Endep

By V. Ur-Gosh. Yeshiva University.

No other cranial nerve deficits or motor or sensory deficits are MRI shows a lesion in the optic tract that has spread into a struc- seen purchase endep 10mg on line. Based on its following vessels/segments is most likely involved in this hemor- anatomical relationship purchase 75mg endep with amex, which of the following structures is most rhage? A 19-year-old man presents with significant paralysis of move- plexus, the glomus choroideum. No other deficits are sents the location of this part of the choroid plexus? Suspecting some type of lesion on the root or along the (A) Anterior horn of the lateral ventricle intracranial course of the oculomotor (III) nerve, the neurolo- (B) Atrium of the lateral ventricle gist orders an MRI. Which of the following describes the ap- (C) Body of the lateral ventricle pearance of the subarachnoid and ventricular spaces in a T2- (D) Caudal roof of the third ventricle weighted image? Which of the following represents the most common cause of (C) Light grey blood in the subarachnoid space (subarachnoid hemorrhage)? The MRI of an 11-year-old boy shows a tumor in the pontine por- that have persisted over several months. Which of the following describes lowing structures represents the border between the medullary the appearance of CSF in the ventricular spaces, and consequently and pontine parts of the fourth ventricle? A 71-year-old morbidly obese man is brought to the emergency problems are on the same side of his body. The son reports that the man complained lesion in the anterior lobe of the cerebellum. Which of the fol- of a sudden excruciating headache and then became stuporous. The MRI of a 49-year-old woman with a brain tumor shows ton- sillar herniation. Which of the following cranial nerves exits the brainstem via the lowing portions of the brainstem would be most adversely affected preolivary sulcus? A 4-year-old boy is brought to the emergency department by his neck, and stupor. A lumbar puncture reveals cloudy cerebrospinal mother who explains that the boy fell off a porch onto a concrete fluid from which organisms are cultured. The examination reveals that the boy has a parietal scalp represents the most frequently seen organisms in cases of adult laceration, is stuporous, and has reactive pupils. Which of the following cranial nerves exits the posterior (dorsal) (E) PET (Positron Emission Tomography) aspect of the brainstem? A sagittal MRI of a 52-year-old man clearly shows a small tumor (B) Hypoglossal (XII) in the area of the long and short gyri. These gyri are characteristi- (C) Trigeminal (V) cally found in which of the following lobes? Which of the following cranial nerves passes between the poste- (D) Occipital rior cerebral artery and the superior cerebellar artery as it exits the (E) Parietal brainstem? A lesion involving the root of which of the following nerves would (B) Oculomotor most likely have an effect on the gag reflex? Answer B: Numbness on the face, resulting from a lesion in the the plane of the scan is at the midline. Neither the interventricu- cerebral cortex, indicates a lesion in the lateral one-third of the lar foramen nor the superior colliculus are on the midline. The an- the interpeduncular fossa and the corpus callosum are on the mid- terior paracentral gyrus and the precentral gyrus are somatomotor line, but extend off the midline well beyond the width of the cere- areas of the cerebral cortex. Answer D: Trauma may cause epidural hemorrhage, subdural hemorrhage, or subarachnoid hemorrhage. Answer D: Tic douloureux (trigeminal neuralgia) is a lancinat- orrhage/hematoma will appear white in CT and will usually pre- ing pain that originates from the territories of the trigeminal sent as a comparatively thin but long defect. The trigger zone is fre- will usually be seen as a shorter but thicker lesion and may appear quently around the corner of the mouth.

As individuals become increasingly more isolated endep 10mg on-line, feelings of self- The social effects of substance-related loathing buy endep 50mg lowest price, guilt, and shame may develop. There is a may determine the social implications of strong relationship between substance use substance use. For example, the availabil- disorders and a variety of accidents; motor ity of substances within a group or as part vehicle accidents, for example, can lead to of a social event may determine whether physical disability not only for the indi- or not individuals participate in that vidual with the substance use disorder, but group or event. Thus, the loss of a driver’s The extent of the social tolerance of in- license and more serious criminal charges dividuals’ behavior while intoxicated may are potential effects of substance abuse either curtail or enhance substance use at and/or dependence. As individuals become increasingly sub- uals who become dependent on illegal stance-dependent, however, the substance substances may engage in illegal activities becomes more important and social con- to gain money for the purchase of addi- tacts and activities become less important. Even if they do not face crim- 226 CHAPTER 7 CONDITIONS RELATED TO SUBSTANCE USE inal charges, they can become focused on increases. Physical disability resulting obtaining the drug rather than on func- from substance abuse and/or dependence tioning in a productive social role. In other instances, the loss of these lems that may extend beyond issues of relationships is permanent. Some individual circumstances, therapeutic individuals may need to learn social recovery may involve the development of skills, work-appropriate behaviors, or good new social roles and relationships or the hygiene or grooming practices; some need reestablishment of old ones. Individuals who began abusing substances at an ear- Vocational Issues ly age may not have developed sufficient work skills or work history to obtain In the early stages of a substance-related employment and may require additional disorder, individuals may be concerned education or job training. If they return to that the use of the substance will interfere the same work setting that originally pre- with their work. If substance use progress- cipitated feelings of inadequacy and that es to abuse or dependence, however, con- contributed to the development of sub- cern may be reversed so that individuals stance abuse and/or dependence, return to become more concerned that their work work may increase the risk of relapse. In will interfere with the use of the sub- some cases, learning new skills or coping stance. The substance becomes ultimate- strategies may enable individuals to return ly important, thus drastically affecting successfully to the work setting. Fear restructuring or job change may be nec- that they will lose their jobs if their em- essary. Some occupations require profes- ployers become aware of these indicators sional licensure. Therefore, revocation of may motivate individuals with a sub- individuals’ licenses may limit their abil- stance use disorder to seek treatment. The ability of individuals to return to Many professional licensing boards have their former employment after treatment provisions for the reinstatement of licen- for substance abuse and/or dependence sure after documented rehabilitation. In some the professional license is reinstated, there instances, the stress and tension imposed may be a probationary period in which by the job may be beyond individuals’ tol- individuals’ work performance is closely erance and coping ability. Although Case Studies 227 decisions may be made on a case-by-case addiction, which by then had gone on to basis, such charges and their impact on include heroin. She has been in and out employment in different fields and in dif- of treatment for the past 10 years, and she ferent locations must be considered. As has been drug-free since she became preg- with most disabilities, the attitudes and nant with her son; however, during her concerns of employers must be addressed, drug use she also developed hepatitis C, especially since social stigma is often which is currently in remission. Em- been uneasy about returning to work but ployers may require particular encourage- knows she needs to support her son. Her ment to reinstate or hire individuals who parents live nearby and have offered to have been convicted of criminal charges. How does the diagnosis of hepatitis increasing awareness of substance abuse C affect Ms. What social factors are important to er, individuals may encounter decreasing consider when helping Ms. He com- pleted high school and obtained a job as Case I a yard laborer at a railroad. Her use continued after col- responsibility was to move cars within the lege and intensified after she obtained a yard, where they were then repaired. She alcohol use did not interfere with his work lost her job after 2 years because of her performance initially, although he drank 228 CHAPTER 7 CONDITIONS RELATED TO SUBSTANCE USE heavily after work every day and was a Questions binge drinker with his wife on days off. What ramifications does the diagno- 3 months in a residential treatment facil- sis of Wernicke’s encephalopathy ity, where he was treated for Wernicke’s have for Mr. Treatment of heroin (diamorphine) addiction: Rehabilitation Education, 15(2), 155–165.

