Ref When The Human Body Case Study
ST PATRICKS INTERNATIONAL COLLEGE
School of Health and Social Care
PHYSIOLOGY
Table of contents Page
Introduction 1
Learning outcome 1 1-8
1.1
1.2
Learning outcome 2 9-11
2.1
2.2
2.3
Learning outcome 3 12-15
3.1
3.2
3.3
Learning outcome 4 16-17
4.1
4.2
4.3 …show more content…
References 18
Introduction
Physiology is the consideration of operative systems of the human body and how these systems interact with each other to help the body to function and maintain the body’s growth. “Physiology is the study of how the body systems work, and the ways in which their integrated activities maintain life and health in the individual” (A.Waugh et al 2010 p.10)
LO1
The human body is made up of several functional systems:
The central nervous system consists of the brain, the spine, the nerves, the eyes, mouth, skin, nose and neurons, its function is to gather information from the sensory organs and send it to the brain. The information will then be analysed by the brain and appropriate action will be taken in the form of muscles or organs.
The cardio vascular system or circulatory system consists of heart, veins, arteries, blood including capillaries carrying the blood, the capillaries carrying blood in arteries carry blood with oxygen while the capillaries inside the veins carry blood with carbon dioxide. The function of the cardio vascular system is to pump and circulate blood and nutrients around the body, bringing blood with carbon dioxide back to the heart. It also transports hormones to distant parts of the body and temperature regulation.
The respitory system consists of lungs, bronchi, trachea, diaphragm, intercostal muscles, bronchioles, alveoli and the mouth, its function is to take in oxygen and let out carbon dioxide. Every time an individual breathes in the air enters the nose where it is first filtered by the nasal hair and its temperature is raised to body temperature, this air then travels downwards into the trachea, through the trachea it then enters the left and right bronchi, these bronchi divide into smaller tubes called bronchioles. The air then travels through the bronchioles and is collected into the alveoli, which are tiny air bags, this is where the gas exchange takes place, the alveoli give their oxygen to the blood and collect carbon dioxide in return. At this point the carbon dioxide makes its way upwards into the bronchioles, then enters the bronchi, passes through the trachea and enters the nose where it is expelled from the body. The respitory system also regulates the PH of the blood.
The digestive system or gastrointestinal system consists of teeth, tongue, the oesophagus, stomach, salivary glands, small intestine, large intestine and bowel. The function of the digestive system is split into two parts, mechanical digestion which takes place in the mouth and chemical digestion which takes place in the stomach. After this the bolus (food) passes into the small intestine where nutrients are absorbed from it, the large intestine is responsible for accumulating the waste products and absorbing any nutrients still left in the bolus. The waste is then stored in the bowel until it is full, it is then released from the body through the anal opening.
The urinary system consists of kidneys, ureter, bladder and urethra, its function is to clear the body of waste and access nutrients in the urine. The kidneys clear the blood of waste materials and access nutrients, these waste materials and excess nutrients are mixed with urine and proceed towards the bladder through the ureter, a tube that leads from each kidney down to the bladder. The urine is then stored in the bladder until it is full, at this time the urine is released through the urethra.
The reproductive system is divided into two parts; the male reproductive system consists of the penis, testes, scrotum, ejaculatory fluid and semen. Its function is to produce and store semen; it also facilitates the transport of semen into the female reproductive system. The female reproductive system is made up of labia major, labia minor, vagina, uterus, fallopian tubes, ovaries, ovum and breasts. The function of the female reproductive system is the production and storage of ovum and also fertilisation of the semen and the ovum inside the uterus. This system is also responsible for the changes in breasts during pregnancy and the production of breast milk.
The muscular skeletal system is made up firstly of two hundred and six bones and is divided into two parts. The axial skeleton which is the central part is formed of the skull, spinal cord and chest bones; it is made up of eighty bones. The appendicular skeleton is attached to the axial skeleton and consists of shoulders, arms, pelus and legs it is made up of one hundred and twenty six bones. The function of the skeletal system is to provide support for the body and protection to the internal organs they also produces red blood cells, white blood cells, platelets, and b cells in the bone marrow and store minerals like calcium and magnesium. The muscular skeletal system is also made up of nearly six hundred and fifty muscles of which there are three types, skeletal muscles are found lining the bones and joints these muscles are voluntary meaning that they can be moved and controlled at will. Smooth muscles line the organs and are involuntary meaning that they contract on their own and can not be controlled consciously, finally cardiac muscles form the heart and are involuntary. The main function of muscles is to facilitate movement.
The endocrine system consists of endocrine glands which produce and secrete hormones which are chemical messages. Some of the major endocrine glands found in the human body are the pituitary gland, which is the most important one and is located in the brain. The thyroid gland which is located in the neck near the pharynx, the para thyroid gland which is located inside the thyroid gland, the pancreas which are located near the lower part of the stomach. The adrenal glands which are located on top of each kidney and the gonads which in males are the testes and in the female are ovaries. The function of the endocrine system is related to things like growth, glucose regulation and development of sexual features.
The integumentary system consists of skin, nails and hair. The skin has many functions, to regulate body temperature, assisting in breathing, excretion of waste materials through sweat and keeping the body impervious by releasing a layer of oil on its surface known as sebum. The skin assists in us feeling sensations such as touch, pressure, pain and temperature and also in vitamin D production and synthesis. The function of nails is to protect the fingertips from mechanical injury and the function of hair is insulation from cold and also to prevent dust particles from entering the body.
The immune system consists of white blood cells, B cells, and T cells the function of this system is to protect and defend the body from infection and illness. The body has three lines of defence, the first line of defence is consists of hair, nails and mucus membrane. The second line of defence is a fever and inflammation, the third and final line of defence is formed of B cells and T cells. The function of B cells is to identify the bacteria and viruses from the healthy cells and mark them; the function of T cells is to then eliminate the bacteria and viruses. If this line is broken then the individual will ultimately die.
