By J. Boss. Bemidji State University. 2018.

Radiographs and electrocardiograms also may be helpful system and the consequences of glandular dysfunctions buy cheap deltasone 40 mg line. Hypersecretion of an endocrine gland is generally Disorders of the Pituitary Gland caused by hyperplasia (increase in size) of the gland buy deltasone 10 mg line, whereas The pituitary is a remarkable gland discount 10mg deltasone. It simultaneously carries out hyposecretion of hormones is the consequence of a damaged or several functions order deltasone 40mg overnight delivery, yet more than 90% of the gland must be de- atrophied gland cheap deltasone 20 mg without a prescription. The diagnosis and treatment of endocrine problems can be difficult because of three complex physiological effects of Panhypopituitarism hormones. Total pituitary impairment, termed panhypopitu- Thus, the clinical symptoms obscure the source of the prob- itarism, brings about a progressive and general loss of hormonal lem. For example, the gonads stop functioning and the per- bolic problems because the primary action of hormones is to son suffers from amenorrhea (lack of menstruation) or aspermia regulate metabolism. The Common diagnostic methods will be discussed in this sec- thyroid and adrenals also eventually stop functioning. People tion, along with the more important endocrine disorders that af- with this condition and those who have had their pituitary sur- fect the major endocrine glands. Diagnosis of Endocrine Disorders Certain endocrine disorders affect the patient’s physical appearance Abnormal Growth Hormone Secretion and behavior; therefore, observation is very important in diagnosis. Inadequate growth hormone secretion during childhood causes The patient’s clinical history is also important in evaluating the pituitary dwarfism (fig. Hyposecretion of growth hor- rate of progress and stage of development of an endocrine disorder. One of the symptoms tory tests, particularly of blood and urine samples. These samples of this disease is premature aging caused by tissue atrophy. By are important because hormones are distributed via the blood, contrast, oversecretion of growth hormone during childhood and urine is produced from the metabolic wastes filtered from the causes gigantism (fig. A radioimmunoassay (RIA) is a laboratory test to deter- length of long bones. Excessive growth hormone secretion in an mine the concentration of hormones in blood and urine. Other adult does not cause further growth in bone length because the blood tests include the protein-bound iodine (PBI) test to deter- epiphyseal plates have already ossified. A urinalysis can be important in the diagnosis of several en- docrine disorders. A high level of glucose in a fasting patient in- dicates diabetes mellitus. A patient who has diabetes insipidus will produce a large volume (5–10 L per day) of dilute urine of low specific gravity. Certain diseases of the adrenal glands can also be detected by examining for changes in urine samples col- Simmonds’ disease: from Morris Simmonds, German physician, 1855–1925 lected over a 24-hour period. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 Chapter 14 Endocrine System 481 (a) (b) (c) FIGURE 14. This disorder affects body fluids, causing edema and increasing Symptoms of this disease include polyuria (excessive urination), blood volume, hence increasing blood pressure. A person with polydipsia (consumption of large amounts of water), and severe ionic myxedema has a low metabolic rate, lethargy, sensitivity to cold, imbalances. This condition is treated with thyroxine or triiodothyronine, both of which are taken orally. Disorders of the Thyroid Endemic Goiter and Parathyroid Glands A goiter is an abnormal growth of the thyroid gland. When this is a result of inadequate dietary intake of iodine, the condition is Hypothyroidism called endemic goiter (fig. An affected child usually appears normal at birth levels of thyroxine secretion. Endemic goiter is thus associated because thyroxine is received from the mother through the pla- with hypothyroidism. The clinical symptoms of cretinism are stunted growth, thickened facial features, abnormal bone development, mental retardation, low body temperature, and general lethargy. If cre- Graves’ Disease tinism is diagnosed early, it can be successfully treated by admin- Graves’ disease, also called toxic goiter, involves growth of istering thyroxine. Endocrine System © The McGraw−Hill Anatomy, Sixth Edition Coordination Companies, 2001 482 Unit 5 Integration and Coordination FIGURE 14. Type I, or insulin-dependent diabetes mellitus, is hyperthyroidism is produced by antibodies that act like TSH and caused by destruction of the beta cells and the resulting lack of stimulate the thyroid; it is an autoimmune disease.