These include large jury awards and settlements generic endep 25 mg online, harsh eco- nomic conditions that reduce returns on funds invested by liability insurers buy endep 75mg low cost, a spate of pull-outs and insolvencies among carriers, and a series of catastrophes unrelated to health care that have caused a global contraction in reinsurance capital. However, sailors in the right vessel using proper tactics can ride out even the most severe weather. A properly designed liability system that reduces the incidence of medi- cal error, limits unnecessary monetary and psychic costs associated with redressing injury, and bears residual insurance risk efficiently would have much greater resilience in troughs of the insurance cycle than the structures and processes currently being used. Unfortunately, the storm analogy—which is used to convey the gravity of the current predicament—carries with it a sense of helplessness as well. There- fore, most malpractice reform proposals at most try to steer flimsy craft into (hopefully) calmer waters. Relatively little attention is paid Chapter 17 / New Directions in Liability Reform 249 to re-engineering the system to survive harsh conditions, although forecasts for the future remain rather bleak. In other words, time and tide have changed both the medical mal- practice problem and its range of potential solutions. Yet the evolution of the health care system since the malpractice crisis of the 1980s has gone unrecognized by policymakers and partisans where liability is concerned. Doctors and Lawyers One can identify several possible explanations for the failure of the political process to integrate liability policy with overall health policy. From the perspective of doctors and lawyers—the key stakeholders in the continuing battle over tort reform—the implications of changing the health system muddy the “message” of their campaigns. As the health care system becomes more complex, so too does the liability system. Because the added complexity does not cut clearly in favor of or against measures such as caps on noneconomic damages, neither side gains advantage by addressing it. In addition, the current heads of professional associations on both sides (i. It is not surprising that many of them see the current crisis through the lens of their earlier experiences or that they attach great importance to winning the unfinished battles of their youths. Government Structure For health care regulators, medical liability remains sui generis. The inherent power of the judicial branch of government to dictate civil procedure, coupled with decentralization and lack of transpar- ency in the private litigation process, segregates liability from other health regulatory concerns and gives it a distinctly “legal” flavor that discomfits nonlawyer bureaucrats. Health policy is also made at the federal level to a larger extent now than in 1975 or 1985, whereas malpractice is still primarily a creature of state law. In many respects, Medicare policy has become health policy, and liability issues are essentially invisible in Medicare and other federal health programs. Politics For federal and state legislators and the political parties they repre- sent, medical liability is a reliable source of campaign contributions, 250 Sage giving them a vested interest both in continuing the contest and in divorcing liability from other health care issues. The longstanding nature of the legislative standoff has bred specialization among lobby- ists for the key organizations, which often is reinforced by legislative rules vesting jurisdiction over civil litigation in judiciary committees that handle few other health care matters. Most significantly, the politi- cal importance of medical malpractice reform extends far beyond its impact on the health care system. One of the largest political questions under active debate in the United States deals with how personal injury lawsuits affect our economy and our social fabric. Business interests, corporate law firms, and the Republican Party view personal injury claims as costly and destructive, whereas organized consumer inter- ests, the trial bar, and the Democratic Party consider recourse to litiga- tion a last line of defense for individual rights in postindustrial society. Because of its emotional resonance with voters and its grassroots con- stituencies, malpractice reform is an attractive “poster child” for (and sometimes against) general tort reform. When malpractice premiums rise rapidly (as they are rising now), tort reformers bottle physician anguish for sale to the voting public. When premiums are stable, tort supporters try to peel physicians (and their patients) away from large business interests, as occurred during the decade-long debate over the right to sue HMOs for physical injury as part of a federal “patient protection act. Accordingly, most of what we know about the malpractice system derives from studies conducted during the crises of the 1970s and 1980s. In many cases, these findings have radically altered policy experts’ understanding of the malpractice system.