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Each specific sensation is The eye is a globe-shaped organ composed of connected to a specific organ or structure in the three distinct tunics montelukast 5 mg with amex asthma 504 form, or layers: the fibrous tunic cheap montelukast 4mg fast delivery asthma symptoms 7-8, body purchase 10 mg montelukast with visa asthma treatment for children under 5. Pronunciation Help Long Sound a—rate ¯ e—rebirth¯ ¯ı—isle o—over ¯ u—unite¯ Short Sound a—alone˘ e—ever ˘ ˘ı—it o—not˘ u—cut˘ Anatomy and Physiology 467 (4) Choroid (10) Retina (1) Sclera (5) Iris (2) Cornea (11) Fovea (in macula) Retinal artery and vein (7) Pupil (12) Optic nerve (8) Lens (13) Optic disc (15) Anterior chamber (17) Vitreous chamber (14) Posterior chamber Inferior rectus muscle (16) Canal of Schlemm (9) Suspensory ligament (3) Conjunctiva (6) Ciliary body Figure 15-1. Fibrous Tunic choroid allows the optic nerve to enter the inside of The outermost layer of the eyeball, the fibrous the eyeball. The anterior portion of the choroid tunic, serves as a protective coat for the more sen- contains two modified structures, the (5) iris and sitive structures beneath. The sclera, or “white of the tile membrane whose perforated center is called the eye,” provides strength, shape, and structure to the (7) pupil. As the sclera passes in front of the eye, it passing through the pupil to the interior of the eye. Rather than As environmental light increases, the pupil con- being opaque, the cornea is transparent, allowing stricts; as light decreases, the pupil dilates. The cornea is iary body is a circular muscle that produces aqueous one of the few body structures that does not con- humor. The ciliary body is attached to a capsular tain capillaries and must rely on eye fluids for bag that holds the (8) lens between the (9) suspen- nourishment. As the ciliary muscle contracts and tiva, covers the outer surface of the eye and lines relaxes, it alters the shape of the lens making it the eyelids. These changes in shape allow the eye to focus on an image, a process called Vascular Tunic accommodation. The (4) choroid pro- The innermost sensory tunic is the delicate, vides the blood supply for the entire eye. It consists of a thin, pigmented cells that prevent extraneous light from outer pigmented layer lying over the choroid and a entering the inside of the eye. It has two types the refractive structures of the eye, focusing light of visual receptors: rods and cones. Cones function in bright light and produce color The adnexa of the eye include all supporting vision. In the cen- control the movement of the eye: the superior, ter of the macula is the (11) fovea. When the eye inferior, lateral, and medial rectus muscles and the focuses on an object, light rays from that object are superior and inferior oblique muscles. Because the fovea is com- cles coordinate the eyes so that they move in a syn- posed of only cones that lie very close to each other, chronized manner. Two movable folds of skin constitute the eyelids, each with eyelashes that protect the front of the Other Structures eye. As light strikes the Lying superior and to the outer edge of each eye are photopigment, a chemical change occurs that stimu- the (2) lacrimal glands, which produce tears that lates rods and cones. The tears collect at the impulses that are transmitted through the (12) optic inner edges of the eyes, the canthi (singular, can- nerve to the brain, where they are interpreted as thus), and pass through pinpoint openings, the vision. The optic nerve and blood vessels of the eye (3) lacrimal canals, to the mucous membranes that enter at the (13) optic disc. It is found in the (14) posterior The ear is the sense receptor organ for hearing and chamber and (15) anterior chamber of the anterior equilibrium. Hearing is a function of the cochlea; segment and provides nourishment for the lens and the semicircular canals and vestibule control equi- the cornea. If aqueous humor fails to drain from the The ear consists of three major sections: the outer eye at the rate at which it is produced, a condition ear, or external ear; the middle ear, or tympanic called glaucoma results. Anatomy and Physiology 469 Temporal bone (6) Stapes (10) Semicircular canals (1) Auricle (5) Incus (4) Malleus Vestibular branch Vestibulocochlear nerve Cochlear branch (7) Cochlea (11) Vestibule (8) Oval window (9) Eustachian tube (2) External auditory (3) Tympanic canal membrane External ear Middle ear Inner ear Figure 15-3. Its inner surfaces are lined with a sions ultimately generates impulses that are sent to highly sensitive hearing structure called the organ of the brain and interpreted as sound. Corti, which contains tiny nerve endings called the An (1) auricle (or pinna) collects waves traveling hair cells. A membrane-covered opening on the through air and channels them to the (2) external external surface of the cochlea called the (8) oval auditory canal, also called the ear canal. The ear window provides a place for attachment of the canal is a slender tube lined with glands that pro- stapes. Its stickiness ear causes the stapes to exert a gentle pumping traps tiny foreign particles and prevents them from action against the oval window. The forces the perilymph to disturb the hair cells, gener- (3) tympanic membrane (also called the tympanum ating impulses that are transmitted to the brain by or eardrum) is a flat, membranous structure drawn way of the auditory nerve, where they are interpret- over the end of the ear canal. The (9) eustachian tube connects the the ear canal strike against the tympanic membrane, middle ear to the pharynx.