Homeostasis is the maintenance of a balanced or steady state in the human body; the elements that need to be balanced are temperature, water, oxygen and carbon dioxide, ions, urea, nutrients and blood pressure. Negative feedback is when the body will fight to correct any change to any of these elements, positive feedback is when the body will not fight to correct any changes to any of its elements. Positive feedback is dangerous for the survival of human cells. These functional systems interact with each other so that the body can grow and function properly:
Regulation of blood glucose level in the body
When a high level of sugar is consumed the blood glucose level becomes high, the brain detects this high level of glucose and sends a message to the pancreas, telling it to release a hormone called insulin. The insulin converts the glucose into glycogen which it stores in the body; this reduces the blood sugar level. When engaging in strenuous physical activity over a continuous period of time, oxygen will not be enough to provide the body with energy. The brain will send another message to the pancreas this time telling it to release a hormone called glucagon; glucagon converts the glycogen back into glucose, increasing the blood sugar level. The glucose is then sent back into the blood, the blood carries it to the muscles and the muscles use it to produce energy. This is how the nervous, endocrine and circulatory systems interact with each other to regulate blood glucose levels.
Regulation of oxygen and carbon dioxide levels in the body When the body engages in strenuous physical activity that it is not used to, it loses a lot of oxygen until the oxygen level in the body is too low and the carbon dioxide level too high. This is a dangerous state for the body to be in as the balance is disturbed. When this happens the brain sends a message to the lungs, telling them to breathe faster so as to eliminate carbon dioxide at a fast pace. As soon as the carbon dioxide level is reduced and the oxygen-carbon dioxide balance regained, the lungs will go back to breathing at a normal pace. On the other hand, if a person is ill or bedridden for a few weeks or months, the oxygen level in the body rises. When this happens the brain sends a message to the lungs, this time telling them to slow down the breathing pace. This slower breathing will retain carbon dioxide in the body for a longer period of time. As soon as the balance between oxygen and carbon dioxide is regained the lungs start breathing normally again. This is how the nervous and respiratory systems work together to regulate oxygen and carbon dioxide levels in the body.
Regulation of water level in the body When the human body is exposed to temperatures higher than the normal body temperature of 37 C the sweat glands start to generate sweat to cool the body down.
This reduces the body water level and is dangerous for the survival of the cells; therefore the cells send a message to the brain. The brain analyses the situation and sends a message to the pituitary gland asking it to release a hormone called ADH (anti-diuretic hormone). ADH is in fact a message to the kidney, telling it to absorb water from the blood and send it back to the cells. After it has refilled the water level, the brain tells the pituitary gland to stop sending ADH to the kidney as there is no more need for water. On the other hand, if an individual has too much intake of fluids, the brain will make sure that the pituitary gland does not send ADH to the kidney. In the absence of ADH the kidney will not absorb any water but excrete it out in the form of urine. This is how the nervous, endocrine, urinary and circulatory systems interact with each other to regulate the water levels in the
body.
Regulation of temperature in the body
Also when the body is exposed to a temperature higher than the normal temperature of 37 C the skin is the first sensory organ to receive the message of rise of temperature. The same message is then passed on to the brain, where the brain analyses it. The brain then sends two messages, the first one to the sweat glands telling them to start sweating to cool down the body. The second message is sent to the veins telling them to enlarge; these enlarged veins are very close to the skin and carry more blood in them than usual. They cause heat to be quickly lost to the environment and so the body cools down faster. As soon as the normal temperature is reached sweating stops and veins go back to their normal size. When the body is exposed to much lower temperatures than normal the brain then sends out three messages, the first messages is sent to the pores telling them to close. The second message is sent to the veins telling them to narrow, as the veins get narrow and less blood flows through them, causing less heat to be lost to the environment and more heat to be retained in the body. The third message is sent to the muscles telling them to start shivering; the friction from this produces more heat. When the normal body temperature is reached the pores in the skin open back up, the veins go back to their normal size and the muscles stop shivering. This is how the nervous, integumentary, circulatory and musculo-skeletal systems interact to regulate body temperature.
LO2
This case study is about a twenty five year old individual who is planning to take part in a marathon in due course of time. Therefore this essay will discuss the effects of exercise on three functional systems in the human body the respiratory system, the cardiovascular system and the muscle-skeletal system.
Cardiovascular system:
The cardiovascular system is responsible for the circulation of oxygen and nutrients around the body, bringing blood with carbon dioxide back to the heart, transporting hormones to distant parts of the body and regulating body temperature. When the body is subjected to a moderate amount of exercise it has many affects on this system:
Heart rate raises from its normal state of 60-80 beats per minute to 150-220 beats per minute, when exercising on a regular basis heart rate will stabilize at 20-40 beats per minute.
Stroke volume is the amount of blood leaving the left ventricle per heartbeat, the immediate effect of exercise on stroke volume is to raise it up from 50-70 mls per beat to 110-130 mls per beat. When exercising on a regular basis stroke volume is raised to 150-200 mls per beat.
Cardiac output is the total amount of blood leaving the heart per minute, when exercising the amount of blood leaving the heart is increased from 5 litres per minute to 8-10 litres per minute. Regular exercise increases cardiac output to 20-40 litres per minute.
Blood pressure is the pressure applied by the blood on the walls of the arteries; it is raised from its normal rate of 120/80 mm hg to 140/90mm Hg during exercise. Regular exercise will raise blood pressure to 250/110mm Hg.
Blood flow to skeletal muscles is the amount of blood flowing through the working muscles, when the body is resting 20% of the total amount of blood in the body is flowing through the skeletal muscles. When the body is subjected to intense physical activity 80% of the total amount of blood in the body is flowing through the skeletal muscles.
Exercise affects the organs of the cardiovascular system differently; the muscles of the heart become thicker and stronger and the heart becomes more efficient in transporting oxygen and nutrients to the body. The arteries and veins enlarge in size to transport blood more efficiently and at a more rapid pace. Capillaries increase in number and the blood volume also increases.
The body temperature also rises during exercise; it rises above normal body temperature which is harmful for the survival of body cells. When this happens the brain sends a message to the sweat glands to start sweating and a message to the veins to enlarge in size all in an effort to cool the body down.
Respiratory system:
The functions of the respiratory system are taking in oxygen and expelling carbon dioxide and also regulating oxygen and carbon dioxide levels in the body. When the body is subjected to intense physical activity it has many effects on this system;
Respiratory rate is the number of breaths taken in and expelled out per minute; it is raised from its normal level of 12-18 breaths per minute to 20-30 breaths per minute during exercise. Respiratory rate stabilizes at 15-20 breaths per minute when exercising regularly for a prolonged period of time.
Tidal volume is the amount of air moving in and out of the lungs in one breath, the normal rate is 0.5-1 litre per breath increased 2-3 litres per breath during exercise. Tidal volume is further increased to 5-6 litres per breath with regular prolonged exercise.