In this case buy deltasone 10mg cheap, the abdominal thrust ducting division that connects the laryngopharynx with the trachea deltasone 5mg online. Respiratory System © The McGraw−Hill Anatomy buy deltasone 20 mg low cost, Sixth Edition Body Companies best deltasone 10 mg, 2001 Chapter 17 Respiratory System 609 Posterior Base of tongue Vestibular folds Vocal folds Cuneiform Corniculate cartilage cartilage Anterior (a) Posterior Epiglottis Glottis Inner lining of trachea (c) Anterior (b) FIGURE 17 cheap 10mg deltasone otc. In (a) the vocal folds are taut; in (b) they are relaxed and the glottis is opened. This third unpaired cartilage connects glottis during swallowing and in speech. There are two groups of la- the thyroid cartilage above and the trachea below. The other paired cuneiform cartilages and corniculate pitches are produced as air passes over the altered vocal folds. Mature males Two pairs of strong connective tissue bands are stretched generally have thicker and longer vocal folds than females; therefore, across the upper opening of the larynx from the thyroid cartilage the vocal folds of males vibrate more slowly and produce lower anteriorly to the paired arytenoid cartilages posteriorly. The loudness of vocal sound is determined by the force of the vocal folds (true vocal cords) and the vestibular folds (false the air passed over the vocal folds and the amount of vibration. The vestibular folds support the vocal vocal folds do not vibrate when a person whispers. The vestibular folds are not essary to convert sound into recognizable speech. Vowel sounds, used in sound production, but rather the vocal folds vibrate to for example, are produced by constriction of the walls of the phar- produce sound. The pharynx, paranasal sinuses, and oral and nasal cavities folds, whereas the rest of the larynx is lined with pseudostratified act as resonating chambers. This is an important anatomical complished through movements of the tongue and lips. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 610 Unit 6 Maintenance of the Body Thyroid cartilage Larynx Cricoid cartilage Tracheal cartilage Trachea Carina Left principal (primary) bronchus Right principal (primary) bronchus Lobar (secondary) bronchus Segmental (tertiary) bronchus FIGURE 17. It is positioned anterior tube into the trachea to permit breathing and to keep the passage- to the esophagus as it extends into the thoracic cavity. A tracheotomy should be performed only by a competent physician as there is a great risk of cutting a recurrent la- of 16 to 20 C-shaped hyaline cartilages form the supporting walls ryngeal nerve or the common carotid artery. These tracheal cartilages ensure that the airway will always remain open. The open part of each of these cartilages faces the esophagus and permits the esophagus to Bronchial Tree expand slightly into the trachea during swallowing. The mucosa (surface lining the lumen) consists of pseudostratified ciliated The bronchial tree is so named because it is composed of a series columnar epithelium containing numerous mucus-secreting gob- of respiratory tubes that branch into progressively narrower tubes let cells (see figs. The trachea bifurcates against dust and other particles as the membrane lining the nasal into right and left principal (primary) bronchi at the level of the cavity and larynx. Medial to the lungs, the trachea splits to form sternal angle behind the manubrium. Because of the more vertical position of the right principal bronchus, foreign particles If the trachea becomes occluded through inflammation, exces- are more likely to lodge here than in the left principal bronchus. A tracheotomy is the procedure of surgi- lobar (secondary) bronchi and segmental (tertiary) bronchi (see cally opening the trachea, and a tracheostomy involves inserting a figs. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 17 Respiratory System 611 Lumen of Tracheal esophagus epithelium Trachealis Tracheal muscle cartilage Lumen of trachea Tracheal epithelium Tracheal Thyroid cartilage gland Tracheal cartilage Adventitia (a) (b) FIGURE 17. There is connect to respiratory bronchioles that lead into alveolar ducts, little cartilage in the bronchioles. The conduction por- encircles their lumina can constrict or dilate these airways. Bron- tion of the respiratory system ends at the terminal bronchioles, chioles provide the greatest resistance to air flow in the conduct- and the respiratory portion begins at the respiratory bronchioles. During an asthma attack, there is a spasm of chioles rather than the pseudostratified columnar epithelium that the smooth muscles in the respiratory bronchioles. Numerous terminal bronchioles absence of cartilage at this level, the air passageways constrict. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 612 Unit 6 Maintenance of the Body Trachea Left principal bronchus Right principal bronchus Bronchioles FIGURE 17. A fluoroscopic examination of the bronchi using a radiopaque medium for contrast is called bronchography. This technique enables the physician to visualize the bronchial tree on a bron- chogram (fig.