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The physician must attempt to understand the patient’s values and to determine issues relevant to the patient when making decisions about the patient’s healthcare buy 10 mg montelukast free shipping asthma treatment with magnesium. Failure to take these steps may adversely affect patient outcome and can harm the physician–patient relationship discount montelukast 4mg amex asthmatic bronchitis quizlet, possibly leading to legal actions against the physician order 10mg montelukast with visa asthma treatment journal articles. The core objective of this chapter is to show the relevance of bioethics to the practice of surgery. Although the application of ethical principles acquired during the career of a skilled physician cannot be conveyed in a brief chapter, basic principles of bioethics are presented so that the student can recognize and respond when challenged with bioethical dilemmas in the clinics and on the ward. Bioethical Principles and Clinical Decision Making 151 Frame the question Identify the principles involved Principle 1: Autonomy Assessment of decisional capacity of patient Capable Incapacitated Identify surrogate Principle 2: Plan Beneficence Principle 3: Principle 4: Nonmaleficence Justice Algorithm 9. Surgeons regularly may encounter the following bioethical situations: • Informed consent and patient autonomy, e. Four Core Moral Principles Biomedical ethics has been described as applied ethics—the use of theory, principles, and rules to resolve problems that arise in the prac- tice of medicine. The four basic principles of bioethics—autonomy, beneficence, nonmaleficence, and justice—are the foundation for medical decision making. Nonmaleficence and justice are derived directly from the first two principles of autonomy and beneficence. The goal in providing surgical care is to recognize situations that require application of these principles. By preparing for such situations before they occur, one can have a thoughtful and organized approach to resolving difficult questions of surgical care. These dilemmas usually are complex and often cannot be resolved by simultaneously honoring the four principles equally. Autonomy Maxim: Do not do to others that which they would not have done unto them, and do for them that which one has contracted to do. The first principle of bioethics is autonomy, which is derived from the principle of mutual respect. A person is autonomous if he or she is self-governing, that is, has self-determination without undue con- straint from external forces. If one is to say that a patient’s autonomy is being respected in a decision-making process, the patient should give informed consent or assent to his care. This concept is in direct contrast to the commonly taught maxim: Do unto others as you would have them do unto you. The emphasis in bioethics is on identifying the patient’s values and desires before determining the best course of action. If the patient is incapaci- tated, the guiding principle in reaching a decision or in creating a plan of action is beneficence, defined as weighing the benefits, risks, and burdens of an intervention in the contest of the individual. In the case of the 90-year-old patient presented above, his current values about his life and death center on attaining a peaceful death at home. In obtaining informed consent for discontinuation of hospital care, the medical team would need to address difficult issues, including: • Whether the patient is capable of giving informed consent • What standards of disclosure should be met (how much information should be provided) 9. Bioethical Principles and Clinical Decision Making 153 For each principle, determine what info is needed Gather info to Clarify clarify issues/ facts relevant principles Identify who should participate in discussion Discussion • Review the facts • Discuss the issues • Establish a plan • Communicate the plan Algorithm 9. The second principle of bioethics is beneficence, which is derived from the morality of the community and is applied by focusing on the individual’s desires in the context of that community. For the physi- cian, there is not only a commitment to do good, but also, more impor- tantly, a duty to