional liability. Telephone conversations are inherently deceptive because reliable communication requires facial expressions and body language to clarify what the voice is saying. Early morning phone conversations between weary attending physicians and hospital house officers are especially dangerous.

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Optimal levels of patient safety are achievable only if the health care system has clear buy 10mg atorlip-10 with mastercard cholesterol test before eating, consistent incentives to gather information about errors buy 10 mg atorlip-10 overnight delivery cholesterol treatment chart, process that information into prevention strategies, coordinate the actions of individual and institutional providers, and communicate effectively with patients. The legal system should provide these incentives by exposing instances of iatrogenic injury, demanding persuasive evidence of avoidability, and awarding damages consistent with loss. The insur- ance markets should support the legal system by offering peace of mind to careful physicians and making compensation available to victims. Insurers should dispose of meritless claims, help providers improve their safety records, and weed out the worst offenders. Chapter 17 / New Directions in Liability Reform 255 Patient Care AVOIDABLE INJURIES The tort reform movement of the 1970s and 1980s was based on two related beliefs: (a) few incidents of actual negligence occur in health care, and (b) most litigation reflects social and financial influences apart from medical quality (10). Subsequent research, much of which is a direct outgrowth of public interest in malpractice reform, largely confirmed the second perception but refuted the first. The Harvard Medical Practice Study (HMPS) reviewed medical records from hos- pitalizations in New York State during 1984 and looked for associated liability claims; it concluded that roughly six unfounded claims were filed for every meritorious one (11). In a follow-up study, the severity of the plaintiff’s condition, not negligence or even medical causation, was the strongest predictor of payment through the legal system for cases evaluated by the HMPS (12). On the other hand, the HMPS reviewers found evidence of negligent injury in 1% of hospitaliza- tions; only one-eighth of these negligent injuries generated lawsuits, and only half of those claims were compensated through litigation. This mismatch between instances of actual negligence and legal pro- ceedings undercuts the deterrent effect of conventional malpractice liability on poor medical care (13). The HMPS helped alert an innovative group of physicians to serious safety problems in the health care system (14). By the late 1980s, qual- ity researchers had established that medical practice was far less coher- ent than it had previously appeared and that little data existed linking health care processes to successful outcomes. The patient safety move- ment grew up alongside these quality improvement efforts, with medi- cal errors demonstrating in salient fashion the need to replace traditional oversight of individual health professionals with a more systematic approach to process re-engineering that matched the growing sophis- tication of the health care industry. In 1999, the Institute of Medicine (IOM) published its landmark report, To Err is Human, and brought patient safety and its cousin, medical quality, onto the national political and policy agenda (15,16). The relationship between liability reform and the patient safety movement remains unsettled. On its face, To Err Is Human envisions a constructive role for institutional liability in promoting system-based safety and criticizes traditional malpractice law primarily for its focus on individual practitioners and, therefore, its chilling effect on efforts to gather and share information about error. However, because the 256 Sage IOM report confirmed as well as contradicted beliefs held by various constituencies, its implications for liability are often misinterpreted or distorted (17). For physicians (including some leaders of the patient safety move- ment), the essence of the report was that safety can best be improved cooperatively by the medical profession through the use of new, self- regulatory methods. The report did not dislodge their belief that mal- practice law continued to represent a hostile outside threat. This tunnel vision was worsened by the efforts of some malpractice liability insur- ers to use “nonpunitive” patient safety theories to bolster old argu- ments for caps on damages and other traditional tort reforms. Patients were partly sympathetic to this view because they believed their doctors are well-intentioned, but they also noticed an obvious fact that largely eluded physicians: the IOM report had vindicated longstanding claims by the plaintiffs’ bar that the medical profession was ignoring an epidemic of medical error. These discordant reactions may have increased patients’ interest in suing and jurors’ willingness to find liability (18) while blinding the medical profession to liability innovations that could be both affordable and safety-enhancing. DEFENSIVE MEDICINE During lulls between malpractice insurance crises, arguments about the pernicious influence of malpractice litigation on overall growth in health care spending (which enjoys a respite much more rarely) have been the mainstay of traditional tort reformers. Certainly, increases in health care costs that do not improve patient safety reduce access to health care at the margin by rendering private health insurance less affordable. However, malpractice insurance premiums and self- funded reserves total only about 1% of annual health expenditures (19). Although this is hardly pocket change in a trillion-dollar health care system, it also does not present a compelling case for reform, especially considering that tort compensation is a transfer payment from provider to patient and not a net social cost. Therefore, budget arguments for malpractice reform typically extend beyond the direct costs of litigation to “defensive medicine,” meaning inducement of health care intended to discourage litigation rather than confer medical benefit (20). Because most filed claims do not reflect underlying negligence and physicians greatly overestimate both litigation and liability risk, there is a good conceptual case for defensive medicine.