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There is increasing interest in examining how tile discount 5mg deltasone visa, and post-infectious form of the disorder purchase deltasone 40 mg online. MR imag- ing may assist in monitoring those with severe disease who undergo marrow transplantation generic 20mg deltasone fast delivery, since success will be indicated by expansion of the marrow cavity cheap deltasone 10mg free shipping. There is an intermediate recessive form of the disease which is milder than that seen in infants and distinct from the less severe autosomal dominant disease deltasone 20 mg with visa. Affected in- dividuals suffer pathological fracture and anemia and are of short stature, with hepatomegaly. The radiographic features include diffuse osteosclerosis with involvement of the skull base and facial bones, abnormal bone mod- eling and a “bone within a bone” appearance. Benign, Autosomal Dominant Type This type of osteopetrosis (Albers-Schonberg disease) is often asymptomatic, and the diagnosis may come to light either incidentally or through the occurrence of a patho- logical fracture. Other presentations include anemia and facial palsy or deafness from cranial nerve compression. Problems may occur after tooth extraction, and there is an b increased incidence of osteomyelitis, particularly of the mandible. Radiographic features are similar to those of the autosomal recessive form of the disease, but less se- vere. The bones are diffusely sclerotic, with thickened cortices and defective modeling. There may be alternat- ing sclerotic and radiolucent bands at the ends of diaphy- ses, a “bone within a bone” appearance, and the vertebral Fig. In type 1, fractures are unusual, show very dense bones, with loss of the in contrast to type II in which fractures are common. Affected children have episodes of fever, In affected individuals, there is obliteration of the marrow bone pain, and progressive enlargement of the skull, with cavity leading to anemia, thrombocytopenia, and recur- bowing of the long bones and associated pathological rent infection. Radiographically, the features resem- hydrocephalus, and cranial nerve involvement resulting ble Paget’s disease of bone, and it is sometimes referred in blindness and deafness. Radiographically, all the bones to as “juvenile” Paget’s disease, osteitis deformans in are dense, with lack of corticomedullary differentiation. There is an increased Modeling of affected bones is abnormal, with expansion rate of bone turnover, with woven bone failing to mature of the metaphyseal region and undertubulation of bone. Radiographically, this increased rate This is most evident in the long bones, particularly the of bone turnover is evidenced by decreased bone density distal femur and proximal humerus. Although the bones with coarsening and disorganisation of the trabecular pat- are dense, they are brittle, and horizontal pathological tern. In the skull, the diploic space is widened and there fractures are common. The diaphyses of the long bones be- base, is involved and the paranasal and mastoid air cells come expanded, with cortical thickening along their con- are poorly developed. The long bones may be bowed, resulting in Metabolic Bone Disease 103 Fig. Parfitt AM (1988) Bone remodelling: Relationship to the organised trabecular amount and structure of bone, and the pathogenesis and pre- pattern b PA skull vention of fracture, in Osteoporosis – Etiology, Diagnosis and shows massive expan- Management, (Eds B. Melton), Raven Press, sion of the skull vault New York, pp 45-93 with sclerosis, the fea- 3. Mundy GR (1999) Osteopetrosis, in Bone remodelling and its tures resembling Paget’s disorders (2nd edn) Martin Dunitz, London, pp 193-199 disease of bone 4. Greulich WW, Pyle SI (1959) Radiographic atlas of skeletal development of the hand and wrist (2nd edn). Tanner JM, Whitehouse RH, Cameron N et al (1983) Assessment of skeletal maturity and prediction of adult height (TW2 method), 2nd edn, Academic Press, London 6. King DG, Steventon DM, O’Sullivan MP et al (1994) Reproducibility of bone ages when performed by radiology registrars: an audit of Tanner and Whitehouse II versus Greulich and Pyle methods, Brit J Radiol 67:848-851 7. Pietka E, Gertych A, Pospiecha Euro Kurkowska S et al (2004) Computer-assisted bone age assessment:graphical user inter- face for image processing and comparison, J Digit Imaging 17(3):175-188 a 8. Nelson DA, Kleerekoper M, Parfitt AM (1988) Bone mass, skin color and body size among black and white women. Jouanny P, Guillemin F, Kuntz C et al (1995) Environmental and genetic factors affecting bone mass.