do good. The principle of beneficence makes explicit society’s common commitment to do good, even when an under- standing of “good” is community-dependent and divergent. Burd nal illness is concealed from the patient, since the shared belief system is that such knowledge unnecessarily hastens death and diminishes the individual’s quality of life. His desire is in direct conflict with the surgery team’s “good,” which is pro- longation of life and return to health. Discharging a patient against medical advice or a patient’s refusal of care confronts physicians with a challenge to their medical authority and their commitment to assist the patient to return to health. The third principle of bioethics is nonmaleficence, which is derived directly from the principle of beneficence and is made explicit in a line from the Hippocratic oath: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and do justice. Until his final hours, he was lucid and adamant that he did not want heroic medical measures to be taken to save his life. Braun’s desires are likely to be in direct conflict with the goal of the healthcare team—to restore him to health. Braun’s death was inevitable, the attending physician approached the family to request permission for an autopsy to determine why Mr. One question to ponder is: In this situ- ation, is it harmful to request that the family consider an autopsy? The fourth principle of bioethics is justice, which requires the recon- ciliation or balance between conflicts inherent in the principles of autonomy and beneficence. In seeking to achieve justice, the physi- cian’s obligation is to balance respect for the patient’s right to self- determination with the physician’s Hippocratic oath: “First do no harm. Braun’s case, his request for a peaceful death at home must be reconciled with the reality that discharging him from the hospital will remove him from access to the life support technology that is keeping him alive.

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See Prothrombin time Practice guidelines proven 4 mg montelukast asthma treatment without steroids, 27 trusted 10 mg montelukast asthma 7, 28 islet cell transplant and effective montelukast 10mg asthma expert panel report 3, 733 P Tx. See also Renovascular hypertension, and, 566 Digital rectal surgery and, 33 Purulent peritonitis, 456 examination Resection. See Surgical Pus, postoperative flank pain and, 688 resection management and, 110 Rectum, 446–477. See Review of systems 624 698 Rotator cuff strains, 601 Secretory diarrhea, 470–471 Shaving, wound infection and, Rotator cuff tears, Securing airway, mechanical 108 supraspinatus tendon ventilation and, 92 Shock. See also Serum sodium 51–52 Skin cancer, nonmelanoma, level termination of, 60 management of, electrolytes and, 66 Speed reading skills algorithm for, 546 Sodium concentration mnemonic for, 162 Skin care, lymphedema and, abnormal, 73 surgery clerkship and, 525 changes in, 72–74 160–164 Skin lesion, 527–541 Sodium deficit, 72, 74 Spermatic cord, 483 case studies of, 527–528 Sodium excess, 69 Spermatocele, 699 evaluation of, 529 stress response and, 72 Spider bite, abdominal pain ulcerated, 180, 181 Sodium level. See also Cardiac 420 abdominal pain and, catheterization; Clean Splenomegaly, 418–420 384–385 operative cases; causes of, 419 lower extremity swelling Contaminated surgery Splinting, fracture and, 595 and, 512 cases; Dirty surgery Spontaneous abortion, 399 Stool softeners, fissures and, cases; Electrolyte(s); Sprain 474 Evidence-based surgery; grades of, 591 Streptokinase catheter Fluid; Focused surgical joint capsule and, 590–591 embolectomy, emboli history; Lung resection Sputum culture, hemoptysis and, 685 surgery; Postoperative and, 237 Stress fracture, 592 care; Postoperative Squamous cell carcinoma in Stress response, 63 infection; Preoperative situ. See Total body water open fractures and, 597 hemoptysis and, 234 Technetium bone scanning, penetrating head injury, 584 Swelling, unilateral, 513. See also Tendinopathies, 590 Surgical excision, melanoma Hetastarch Tendon avulsions, 590 and, 537 crystalloid solution v. See Talar neck, displaced fractures and, 405 Wound sepsis of, 617 Throat pain, 286 788 Index Thrombolytic therapy. See Topical