Vital capacity is the maximum amount of air that can be expelled out after maximum inhalation; the normal rate is 2-3 litres which are increased to 8-10 litres during exercise. Vital capacity is further increased to 15-20 litres as a result of regular prolonged exercise.
The organs in the respiratory system are affected by exercise in different ways, the lungs expand and their overall capacity increases. The lungs assist in gas exchange more efficiently and eliminate carbon dioxide at a more rapid rate. The number of alveoli in the lungs increases which in turn increases the overall capacity of the lungs, enabling the lungs to hold more air in them making them more efficient. The muscles of respiration like diaphragm (abdominal) and intercostals (chest) increase in strength, which further assists in contraction and expansion of the lungs.
Musclo-skeletal system:
The functions of the musclo-skeletal system are to assist movement of the body, to support the structure of the body, to protect internal organs, to provide scaffolding for the body to grow, storage of calcium and other vital minerals and to assist in the production of red blood cells, white blood cells, platelets and b cells.
The immediate effects of exercise on the musclo-skeletal system are pain, tenderness, fatigue, strain, stress fractures inflammation and swelling and also a slow recovery rate. After consistent exercise over a long period in time the muscles become bigger and stronger as the size of the muscle fibres increase, muscles carry more oxygen and nutrients inside them, the development of slow twitch fibres (which produce more power and less speed) and fast twitch fibres (which produce more speed less power) occurs, bones become stronger due to more concentration of calcium and minerals, bones become less prone to fracture, the flexibility of muscles, tendons and ligaments increases, muscles become more efficient in producing energy, fatigue sets in later and the body has a faster recovery rate.
So these are the ways that intense physical activity affects these specific functional systems of the body.
LO3
This case study is about a 65 year old individual who is obese and is currently suffering from fever; therefore this essay will explain the two conditions and also the clinical tests and support measures for them.
Influenza is a condition resulting from a virus which affects the respiratory system; it spreads through the air and through touch. The signs and symptoms of influenza can range from high fever, runny nose, sore throat, coughing and tiredness to chest congestion, loss of appetite, dehydration, nausea and vomiting and general aches and pains in the body.
1. The first thing to do when testing a patient for influenza is to take their medical history, this is very important as it provides vital information about the individuals past and present medical conditions, allergies, medication history as well as work schedule, occupation and daily activities.
2. The next thing to do would be to record the patients temperature, this is very important as it is an essential component to know if the body is suffering from infection. Fever is also the second line of defence and the high temperature will either kill or contain the virus. Temperature can be measured using a chemical thermometer; there are various sites on the body used to do this including the mouth, ears, armpits, inner elbow and rectum.
3. Recording pulse and respiratory rate is vital as it provides essential information regarding the condition of the vital organs like heart and lungs during infection. Respiratory rate can be measured by simply observing the movement of the chest while the patient is breathing. Pulse rate can be measured using the index and middle fingers placed on the inner wrist in line with the thumb with the palm facing upwards. There are other sites on the body used for measuring pulse such as the inner part of the neck near the windpipe, also the inner part of the elbow and ankle joints.
4. Blood pressure also forms one of the vital parameters that need to be measured to check the condition of the body. As it measures the pressure of the blood applied to the artery walls and signifies the stress that the heart is currently undergoing during infection. Blood pressure is measured using a device known as a sphygmomanometer or blood pressure apparatus. It consists of a pressure cuff, a pressure pump and a stethoscope.
5. Blood tests can be taken, they will provide information about the presence of virus in the blood stream and the number of white blood cells in the blood will also indicate the ability of the body to fight off the virus. WBC count is generally very high in response to infection in a healthy human being, but as this individual is aged and obese this will lower his immunity and this may cause the virus to proceed and develop into pneumonia. A blood test is performed by inserting a syringe into the vein and extracting the blood, then sending it off to the lab for analysis. The main site on the body for extracting blood is the inner part of the elbow; the other less common site is the back of the hand. A chest X-ray provides information regarding the consolidation of the virus inside one or both of the lungs.
6. The chest x-ray is performed using an x-ray machine and the chest is x-rayed from different angles; antero-posterior (from the front), postero-anterior (from the back) and oblique (from the side), to cover the lungs from all possible angles.
7. Rapid Influenza Diagnostics Test (RIDT) is used for detecting influenza virus strains in the blood and to establish a cause for infection as flu. A swab is taken from the back of the throat and sent off for analysis, the lab report can be obtained within thirty minutes; establishing the presence or absence of the virus.
8. A Computerised Tomography (CT scan) will provide clear images of the infection in the lungs, these images will be used by the operating surgeon to pinpoint the site of infection and operate upon it. CT scan is carried out by putting the body of the individual into the scanning machine so that images of the whole body can be produced from all possible angles multiple times.
9. Breath sounds are auscultated and recorded to establish the presence of infection in the throat and lungs and also to roughly judge the extent of the spread of infection. A stethoscope is used to listen to abnormal breath sounds.
10. Throat examination will also establish the presence of the virus as it makes the throat go red and inflamed. The inside of the throat is observed with the assistance of a high power low beam torch and a tongue depressor.
There are different measures which can be taken to counter influenza; these include a healthier diet and plenty of fluids to give the body nutrients and vitamins. The patient will also need plenty of rest so that the body can recover antibiotics to help kill the infection and isolation to prevent the virus from spreading to others.
Obesity is the excess accumulation of fat in the body, there are many different causes ranging from alcoholism, lack of physical activity and bad diet (high intake of cholesterol, salt and sugar) to psychological stress, medication, hypothyroidism or it being hereditary. There are different clinical tests for obesity:
1. Recording medical history for obesity will provide information regarding past and present medical conditions affecting the individual.
2. Measuring weight and height is important as they form essential components for measuring BMI of the patient. Weight is measured using an analog or electric scale and height is measured using a measuring tape or a scale fixed to the wall.
3. BMI (Body Mass Index) is used to measure the amount of fat as opposed to muscles and bones. The formula used to calculate BMI is: BMI=WEIGHT/HEIGHT 2x703, a BMI of 18.5 and lower means the individual is underweight and a BMI of 30 and above means the individual is obese.
4. Measuring waist circumference is important as the waist is the main site in the body where most fat is accumulated. An individual is considered to be obese when their waist circumference is between 37-40 inches for a man and 31-35 inches for a woman.
