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An arterial blood sample taken from a (C) Thick ascending limb section is followed by answers or by patient has a pH of 7 discount zestoretic 17.5mg amex blood pressure chart for children. What (E) Collecting duct ONE lettered answer or completion that is is the plasma [HCO ]? Which segment can establish the (C) Excreted in the urine as free (B) 3:1 steepest pH gradient (tubular fluid-to- hydrogen ions (C) 3:2 blood)? An arterial Plasma Po2 Pco2 [HCO32] made in a healthy adult: blood sample revealed a pH of 7 zestoretic 17.5mg with visa blood pressure exercise. Balti- (A) Acute renal failure Net acid excretion by the kidneys is more: Williams & Wilkins, 1998. Management of poisoning (B) 30 mEq/day life-threatening acid base disorders. N (C) Methanol intoxication (C) 88 mEq/day Engl J Med 1998;338:26–34, 107–111. In: Schrier RW, Gottschalk CW, (E) 92 mEq/day (E) Uncontrolled diabetes mellitus eds. Which of the following arterial blood Boston: Little, Brown, 1997;189–201. Philadelphia: Lippincott (A) 0 mEq Plasma Williams & Wilkins, 2000;391–442. Protection of acid- (C) 300 mEq pH (mm Hg) (mm Hg) (mEq/L) base balance by pH regulation of acid (D) 500 mEq (A) 7. Acid and basics: A guide to un- (B) Adrenal cortical insufficiency emergency department shortly before derstanding acid-base disorders. Clinical Physiology of Acid-Base (D) An increase in intracellular pH attempted to kill herself by swallowing and Electrolyte Disorders. New (E) An increase in tubular sodium the contents of a bottle of aspirin York: McGraw-Hill, 1994. A homeless woman was found on a hot the following set of arterial blood Basic Concepts and Clinical Manage- summer night lying on a park bench in values is expected? CASE STUDIES FOR PART IV • • • microscopy, but effacement of podocyte foot processes CASE STUDY FOR CHAPTER 23 and loss of filtration slits is seen with the electron micro- Nephrotic Syndrome scope. No immune deposits or complement are seen af- A 6-year-old boy is brought to the pediatrician by his ter immunostaining. The biopsy indicates minimal mother because of a puffy face and lethargy. The podocyte cell surface and weeks before, he had an upper respiratory tract infec- glomerular basement membrane show reduced staining tion, probably caused by a virus. What features in this case would cause suspicion of swelling, and pitting edema in the legs are observed. Why does the abnormally high rate of urinary protein excre- reveals no cellular elements or casts. Answers to Case Study Questions for Chapter 23 The child is treated with the corticosteroid prednisone, 1. The child has the classical feature of nephrotic syndrome: and the edema and proteinuria disappear in 2 weeks. She is transferred to a general hospital and, dur- ability of the glomerular filtration barrier to the normal ing transfer, has three grand mal seizures and arrives in plasma proteins. This condition might be a result of an in- a semiconscious, uncooperative state. A blood sample creased size of “holes” or pores in the basement membrane reveals a plasma [Na ] of 103 mEq/L. The decreased staining with a 362 mOsm/kg H O and urine [Na ] is 57 mEq/L. She is 2 cationic dye, however, suggests that there was a loss of given an intravenous infusion of hypertonic saline (1. Several days after serum albumin bears a net negative charge at physiological she had improved, bronchoscopy is performed. Proteins that have leaked across the glomerular filtration sion of 1 L of 1. Assume barrier are not only excreted in the urine but are reabsorbed that her total body water is 25 L (50% of her body weight).

