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At birth knee pain treatment bangalore order ibuprofen on line, when the baby takes its first breath, the lungs expand with air and pressure in the right atrium falls below that in the left atrium. Consequently, the oval foramen closes for its first and last time, and its valve usually fuses with the interatrial septum. The closed oval foramen is represented in the postnatal interatrial septum by the depressed oval fossa. This left-toright shunt of blood overloads the pulmonary vascular system, resulting in hypertrophy of the right atrium and ventricle and pulmonary arteries. A large shunt increases pulmonary blood flow, which causes severe pulmonary disease (hypertension, or increased blood pressure) and may cause cardiac failure. The classical percussion technique is to create vibration by tapping the chest with a finger while listening and feeling for differences in sound wave conduction. Cardiac percussion is performed at the 3rd, 4th, and 5th intercostal spaces from the left anterior axillary line to the right anterior axillary line. Normally, the percussion note changes from resonance to dullness (because of the presence of the heart) approximately 6 cm lateral to the left border of the sternum. Stroke or Cerebrovascular Accident 898 Thrombi (clots) form on the walls of the left atrium in certain types of heart disease. If these thrombi detach, or pieces break off from them, they pass into the systemic circulation and occlude peripheral arteries. Basis for Naming Cusps and Sinuses of Aortic and Pulmonary Valves the following account explains the embryological basis for naming the pulmonary and aortic valves. The truncus arteriosus, the common arterial trunk from both ventricles of the embryonic heart, has four cusps. Consequently, the cusps are named according to their embryological origin, not their postnatal anatomical position. Thus, the pulmonary valve has right, left, and anterior cusps, and the aortic valve has right, left, and posterior cusps. The right coronary artery usually arises from the right aortic sinus, superior to the right cusp of the aortic valve, and the left coronary usually has a similar relation to the left cusp and sinus. The posterior cusp and sinus do not give rise to a coronary artery; thus, they are also referred to as a "noncoronary" cusp and sinus. Valvular Heart Disease Disorders involving the valves of the heart disturb the pumping efficiency of the heart. Stenosis is the failure of a valve to open fully, slowing blood flow from a chamber. Insufficiency or regurgitation, on the other hand, is failure of the valve to close completely, usually owing to nodule formation on (or scarring and contraction of) the cusps so that the edges do not meet or align. This allows a variable amount of blood (depending on the severity) to flow back into the chamber it was just ejected from. Restriction of high-pressure blood flow (stenosis) or passage of blood through a narrow opening into a larger vessel or chamber (stenosis and regurgitation) produces turbulence. Turbulence sets up eddies (small 901 whirlpools) that produce vibrations that are audible as murmurs. Superficial vibratory sensations (thrills) may be felt on the skin over an area of turbulence. The clinical significance of a valvular dysfunction ranges from slight and physiologically insignificant to severe and rapidly fatal. Factors such as degree, duration, and etiology (cause) affect secondary changes in the heart, blood vessels, and other organs, both proximal and distal to the valve lesion. Insufficiency may result from pathology of the valve itself or its supporting structures (anulus, tendinous cords, dilation of chamber wall, etc. Valvular stenosis, on the other hand, is almost always the result of a valve abnormality and is essentially always a chronic process (Kumar et al. Because valvular diseases are mechanical problems, damaged or defective cardiac valves can be replaced surgically in a procedure called valvuloplasty. Most commonly, artificial valve prostheses made of synthetic materials are used in these valve replacement procedures, but xenografted valves (valves transplanted from other species, such as pigs) are also used. Mitral Valve Insufficiency (Mitral Valve Prolapse) A prolapsed mitral valve is an insufficient or incompetent valve with one or both leaflets enlarged, redundant, or "floppy" and extending back into the left atrium during systole. As a result, blood regurgitates into the left atrium when the left ventricle contracts, producing a characteristic heart sound or murmur. This is an extremely common condition, occurring in up to 1 in every 20 people, most often in young females. Usually, it is an incidental finding on physical examination; but it is of clinical importance in a small fraction of those affected, with the patient suffering chest pain and fatigue. Pulmonary Valve Stenosis In pulmonary valve stenosis, the valve cusps are fused, forming a dome with a narrow central opening. Both types of pulmonary stenoses produce a restriction of right ventricular outflow and may occur together. Pulmonary Valve Incompetence 902 If the free margins (lunules) of the cusps of a semilunar valve thicken and become inflexible or are damaged by disease, the valve will not close completely. An incompetent pulmonary valve results in a backrush of blood under high pressure into the right ventricle during diastole. Pulmonic regurgitation may be heard through a stethoscope as a heart