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By N. Goose. Lycoming College. 2018.

The exact mechanism is not known buy aciclovir 800mg on line, but hypoxia 342 PART V RESPIRATORY PHYSIOLOGY A Regional hypoxia cal changes (hypertrophy and proliferation of smooth mus- cle cells aciclovir 200 mg without prescription, narrowing of arterial lumens effective 200 mg aciclovir, and a change in con- tractile function) discount aciclovir 200 mg line. Pulmonary hypertension causes a sub- stantial increase in workload on the right heart buy cheap aciclovir 800 mg, 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. When alveoli are oxygenated on the newborn’s first breath, pulmonary vascular smooth muscle relaxes, the vessels dilate, and vascular resistance falls dramatically. The foramen ovale and ductus arteriosus close and pulmonary B Generalized hypoxia blood flow increases enormously. FLUID EXCHANGE IN PULMONARY CAPILLARIES Starling forces, which govern the exchange of fluid across capillary walls in the systemic circulation (see Chapter 16), Hypoxia Hypoxia also operate in the pulmonary capillaries. Net fluid transfer across the pulmonary capillaries depends on the difference be- tween hydrostatic and colloid osmotic pressures inside and outside the capillaries. In the pulmonary circulation, two ad- ditional forces play a role in fluid transfer—surface tension and alveolar pressure. The force of alveolar surface tension (see Chapter 19) pulls inward, which tends to lower intersti- Effect of alveolar hypoxia on pulmonary ar- tial pressure and draw fluid into the interstitial space. Hypoxia-induced vasoconstriction is trast, alveolar pressure tends to compress the interstitial unique to vessels of the lungs and is the major mechanism regulat- space and interstitial pressure is increased (Fig. A, With regional hypoxia, precapillary constriction diverts blood flow away from poorly ventilated regions; there is little change in pulmonary arterial Low Capillary Pressure Enhances Fluid Removal pressure. B, In generalized hypoxia, which can occur with high altitude or with certain lung diseases, precapillary constriction oc- Mean pulmonary capillary hydrostatic pressure is normally 8 curs throughout the lungs and there is a marked increase in pul- to 10 mm Hg, which is lower than the plasma colloid os- monary arterial pressure. This is functionally important because the low hydrostatic pressure in the pulmonary cap- illaries favors the net absorption of fluid. Alveolar surface can directly act on pulmonary vascular smooth muscle tension tends to offset this advantage and results in a net cells, independent of any agonist or neurotransmitter re- force that still favors a small continuous flux of fluid out of leased by hypoxia. This excess fluid Two types of alveolar hypoxia are encountered in the travels through the interstitium to the perivascular and peri- lungs, with different implications for pulmonary vascular bronchial spaces in the lungs, where it then passes into the resistance. In regional hypoxia, pulmonary vasoconstric- lymphatic channels (see Fig. The lungs have a more tion is localized to a specific region of the lungs and diverts extensive lymphatic system than most organs. Lymphatic channels, like small pulmonary blood monary arterial pressure, and when alveolar hypoxia no vessels, are held open by tethers from surrounding connec- longer exists, the vessels dilate and blood flow is restored. Generalized hy- poxia occurs when the partial pressure of alveolar oxygen Fluid Imbalance Leads to Pulmonary Edema (PAO2) is decreased with high altitude or with the chronic hypoxia seen in certain types of respiratory diseases (e. Generalized hy- the lung interstitial spaces and alveoli, and usually results poxia can lead to pulmonary hypertension (high pul- when capillary filtration exceeds fluid removal. Pulmonary monary arterial pressure), which leads to pathophysiologi- edema can be caused by an increase in capillary hydrostatic CHAPTER 20 Pulmonary Circulation and the Ventilation-Perfusion Ratio 343 CLINICAL FOCUS BOX 20. These struc- Hypoxia has opposite effects on the pulmonary and sys- tural changes occur in