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The hair follicle generic 17.5mg zestoretic fast delivery pulse pressure 120, which physically sup- ports and provides nourishment to the hair purchase zestoretic 17.5 mg overnight delivery pulse pressure 75, is derived from spe- cialized mesenchyme called the hair papilla, which is localized around the hair bulb, and from the epithelial cells of the hair bulb called the hair matrix. Continuous mitotic activity in the ep- ithelial cells of the hair bulb results in the growth of the hair. Sebaceous glands and sweat glands are the two principal types of integumentary glands. Sebaceous glands develop as proliferations from the sides of the developing hair follicle. Sweat glands become coiled as the secretory portion of the developing gland proliferates into the dermal mesenchyme. Mammary glands (exhibit III) are modified sweat glands that develop in the skin of the anterior thoracic region. EXHIBIT III The development of mammary glands at (a) 12 weeks, (b) 16 weeks, and (c) about 28 weeks. Squamous cell carcinoma arises from cells immediately su- Malignant melanoma, the most life-threatening form of perficial to the stratum basale. Normally, these cells undergo very skin cancer, arises from the melanocytes located in the stratum little division, but in squamous cell carcinoma they continue to basale. Often, it begins as a small molelike growth, which en- divide as they produce keratin. The result is usually a firm, red larges, changes color, becomes ulcerated, and bleeds easily. If untreated, how- Metastasis occurs quickly, and unless treated early—usually by ever, it may invade the dermis and metastasize. Treatment usu- widespread excision and radiation therapy—this cancer is often ally consists of excision and radiation therapy. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 122 Unit 4 Support and Movement FIGURE 5. Burns Burns are classified as first degree, second degree, or third degree, based on their severity (fig. In first-degree burns, A burn is an epithelial injury caused by contact with a thermal, the epidermal layers of the skin are damaged and symptoms are radioactive, chemical, or electrical agent. Burns generally occur restricted to local effects such as redness, pain, and edema on the skin, but they can involve the linings of the respiratory (swelling). The extent and location of a burn is frequently erally follows in a few days. Second- less important than the degree to which it disrupts body home- degree burns involve both the epidermis and dermis. Burns that have a local effect (local tissue destruction) pear and recovery is usually complete, although slow. Systemic gree burns destroy the entire thickness of the skin and effects directly or indirectly involve the entire body and are a frequently some of the underlying muscle. Possible systemic effects include body dehydration, or charred and is insensitive to touch. As a result, ulcerating shock, reduced circulation and urine production, and bacterial wounds develop, and the body attempts to heal itself by forming infections. Integumentary System © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 5 Integumentary System 123 (a) Basal cell carcinoma (a) (b) Squamous cell carcinoma (b) (c) Malignant melanoma FIGURE 5. As a way of estimating the extent of damaged skin suffered in burned patients, the rule of nines (fig. An estimation of the percentage of surface area edema—such as with a sunburn; (b) second-degree burns involve damaged is important in treating with intravenous fluid, which the epidermis and dermis and are characterized by intense pain, redness, and blistering; and (c) third-degree burns destroy the entire replaces the fluids lost from tissue damage. As the affected area is warmed, there Frostbite is a local destruction of the skin resulting from freezing. In Like burns, frostbite is classified by its degree of severity: first de- third-degree frostbite, there will be severe edema, some bleed- gree, second degree, and third degree. In first-degree frostbite, ing, and numbness followed by intense throbbing pain and the skin will appear cyanotic (bluish) and swollen. Gangrene will follow untreated mation and hyperemia (engorgement with blood) are symptoms third-degree frostbite.

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Spinal reflexes control not bundles or tracts of myelinated fibers of only muscle reflexes but also the reflexes sensory (afferent) and motor (efferent) of internal organs order zestoretic 17.5mg with mastercard hypertension glaucoma. The projections of the H peripheral nervous system (those nerves are named according to the direction to lying outside the central nervous system) which they project purchase zestoretic 17.5 mg free shipping blood pressure medication that doesn't cause cough. In most instances, sensory extend toward the back, and the anterior 73 74 CHAPTER 3 CONDITIONS OF THE NERVOUS SYSTEM: PART II horns project toward the front. Cere- the brain and are contained entirely brospinal fluid, which nourishes and pro- within the central nervous system. Lower tects the spinal cord, fills both the central motor neurons, although originating in the canal, located within the center of the central nervous system, have fibers gray matter, and the subarachnoid space extending to the peripheral nerves in vol- surrounding the outer portion of the untary muscles. The the motor cortex of the brain, extend location of the dysfunction determines down the spinal cord through descending the nature of the disorder. Sensory (afferent) impulses A nerve is a bundle of fibers outside the from the body enter the spinal cord central nervous system that transmits through spinal nerve roots that also information between the central nervous extend through openings between verte- system and various parts of the body. The brae and then travel up ascending tracts in peripheral nervous system consists of all the spinal cord to the brain. For ly, the peripheral nerves must be connect- example, the nerve roots that leave the ed to the central nervous system. Some spinal cord at the cervical level are labeled peripheral nerves connect directly to the C-1 through C-8, and the nerve roots that brain (cranial nerves), and others connect leave at the thoracic level are labeled T-1 directly to the spinal cord (spinal nerves). The sensory (afferent) Cranial and spinal nerves are essential nerves carry body sensations into the sen- links between the rest of the body and the sory nerve roots (posterior roots) at the back central nervous system. Some brain down the spinal cord and exit from cranial nerves contain only sensory fibers, motor nerve roots (anterior roots) at the whereas others contain both sensory and front of the spinal cord. Cranial nerves mediate fibers then carry impulses to the volun- many aspects of sensation and muscular tary muscles in the body. Many types of neurons work together Cranial nerves and their related