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If direct pressure does not stop the bleeding buy discount kamagra oral jelly 100mg on-line erectile dysfunction band, the pressure especially if there has been considerable blood loss buy discount kamagra oral jelly 100mg erectile dysfunction treatment charlotte nc. In first-aid treatment for shock is essential and includes the follow- the case of a severe wound to the hand, for example, com- ing steps. Lay the person on be done while pressure continues to be applied to the his or her back with the feet elevated. Once the bleeding has stopped, leave the bandage in place and mental confusion. Get the victim to the victim has sustained an injury in which raising the the hospital or medical treatment center at once. If the weather is Shock is the medical condition that occurs when body tissues do cold, place a blanket under and over the person. It is often linked with weather is hot, position the person in the shade on top of a crushing injuries, heat stroke, heart attacks, poisoning, severe blanket. Loosen tight collars, belts, or other restrictive burns, and other life-threatening conditions. Do not give the person anything to drink, even if he tients experiencing shock include the following. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 598 Unit 6 Maintenance of the Body 3. If the victim has blood coming from the mouth, or if there is in- Clinical Case Study Answer dication that the victim may vomit, position the person Mural thrombus (a blood clot adherent to the inner surface of one of the on his or her side to prevent choking or inhaling the heart’s chambers) is a fairly common complication of myocardial infarc- blood or vomitus. This is the most likely cause of the symp- accordingly (see arterial pressure points [fig. Because the embolus traveled and lodged in the systemic circulation (as opposed to the pulmonary circula- control of bleeding [fig. Immobilize fractures and tion), the mural thrombus was probably located in the left side of the sprains. The embolus traveled to a point in the femoral artery and lodged and take the necessary precautions. The route of travel was as follows: left side of the heart → ascending aorta → descending thoracic aorta → abdominal aorta → right common iliac artery → right external iliac artery → femoral artery. The standard treatment for this problem is emergency surgery to extract the clot from the leg. Anticoagulation (blood-thinning) therapy is then continued or instituted. 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, 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.

Pulmonary circulation is characterized as normally dilated cheap kamagra oral jelly 100 mg with visa erectile dysfunction breakthrough, while the systemic circulation is characterized as nor- mally constricted effective kamagra oral jelly 100 mg erectile dysfunction herbal treatment options. Pressures are given in mm Hg; a bar over the number indicates mean pressure. High capillary pressure is a major threat to the lungs and can cause pulmonary edema, an abnormal accumulation of fluid, which can flood the alveoli and im- pair gas exchange. When cardiac output increases from a resting level of 5 L/min to 25 L/min with vigorous exercise, the decrease in pulmonary vascular resistance not only min- imizes the load on the right heart but also keeps the capil- lary pressure low and prevents excess fluid from leaking out of the pulmonary capillaries. Pulmonary vascular resist- Pulmonary vascular resistance is also significantly affected ance falls as cardiac output increases. Because pulmonary capillaries have little rial pressure rises, pulmonary vascular resistance decreases. CHAPTER 20 Pulmonary Circulation and the Ventilation-Perfusion Ratio 341 FIGURE 20. These two mechanisms are responsible for decreasing pulmonary vascular resistance when arterial pressure in- creases. Capillary recruitment (the opening up of previously closed vessels) results in the perfusion of an increased number of vessels and a drop in resistance. Capillary distension (an increase in the caliber of vessels) also results in a lower resistance and higher blood flow. It is the change in transmural pressure (pressure inside the capillary minus pressure outside the capillary) that influences vessel diameter. From a functional point of view, pulmonary ves- sels can be classified into two types: extra-alveolar vessels (pulmonary arteries and veins) and alveolar vessels (arteri- oles, capillaries, and venules). The extra-alveolar vessels are subjected to pleural pressure—any change in pleural pres- sure affects pulmonary vascular resistance in these vessels by changing transmural pressure. Alveolar vessels, however, are subjected primarily to alveolar pressure. Transmural pressure in the extra-alveolar vessels in- creases, and they become distended (Fig. However, alveolar diameter increases at high lung volumes, causing transmural pressure in alveolar vessels to decrease. As the alveolar vessels become compressed, pulmonary vascular re- sistance increases. At low lung volumes, pulmonary vascular resistance also increases, as a result of more positive pleural pressure, which compresses the extra-alveolar vessels. Since alveolar and extra-alveolar vessels can be viewed as two groups of resistance vessels connected in series, their resist- ances are additive at any lung volume. Pulmonary vascular resistance is lowest at functional residual capacity (FRC) and increases at both higher and lower lung volumes (Fig. Since smooth muscle plays a key role in determining the caliber of extra-alveolar vessels, drugs can also cause a