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Muscular System © The McGraw−Hill Anatomy discount 10mg atorlip-10 amex cholesterol medication harmful, Sixth Edition Companies purchase atorlip-10 10 mg on line cholesterol breakdown, 2001 234 Unit 4 Support and Movement 3. The skeletal system provides a INTRODUCTION framework for the body, but skeletal muscles maintain pos- TO THE MUSCULAR SYSTEM ture, stabilize the flexible joints, and support the viscera. Certain muscles are active postural muscles whose primary Skeletal muscles are adapted to contract in order to carry out the function is to work in opposition to gravity. Some postural functions of generating body movement, producing heat, and sup- muscles are working even when you think you are relaxed. As you are sitting, for example, the weight of your head is Objective 1 Define the term myology and describe the balanced at the atlanto-occipital joint through the efforts three principal functions of muscles. If you start to get sleepy, your head will suddenly nod forward as the Objective 2 Explain how muscles are described according postural muscles relax and the weight (resistance) over- to their anatomical location and cooperative function. Muscle tissue in the body is of three types: smooth, cardiac, Myology is the study of muscles. Although these three types differ in make up the muscular system, and technically each one is an structure and function, and the muscular system refers only to organ—it is composed of skeletal muscle tissue, connective tissue, the skeletal muscles composed of skeletal tissue, the following and nervous tissue. Each muscle also has a particular function, such basic properties characterize all muscle tissue: as moving a finger or blinking an eyelid. Collectively, the skeletal muscles account for approximately 40% of the body weight. Muscle tissue is sensitive to stimuli from nerve Muscle cells (fibers) contract when stimulated by nerve impulses. Muscle tissue responds to stimuli by con- cause a noticeable effect, but isolated fiber contractions are im- tracting lengthwise, or shortening. Once a stimulus has subsided and the fibers cient number of skeletal muscle fibers are activated, the muscle within muscle tissue are relaxed, they may be stretched contracts and causes body movement. The fibers are then prepared for another (2) heat production, and (3) body support and maintenance of contraction. The most obvious function performed by dency to recoil to their original resting length. A histological description of each of the three muscle types Even the eyeball and the auditory ossicles have associated was presented in chapter 4 and should be reviewed at this skeletal muscles that are responsible for various move- time. The contraction of skeletal muscle is equally impor- chapter 13 in the autonomic nervous system and in chapter 16, tant in breathing and in moving internal body fluids. Smooth muscle is widespread stimulation of individual skeletal muscle fibers maintains a throughout the body and is also involuntary. It is discussed in state of muscle contraction called tonus, which is impor- chapter 13 and, when appropriate, in connection with the organs tant in the movement of blood and lymph. The remaining information presented in this important in continuously exercising skeletal muscle fibers. Muscles are usually described in groups according to Likewise, the involuntary contraction of cardiac muscle tis- anatomical location and cooperative function. Body temperature is held remarkably skeleton include those that act on the pectoral and pelvic girdles constant. Metabolism within the cells releases heat as an and those that move limb joints. The Knowledge Check rate of heat production increases greatly during strenuous exercise. Muscular System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 9 Muscular System 235 Frontalis Brachialis Orbicularis oculi Temporalis Zygomaticus Occipitalis Masseter Sternocleidomastoid Orbicularis oris Sternocleido- Trapezius Trapezius mastoid Teres major Deltoid Deltoid Infraspinatus Latissimus dorsi Pectoralis Rhomboideus Triceps Serratus anterior major brachii Brachialis Latissimus External dorsi Biceps brachii abdominal oblique Brachio- External abdominal Rectus abdominis radialis oblique Brachioradialis Gluteus medius Tensor fasciae latae Gluteus maximus Iliopsoas Pectineus Adductor Adductor longus magnus Gracilis Iliotibial tract Vastus lateralis Sartorius Gracilis Biceps femoris Vastus medialis Vastus lateralis Semitendinosus Sartorius Semimembranosus Peroneus longus Extensor digitorum longus Gastrocnemius Gastrocnemius Soleus Tibialis anterior Soleus Peroneus longus Tendo calcaneus Margulies/Waldrop (a) (b) Margulies/Waldrop FIGURE 9. Objective 5 Describe the various types of muscle fiber STRUCTURE architecture and discuss the biomechanical advantage of OF SKELETAL MUSCLES each type. Skeletal muscle tissue and its binding connective tissue are arranged in a highly organized pattern that unites the forces of the contracting muscle fibers and directs them onto the structure being moved. Muscle Attachments Skeletal muscles are attached to a bone on each end by tendons Objective 3 Compare and contrast the various binding (fig. A tendon is composed of dense regular connective tis- connective tissues associated with skeletal muscles.

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