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Erythrocytes are disc-shaped cells that coronary sinus collects and empties the paired vertebral arteries buy cheap nolvadex 10mg line, which lack nuclei but contain hemoglobin 10mg nolvadex sale. Contraction of the atria and ventricles is surrounding the pituitary gland effective 20mg nolvadex. Leukocytes have nuclei and are classified the atria and then enter the 3 cheap 20 mg nolvadex free shipping. 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. The wall of the heart consists of the conduction is called an electrocardiogram Principal Veins of the Body epicardium, myocardium, and (ECG or EKG). Blood from the head and neck is drained (a) The right atrium receives blood from Blood Vessels (pp. Arteries and veins have a tunica externa, blood from the brain is drained by the and the right ventricle pumps blood tunica media, and tunica interna. Arteries ventricle pumps blood into the transport blood away from the heart. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 600 Unit 6 Maintenance of the Body 3. In the thorax, the superior vena cava is oxygen and nutrients are obtained from 2. Lymphatic capillaries drain interstitial formed by the union of the two the placenta rather than from the fetal fluid, which is formed from blood plasma; brachiocephalic veins and also collects lungs and GI tract. Fully oxygenated blood is carried only in capillaries, it is called lymph. The lower extremity is drained by both the umbilical vein, which drains the 3. This blood is carried via the via two large lymph ducts—the thoracic the fifth lumbar vertebra, the right and ductus venosus to the inferior vena cava duct and the right lymphatic duct. Partially oxygenated blood is shunted contain phagocytic cells and lymphatic 5. Blood from capillaries in the GI tract is from the right to the left atrium via the nodules that produce lymphocytes. Lymphoid organs include the lymph (a) This venous blood then passes through trunk to the aorta via the ductus nodes, tonsils, spleen, and thymus. The lymphatic system returns excess characterized by two capillary beds in interstitial fluid to the venous system and a series is called a portal system. Structural adaptations in the fetal cardiovascular system reflect the fact that Review Activities Objective Questions (c) depolarization of the ventricles. Which of the following is not a formed (d) repolarization of the ventricles.

Below the inguinal ligament purchase 10 mg nolvadex with amex, a branch (D6) extends to the pectineal muscle (B7) nolvadex 10mg without a prescription. The anterior cutaneous branches (B–D1) origi- nate slightly more distally purchase 20 mg nolvadex overnight delivery, with the strongest one continuing along the middle of the thigh down to the knee purchase nolvadex 10 mg with amex. They supply sensory fibers to the skin of the anterior and medial aspects of the thigh. The lateral group of branches (D8) consists of muscularbranches for the sartorius muscle (B9), the rectus femoris muscle (B10), the lateral vastus muscle (B11), and the inter- mediate vastus muscle (B12). The muscular branch (D13) for the medial vastus muscle (B14) runs along the medial margin of the Kahle, Color Atlas of Human Anatomy, Vol. Lumbar Plexus 89 1 A Skin supplied by the lateral cutaneous nerve of thigh 15 (according to Lanz-Wachsmuth) L 1 2 4 L 2 L 3 5 L 4 1 7 3 9 6 C Skin supplied by the femoral nerve (according to Lanz- 2 Wachsmuth) 12 13 1 10 11 2 8 14 15 D Sequence of branches 15 B Muscles supplied by the femoral nerve (according to Lanz-Wachsmuth) Kahle, Color Atlas of Human Anatomy, Vol. Standing on the affected leg Obturator Nerve (L2–L4) and lifting the healthy leg makes the pelvis of the other side drop (Trendelenburg’s symptom). Medial to the greater psoas muscle, it extends along the Inferior Gluteus Nerve (L5–S2) (F) lateral wall of the small pelvis down to the The nerve leaves the pelvis through the in- obturator canal through which it passes to frapiriform foramen and gives off several reach the thigh. It gives off a muscular branches to the gluteus maximus muscle branch to the external obturator muscle (F14). The superficial Clinical Note: Paralysis of the nerve weakens branch (AB2) runs between the long adduc- extension of the hip joint (for example, when tor muscle (A3) and short adductor muscle standing up or climbing stairs). The nerve also gives off branches to the pectineal muscle and the gracilis muscle (A5) and finally ter- Posterior Cutaneous Nerve of Thigh minates in a cutaneous branch (A–C6) to the (S1–S3) (D) distal region of the medial aspect of the The nerve leaves the pelvis together with thigh. The deep branch (AB7) runs along the sciatic nerve and inferior gluteus nerve external obturator muscle and then down to through the infrapiriform foramen and the great adductor muscle (A8). Located Clinical Note: Paralysis of the obturator nerve directly beneath the fascia lata, it extends (for example, as a result of pelvic fracture) causes along the middle of the thigh into the pop- loss of adductor muscle function. This exclusively sensory nerve standing and walking, and the affected leg can no longer be crossed over the other leg. It pro- Sacral Plexus (D–F) vides sensory innervation to the posterior aspect of the thigh from the lower buttock The lumbosacral trunk (parts of L4 and L5) region into the popliteal fossa and reaches and the anterior branches of S1–S3 join on to the proximal aspect of the lower leg. Autonomic extendfromtheplexustothemusclesofthe zone (dark blue) and maximum zone (light pelvic region, namely, to the piriform blue). Superior Gluteus Nerve (L4–S1) (E) The nerve extends across the upper margin of the piriform muscle in dorsal direction through