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Steps must be taken to prevent hoarding and then overdosing at a later date cheap 1 mg arimidex fast delivery menstruation bright red blood. The patient must understand in advance the physician’s policy regarding lost pre- scriptions and drugs destroyed by the dog or flushed down the toilet or stolen from a woman’s purse buy 1 mg arimidex with amex women's health lexington ky. Some drugs that patients are permitted to refill require close monitoring. If a patient fails to comply with monitoring instructions, the privilege to refill may have to be withdrawn. Finally, there must be systems in place to warn patients of drug recalls. Procedures It is clearly a breach of the standard of care for physicians or their assistants to perform procedures for which they are not adequately trained. In one case, a woman’s face was badly scarred by a physician who was trained in the use of a laser by a salesperson. Soft tissue injections around the scapula or into an intercostal muscle have perforated lungs. Joint injections by those not properly trained have caused destructive septic arthritis. These and similar misadventures have led to lawsuits that are very difficult to defend. The Language Barrier The problems related to language barriers are well known to phy- sicians. Patients with limited English skills cannot be denied health care or in any way be discriminated against by health care providers. In 2000, President Clinton issued Executive Order 13166, requiring equal access to federally funded health care services for patients with limited English proficiency. A language barrier will probably not shield a physician from allegations of negligence. In one recent case, a physician failed to diagnose a subarachnoid hemorrhage because he could not understand the history of onset or severity of a headache. Interpreters on the telephone or, bet- ter still, in the office are invaluable. Before discharging a patient, a physician should be certain that he or she understands the medical problems and that the patient understands the necessary advice and follow-up. SUMMATION At any given time, 15–20% of physicians are defendants in malprac- tice lawsuits. The average lawsuit takes more than 3 years from incep- tion to resolution. The experience can destroy a physician’s health, family relationships, standing in the community, self-confidence, and financial security. There have even been suicides where objective evaluation indicated that the physician was not guilty of wrongdoing. Risk managers have been criticized for advising strategies that are too time-consuming. New laws, rules, and court decisions continue to create additional responsibilities and risks for physicians. Finally, it should be kept in mind that a family physician’s best friends in a malpractice lawsuit are the contemporaneous, thoughtful, clearly written medical record and a supportive, competent, caring nurse. Chapter 9 / Emergency Medicine 101 9 Emergency Medicine Michael Jay Bresler, MD, FACEP SUMMARY This chapter reviews some general medical and legal principles, most of which are important regardless of medical specialty. They are particularly relevant to emergency physicians but are also important to physicians from other specialties who treat patients in the emergency department (ED). I then discuss some specific emergency medical conditions that often result in litigation. The topics presented are not meant to be an exhaustive list of potential liability problems, but rather a sample of some of the more com- mon issues that confront physicians and their patients. Key Words: Emergency; emergency medicine; emergency depart- ment; medical-legal; risk management. Emergency physicians revel in the excitement, chaos, and challenge presented by emergency patients. Unfortunately, we are also appreciated by another class of people—plaintiff attor- neys.

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Details of the cerebral arterial cir- brainstem buy arimidex 1 mg mastercard menstruation hormones, and cerebellum effective 1mg arimidex menstruation synchronization, which shows the arterial patterns created cle and the vertebrobasilar arterial pattern are shown in Figure 2-21 on by the internal carotid and vertebrobasilar systems. Gyri and sulci can be identified by compari- of the cerebral arterial circle and its major branches. Superior ophthalmic vein –from area of ophthalmic artery Sphenoparietal sinus –middle cerebral vein Cavernous sinus –cerebral vein Superior petrosal sinus Intercaverous sinuses –cerebellar veins –inferior cerebral veins –tympanic veins Inferior petrosal sinus Basilar plexus –veins of pons and medulla –auditory veins Sigmoid sinus Internal jugular vein Transverse sinus Anterior vertebral –emissary veins venous plexus –inferior cerebral veins –inferior cerebellar veins Occipital sinus –posterior internal vertebral Sinus confluens venous plexus –straight