5. Measuring and recording blood pressure is essential in this case as the patient is a known case of obesity and might have an excess fat deposition inside his major arteries supplying the heart. Measuring and periodic recording of BP is necessary to check the condition of the heart. BP is measured using a sphygmomanometer, but can also be measured using a new device which is much smaller in size and less complicated; it consists of a monitor and a wrist band.
6. Blood tests will provide information about the amount of cholesterol, glucose and Thyroid Stimulating Hormone (TSH) in the blood. Blood test is performed by extracting blood from a vein with a syringe.
7. A urine test will provide information about functioning of the kidneys and measure excess amount of glucose in the urine. A urine test is carried out by collecting a specimen of urine in an enclosed disposable bottle and sending it off for analysis.
8. Basal Metabolic Rate (BMR) is the amount of calories spent by the body when it is at rest. This energy is required for sustaining and providing nutrition to the vital organs of the body including the heart, lungs and liver, even when the individual is resting.
9. Electro Cardio Graph/Gram (ECG) is used foe assessing the condition of the heart and also to detect any underlying condition that has gone previously undetected or does not present any signs or symptoms. ECG is recorded using an ECG machine and electronic leads which are connected to the chest, arms and legs of the patient. These leads collect signals from different parts of the body and send them back to the ECG machine; the machine then exhibits these signals in the form of a graph which can be interpreted by the physician or surgeon operating on the patient.
10. A stress test is used to detect any underlying condition affecting the heart and also to assess how much stress the heart can bear when exposed to strenuous physical activity. A stress test is performed by attaching ECG leads to the chest and asking the patient to walk on a treadmill or static cycle. The vital parameters like heart rate, blood pressure and respiratory rate are constantly monitored throughout the duration of the test. If the patient shows any signs of distress or if his vital parameters change then the test is immediately discontinued and a report prepared, this report is presented to the physician who will then prescribe appropriate exercise.
There are different support measures that can be prescribed to reduce obesity such as a healthier diet to cut down the amount of cholesterol, sugars and salt consumed, change in behaviour in relation to things like diet, physical activity and alcoholism, and a good exercise regime will help to burn excess fat. Also support groups to help maintain the correct frame of mind to achieve these things.
LO4
This case study is concerned with an 85 year old lady who is suffering from three conditions, type 2 diabetes, hypertension and osteoarthritis. Therefore this essay will discuss these three conditions, their causes, signs and symptoms, effects on the body and support measures for dealing with them. Additionally it will explain the effects of ageing on the human body.
Hypertension
Hypertension or high blood pressure occurs when the pressure exerted by the blood on the walls of the arteries goes up to or beyond 140/90 mm hg. Hypertension has several different causes, it can be caused by bad diet, high consumption of fats, starch, glucose and salt or physical and psychological stress. It can also be caused by side effects of medication, genetics, old age, alcoholism, obesity and smoking. There are many signs and symptoms of hypertension that range from tiredness, disorientation, headache and palpitations to anxiety restlessness, bleeding through the nose, excessive sweating and mild tremors. There are some severe effects that hypertension can have on the body, it can cause stroke (Hemiplegia) which occurs when the corotid artery becomes blocked, it can also cause heart attack, DVT (Deep Vein Thrombosis), varicose veins, liver and kidney failure. Support measures for hypertension is this 85 year old patient would include a healthier diet plan, regulation of smoking and alcohol consumption if relevant. The patient would also benefit from relaxation therapy, mild physical activity, regular body check ups, administering and recording the dosage of medication and psychological and physical support.
Type 2 Diabetes
Type 2 diabetes is caused due to insulin resistance; this is when the body will not accept the insulin produced by the pancreas. The causes of type 2 diabetes are hypertension, excessive consumption of sugar, type 1 diabetes, obesity and old age. There are different signs and symptoms which may present in a patient with type 2 diabetes like weakness and fatigue polyuria, blurred or loss of vision and general body aches. There are some serious effects that type 2 diabetes can have on the human body, these include heart attack, kidney and Liver failure, glaucoma, non healing wounds, muscle and bone pain and UTI. There are many different support measures for type 2 diabetes that can be prescribed for this patient, including, diet plan, encouragement to drink plenty of fluids, keeping any wounds clean and dry, taking care of feet, application of absorbent pads, application of absorbent creams, periodic turning of the individual in bed, keeping the genitals clean and dry, physical and psychological support and maintaining records of charts and fluid intake/output, food intake and any pressure sores and creams used.
Osteoarthritis
Osteoarthritis is caused when inflammation and degeneration of the articular cartilage lining the joints of the body occurs. This condition mainly affects the weight bearing joints in the body like the spine, hips, knees and ankles. As the patient advances in age, arthritis can spread to non weight bearing joints including fingers, wrists and shoulders. This is a very painful condition where the two bones forming the joint come into contact with each other leading to locking the joint in to one place severely limiting movement. Causes of osteoarthritis can be things like old age, genetics, obesity, injury sustained to joint when younger, weak thigh muscles, lack of vitamins and rheumatoid arthritis. Signs and symptoms of osteoarthritis can include pain and tenderness, swelling and inflammation, stiff joints and occasional locking of joints, restricted movement and creaking of joints while moving. There are many support measures for osteoarthritis which can be prescribed for this patient including administering painkillers, steroid injections in to the joint, walking aids, mild physical activity, hydrotherapy, diet, knee brace for support, physical and psychological support and surgery-Total Knee Replacement (TKR).
Effects of ageing on the human body
Ageing has many effects on the human body and affects each functional system in different ways. In the nervous system it can affect the brain causing loss of short and long term memory, alzheimer’s disease an dementia. In the respiratory system the overall capacity of the lungs is decreased and the number of alveoli available for gas exchange is reduced. In the urinary system kidney function is reduced, the kidneys can no longer efficiently clean the blood of waste and nephrons inside them lose their ability to clear wastes and absorb nutrients. In the immune system the number of WBC’s produced in the bone marrow is reduced thereby reducing the body’s overall capacity to fight against infections. Lastly in the Integumentary system the skin loses its natural elasticity and oiliness; it becomes coarse, wrinkled and dry. Due to loss of collagen it also becomes easily breakable. The nails become brittle and the hair turns white due to lack of nutrition. The hair roots also become loose which results in hair loss.