the suprapiriform foramen to the gluteus medius (E11) and minimus (E12) muscles and supplies both with motor fibers. The nerve continues between the two muscles to the tensor muscle of the fas- cia lata (E13). Lumbar Plexus, Sacral Plexus 91 L 1 L 2 L 3 1 1 2 6 7 2 7 4 8 6 3 5 B Sequence of branches 6 C Skin supplied by the obturator nerve (according to Lanz-Wachsmuth) A Muscles supplied by the obturator nerve (according to Lanz-Wachsmuth) D Skin supplied by the 11 posterior cutaneous nerve of thigh (according to 12 9 Lanz-Wachsmuth) 10 13 14 F Muscles supplied by E Muscles supplied by the superior the inferior gluteal gluteal nerve (according to Lanz- nerve (according to Wachsmuth) Lanz-Wachsmuth) Kahle, Color Atlas of Human Anatomy, Vol. Thesuperficialperonealnerve givesoff muscu- The sciatic nerve leaves the pelvis through lar branches (AC8) to the long (A9) and short the infrapiriform foramen and extends (A10) peroneal muscles. The rest of the beneath the gluteus maximus muscle and nerve is exclusively sensory; it ramifies into bicepsmusclealongtheposterioraspectsof terminal branches, the medial dorsal cu- the internal obturator muscle, the quadrate taneous nerve (BC11) and the intermediate muscle of femur, and the great adductor dorsal cutaneous nerve (BC12), which supply muscle in the direction of the knee joint. In the thigh, the peroneal nerve lies muscular branches (AC13) to the extensor laterally and the tibial nerve medially. The terminal branch is sensory and sup- plies the apposing skin surfaces of the inter- Common peroneal nerve (common fibu- digital space between great toe and second lar nerve) (L4 – S2). The foot can no After division of the sciatic nerve, the com- longer be lifted in the ankle joint. When walking, the foot hangs down and the toes drag along the mon peroneal nerve extends along the bi- floor. The leg must be lifted higher than normal, ceps muscle at the lateral edge of the pop- resulting in the so-called steppage gait. It then winds around the neck of the fibula to the Innervation of the skin (B). Autonomic anterior aspect of the lower leg and enters zone (dark blue) and maximum zone (light into the long peroneal (fibular) muscle.

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All of the above 106 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM 3 purchase 10 mg nolvadex with mastercard. The goal of patient and family education in multiple sclerosis is to: a order nolvadex 10 mg without a prescription. Reduce healthcare costs Case Study 6 Martin generic 20mg nolvadex with amex, a twenty-three-year-old with a five-year history of multiple scle- rosis buy 10 mg nolvadex free shipping, developed vertigo and incoordination of gait over a seven-day period, which stabilized and slowly improved over the next month. Two years later the symptoms returned, along with ill-defined difficulty with blurred vision, which also improved when a course of intravenous steroids was given. Within the next year he began to note severe spas- ticity of his lower extremities with resultant problems with gait, trans- fers, and bed mobility. His motor and cerebellar symptoms pro- gressed and he was nonambulatory at age twenty five. He was seen at the MS Center complaining of pain and rigidity in his legs, bowel and bladder incontinence, and anxiety. Injectable therapy is indicated in light of this patient’s condition and history. All of the above CHAPTER 21: CASE STUDIES 107 Case Study 7 Felicia lives alone. She has secondary pro- gressive MS and has minimal household assistance. She is fiercely independent yet is exposed to household dangers (cooking, toileting, bathing). She was hospitalized in August for an acute exacerbation (right arm weakness and increased tremor), then sent to subacute rehabilitation. She made little progress and was advised that it would be safer for her to consider long-term living options (assisted living, nursing home) rather than return home. She refused and returned to her home with 2 hours of home health aide assistance three times a week. She calls the MS Center three or four times a week with ques- tions and concerns (What medications am I on? What are the emotional reactions that an MS nurse might experi- ence with this patient? Helen has two young children (12 and 10) who are doing very poorly in school and who are not supervised in the afternoon. Her husband complains that he is unable to sleep and rest because of his wife’s sleep patterns. She has emotional outbursts, screaming at her family for minimal infrac- tions of “the rules” and is emotionally labile with unexpected crying jags. The children are having problems in school with homework, interpersonal relations, and cleanliness. What mental/social services health services might be helpful at this time? False CHAPTER 21: CASE STUDIES 109 Case Study 9 Thomas has been married to Theresa for twenty years. She worked until two years ago and raised two children, both of whom are now in col- lege. She is no longer able to do laundry, prepare meals, or manage the house (shopping, cleaning, pay bills) due to fatigue, forgetfulness, and prob- lems with her handwriting. Frequently, when Thomas returns home from work, Theresa is sitting watching TV. Thomas is then faced with the tasks of cleaning her (and the furniture), preparing dinner, doing house- hold tasks, and assisting Theresa with her personal hygiene before bed. He com- plains of disturbance in his sleep patterns (Theresa occasionally wan- ders at night and has to be assisted to the bathroom), decreased appetite, and a feeling of hopelessness. What assistance can you offer Thomas to help him cope with his wife’s advancing disability? Education about multiple sclerosis and personalized information about his wife d.

