By C. Altus. The Art Institute of Washington.

The patient was wearing a seat belt in the back seat of a car that was struck in the front by another car buy altace 2.5mg otc arteria gastroepiploica dextra. Her airway is patent altace 10 mg sale pulse pressure 25, breath sounds equal bilaterally, and skin is warm with 2+ pulses. He states that the pain started on the left side of his lower back and now involves the right and radiates down both legs. He has a medical history of chronic hypertension and underwent a “vessel surgery” many years earlier. Upon arrival, she does not open her eyes, is verbal but not making any sense, and withdraws to painful stimuli. As you prepare to intu- bate the patient, a colleague notices that her left pupil has become dilated compared to the right. The man tells you his name and complains of right-sided chest pain and difficulty breathing. On primary survey, his airway is patent and his oropharynx has no blood or displaced teeth. He is breathing at 32 beats per minute with retractions and an oxygen saturation of 88% on 15 L of oxygen. These individuals are often amnestic to the event and frequently ask the same questions over and over again (perseverations). Headache with or without vomiting is generally present; however, there are no focal neurologic findings on examination. Diffuse axonal injury (b) is caused by microscopic shearing of brain nerve fibers. Patients typically present unconscious and remain in a coma for a prolonged period of time. The clinical features of a cerebral contusion (c) are similar to those of a concussion except neuro- logic dysfunction is more profound and prolonged and focal deficits may be present if contusions occur in the sensorimotor area. Posttraumatic epilepsy (d) is associated with intracranial hematomas and depressed skull fractures. Some scientists believe that head trauma predis- poses to Alzheimer disease (e); however, this would take years to develop. Although they are all associated with potentially fatal complications, they should be viewed clinically as a continuous spec- trum of myocardial damage: concussion (no permanent cell damage), contu- sion (permanent cell damage), infarction (cell death), tamponade (bleeding into the pericardium), and rupture (exsanguination). The mechanism of injury in a cardiac contusion involves a high-speed deceleration, which causes the heart to move forward, forcibly striking the sternum. In addition, the direct force of hitting an object (eg, the steering wheel) also can damage 148 Trauma Answers 149 the heart. The right ventricle is the most commonly injured because it is the most anterior aspect of the heart and is closest to the sternum. The earliest signs of hemorrhagic shock are tachycardia and cutaneous vaso- constriction. The amount of blood loss present can be estimated based on the individual’s initial clinical presentation. Many of these injuries are treat- able mainly because the patients are young and otherwise healthy. The pri- mary role of the emergency physician is to assess, resuscitate, and stabilize the trauma patient by priority. The first, classified as immediate death, is the period with the greatest number of fatalities. This occurs within seconds to minutes of the injury and these patients generally die at the scene. The cause is most commonly because of massive head injury, followed by high cervical spine injury with spinal cord disruption, cardiac and great vessel rupture, and airway obstruc- tion. The second peak period, classified as early death, occurs within min- utes to a few hours of injury. This is the period called the “golden hour” where intervention is critical and significantly reduces the morbidity and mortality rate in these patients.