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This means that there must be a defined and accepted standard of care that the defendant is required to adhere to in treating the plaintiff deltasone 10mg with amex, something the defendant should not have done that he or she did or some act that he or she did that should not have been done buy deltasone 10mg low price. Standards of care can be found in statutes purchase 20mg deltasone with mastercard, regulations proven deltasone 20mg, court decisions order deltasone 10mg without a prescription, published professional articles, and tes- timony by expert medical witnesses. When the standard of care is a statute, regulation, or rule of a professional organization, its violation is called negligence per se. The second element that must be proved to successfully prosecute a medical malpractice case is that the defendant breached this stan- dard of care, which is to say that he or she acted contrary to or in violation of it. This is usually an evidentiary matter where each side presents whatever testimony or documentary evidence that shows conduct by the defendant in conformity with or in violation of the standard of care. Where there is a conflict in the evidence about breach, the factfinder—most commonly a jury—must decide whether the evidence presented favors the plaintiff or defendant on this point. Third, it must be proved that the defendant’s breach of the duty of care owed to the plaintiff caused the plaintiff injury. Not surprisingly, factual causation is determined by the factfinder or jury, unless the case is before a judge acting by stipulation as the factfinder or by an arbitrator. The test for factual causation, what was once called “but for” causation, is whether the breach was a substantial factor in bringing about injury to the plaintiff. However, legal causation, what the law used to call proxi- mate cause, is a policy or scope of liability determination made by the court or judge. It is an aspect of negligence liability in which courts address whether they are going to draw a “bright line,” beyond which they will not impose liability as a matter of law even if the conduct at issue is deemed factually responsible for the plaintiff’s injury. Finally, as already implied, a plaintiff must prove that satisfaction of all the foregoing elements resulted in his compensable injury. In other words, a plaintiff must prove that his or her injuries are of a nature that may be redressed by monetary damages. Economic loss is damage that can be objectively measured like lost wages and medical care, both past and future. Noneconomic damage is subjective and immeasurable, like pain and suffering or loss of consortium (i. Chapter 2 / Litigation 17 Procedural and Evidentiary Rules Procedural rules determine how and when the substantive rules do or do not come into play and how information is gathered that bears on the substantive rules. Finding information that may include or lead to admissible evidence is done through the procedural rules of dis- covery. The most common procedural rules of discovery include written interrogatories, requests for admission, requests to produce documents, oral depositions, and requests for designation of experts. Procedural rules that can terminate litigation or alter its focus are the subject of law and motion practice. Evidentiary rules determine what facts get considered or precluded from consideration by the court, jury, or arbitrators to determine whether the substantive conditions of liability are satisfied. These rules determine what testimony, documents, photographs, record- ings, and the like are admissible and what weight should be given to particular evidence admitted. How Medical Malpractice Reform Changes the Conventional Rules of the Litigation Game Numerous states faced with malpractice insurance crises over the past 30 years have made changes to their litigation rules—substantive, procedural, and evidentiary—in an attempt to cabin the number of lawsuits and the size of awards to better protect the public’s access to uninterrupted health care. In 1975, California was the first state to do this in a significant way when it enacted MICRA in response to the medical malpractice insurance crisis the state was then undergoing and has since avoided repeating. MICRA exists to reduce the cost and increase the efficiency of medical malpractice litigation by revising numerous legal rules applicable to such litigation. This comprehen- sive reform package illustrates how changes in all three categories of litigation rules can produce stability and certainty in the determination of who gets how much, from whom, and under what circumstances when someone is injured in the course of medical treatment and seeks redress. MICRA’s success in accomplishing its stated purpose has made it a model for states experiencing problems in assuring continued access to health care stemming from an unstable litigation and liability insur- ance climate; it is also a model for federal legislation endorsed by the President George W. Bush and the House of Representatives but thus far blocked from enactment by a lack of support in the US Senate. This ceiling on a subjective, immeasurable component of recoverable damage is the heart of MICRA and the provision most vexing to personal injury lawyers who traditionally relied on these damages to cover their attor- ney fees. Another reform in MICRA is the sliding contingency fee scale for plaintiff attorneys, which assures that the greater a plaintiff’s injuries and damages, the larger the percentage of the total award that goes to the plaintiff, with a corresponding reduced share to the plaintiff’s law- yer. As a report of an American Bar Association commission explained long ago about this kind of provision: “[In] order to relate the attorney’s fee more to the amount of legal work and expense involved in handling a case and less to the fortuity of the plaintiff’s economic status and degree of injury, a decreasing maximum schedule of attorney’s fees, reasonably generous in the lower recovery ranges and thus unlikely to deny potential plaintiffs access to legal representation, should be set on a state-by-state basis. Chapter 2 / Litigation 19 is the time during which a suit must be filed after the injury occurs or, absent an express waiver by the defendant, it is barred. Before MICRA and analogous statutes in other states, the limitations period was prac- tically open-ended, making stale claims common and resulting in a “long-tail” for liability that prevented accurate claims forecasting and predictable premium setting.

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