both large and small arteries. Hypoxia relaxes vascular smooth mus- there is abnormal extension of smooth muscle into pe- cle in systemic vessels and elicits vasoconstriction in the ripheral pulmonary vessels where muscularization is not pulmonary vasculature. Hypoxic pulmonary vasoconstric- normally present; this is especially pronounced in precap- tion is the major mechanism regulating the matching of re- illary segments. These changes lead to a marked increase gional blood flow to regional ventilation in the lungs. With severe, chronic hy- regional hypoxia, the matching mechanism automatically poxia-induced pulmonary hypertension, the obliteration of adjusts regional pulmonary capillary blood flow in re- small pulmonary arteries and arterioles, as well as pul- sponse to alveolar hypoxia and prevents blood from per- monary edema, eventually occur. Regional hy- part, by the hypoxia-induced vasoconstriction of pul- poxic vasoconstriction occurs without any change in monary veins, which results in a significant increase in pul- pulmonary arterial pressure. Hypoxia-induced pulmonary hypertension strict with hypoxia; however, only the arterial side under- affects individuals who live at a high altitude (8,000 to goes major remodeling. The postcapillary segments and 12,000 feet) and those with chronic obstructive pulmonary veins are spared the structural changes seen with hypoxia. Because of the hypoxia-induced vasoconstriction and vas- With chronic hypoxia-induced pulmonary hyperten- cular remodeling, pulmonary arterial pressure increases.

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On strain MR aciclovir 400mg for sale, nonspecific contour irregularity of the muscle sur- face is the only finding discount aciclovir 800mg online. DOMS Exercise can be followed by pain purchase aciclovir 200mg amex, muscle soreness aciclovir 800 mg fast delivery, and able to injury because it is the structurally weakest region muscle swelling aciclovir 200 mg mastercard, particularly in the deconditioned indi- in the myotendinous unit due to its limited capacity for vidual. Muscle strains are most common in exercise has been termed delayed onset muscle soreness the long fusiform muscles of the thigh or calf. Unlike the acute onset of symptoms with mus- Strains are subdivided into three grades by orthopedic cle strain, the symptoms of DOMS develop gradually 1- surgeons. A grade 1 strain demonstrates normal muscle 2 days following exercise, peak 2-3 days following the morphology and only mild abnormalities of muscle sig- activity, and then resolve after approximately 1 week. On nal, particularly in the region of the myotendinous junc- T1-weighted images, mild enlargement of the muscle tion. Increased signal is seen on T2-weighted alterations in the muscle morphology. The muscle architecture remains pre- images show irregularity, thinning, and mild waviness of served as the edema parallels the muscle fascicles. Muscle edema and hemorrhage are changes and clinical symptoms are maximal in the region more prominent, often collecting in the subfascial regions of the myotendinous junction. Large amounts of hemorrhage may be present, ob- Laceration and Contusion scuring the anatomy. The diagnosis is obvious if the ten- don ends are retracted, producing a gap in the soft tissues A muscle laceration is typically produced by direct trau- at the expected position of the myotendinous junction, and ma, usually a penetrating wound extending into the mus- allowing the muscle to bunch up away from the region. Less commonly, muscle can be lacerated by the sharp bone ends of a fracture. The area of the laceration can be Parenchymal Hemorrhage seen on MR as a linear defect in the muscle, filled with blood and fluid, but MR is not frequently used to assess Hemorrhage within muscle has two different appear- muscle laceration. Muscle injuries related to a single ances, depending on the pattern of bleeding. Hemorrhage episode of severe trauma are subdivided into muscle strain dissecting within the muscle stroma, not forming a dis- and muscle contusion, depending on the mechanism of in- crete collection, is known as parenchymal hemorrhage. A muscle strain