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Other Body-Building Drugs Other drugs may be used by body builders (93) trusted 5 mg altace lower blood pressure quickly for test, including tamoxifen to reduce or prevent gynecomastia; diuretics to counteract the fluid retention caused by anabolic steroids; thyroxine to increase the rate of metabolism proven altace 5mg hypertension nursing teaching, which might theoretically increase the ability of anabolic steroids to boost physical strength (94); and β human chorionic gonadotrophin to alleviate testicular atrophy (95). Nalbuphine (Nubain) is an opioid agonist/antagonist analgesic used for the treat- 304 Stark and Norfolk ment of moderate-to-severe pain, and dependence has been reported associated with anabolic steroid use (96). Furthermore, there has been a case report of a 21-year-old body builder who was admitted after taking excessive amounts of insulin intravenously; apparently, insulin is advertised in body-building magazines as having ana- bolic properties (97). The recreational use of caffeine to toxic levels has been reported in a body builder who presented with a grand mal seizure (98). Clenbuterol, which is a sympathomimetic agonist (used as a oral bronchodila- tor in some European countries but not licensed for human use in the United Kingdom or United States) is said to have an “anabolic-like” effect but at high dose may cause cardiac dysrhythmias, tremor, and serious hypokalemia (99). It has been used as an anesthetic (although it has little analgesic effect), to alleviate narcolepsy, and to treat alcohol and opiate dependence (101). There have been reports of abuse in the United Kingdom and United States within the dance scene and gay clubs and with body builders because it is said to promote slow-wave sleep during which growth hormone is secreted (102). It is available as a color- less, odorless liquid, powder, or a capsule to be taken orally; it is rarely injected. It has a half-life of 30 minutes (103), and effects can last from 45 minutes to 8 h (104). Initial effects include euphoria followed by profound sedation, confu- sion, agitation, amnesia, nausea, vomiting, diarrhea, ataxia, seizures, hypoto- nia, tremor, vertigo and dizziness, bradycardia, hypotension, hypothermia, coma (105), and respiratory collapse. Tolerance and physi- cal dependence after high-dose use can develop with a withdrawal syndrome, which may include insomnia, muscular cramping, tremor, and anxiety (101). A rapid deterioration into delirium may occur in more frequent high-dose dependent users. Withdrawal is not associated with seizures, but if suspected, hospital admission should be considered (108). Ketamine Ketamine is a commercially available anesthetic for intravenous and intra- muscular use. It contains analgesic properties and is available on the street in Substance Misuse 305 powder, tablet, and liquid form; it can be smoked or taken intranasally (“snorted”), orally, intramuscularly, or intravenously (109). The onset of effects depends on the route of administration; when taken orally, effects start within 20 minutes and can last up to 3 hours, whereas given intravenously, effects will be seen within 30 seconds and last about 30 minutes (110). Physical effects may include a cocaine-like “rush,” hypertension, dysrhythmias, nausea, and vomiting, slurred speech, nystagmus, lack of coor- dination, and seizures. On recovery, “emergence phenomena” may occur, with psychological dissociation or out of body (flying or floating) sensations, con- fusion, hallucinations, synesthesia, and depersonalization (112). Such disso- ciative states may result in the individual becoming divorced from reality, and these effects, coupled with possible loss of coordination and pronounced anal- gesia, can result in serious accidents to users. A dose-dependent depression of respiration may occur (113), and this can be a particular problem when taken with other respiratory depressant drugs, such as benzodiazepines and alcohol, occasionally resulting in death (114). Alkyl Nitrites The alkyl nitrites are volatile yellowish clear liquids that have a distinc- tive sweet smell. All the nitrites have vasodilatory properties and are used as a euphoric relaxant within the dance culture and to relax the anal sphincter and enhance sexual performance. The effect of inhaling the vapor, usually from the bottle or poured onto a cloth, is instantaneous and short-lived, resulting in a “rush,” but adverse effects, such as dizziness, flushing, tachycardia and pal- pitations, headache, cold sweats, and hypotension, may occur (115,116). Swal- lowing of volatile nitrites as opposed to inhaling them may result in severe methemoglobinemia (117). One review found that the incidence of alcohol-related violent crime ranged from 24 to 85%, which contrasted dramatically with the 12–38% incidence of alcohol-related nonviolent crime (118). Although some have confirmed the association between alcohol and crime (119,120), a direct causal link between the two has been disputed (121). Nonetheless, alcohol assumes an importance in clinical forensic medicine because of its link with criminal activity and by virtue of the significant role it plays in a large number of assessments regarding fitness for detention (122–124). Accordingly, a thor- ough understanding of the metabolism, effects, and problems associated with 306 Stark and Norfolk alcohol is essential for any doctor practicing in this field, not least because those detainees with alcohol problems, particularly those with gross intoxi- cation, are an extremely vulnerable group for whom police custody may be inappropriate (125). The Metabolism of Alcohol Ethanol, hereafter referred to as alcohol, is produced by the fermentation of sugar by yeast, a process that halts at a concentration of alcohol by volume of approx 15% because of the death of yeast above these levels.