sinus –superior sagittal sinus 2-19 Ventral view of the cerebral hemispheres, diencephalon, principal sinuses and veins. The listings preceded by a dash (–) under brainstem, and cerebellum showing the locations and relationships of principal sinuses are the main tributaries of that sinus. Lateral to the internal carotid bifurcation is the brain structures and cranial nerves to the arteries forming the verte- M1 segment of the middle cerebral artery (MCA), which divides and brobasilar system and the cerebral arterial circle (of Willis). The terior spinal artery usually originates from the posterior inferior M3 branches of the MCA are those located on the inner surface of the cerebellar artery (left), but it may arise from the vertebral (right). Between the basilar bifurcation and the posterior com- basilar (right), it most frequently originates from the anterior infe- municating artery is the P1 segment of the posterior cerebral artery; rior cerebellar artery (left). Many vessels that arise ventrally course P2 is between the posterior communicator and the first temporal around the brainstem to serve dorsal structures. The cere- structures and cranial nerves on the ventral aspect of the thalamus and bellum and portions of the temporal lobe have been removed. Anterior cerebral artery Olfactory tract Medial olfactory stria Optic nerve Lateral olfactory stria Optic chiasm Anterior perforated substance Optic tract Infundibulum Mammillary body Posterior perforated substance Crus cerebri Trochlear nerve Basilar pons Lateral geniculate body Trigeminal nerve Medial geniculate body Abducens nerve Middle cerebellar peduncle Facial nerve Vestibulocochlear nerve Pyramid 2-23 View of the ventral aspect of the diencephalon and part of the Note structures of the hypothalamus, cranial nerves, and optic struc- brainstem with the medial portions of the temporal lobe removed. The Brain: Gross Views, Vasculature, and MRI 27 Fornix Choroid plexus, third ventricle Optic tract Posterior choroidal arteries Thalamogeniculate artery Lateral geniculate body Dorsal thalamus Posterior cerebral artery Mammillary body Medial geniculate body Quadrigeminal artery Superior colliculus Posterior communicating artery Crus cerebri Internal carotid artery Brachium of inferior colliculus Oculomotor nerve Inferior colliculus Superior cerebellar artery Trochlear nerve Trigeminal nerve Motor root Sensory root Superior cerebellar peduncle Anterior medullary velum Basilar artery Middle cerebellar peduncle Anterior inferior cerebellar artery Vestibulocochlear nerve Labyrinthine artery Facial nerve Abducens nerve Posterior inferior cerebellar artery Glossopharyngeal nerve Choroid plexus, Vagus nerve fourth ventricle Hypoglossal nerve Restiform body Accessory nerve Cuneate tubercle Gracile tubercle Posterior inferior cerebellar artery Posterior spinal artery Anterior spinal artery Vertebral artery 2-24 Lateral view of the brainstem and thalamus showing the rela- tively, are shown as dashed lines. Compare with Figure 2-22 on the fac- tionship of structures and cranial nerves to arteries. Compare to Figure 28 External Morphology of the Central Nervous System Anterior paracentral gyrus (APGy) Central sulcus (CSul) Paracentral sulcus (ParCSul) Posterior paracentral gyrus (PPGy) Precentral sulcus (PrCSul) Marginal sulcus (MarSul) Precuneus (PrCun) Cingulate gyrus (CinGy) Superior frontal gyrus (SFGy) Parieto-occipital sulcus (POSul) Cingulate sulcus (CinSul) Cuneus (Cun) Calcarine sulcus (CalSul) Lingual gyrus (LinGy) Sulcus of corpus callosum (SulCC) Isthmus of cingulate gyrus Paraterminal gyri Occipitotemporal gyri Parolfactory gyri (ParolfGy) Parahippocampal gyrus Temporal pole Uncus Rhinal sulcus APGy PrCSul CSul PPGy ParCSul MarSul SulCC CinGy PrCun CinSul POSul ParolfGy Cun CalSul LinGy SFGy MarSul Corpus callosum POSul CalSul Colloid cyst Internal cerebral vein 2-26 Midsagittal view of the right cerebral hemisphere and dien- A colloid cyst (colloid tumor) is a congenital growth usually dis- cephalon, with brainstem removed, showing the main gyri and sulci covered in adult life once the flow of CSF through the interventricular and two MRI (both T1-weighted images) showing these structures foramina is compromised (obstructive hydrocephalus). The lower MRI is from a patient with a may have headache, unsteady gait, weakness of the lower extremities, small colloid cyst in the interventricular foramen. When compared to visual or somatosensory disorders, and/or personality changes or con- the upper MRI, note the enlarged lateral ventricle with resultant thin- fusion. The Brain: Gross Views, Vasculature, and MRI 29 Internal frontal branches Paracentral branches Callosomarginal branch of ACA Internal parietal branches Parietooccipital Pericallosal branch branches of PCA of ACA Frontopolar branches of ACA Orbital branches of ACA Anterior cerebral artery (ACA) Calcarine branch of PCA Posterior temporal branches of PCA Posterior cerebral artery (PCA) Anterior temporal branches of PCA 2-27 Midsagittal view of the cerebral hemisphere and dien- to serve medial regions of the frontal and parietal lobes, and the same cephalon showing the locations and branching patterns of anterior and relationship is maintained for the occipital and temporal lobes by posterior cerebral arteries. The positions of gyri and sulci can be ex- branches of the posterior cerebral artery. Inferior sagittal sinus Posterior vein of corpus callosum Superior sagittal sinus Internal occipital veins TV Veins of the caudate nucleus Straight sinus Septal veins Sinus confluens Transverse sinus Superior Anterior cerebral vein cerebellar vein Occipital Basal vein sinus Great Internal cerebral vein cerebral vein 2-28 Midsagittal view of the cerebral hemisphere and dien- (facing page). See cephalon that shows the locations and relationships of sinuses Figures 8-2 (p. The MRI (T1- weighted image) shows many brain structures from the same perspec- tive. The Brain: Gross Views, Vasculature, and MRI 31 Body of fornix (For) Dorsal thalamus (DorTh) Septum pellucidum (Sep) Massa intermedia Choroid plexus of third ventricle Interventricular foramen Stria medullaris thalami Column of fornix Habenula Anterior commissure (AC) Suprapineal recess Lamina terminalis Posterior commissure Pineal (P) Supraoptic recess Superior colliculus (SC) Optic chiasm (OpCh) Quadrigeminal HythHyth cistern (QCis) Inferior colliculus (IC) Optic nerve Cerebral aqueduct (CA) Anterior medullary velum (AMV) Fourth ventricle (ForVen) Infundibulum (In) Infundibular recess Mammillary body (MB) Hypothalamic sulcus Posterior inferior Oculomotor nerve cerebellar artery Interpeduncular fossa (IpedFos) Medulla Basilar pons (BP) For DorTh Sep Internal cerebral vein P AC Tentorium cerebelli Hypothalamus QCis OpCh SC In IC Pituitary gland AMV MB ForVen IpedFos BP CA 2-30 A midsagittal view of the right cerebral hemisphere and di- image) shows these brain structures from the same perspective. Hyth encephalon with the brainstem in situ focusing on the details primarily hypothalamus. The MRI (T1-weighted 32 External Morphology of the Central Nervous System A D Midbrain Anterior quadrangular Anterior lobule lobe (AntLb) Posterior quadrangular lobule Posterior Primary superior fissure fissure E Superior semilunar Hemisphere lobule Bpon Vermis (Ver) AntLb SCP B Fourth ventricle Basilar pons (Bpon) Medulla (Med) Flocculus (Fl) Tonsil (Ton) F Biventer lobule Gracile Med lobule Ton Inferior semilunar PostLb lobule Hemisphere Vermis (Ver) Ver C Colliculi: Anterior Superior Cerebellar peduncles: lobe (AntLb) Inferior Superior (SCP) G Middle (MCP) Inferior Primary fissure AntLb Horizontal MCP fissure Fl Flocculus (Fl) Posterior Tonsil (Ton) lobe (PostLb) Nodulus Med PostLb 2-31 Rostral (A, superior surface), caudal (B, inferior surface), with cerebellar structures seen in axial MRIs at comparable levels (D, and an inferior view (C, inferior aspect) of the cerebellum. Structures seen on the inferior surface of the cerebellum, such as in C shows the aspect of the cerebellum that is continuous into the the tonsil (F), correlate closely with an axial MRI at a comparable level. The view in C correlates with su- In G, note the appearance of the margin of the cerebellum, the general perior surface of the brainstem (and middle superior cerebellar pe- appearance and position of the lobes, and the obvious nature of the duncles) as shown in Figure 2-34 on page 34. Note that the superior view of the cerebellum (A) correlates closely The Brain: Gross Views, Vasculature, and MRI 33 A B II,III V II,III IV I V Midbrain (Mid) Primary fissure (PriFis) PriFis Basilar pons (Bpon) VI Mid VII VII Fourth Bpon ventricle (ForVen) ForVen Medulla Med VIII (Med) VIII X X IX IX Posterolateral fissure (PostLatFis) II,III IV V C PriFis Mid VI Bpon VII ForVen Med X IX VIII 2-32 A median sagittal view of the cerebellum (A) showing its re- Lobules I-V are the vermis parts of the anterior lobe; lobules VI-IX lationships to the midbrain, pons, and medulla. This view of the cere- are the vermis parts of the posterior lobe; and lobule X (the nodulus) bellum also illustrates the two main fissures and the vermis portions of is the vermis part of the flocculonodular lobe. Designation of these lobules follows the method devel- larities between the gross specimen (A) and a median sagittal view of oped by Larsell. Peduncles Middle cerebellar Superior cerebellar Inferior colliculus Trochlear nerve Flocculus Crus cerebri Trigeminal nerve: Sensory root Motor root Basilar pons 2-33 Lateral and slightly rostral view of the cerebellum and brain- relative positions of, and distinction between, motor and sensory roots stem with the middle and superior cerebellar peduncles exposed. See page 40, Figure 2-41D for an MRI show- the relationship of the trochlear nerve to the inferior colliculus and the ing the trochlear nerve.

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