is caused by an indirect injury, When blood forms a discrete collection, the mass is re- whereas a contusion is due to direct concussive trauma ferred to as a hematoma. The muscle alter- and hematoma coexist in most cases with extensive ations of contusion are identical to those seen high-grade bleeding. Parenchymal hemorrhage does not have a brain muscle strains but the location of the injury is independent correlate so its appearance is less well-known to radiolo- of the myotendinous junction, corresponding instead with gists. Contusions are more likely to be asso- little mass effect and has a lacy, feathery appearance ciated with extensive hemorrhage within the muscle. Parenchymal hemorrhage is best seen on inversion re- covery or T2-weighted sequences, and is often normal ap- Muscle Strain pearing on T1-weighted images. The appearance of a sub- acute parenchymal bleed is very nonspecific as the blood Muscle strains typically involve the myotendinous junc- does not undergo a phase of methemoglobin formation, tion of the muscle. A sagittal T1-weighted MR of the hip shows a Soft-tissue hemorrhage can collect as a discrete hematoma. The MR joint caused by a large appearance of hematomas is highly variable depending up- hematoma. The MR appearance of muscle hematomas high signal intensity at the anterior periphery follows the same progression as in the brain but the time of the lesion produced course may be longer and less predictable. Acute blood has by methemoglobin low signal intensity on both T1- and T2-weighted images due to the presence of intracellular deoxyhemoglobin. Subacute hematomas have a distinctive appearance due to the formation of methemoglobin, particularly at the pe- riphery of the hematoma (Fig. Methemoglobin pro- duces T1 shortening, resulting in high signal intensity within the hematoma on T1-weighted images. Fluid-fluid levels within the hematoma are common, particularly in large hematomas. In chronic hematoma, some of the iron in the methemoglobin is converted to hemosiderin and fer- ritin, which deposit in the hemorrhage and adjacent tissues. These substances result in signal loss on both T1- and T2- weighted images, producing a low-signal halo around the hematoma. Myositis Ossificans Myositis ossificans is a circumscribed mass of calcified and ossified granulation tissue that forms as a response to trauma. The early MR appearance is very nonspecific and can easily be mistaken for a neoplasm.

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Small segments of gray potentially harmful substances buy aciclovir 800 mg with amex, such as matter are also embedded deep within cer- 28 CHAPTER 2 CONDITIONS OF THE NERVOUS SYSTEM: PART I tain parts of the white matter of the brain cheap 400 mg aciclovir otc. Gray matter consists of groups of neuron Each hemisphere has centers for receiving cell bodies buy aciclovir 800mg on-line. It is called gray matter because information and for initiating responses purchase aciclovir 800 mg mastercard. The gray mat- The left hemisphere mostly receives infor- ter of the brain receives purchase aciclovir 200 mg without prescription, sorts, and process- mation from and sends information to the es nerve messages, and the gray matter of right side of the body, and the right hemi- the spinal cord serves as a center for reflex sphere mostly receives information from action (automatic response to stimuli). Deep within the cerebral hemi- The Brain spheres are groups of gray matter called basal ganglia, which are part of the The brain, which is directly connected extrapyramidal system. In addition, it is the site of Basal ganglia help to maintain contractile consciousness and intellectual function. The basal ganglia is covered with a thin outer layer of gray also play a role in enabling individuals to matter called the cortex, which contains react swiftly, appropriately, and automat- billions of nerve cells. The cortex has three ically to stimuli that demand an immedi- specialized areas that serve three major ate response, such as, after tripping, functions: enabling the individual to adjust move- ment in order to avoid a fall. The motor cortex coordinates voluntary Each