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Lined with a fold of highly elastic mucous membrane purchase 10 mg altace mastercard hypertension follow up, the vagina can enlarge greatly during childbirth altace 5 mg sale blood pressure chart per age. A folded mem- brane of connective tissue called the hymen lies at the opening of the vaginal canal until it is ruptured or torn, often by sexual intercourse but sometimes by other physical activities. At either side of the vaginal opening are two Bartholin glands that secrete a lubricating mucous. On the outside, the female genitalia extends toward the posterior from a mound of soft, fatty tissue called the mons pubis that covers the bone structure called the pubic symphysis. Behind this, the vulva consists of two flaps of fatty tissue: the outer lips, or labia majora; and the smaller, hairless inner lips, the labia minora. Just above where the inner lips join is a small flap of tissue called the clitoral hood, under which is the clitoris, erectile tissue that swells during sexual arousal. Below the clitoris is the exter- nal opening of the urethra and below that is the introitus, the opening to the vagina. Tunica albuginea Secondary follicle Cortex of stroma Germinal epithelium Follicular fluid Primary follicle Cumulus oophorus Graafian follicle Membrana granulosa Blood vessels Medulla of stroma entering Blood clot hilus of ovary Corpus albicans Early corpus luteum Figure 14-1: Mature Corona radiata The ovary. Pituitary Chapter 14: Carrying Life Forward: The Female Reproductive System 223 11. Use the terms that follow to identify the anatomy of the female reproductive system shown in Figure 14-2. Normal human diploid, or 2N, cells contain 23 pairs of homologous chromosomes for a total of 46 chromosomes each. One chromosome from each pair comes from the individual’s mother, and the other comes from the father. Each homol- ogous pair contains the same type of genetic information, but the expression of this genetic information may differ from one chromosome of the pair to the homologous chromosome. For example, one chromosome from the mother may carry the genetic coding for blue eyes, whereas the homologous chromosome from the father may code for brown eyes. Although all the body’s cells have 46 chromosomes — including the cells that eventu- ally mature into the ovum and the sperm — each gamete (either ovum or sperm) must offer only half that number if fertilization is to succeed. As you see in Figure 14-3, the number of chromosomes is cut in half during the first meiotic division, producing gametes that are haploid, or 1N. The second mei- otic division produces four haploid sperms in the male but only one functional haploid ovum in the female. When fertilization occurs, the new zygote will contain 23 pairs of homologous chromosomes for a total of 46 chromosomes. The zygote then proceeds through mitosis to produce the body’s cells, distributing copies of all 46 chromosomes to each new cell. Zygote Chapter 14: Carrying Life Forward: The Female Reproductive System 225 Think you’ve conquered this process? Fill in the blanks to complete the following sentences: Meiosis produces sperm and ovum, which contributes to making a 41. The number of chromosomes is cut in half during the first meiotic division, producing gametes that are 45. But that doesn’t mean that sexual intercourse outside that time frame can’t lead to pregnancy. Research indicates that spermatozoa can survive up to seven days inside the uterus and Fallopian tubes. If a sperm is still motile — that is, if it’s still whipping its flagellum tail — when an ovum comes down the tube, it will do what it was made to do and penetrate the ovum’s membrane. When the sperm penetrates the ovum, it releases enzymes that allow it to digest its way into the ovum, leaving its flagellum behind. After that first sperm penetrates, the mem- brane instantly solidifies around the ovum, preventing any other sperm from getting inside. Over the next three to five days, the zygote moves through the Fallopian tube to the uterus, undergoing cleavage (mitotic cell division) along the way: Two cells become four smaller cells, four cells become eight smaller cells, and then those eight cells become a solid 16-cell ball called a morula. After five days of cleavage, the cells form a hollow ball of approximately 32 cells called a blastula, or blasto- cyst. The inner hollow region is called the blastocoele, and the outer-layer cells are called the trophoblast. Within three days of its arrival in the uterine cavity (generally within a week of fertiliza- tion), the blastocyst implants in the endometrium, and some of the blastocyst’s cells — called totipotent embryonic stem cells — organize into an inner cell mass called the embryonic disk, or embryoblast.