References
Waugh, A Grant A. (2010) Ross and Wilson Anatomy and Physiology in Health and Illness, [online] Elsevier health sciences, available at: googlebooks http://books.google.co.uk (accessed on 5th February 2014)
School of Health and Social Care
PHYSIOLOGY
Table of contents Page
Introduction 1
Learning outcome 1 1-8
1.1
1.2
Learning outcome 2 9-11
2.1
2.2
2.3
Learning outcome 3 12-15
3.1
3.2
3.3
Learning outcome 4 16-17
4.1
4.2
4.3 …show more content…
References 18
Introduction
Physiology is the consideration of operative systems of the human body and how these systems interact with each other to help the body to function and maintain the body’s growth. “Physiology is the study of how the body systems work, and the ways in which their integrated activities maintain life and health in the individual” (A.Waugh et al 2010 p.10)
LO1
The human body is made up of several functional systems:
The central nervous system consists of the brain, the spine, the nerves, the eyes, mouth, skin, nose and neurons, its function is to gather information from the sensory organs and send it to the brain. The information will then be analysed by the brain and appropriate action will be taken in the form of muscles or organs.
The cardio vascular system or circulatory system consists of heart, veins, arteries, blood including capillaries carrying the blood, the capillaries carrying blood in arteries carry blood with oxygen while the capillaries inside the veins carry blood with carbon dioxide. The function of the cardio vascular system is to pump and circulate blood and nutrients around the body, bringing blood with carbon dioxide back to the heart. It also transports hormones to distant parts of the body and temperature regulation.
The respitory system consists of lungs, bronchi, trachea, diaphragm, intercostal muscles, bronchioles, alveoli and the mouth, its function is to take in oxygen and let out carbon dioxide. Every time an individual breathes in the air enters the nose where it is first filtered by the nasal hair and its temperature is raised to body temperature, this air then travels downwards into the trachea, through the trachea it then enters the left and right bronchi, these bronchi divide into smaller tubes called bronchioles. The air then travels through the bronchioles and is collected into the alveoli, which are tiny air bags, this is where the gas exchange takes place, the alveoli give their oxygen to the blood and collect carbon dioxide in return. At this point the carbon dioxide makes its way upwards into the bronchioles, then enters the bronchi, passes through the trachea and enters the nose where it is expelled from the body. The respitory system also regulates the PH of the blood.
The digestive system or gastrointestinal system consists of teeth, tongue, the oesophagus, stomach, salivary glands, small intestine, large intestine and bowel. The function of the digestive system is split into two parts, mechanical digestion which takes place in the mouth and chemical digestion which takes place in the stomach. After this the bolus (food) passes into the small intestine where nutrients are absorbed from it, the large intestine is responsible for accumulating the waste products and absorbing any nutrients still left in the bolus. The waste is then stored in the bowel until it is full, it is then released from the body through the anal opening.
The urinary system consists of kidneys, ureter, bladder and urethra, its function is to clear the body of waste and access nutrients in the urine. The kidneys clear the blood of waste materials and access nutrients, these waste materials and excess nutrients are mixed with urine and proceed towards the bladder through the ureter, a tube that leads from each kidney down to the bladder. The urine is then stored in the bladder until it is full, at this time the urine is released through the urethra.
The reproductive system is divided into two parts; the male reproductive system consists of the penis, testes, scrotum, ejaculatory fluid and semen. Its function is to produce and store semen; it also facilitates the transport of semen into the female reproductive system. The female reproductive system is made up of labia major, labia minor, vagina, uterus, fallopian tubes, ovaries, ovum and breasts. The function of the female reproductive system is the production and storage of ovum and also fertilisation of the semen and the ovum inside the uterus. This system is also responsible for the changes in breasts during pregnancy and the production of breast milk.
The muscular skeletal system is made up firstly of two hundred and six bones and is divided into two parts. The axial skeleton which is the central part is formed of the skull, spinal cord and chest bones; it is made up of eighty bones. The appendicular skeleton is attached to the axial skeleton and consists of shoulders, arms, pelus and legs it is made up of one hundred and twenty six bones. The function of the skeletal system is to provide support for the body and protection to the internal organs they also produces red blood cells, white blood cells, platelets, and b cells in the bone marrow and store minerals like calcium and magnesium. The muscular skeletal system is also made up of nearly six hundred and fifty muscles of which there are three types, skeletal muscles are found lining the bones and joints these muscles are voluntary meaning that they can be moved and controlled at will. Smooth muscles line the organs and are involuntary meaning that they contract on their own and can not be controlled consciously, finally cardiac muscles form the heart and are involuntary. The main function of muscles is to facilitate movement.
The endocrine system consists of endocrine glands which produce and secrete hormones which are chemical messages. Some of the major endocrine glands found in the human body are the pituitary gland, which is the most important one and is located in the brain. The thyroid gland which is located in the neck near the pharynx, the para thyroid gland which is located inside the thyroid gland, the pancreas which are located near the lower part of the stomach. The adrenal glands which are located on top of each kidney and the gonads which in males are the testes and in the female are ovaries. The function of the endocrine system is related to things like growth, glucose regulation and development of sexual features.
The integumentary system consists of skin, nails and hair. The skin has many functions, to regulate body temperature, assisting in breathing, excretion of waste materials through sweat and keeping the body impervious by releasing a layer of oil on its surface known as sebum. The skin assists in us feeling sensations such as touch, pressure, pain and temperature and also in vitamin D production and synthesis. The function of nails is to protect the fingertips from mechanical injury and the function of hair is insulation from cold and also to prevent dust particles from entering the body.
The immune system consists of white blood cells, B cells, and T cells the function of this system is to protect and defend the body from infection and illness. The body has three lines of defence, the first line of defence is consists of hair, nails and mucus membrane. The second line of defence is a fever and inflammation, the third and final line of defence is formed of B cells and T cells. The function of B cells is to identify the bacteria and viruses from the healthy cells and mark them; the function of T cells is to then eliminate the bacteria and viruses. If this line is broken then the individual will ultimately die.