functions to transmit impulses through the spinal are illustrated in Table 3–1. Sensory impulses entering the spinal Peripheral nerves that connect and cord at the lumbar region are relayed ver- transmit messages directly to the spinal tically to the brain through a number of cord are called spinal nerves. Each nerve divides impulses from the brain to the peripher- and then subdivides into a number of al nerves, however, are conducted branches. Nerves at each level travel to through two separate categories of motor specific parts of the body, conveying neurons. Upper motor neurons originate in information between those areas and the Normal Structure and Function of the Spinal Cord and Peripheral Nervous System 75 Table 3–1 Cranial Nerves and Related Functions Cranial Nerve Area of Function I. Trigeminal Sensation in head, face, and teeth, motor activity of chewing VI. Facial Taste, sensation of external ear, control of salivary glands, tears, muscles in facial expression VIII. Glossopharyngeal Swallowing, sensation of pain, taste, touch from tongue and throat X. Vagus Heartbeat, digestion, speech, swallowing, respiratory function, gland functions XI. Accessory Movement of head and shoulders, muscles of pharynx and larynx in throat, production of voice sounds XII. Spinal nerves and body, the autonomic nervous system their related functions are illustrated in stimulates immediate, involuntary re- Table 3–2. For example, in response to a Nerves control both voluntary and in- speck of dust in the eye, tears are pro- voluntary functions in the body. In response to a fearful situation, that control voluntary functions (such as the heart beats faster. Nerves that are concerned with the control of invol- Table 3–2 Spinal Nerves and untary functions are part of a subcatego- Related Functions ry of the peripheral nervous system called the autonomic nervous system. Spinal Nerve Area of Function The autonomic nervous system inte- grates the work of vital organs, such as the Cervical (C1-C8) Back of head, neck, heart and lungs. Its primary function is to shoulders, arms, hands, coordinate the activity of internal organs diaphragm so that they can make adaptive respons- Thoracic (T1-T12) Chest, back, regions of es to changing external situations in abdomen order to maintain internal equilibrium. Lumbar (L1-L5) Lower back, parts of Nerve fibers monitor the activities of thighs and legs internal organs as well as changes in the Sacral (S1-S5) Regions of thighs, external environment. When changes are buttocks, legs, bowel, necessary to maintain internal homeosta- bladder, genital function sis (equilibrium), or to protect the 76 CHAPTER 3 CONDITIONS OF THE NERVOUS SYSTEM: PART II The autonomic nervous system is divid- rupted. Consequently, some damage to ed into two subsystems: motor, sensory, or reflex function below the injury occurs.

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Exposure to poison oak deposits allergic pathogens on the skin which incite dorsal displacement and angulation buy 17.5mg zestoretic overnight delivery hypertension quality measures. The cells of the immune system already within there are multiple fragments in each fracture zestoretic 17.5 mg generic blood pressure medication that doesn't cause dizziness. It is an open fracture because the skin release locally acting cytokines which result in recruitment of other the fractured bones are exposed to the outside of the body through a soft inflammatory cells to the area as well as increased permeability of the blood tissue defect. The fracture fragments are displaced dorsally because of the vessels in the area. This type of fracture of the distal radius is classically inflammatory cells results in the local pruritis (itching). In an open fracture the ends of the fracture fragments are exposed to the intercellular spaces particularly within the stratum spinosum. This exposes the bone marrow cavity intracellular fluid in this area may cause blistering. The bone marrow is a good growth reaction to the allergic pathogen requires recruitment of additional medium for bacteria. These fractures are at greater risk of developing inflammatory cells, appearance of symptoms is delayed approximately 24 infection within the bone which may interfere with healing. Considering the amount of displacement seen on the radiographs, vascular 3. Topical steroids are the basis of treatment for poison oak to inhibit the and nervous injuries associated with the bony trauma would be quite possible. Often antihistamine medications are given to Vascular injury may be manifest as a pulseless cold hand. Neurologic injury decrease pruritis in order to diminish risk of secondary infection because of could have symptoms of either weakness or decreased sensation. The antihistamines may also relieve emergencies which would require immediate surgical attention. Continuing vascular and neurologic exams must be performed on the patient over the ensuing 24 to 48 hours to watch for Clinical Practicum 6. In the subdural space on the left there is a fluid collection causing mass swelling or hemorrhage secondary to an injury causes increased pressure effect on the brain. This pressure on the brain can explain the significant within one of the compartments defined by the fascial planes between the changes in the patient’s mental status. This increased pressure within the evidence of mass effect on the brain, concern for herniation of brain tissue is compartment causes vascular compromise leading to neurologic injury. The brain can herniate laterally under the falx cerebri or downward Clinical Practicum 7. This defect is area of decreased density just superior to the acetabulum on the plain film caused by erosion of bone secondary to the patient’s sinus infection. This may represent several different communication of the frontal sinus with the subdural space allows infected entities, but considering the patient’s history of thyroid cancer, this is most fluid to move from one space to the other. The proximity of this lesion to the to the fluid collection in the subdural space. The diagnosis is a subdural empyema secondary to the patient’s sinus weight bearing. The risk of pathologic fracture in this patient is great considering its location near the acetabulum and the weight- Clinical Practicum 6. Retropulsion of fracture fragments into the spinal canal causes compression of the spinal cord. Examination of the radiograph shows narrowing of the joint spaces of several is most likely the cauda equina. The injury may be due to compression and of the distal and proximal interphalangeal joints. This joint space narrowing swelling secondary to the fracture or due to damage to the nerves is due to erosion of the articular cartilage. Osteophytes are bony innervating the legs originate at the lumbar and sacral levels of the spine. Soft tissue swelling is also seen around several of the affected joints.

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