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Cortisol purchase 20 mg nolvadex free shipping, like other steroid hormones buy 20 mg nolvadex with visa, ercise intolerance and a reduced sense of well-being is carried in the blood largely bound to carrier proteins order 20 mg nolvadex with visa, (including effects on libido) nolvadex 20mg with mastercard. Lean body mass (muscle) although a small percentage exists free in solution. The is lost, and excess body fat deposition occurs in the ab- majority of cortisol is bound to a specific carrier pro- dominal region. GH replacement can reverse these ef- tein, corticosteroid-binding globulin (CBG), while fects. Thyroid dysfunction is ruled out by the normal smaller amounts are bound nonspecifically to albumin. Glucocorticoid deficiency Few, if any, cortisol receptors would be expected in the usually results from primary adrenal insufficiency, as in plasma and transthyretin binds primarily thyroxine. Hormones generally circulate at con- creased sense of well-being, GI disturbances, and ab- 9 12 centrations from 10 to 10 M. Primary adrenal insuffi- much larger changes in a variety of biological parame- ciency is also characterized by high blood levels of ters as a result of signal amplification, in which the ACTH, which can result in hyperpigmentation as a re- rather weak hormonal signal is amplified into a larger sult of the melanocyte-stimulating activity of the biological response. Adrenal insuffi- ciency is not usually associated with a redistribution of Chapter 32 body fat to central stores. Prolactin does not appear to have a major physiological effect in human males. Destruction of the neurons in the par- Acromegaly results from excessive GH secretion in an aventricular nuclei of the hypothalamus decreases adult; the symptoms are not consistent with CRH release, which causes decreased synthesis and se- acromegaly. The data demonstrate a higher aver- would lead to an increase in portal blood AVP, which age ACTH and higher average cortisol concentration increases ACTH secretion by corticotrophs. This is opposite the usual diurnal or emotional stress increases ACTH release. Glucocor- pattern in which ACTH and cortisol are high in the ticoids feed back to the hypothalamus and anterior pi- morning. It is possible that the subject works nights tuitary to decrease ACTH synthesis and secretion. Pri- and has a reversed but normal diurnal rhythm of mary adrenal insufficiency is characterized by a lack of ACTH and cortisol release. There is no adrenal disease glucocorticoids in the blood, resulting in an increase in (primary or secondary) because both ACTH and cor- ACTH synthesis and secretion. Increased PKA activity tisol are higher at the same time and then are lower at in corticotrophs increases ACTH synthesis and secre- the same time. Somatostatin, given as a long-acting hormones exert a negative-feedback signal on the hy- analog octreotide, is effective in reducing excess secre- pothalamic-pituitary-thyroid axis to inhibit their own tion of GH. Glucocorticoid would feed back to inhibit the hy- decrease the sensitivity of thyrotrophs to TRH, decrease pothalamic-pituitary-adrenal axis but have little effect the formation of IP3 in thyrotrophs, inhibit the expres- on GH release. Because acromegaly is characterized by sion of the genes for the and subunits of TSH in excessive GH secretion, the administration of GH thyrotrophs, and decrease the secretion of TSH by thy- would be inappropriate. Thyroid hormones have no effect on ACTH counter the diabetogenic effects of excess GH, but it release. Galactorrhea is commonly associated thickening, or hypertrophy of the liver. Prolactin is thyroid hormone would stimulate GH release in a situ- important in maintaining breast milk production after ation of high GH. GHRH increases cAMP and stimu- APPENDIX A Answers to Review Questions 731 lates GH synthesis and secretion; somatostatin de- because of the protective actions of the thyroid hor- creases cAMP and inhibits GH synthesis and secretion mone-binding proteins. TRH stimulates TSH secretion the iodination of thyroglobulin to form MIT and DIT, and the synthesis of the and subunits of TSH by precursor molecules for T3. The high TSH rules out a defect in the Chapter 33 hypothalamic-pituitary axis and suggests an unrespon- sive thyroid gland, most likely a result of autoimmune 1. The presence of antibodies to thyroid colloid by the apical membrane of the follicular cell. The absence of a goiter rules out hypothy- somal vesicles to release thyroid hormones. T4 and T3 roidism as a result of iodine deficiency; low serum thy- are stored in thyroglobulin in the colloid, not in secre- roid hormone levels would result in elevated TSH with tory vesicles in the follicular cell.

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