hemisphere of the cerebrum is movements of the body. The frontal lobe is recognition or perception of sensory located in the front of each hemisphere stimuli, such as touch, pain, smell, and contains motor areas that initiate vol- taste, vision, and hearing. The associational cortex is involved in ments, such as those involved in writing. The cerebrum is divided into two halves, The parietal lobe is located in the middle called hemispheres: the right hemisphere of each hemisphere and is primarily the and the left hemisphere. The two hemi- sensory area, integrating and interpreting spheres communicate with each other. Some memory functions specific areas within them are bundles of are also located in the parietal lobe, espe- Normal Structure and Function of the Nervous System 29 Subarachnoid Parietal Lobe Space Pia Mater Wernicke’s Area Arachnoid Frontal Membrane Lobe Broca’s Subdural Area Space Ventricles Epidural Space Temporal Dura Lobe Mater Occipital Brain Lobe Stem Cerebellum Figure 2–2 The Brain. The temporal lobe is located is the major area responsible for receptive under the frontal and parietal lobes and function, or the ability to integrate visual is primarily responsible for the interpreta- and auditory information in order to tion of and distinction between auditory understand a communication received. The occipital lobe is located at the area located in front of the temporal lobe back or posterior portion of each hemi- and in the frontal cortex is called Broca’s sphere. It is the primary area for reception area, which contributes to expressive and interpretation of visual stimuli. The thala- as expressing thoughts in a coordinated mus acts as a relay station that sorts, inter- way so that others may comprehend it. Language function is located in the left Below the thalamus is the hypothalamus, hemisphere of the cerebrum in most indi- which coordinates neural and endocrine viduals, whether they are right- or left- activities. An area located over the temporal internal environment and behaviors that 30 CHAPTER 2 CONDITIONS OF THE NERVOUS SYSTEM: PART I are important to survival, such as eating, ried by four major arteries, two carotid drinking, and reproduction. The ver- hypothalamus is the pituitary gland, an tebral arteries join to form the basilar endocrine gland that will be discussed in artery. A band of gray THE BRAIN matter called the hippocampus is involved in learning and long-term memory, help- Traumatic and Atraumatic ing to determine where important and rel- Brain Damage evant aspects of facts will be stored. The brain, like any other tissue, needs Beneath the occipital lobe of the cere- oxygen in order to function. The damage are dependent on: cerebellum also regulates and coordinates fine movements of the extremities, which • the cause of the damage have been initiated by the frontal lobe. Atraumatic (nontraumatic) brain dam- is the primary center of involuntary func- age caused by interference with oxy- tions. Control of vital organ functions gen reaching the brain (such as with such as regulation of heartbeat or respira- choking, carbon monoxide poison- tion occurs in the brain stem. Areas in the ing, or infection) or problems with- brain stem also regulate the diameter of in the brain itself (such as stroke, or blood vessels, consequently helping to structural problems within the brain control blood pressure. Reflex actions, or blood vessels in the brain) such as coughing and swallowing, are con- 2. The brain stem by an outside force that impacts the also contains scattered groups of cells, head hard enough to cause damage called the reticular formation, that are to the brain involved in the initiation and mainte- nance of wakefulness and alertness. Both atraumatic (nontraumatic) and trau- The brain requires both oxygen and matic brain damage are considered acquired nourishment in the form of glucose to brain injuries because they occur after birth function and survive. Oxygen and glucose and are not the result of genetic disorder, are transported to the brain by blood car- birth trauma, or degenerative disease. Conditions Affecting the Brain 31 Atraumatic Brain Damage bral thrombosis.