Homeostasis is the maintenance of a balanced or steady state in the human body; the elements that need to be balanced are temperature, water, oxygen and carbon dioxide, ions, urea, nutrients and blood pressure. Negative feedback is when the body will fight to correct any change to any of these elements, positive feedback is when the body will not fight to correct any changes to any of its elements. Positive feedback is dangerous for the survival of human cells. These functional systems interact with each other so that the body can grow and function properly:
Regulation of blood glucose level in the body
When a high level of sugar is consumed the blood glucose level becomes high, the brain detects this high level of glucose and sends a message to the pancreas, telling it to release a hormone called insulin. The insulin converts the glucose into glycogen which it stores in the body; this reduces the blood sugar level. When engaging in strenuous physical activity over a continuous period of time, oxygen will not be enough to provide the body with energy. The brain will send another message to the pancreas this time telling it to release a hormone called glucagon; glucagon converts the glycogen back into glucose, increasing the blood sugar level. The glucose is then sent back into the blood, the blood carries it to the muscles and the muscles use it to produce energy. This is how the nervous, endocrine and circulatory systems interact with each other to regulate blood glucose levels.
Regulation of oxygen and carbon dioxide levels in the body When the body engages in strenuous physical activity that it is not used to, it loses a lot of oxygen until the oxygen level in the body is too low and the carbon dioxide level too high. This is a dangerous state for the body to be in as the balance is disturbed. When this happens the brain sends a message to the lungs, telling them to breathe faster so as to eliminate carbon dioxide at a fast pace. As soon as the carbon dioxide level is reduced and the oxygen-carbon dioxide balance regained, the lungs will go back to breathing at a normal pace. On the other hand, if a person is ill or bedridden for a few weeks or months, the oxygen level in the body rises. When this happens the brain sends a message to the lungs, this time telling them to slow down the breathing pace. This slower breathing will retain carbon dioxide in the body for a longer period of time. As soon as the balance between oxygen and carbon dioxide is regained the lungs start breathing normally again. This is how the nervous and respiratory systems work together to regulate oxygen and carbon dioxide levels in the body.
Regulation of water level in the body When the human body is exposed to temperatures higher than the normal body temperature of 37 C the sweat glands start to generate sweat to cool the body down.
This reduces the body water level and is dangerous for the survival of the cells; therefore the cells send a message to the brain. The brain analyses the situation and sends a message to the pituitary gland asking it to release a hormone called ADH (anti-diuretic hormone). ADH is in fact a message to the kidney, telling it to absorb water from the blood and send it back to the cells. After it has refilled the water level, the brain tells the pituitary gland to stop sending ADH to the kidney as there is no more need for water. On the other hand, if an individual has too much intake of fluids, the brain will make sure that the pituitary gland does not send ADH to the kidney. In the absence of ADH the kidney will not absorb any water but excrete it out in the form of urine. This is how the nervous, endocrine, urinary and circulatory systems interact with each other to regulate the water levels in the
body.
Regulation of temperature in the body
Also when the body is exposed to a temperature higher than the normal temperature of 37 C the skin is the first sensory organ to receive the message of rise of temperature. The same message is then passed on to the brain, where the brain analyses it. The brain then sends two messages, the first one to the sweat glands telling them to start sweating to cool down the body. The second message is sent to the veins telling them to enlarge; these enlarged veins are very close to the skin and carry more blood in them than usual. They cause heat to be quickly lost to the environment and so the body cools down faster. As soon as the normal temperature is reached sweating stops and veins go back to their normal size. When the body is exposed to much lower temperatures than normal the brain then sends out three messages, the first messages is sent to the pores telling them to close. The second message is sent to the veins telling them to narrow, as the veins get narrow and less blood flows through them, causing less heat to be lost to the environment and more heat to be retained in the body. The third message is sent to the muscles telling them to start shivering; the friction from this produces more heat. When the normal body temperature is reached the pores in the skin open back up, the veins go back to their normal size and the muscles stop shivering. This is how the nervous, integumentary, circulatory and musculo-skeletal systems interact to regulate body temperature.
LO2
This case study is about a twenty five year old individual who is planning to take part in a marathon in due course of time. Therefore this essay will discuss the effects of exercise on three functional systems in the human body the respiratory system, the cardiovascular system and the muscle-skeletal system.
Cardiovascular system:
The cardiovascular system is responsible for the circulation of oxygen and nutrients around the body, bringing blood with carbon dioxide back to the heart, transporting hormones to distant parts of the body and regulating body temperature. When the body is subjected to a moderate amount of exercise it has many affects on this system:
Heart rate raises from its normal state of 60-80 beats per minute to 150-220 beats per minute, when exercising on a regular basis heart rate will stabilize at 20-40 beats per minute.
Stroke volume is the amount of blood leaving the left ventricle per heartbeat, the immediate effect of exercise on stroke volume is to raise it up from 50-70 mls per beat to 110-130 mls per beat. When exercising on a regular basis stroke volume is raised to 150-200 mls per beat.
Cardiac output is the total amount of blood leaving the heart per minute, when exercising the amount of blood leaving the heart is increased from 5 litres per minute to 8-10 litres per minute. Regular exercise increases cardiac output to 20-40 litres per minute.
Blood pressure is the pressure applied by the blood on the walls of the arteries; it is raised from its normal rate of 120/80 mm hg to 140/90mm Hg during exercise. Regular exercise will raise blood pressure to 250/110mm Hg.
Blood flow to skeletal muscles is the amount of blood flowing through the working muscles, when the body is resting 20% of the total amount of blood in the body is flowing through the skeletal muscles. When the body is subjected to intense physical activity 80% of the total amount of blood in the body is flowing through the skeletal muscles.
Exercise affects the organs of the cardiovascular system differently; the muscles of the heart become thicker and stronger and the heart becomes more efficient in transporting oxygen and nutrients to the body. The arteries and veins enlarge in size to transport blood more efficiently and at a more rapid pace. Capillaries increase in number and the blood volume also increases.
The body temperature also rises during exercise; it rises above normal body temperature which is harmful for the survival of body cells. When this happens the brain sends a message to the sweat glands to start sweating and a message to the veins to enlarge in size all in an effort to cool the body down.
Respiratory system:
The functions of the respiratory system are taking in oxygen and expelling carbon dioxide and also regulating oxygen and carbon dioxide levels in the body. When the body is subjected to intense physical activity it has many effects on this system;
Respiratory rate is the number of breaths taken in and expelled out per minute; it is raised from its normal level of 12-18 breaths per minute to 20-30 breaths per minute during exercise. Respiratory rate stabilizes at 15-20 breaths per minute when exercising regularly for a prolonged period of time.
Tidal volume is the amount of air moving in and out of the lungs in one breath, the normal rate is 0.5-1 litre per breath increased 2-3 litres per breath during exercise. Tidal volume is further increased to 5-6 litres per breath with regular prolonged exercise.