change in resistance. A, At high lung volumes, alveo- constrictors, particularly at low lung volumes when the ves- lar vessels are compressed but extra-alveolar vessels are actually sel walls are already compressed. Drugs that relax smooth distended because of the lower pleural pressure. However, at low lung volumes, the extra-alveolar vessels are compressed from the muscle in the pulmonary circulation include adenosine, pleural pressure and alveolar vessels are distended. B, Total pul- acetylcholine, prostacyclin (prostaglandin I2), and isopro- monary vascular resistance as a function of lung volumes follows a terenol. The pulmonary circulation is richly innervated U-shaped curve, with resistance lowest at functional residual ca- with sympathetic nerves but, surprisingly, pulmonary vas- pacity (FRC). Hypox- Low Oxygen Tension Increases emia causes vasodilation in systemic vessels but, in pul- monary vessels, hypoxemia or alveolar hypoxia causes Pulmonary Vascular Resistance vasoconstriction of small pulmonary arteries. This unique Although changes in pulmonary vascular resistance are ac- phenomenon of hypoxia-induced pulmonary vasocon- complished mainly by passive mechanisms, resistance can striction is accentuated by high carbon dioxide and low be increased by low oxygen in the alveoli, alveolar hy- blood pH. The exact mechanism is not known, but hypoxia 342 PART V RESPIRATORY PHYSIOLOGY A Regional hypoxia cal changes (hypertrophy and proliferation of smooth mus- cle cells, narrowing of arterial lumens, and a change in con- tractile function). Pulmonary hypertension causes a sub- stantial increase in workload on the right heart, often leading to right heart hypertrophy (see Clinical Focus Box 20. Generalized hypoxia plays an important nonpatho- physiological role before birth. In the fetus, pulmonary vas- cular resistance is extremely high as a result of generalized Hypoxia hypoxia—less than 15% of the cardiac output goes to the lungs, and the remainder is diverted to the left side of the heart via the foramen ovale and to the aorta via the ductus arteriosus.

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Too often cheap kamagra oral jelly 100 mg on line youth erectile dysfunction treatment, malpractice suits hinge on a credibility test between the memory of the physician and the testimony of the patient kamagra oral jelly 100 mg online erectile dysfunction patanjali medicine. When there is any doubt, the doctor should meet the patient in the emergency room for a formal evaluation. A famous plaintiff attorney once stated that he would never have a problem earning a good living by suing doctors as long as they persisted in the “stupidity” of treating patients over the telephone. Chapter 8 / Risk Management 99 Prescription Errors These are a common source of litigation for family physicians. There are so many instances of patients receiving Purinethol when propylthiouracil was prescribed that in June 2003, GlaxoSmithKline sent health care professionals a “Medication Errors Alert,” warning of the consequences of this error. Patients must be well-informed regarding the drugs they are pre- scribed. It is a good idea to include the indication on the prescription so that a patient does not inadvertently take an antibiotic in place of an antihypertensive, for example. Because Purinethol has its name imprinted on every tablet, an informed patient would not take the wrong drug. Patients need to be alerted about other look-alike and sound-alike medications. They should also be alerted regarding correct dosages, allergies, side effects, and the appropriate use of controlled substances. Informed consent is required and should be documented, especially for drugs that may have serious side effects. Excessive prescribing and inappropriate use of prescription drugs are grounds for malpractice suits as well as loss of prescribing privileges and suspension or loss of a medical license. Refill practices must be clearly defined for the benefit of patients and pharmacists. The pharmacist must understand the physician’s policy concerning controlled substances. Steps must be taken to prevent hoarding and then overdosing at a later date. The patient must understand in advance the physician’s policy regarding lost pre- scriptions and drugs destroyed by the dog or flushed down the toilet or stolen from a woman’s purse. Some drugs that patients are permitted to refill require close monitoring. If a patient fails to comply with monitoring instructions, the privilege to refill may have to be withdrawn. Finally, there must be systems in place to warn patients of drug recalls. Procedures It is clearly a breach of the standard of care for physicians or their assistants to perform procedures for which they are not adequately trained. In one case, a woman’s face was badly scarred by a physician who was trained in the use of a laser by a salesperson. Soft tissue injections around the scapula or into an intercostal muscle have perforated lungs. Joint injections by those not properly trained have caused destructive septic arthritis. These and similar misadventures have led to lawsuits that are very difficult to defend. The Language Barrier The problems related to language barriers are well known to phy- sicians. Patients with limited English skills cannot be denied health care or in any way be discriminated against by health care providers. In 2000, President Clinton issued Executive Order 13166, requiring equal access to federally funded health care services for patients with limited English proficiency. A language barrier will probably not shield a physician from allegations of negligence.