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Hypochondriasis Somatoform Disorders Hypochondriasis discount aciclovir 400 mg without a prescription, another type of som- atoform disorder purchase aciclovir 400 mg fast delivery, is characterized by pre- Somatoform disorders are conditions in occupation with physical illness generic 200 mg aciclovir. Indi- which individuals experience physical viduals with this condition may fear or symptoms for which no organic cause can believe they have a serious physical illness Common Psychiatric Disabilities 189 or perceive the symptoms of a coexisting new identity without being able to recall disease or condition in an exaggerated their previous identity aciclovir 200mg generic. For example buy aciclovir 800 mg visa, they may perceive a sia is the inability to recall events that cough associated with a common cold as occurred within a certain period of time a sign of tuberculosis or lung cancer. Dissociative Pain Disorder identity disorder, formerly known as multi- ple personality disorder, is a condition in Pain disorder is a preoccupation with which at least two personalities exist with- pain that is severe enough to cause in the same individual and control the impairment in function at home, school, individual’s behavior. Personality Disorders Individuals with pain disorder do not con- sciously produce the symptoms of a pain Everyone has personality traits or char- and actually experience the pain report- acteristics. This disorder can be extremely inca- they can interfere with the ability to func- pacitating, often severely limiting social tion, especially during times of crisis. Personality disorders describe disorders characterized by inflexible or maladaptive Factitious Disorders behaviors that have usually lasted a long time and that impair interpersonal or Although not severely disabling, a vari- occupational functioning or cause subjec- ety of other types of mental disorders may tive distress (American Psychiatric Asso- interfere with effective functioning. They may assume the sick role (American Psychiatric rationalize their actions, blaming others Association, 2000). A factitious disorder for their situation or misfortune without differs from malingering (in which indi- examining their own responsibility for the viduals also produce symptoms intention- situation at hand. When a personality disorder exists in combination with other mental Dissociative Disorders disorders, the prognosis is more guarded, and treatment and management of the Conditions in which individuals expe- personality disorder are more difficult. At rience an alteration in memory, conscious- times, these individuals may not have a ness, or identity for no organic reason are full-blown personality disorder but rather called dissociative disorders. Dissociative maladaptive personality traits that may fugue is a condition in which individuals interfere with the treatment or diagnosis leave their environment and assume a of the concomitant disorder. The diagnosis of mental conditions is The most commonly used intelligence often an art as well as a science. It requires tests are the Wechsler Intelligence Scale for skill and experience on the part of those Children-Revised, the Wechsler Preschool evaluating individuals’ symptoms and and Primary Scale of Intelligence, the interpreting the results of the various tests Stanford-Binet, and the Wechsler Adult designed to measure psychological or intel- Intelligence Scale-Revised. Many professionals may The limitations of intelligence testing be involved in testing and evaluation; psy- originate from: chiatrists and clinical psychologists are fre- • the difficulty of tapping all aspects of quently involved in the diagnosis of intellectual ability mental disorders. Diagnosis is usually • the individual’s ability to take the test based on information from a variety of dif- • the degree to which the test measures ferent sources. There is considerable individual can be obtained through psychological variability in abilities, however, and results testing. Psychological tests may be used to of intelligence tests, like results of other evaluate intelligence, personality, or forms of psychological tests, must be eval- behavior. Much vide partial information needed for the ac- intelligence testing involves sampling curate diagnosis of a mental condition. No individuals’ intellectual capacity in a vari- single test is adequate to offer a definitive ety of different spheres. Often, because on cognitive processes, including problem mental disorders affect a variety of func- solving, adaptive thinking, and other tions, several psychological tests that aspects of performance. Tests alone should measure different functions may be nec- not determine a definitive diagnosis. Mental Status Examination and Intelligence Tests Assessment Through Interviews The term intelligence is difficult to define. The structured interview is one way in Theoretically, intelligence consists of a num- which the mental functioning of individ- ber of skills and abilities, some of which uals with a suspected mental disorder may cannot be measured. Diagnostic Procedures in Psychiatric Disability 191 Structured interviews provide informa- ical scales that can be useful in the diag- tion regarding individuals’ orientation, nosis of a variety of mental disorders, form and content of thought, speech, ranging from schizophrenia to depression, affect, and degree of insight. Apperception Test, also have criteria on The mental status examination is a spe- which interpretations are based, but they cific type of structured interview used as are generally more subjective in nature. Such an examination ing individuals to describe vague and am- may be used to detect dementia or im- biguous pictures. There are no right or paired intellectual function, as well as to wrong answers. Although Projective tests may be more time con- some mental status instruments are part suming than are objective tests, and pro- of other instruments that measure func- fessionals who administer them require tional status, a number of short screening special training. As with all other clinical instruments have been devised especially data, the results of personality assessment for the purpose of evaluating mental sta- tests are only part of the total information tus.

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