Vital capacity is the maximum amount of air that can be expelled out after maximum inhalation; the normal rate is 2-3 litres which are increased to 8-10 litres during exercise. Vital capacity is further increased to 15-20 litres as a result of regular prolonged exercise.
The organs in the respiratory system are affected by exercise in different ways, the lungs expand and their overall capacity increases. The lungs assist in gas exchange more efficiently and eliminate carbon dioxide at a more rapid rate. The number of alveoli in the lungs increases which in turn increases the overall capacity of the lungs, enabling the lungs to hold more air in them making them more efficient. The muscles of respiration like diaphragm (abdominal) and intercostals (chest) increase in strength, which further assists in contraction and expansion of the lungs.
Musclo-skeletal system:
The functions of the musclo-skeletal system are to assist movement of the body, to support the structure of the body, to protect internal organs, to provide scaffolding for the body to grow, storage of calcium and other vital minerals and to assist in the production of red blood cells, white blood cells, platelets and b cells.
The immediate effects of exercise on the musclo-skeletal system are pain, tenderness, fatigue, strain, stress fractures inflammation and swelling and also a slow recovery rate. After consistent exercise over a long period in time the muscles become bigger and stronger as the size of the muscle fibres increase, muscles carry more oxygen and nutrients inside them, the development of slow twitch fibres (which produce more power and less speed) and fast twitch fibres (which produce more speed less power) occurs, bones become stronger due to more concentration of calcium and minerals, bones become less prone to fracture, the flexibility of muscles, tendons and ligaments increases, muscles become more efficient in producing energy, fatigue sets in later and the body has a faster recovery rate.
So these are the ways that intense physical activity affects these specific functional systems of the body.
LO3
This case study is about a 65 year old individual who is obese and is currently suffering from fever; therefore this essay will explain the two conditions and also the clinical tests and support measures for them.
Influenza is a condition resulting from a virus which affects the respiratory system; it spreads through the air and through touch. The signs and symptoms of influenza can range from high fever, runny nose, sore throat, coughing and tiredness to chest congestion, loss of appetite, dehydration, nausea and vomiting and general aches and pains in the body.
1. The first thing to do when testing a patient for influenza is to take their medical history, this is very important as it provides vital information about the individuals past and present medical conditions, allergies, medication history as well as work schedule, occupation and daily activities.
2. The next thing to do would be to record the patients temperature, this is very important as it is an essential component to know if the body is suffering from infection. Fever is also the second line of defence and the high temperature will either kill or contain the virus. Temperature can be measured using a chemical thermometer; there are various sites on the body used to do this including the mouth, ears, armpits, inner elbow and rectum.
3. Recording pulse and respiratory rate is vital as it provides essential information regarding the condition of the vital organs like heart and lungs during infection. Respiratory rate can be measured by simply observing the movement of the chest while the patient is breathing. Pulse rate can be measured using the index and middle fingers placed on the inner wrist in line with the thumb with the palm facing upwards. There are other sites on the body used for measuring pulse such as the inner part of the neck near the windpipe, also the inner part of the elbow and ankle joints.
4. Blood pressure also forms one of the vital parameters that need to be measured to check the condition of the body. As it measures the pressure of the blood applied to the artery walls and signifies the stress that the heart is currently undergoing during infection. Blood pressure is measured using a device known as a sphygmomanometer or blood pressure apparatus. It consists of a pressure cuff, a pressure pump and a stethoscope.
5. Blood tests can be taken, they will provide information about the presence of virus in the blood stream and the number of white blood cells in the blood will also indicate the ability of the body to fight off the virus. WBC count is generally very high in response to infection in a healthy human being, but as this individual is aged and obese this will lower his immunity and this may cause the virus to proceed and develop into pneumonia. A blood test is performed by inserting a syringe into the vein and extracting the blood, then sending it off to the lab for analysis. The main site on the body for extracting blood is the inner part of the elbow; the other less common site is the back of the hand. A chest X-ray provides information regarding the consolidation of the virus inside one or both of the lungs.
6. The chest x-ray is performed using an x-ray machine and the chest is x-rayed from different angles; antero-posterior (from the front), postero-anterior (from the back) and oblique (from the side), to cover the lungs from all possible angles.
7. Rapid Influenza Diagnostics Test (RIDT) is used for detecting influenza virus strains in the blood and to establish a cause for infection as flu. A swab is taken from the back of the throat and sent off for analysis, the lab report can be obtained within thirty minutes; establishing the presence or absence of the virus.
8. A Computerised Tomography (CT scan) will provide clear images of the infection in the lungs, these images will be used by the operating surgeon to pinpoint the site of infection and operate upon it. CT scan is carried out by putting the body of the individual into the scanning machine so that images of the whole body can be produced from all possible angles multiple times.
9. Breath sounds are auscultated and recorded to establish the presence of infection in the throat and lungs and also to roughly judge the extent of the spread of infection. A stethoscope is used to listen to abnormal breath sounds.
10. Throat examination will also establish the presence of the virus as it makes the throat go red and inflamed. The inside of the throat is observed with the assistance of a high power low beam torch and a tongue depressor.
There are different measures which can be taken to counter influenza; these include a healthier diet and plenty of fluids to give the body nutrients and vitamins. The patient will also need plenty of rest so that the body can recover antibiotics to help kill the infection and isolation to prevent the virus from spreading to others.
Obesity is the excess accumulation of fat in the body, there are many different causes ranging from alcoholism, lack of physical activity and bad diet (high intake of cholesterol, salt and sugar) to psychological stress, medication, hypothyroidism or it being hereditary. There are different clinical tests for obesity:
1. Recording medical history for obesity will provide information regarding past and present medical conditions affecting the individual.
2. Measuring weight and height is important as they form essential components for measuring BMI of the patient. Weight is measured using an analog or electric scale and height is measured using a measuring tape or a scale fixed to the wall.
3. BMI (Body Mass Index) is used to measure the amount of fat as opposed to muscles and bones. The formula used to calculate BMI is: BMI=WEIGHT/HEIGHT 2x703, a BMI of 18.5 and lower means the individual is underweight and a BMI of 30 and above means the individual is obese.
4. Measuring waist circumference is important as the waist is the main site in the body where most fat is accumulated. An individual is considered to be obese when their waist circumference is between 37-40 inches for a man and 31-35 inches for a woman.