The main rection in response to noxious stimulation in both the small anatomic regions of the large intestine are the ascending colon cheap kamagra oral jelly 100 mg mastercard icd-9-cm code for erectile dysfunction, transverse colon order kamagra oral jelly 100 mg online erectile dysfunction jack3d, descending colon, sigmoid and the large intestines. The hepatic flexure is the boundary between and, sometimes, diarrhea are associated with this motor be- the ascending and the transverse colon; the splenic flexure is the havior. Application of irritants to the mucosa, the introduc- boundary between the transverse and the descending colon. The tion of luminal parasites, enterotoxins from pathogenic bac- sigmoid colon is so defined by its shape. The rectum is the most teria, allergic reactions, and exposure to ionizing radiation distal region. The cecum is the blind ending of the colon at the all trigger the propulsive response. Inter- propulsion is a defensive adaptation for the rapid clearance nal and external anal sphincters close the terminus of the large in- of undesirable contents from the intestinal lumen. The longitudinal muscle layer is restricted to bundles of also accomplish mass movement of intraluminal material in fibers called tenia coli. Chemoreceptors and mechanoreceptors in the ce- cum and ascending colon provide feedback information for controlling delivery from the ileum, analogous to the feed- MOTILITY IN THE LARGE INTESTINE back control of gastric emptying from the small intestine. In the large intestine, contractile activity occurs almost Dwell-time of material in the ascending colon is found continuously. Whereas the contents of the small intestine to be short when studied with gamma scintigraphic imag- move through sequentially with no mixing of individual ing of radiolabeled markers. When radiolabeled chyme is meals, the large bowel contains a mixture of the remnants instilled into the human cecum, half of the instilled volume of several meals ingested over 3 to 4 days. This period is long in undigested residue from the ileum does not predict the time comparison with an equivalent length of small intestine, of its elimination in the stool. It The large intestine is subdivided into functionally dis- suggests that the ascending colon is not the primary site for tinct regions corresponding approximately to the ascend- the large intestinal functions of storage, mixing, and re- ing colon, transverse colon, descending colon, rectosig- moval of water from the feces. The The motor pattern of the ascending colon consists of or- transit of small radiopaque markers through the large intes- thograde or retrograde peristaltic propulsion. Forward propulsion in this region is The Ascending Colon Is Specialized for probably controlled by feedback signals on the fullness of Processing Chyme Delivered From the the transverse colon. Terminal Ileum Power propulsion in the terminal length of ileum may de- The Transverse Colon Is Specialized for the liver relatively large volumes of chyme into the ascending Storage and Dehydration of Feces colon, especially in the digestive state. Neuromuscular mechanisms analogous to adaptive relaxation in the stom- Radioscintigraphy shows that the labeled material is moved ach permit filling without large increases in intraluminal relatively quickly into the transverse colon (Fig. This suggests that the transverse colon is the primary location for the removal of water and electrolytes and the storage of solid feces in the large intestine. A segmental pattern of motility programmed by the ENS accounts for the ultraslow forward movement of feces in the transverse colon. Ring-like contractions of the circular mus- cle divide the colon into pockets called haustra (Fig. The motility pattern, called haustration, differs from seg- mental motility in the small intestine, in that the contracting segment and the receiving segments on either side remain in their respective states for longer periods. In addition, there is uniform repetition of the haustra along the colon. The con- tracting segments in some places appear to be fixed and are marked by a thickening of the circular muscle. Haustrations are dynamic, in that they form and reform at different sites. The most common pattern in the fasting individual is for the contracting segment to propel the con- tents in both directions into receiving segments. This mechanism mixes and compresses the semiliquid feces in the haustral pockets and probably facilitates the absorption of water without any net forward propulsion. Net forward propulsion occurs when sequential migration of the haustra occurs along the length of the bowel. Successive scintigrams reveal that the film shows haustral contractions in the ascend- longest dwell-time for intraluminal markers injected initially into ing and the transverse colon. Ongoing activity of in- hours, indicating that most of the marker has been excreted with hibitory motor neurons maintains the relaxed state of the circular the feces. Inactivity of inhibitory motor neurons per- mits the contractions between the pockets.