drug therapy, burn Transverse fracture, 592 also Anticoagulation wounds and, 628 Trauma. See Cadaveric Traumatic injury cases and, 106 donor(s); Donor; Kidney gastrointestinal bleeding and, Ticlopidine (Ticlid), stroke and, transplantation; Liver 359 314 transplantation; Organ shock following, 121 Tidal volumes, 93 transplantation; Traumatic shock, 121 Timed barium esophagogram, Pancreas transplantation Trauma triage, 550–551 esophageal swallowing Transsphenoidal resection of Triage of resources, 156 disorders and, 206 pituitary gland, Trials, clinical. See Unfractionated upper gastrointestinal benign, 245 heparin bleeding and, 362 of head and neck, 185–189 Ulcer(s). See Transurethral acute epididymitis and, 698 and, 368–370 resection of prostate testis torsion and, 679 Uric acid stones, 673 790 Index Urinalysis V Ventricular septal defect, flank pain and, 689 Vacuum assisted core biopsy, congenital heart disease ureteral injury and, 665, 684 349 and, 261 Urinary calculi, 690 Valve. See also 713 Ventilation, 90 Regurgitation Urine respiratory system and, 91, bilious, neonate and, 648 bilirubin metabolism and, 92 flank pain and, 686 434 Ventilation/perfusion scan gastrointestinal bleeding and, leaks, kidney transplantation (V/Q), embolism and, 360 and, 713 517 intestinal obstruction and, output, renal dysfunction Ventilator modes, 92, 93 401 and, 96 conventional, 94 V/Q. See Venous Uterine disease, pain and, 382 Ventral incisional hernias, 494 thromboembolism Index 791 W testis torsion and, 679 Wound infection. See Wound Warfarin, 13 wound infection and, 103 sepsis emboli and, 519, 520 wounds and, 101 Wound sepsis Watchful waiting, hernias and, Whole blood, 146 kidney transplantation and, 489 Whole organ pancreas 713 Water. Requests to the Publisher for permission should be addressed to the Legal Department, Wiley Publishing, Inc. Trademarks: Wiley, the Wiley Publishing logo, For Dummies, the Dummies Man logo, A Reference for the Rest of Us! For general information on our other products and services, please contact our Customer Care Department within the U. Elliott, PhD, is a clinical psychologist and a member of the faculty at Fielding Graduate University. He is a Founding Fellow in the Academy of Cognitive Therapy, an inter- national organization that certifies cognitive therapists. He has a part-time private practice in Albuquerque, New Mexico, that specializes in the treatment of anxiety and depression. In addition, he has written many articles and book chapters in the area of cognitive behavior therapies. He has made numerous presentations nationally and internationally on new devel- opments in assessment and therapy of emotional disorders. He is coauthor of Depression For Dummies (Wiley), Overcoming Anxiety For Dummies (Wiley), Why Can’t I Get What I Want? Smith, PhD, is a clinical psychologist at the Presbyterian Medical Group, Behavioral Medicine Outpatient Clinic in Albuquerque, New Mexico. She specializes in the assessment and treatment of both adults and children with depression, anxiety, and other emotional dis- orders. In addition, she has presented on cognitive therapy and mental health issues to both national and international audiences. Smith is coauthor of Depression For Dummies (Wiley), Overcoming Anxiety For Dummies (Wiley), Hollow Kids: Recapturing the Soul of a Generation Lost to the Self-Esteem Myth, (Prima, 2001) and Why Can’t I Be the Parent I Want to Be? Dedication We dedicate this book to our kids: Alli, Brian, Grant, Nathan, Sara, and Trevor. And finally to our parents: Edna Louise Smith, Joe Bond Elliott, Tea Elliott, William Thomas Smith (1914-1999), and Suzanne Wieder Elliott (1923–2004). We no longer need to apologize to our family and friends for our neglect; they’re used to it by now! We appreciate the efforts of our agents, Ed and Elizabeth Knappman who have encouraged our pursuits. Thanks also to Elizabeth Deardorf for making our dogs smile in our authors’ picture. Finally, we have been privileged to hear the many stories of suffering, hurt, trauma, hope, recovery, and resilience from our clients over the years. Publisher’s Acknowledgments We’re proud of this book; please send us your comments through our Dummies online registration form located at www.