5. Measuring and recording blood pressure is essential in this case as the patient is a known case of obesity and might have an excess fat deposition inside his major arteries supplying the heart. Measuring and periodic recording of BP is necessary to check the condition of the heart. BP is measured using a sphygmomanometer, but can also be measured using a new device which is much smaller in size and less complicated; it consists of a monitor and a wrist band.
6. Blood tests will provide information about the amount of cholesterol, glucose and Thyroid Stimulating Hormone (TSH) in the blood. Blood test is performed by extracting blood from a vein with a syringe.
7. A urine test will provide information about functioning of the kidneys and measure excess amount of glucose in the urine. A urine test is carried out by collecting a specimen of urine in an enclosed disposable bottle and sending it off for analysis.
8. Basal Metabolic Rate (BMR) is the amount of calories spent by the body when it is at rest. This energy is required for sustaining and providing nutrition to the vital organs of the body including the heart, lungs and liver, even when the individual is resting.
9. Electro Cardio Graph/Gram (ECG) is used foe assessing the condition of the heart and also to detect any underlying condition that has gone previously undetected or does not present any signs or symptoms. ECG is recorded using an ECG machine and electronic leads which are connected to the chest, arms and legs of the patient. These leads collect signals from different parts of the body and send them back to the ECG machine; the machine then exhibits these signals in the form of a graph which can be interpreted by the physician or surgeon operating on the patient.
10. A stress test is used to detect any underlying condition affecting the heart and also to assess how much stress the heart can bear when exposed to strenuous physical activity. A stress test is performed by attaching ECG leads to the chest and asking the patient to walk on a treadmill or static cycle. The vital parameters like heart rate, blood pressure and respiratory rate are constantly monitored throughout the duration of the test. If the patient shows any signs of distress or if his vital parameters change then the test is immediately discontinued and a report prepared, this report is presented to the physician who will then prescribe appropriate exercise.
There are different support measures that can be prescribed to reduce obesity such as a healthier diet to cut down the amount of cholesterol, sugars and salt consumed, change in behaviour in relation to things like diet, physical activity and alcoholism, and a good exercise regime will help to burn excess fat. Also support groups to help maintain the correct frame of mind to achieve these things.
LO4
This case study is concerned with an 85 year old lady who is suffering from three conditions, type 2 diabetes, hypertension and osteoarthritis. Therefore this essay will discuss these three conditions, their causes, signs and symptoms, effects on the body and support measures for dealing with them. Additionally it will explain the effects of ageing on the human body.
Hypertension
Hypertension or high blood pressure occurs when the pressure exerted by the blood on the walls of the arteries goes up to or beyond 140/90 mm hg. Hypertension has several different causes, it can be caused by bad diet, high consumption of fats, starch, glucose and salt or physical and psychological stress. It can also be caused by side effects of medication, genetics, old age, alcoholism, obesity and smoking. There are many signs and symptoms of hypertension that range from tiredness, disorientation, headache and palpitations to anxiety restlessness, bleeding through the nose, excessive sweating and mild tremors. There are some severe effects that hypertension can have on the body, it can cause stroke (Hemiplegia) which occurs when the corotid artery becomes blocked, it can also cause heart attack, DVT (Deep Vein Thrombosis), varicose veins, liver and kidney failure. Support measures for hypertension is this 85 year old patient would include a healthier diet plan, regulation of smoking and alcohol consumption if relevant. The patient would also benefit from relaxation therapy, mild physical activity, regular body check ups, administering and recording the dosage of medication and psychological and physical support.
Type 2 Diabetes
Type 2 diabetes is caused due to insulin resistance; this is when the body will not accept the insulin produced by the pancreas. The causes of type 2 diabetes are hypertension, excessive consumption of sugar, type 1 diabetes, obesity and old age. There are different signs and symptoms which may present in a patient with type 2 diabetes like weakness and fatigue polyuria, blurred or loss of vision and general body aches. There are some serious effects that type 2 diabetes can have on the human body, these include heart attack, kidney and Liver failure, glaucoma, non healing wounds, muscle and bone pain and UTI. There are many different support measures for type 2 diabetes that can be prescribed for this patient, including, diet plan, encouragement to drink plenty of fluids, keeping any wounds clean and dry, taking care of feet, application of absorbent pads, application of absorbent creams, periodic turning of the individual in bed, keeping the genitals clean and dry, physical and psychological support and maintaining records of charts and fluid intake/output, food intake and any pressure sores and creams used.
Osteoarthritis
Osteoarthritis is caused when inflammation and degeneration of the articular cartilage lining the joints of the body occurs. This condition mainly affects the weight bearing joints in the body like the spine, hips, knees and ankles. As the patient advances in age, arthritis can spread to non weight bearing joints including fingers, wrists and shoulders. This is a very painful condition where the two bones forming the joint come into contact with each other leading to locking the joint in to one place severely limiting movement. Causes of osteoarthritis can be things like old age, genetics, obesity, injury sustained to joint when younger, weak thigh muscles, lack of vitamins and rheumatoid arthritis. Signs and symptoms of osteoarthritis can include pain and tenderness, swelling and inflammation, stiff joints and occasional locking of joints, restricted movement and creaking of joints while moving. There are many support measures for osteoarthritis which can be prescribed for this patient including administering painkillers, steroid injections in to the joint, walking aids, mild physical activity, hydrotherapy, diet, knee brace for support, physical and psychological support and surgery-Total Knee Replacement (TKR).
Effects of ageing on the human body
Ageing has many effects on the human body and affects each functional system in different ways. In the nervous system it can affect the brain causing loss of short and long term memory, alzheimer’s disease an dementia. In the respiratory system the overall capacity of the lungs is decreased and the number of alveoli available for gas exchange is reduced. In the urinary system kidney function is reduced, the kidneys can no longer efficiently clean the blood of waste and nephrons inside them lose their ability to clear wastes and absorb nutrients. In the immune system the number of WBC’s produced in the bone marrow is reduced thereby reducing the body’s overall capacity to fight against infections. Lastly in the Integumentary system the skin loses its natural elasticity and oiliness; it becomes coarse, wrinkled and dry. Due to loss of collagen it also becomes easily breakable. The nails become brittle and the hair turns white due to lack of nutrition. The hair roots also become loose which results in hair loss.
References
Waugh, A Grant A. (2010) Ross and Wilson Anatomy and Physiology in Health and Illness, [online] Elsevier health sciences, available at: googlebooks http://books.google.co.uk (accessed on 5th February 2014)