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They may talk to members individually quality 5mg altace arrhythmia from clonidine, together altace 5 mg sale prehypertension diastolic blood pressure, and in Originally it was thought that dyslexia affected more subgroups. They may ask family members to reenact sit- males than females (in a ratio of 5:1), but later studies uations, or to do “homework” by modifying elements of found males to be only slightly more likely than females their behavior and responses. Figures for diagnosed child dyslexics are one of the goals of family counseling is to reframe prob- skewed because for various reasons boys tend to be re- lems so that family members can see specific events and ferred more frequently for. Thomas Edison, Albert Ein- stein, Woodrow Wilson, General George Patton, and Au- guste Rodin are thought to have been dyslexic. There are many treatment approaches available to the public, ranging from visual stimulation to diets to en- hancement of regular language education. However, it is generally agreed that specialized education is the only gist, Educational Researcher, Review of Educational Re- search, American Educational Research Journal. In their research, they have found that preschoolers understand that thinking is a human, Flavell’s first position was as a clinical psychologist mental activity and that it can involve things that are in at a Veterans Administration Hospital in Colorado. They distin- ever he left there a year later to accept a position at the guish thinking from other activities such as talking, feel- University of Rochester in New York, first as a clinical ing, seeing, or knowing. However preschoolers greatly associate and then as an assistant professor of psycholo- underestimate the amount that they and others think, and gy. In though Flavell first undertook to write a book on theories other words, Flavell has found that, although preschool- of developmental psychology, he soon switched to a ers know that rocks do not think, they also don’t believe major study of the work of , publishing that their parents think all that much. This Throughout his career, Flavell’s books have received was the first major work in English on the research and critical acclaim for both their scholarship and their lively theories of Piaget and marked the start of the modern sci- and entertaining prose. That same year, Flavell of the and con- traveled to Paris for additional studies at the Sorbonne. Flavell’s research at Rochester focused on children’s understanding of the roles of others and on children’s Margaret Alic communication skills and developing skills. He first evaluated the skills needed for role-taking, the un- derstanding of what another person sees, knows, needs, Coombs, Karen. He served as president of the Society for Research in Child Development from 1979 to 1981. Since his arrival at Stanford, Flavell and his long- time research associates, his wife, Ellie Flavell, and Frances L. Greene, have studied preschoolers at the Bing Nursery School on the Stanford campus. They have also Forensic psychologists often work within the judi- studied elementary-school and college students. In re- cial system in such diverse areas as determining an in- cent years, Flavell has researched and developed his the- mate’s readiness for parole; evaluation of Austrian psychoanalyst and pioneer in the field of child psychoanalysis; daughter of psychoanalyst Sigmund Freud. Systematic representation of data, arranged so that the observed frequency of occurrence of data falling within certain ranges, classes, or categories, is shown. Children realize that they ness of physical difference is followed by awareness of are male or female and are aware of the gender of others the cultural differences between males and females and by the age of three. However, at these ages they still do identification with the parent of the same sex, whose be- not understand that people cannot change genders the havior the child begins to imitate. Like its female gender is permanent, which occurs at about the age of counterpart, which Freud termed the Electra complex, seven. At this point they start the behavior of the Oedipus complex revolves around a child’s wish to members of their own sex. Although it has been support- possess the parent of the opposite sex, while simultane- ed by some research studies, Kohlberg’s theory has also ously wishing to eliminate the parent of the same sex, been criticized on the grounds that children do show cer- who is perceived as a rival. This cestuous desires toward his mother, while regarding his points to the fact that there are others factors, such as father as a rival for her affections. Fearing that the father parental , that influence the adoption of will cut off his penis in retaliation—a phenomenon sex-typed behavior. Freud called castration anxiety—the boy represses his forbidden desires and finally comes to identify with the father, internalizing his values and characteristics, which form the basis for the child’s. In the female version of this theory, the young girl’s discovery of sexu- al difference results in penis envy, which parallels castra- tion anxiety in boys. The girl blames her mother for de- priving her of a penis, and desires her father because he possesses one.

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