murmur, an abnormal sound from the heart, produced in this case by damage to the cusps of the pulmonary valve. Aortic Valve Stenosis Aortic valve stenosis is the most frequent valve abnormality. For those born in the early- and mid20th century, rheumatic fever was a common cause but now accounts for <10% of cases of aortic stenosis. The great majority of aortic stenoses is a result of degenerative calcification and comes to clinical attention in the sixth decade of life or later. Aortic stenosis causes extra work for the heart, resulting in left ventricular hypertrophy. Aortic Valve Insufficiency Insufficiency of the aortic valve results in aortic regurgitation (backrush of blood into the left ventricle), producing a heart murmur and a collapsing pulse (forcible impulse that rapidly diminishes). Echocardiography Echocardiography (ultrasonic cardiography) is a method of graphically recording the position and motion of the heart by the echo obtained from beams of ultrasonic waves directed through the thoracic wall. This technique may detect as little as 20 mL of fluid in the pericardial cavity, such as that resulting from pericardial effusion. Doppler echocardiography is a technique that demonstrates and records the flow of blood through the heart and great vessels by Doppler ultrasonography, making it especially useful in the diagnosis and analysis of problems with blood flow through the heart, such as septal defects, and in delineating valvular stenosis and regurgitation, especially on the left side of the heart. Sonographer placing transducer in a left intercostal space in the parasternal line, overlying the heart. Coronary Angiography Using conventional coronary angiography, the coronary arteries can be visualized with coronary arteriograms. A long, narrow catheter is passed into the ascending aorta via the femoral artery in the inguinal region. Under fluoroscopic control, the tip of the catheter is placed just inside the opening of a coronary artery. A small injection of radiopaque contrast material 904 is made, and cineradiographs are taken to show the lumen of the artery and its branches, as well as any stenotic areas that may be present. It has many causes, all of which result in a reduced blood supply to the vital 905 myocardial tissue. The three most common sites of coronary artery occlusion and the percentage of occlusions involving each artery are. The most common cause of ischemic heart disease is coronary artery insufficiency resulting from atherosclerosis. Coronary Atherosclerosis the atherosclerotic process, characterized by lipid deposits in the intima (lining layer) of the coronary arteries, begins during early adulthood and slowly results in stenosis of the lumina of the arteries. As coronary atherosclerosis progresses, the collateral channels connecting one coronary artery with the other expand, which may initially permit adequate perfusion of the heart during relative inactivity. Despite this compensatory mechanism, the myocardium may not receive enough oxygen when the heart needs to perform increased amounts of work. Slowly Progressive Coronary Artery Disease In slow occlusion of a coronary artery, the collateral circulation has time to increase so that adequate perfusion of the myocardium can occur when a 907 potentially ischemic event occurs. On sudden blockage of a large coronary branch, some infarction is probably inevitable, but the extent of the area damaged depends on the degree of development of collateral anastomotic channels.

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The ostomy prevents fecal contents from going through the anastomosis; thus florida pain treatment center cheap ibuprofen online american express, if the anastomosis has a small imperfection causing a leak, the result is not catastrophic peritonitis. Colonoscopy, Colorectal Cancer Sigmoidoscopy, and the interior of the colon can be observed and photographed in a procedure called colonoscopy or coloscopy, using a long, flexible fiberoptic endoscope (colonoscope) inserted into the colon through the anus and rectum. The interior of the sigmoid colon is observed with a sigmoidoscope, a shorter endoscope, in a procedure called sigmoidoscopy. Small instruments can be passed through both instruments and used to facilitate minor operative procedures, such as biopsies or removal of polyps. Most tumors of the large intestine occur in the sigmoid colon and rectum (often near the rectosigmoid junction) or ascending colon. Colorectal cancers have different characteristics based on their location within the colon or rectum. Diverticulosis Diverticulosis is a disorder in which multiple false diverticula (external evaginations or outpocketings of the mucosa of the colon) develop along the intestine. Colonic diverticula are not true diverticula because they are formed from protrusions of mucous membrane only, evaginated through weak points (separations) developed between muscle fibers rather than involving the whole wall of the colon. They 1140 occur most commonly on the mesenteric side of the two nonmesenteric teniae coli, where nutrient arteries perforate the muscle coat to reach the submucosa. Diverticula are subject to infection and rupture, leading to diverticulitis, which can distort and erode the nutrient arteries, leading to hemorrhage. Diets high in fiber have proven beneficial in reducing the occurrence of diverticulosis. Volvulus of Sigmoid Colon Rotation and twisting of the mobile loop of the sigmoid colon and mesocolon-volvulus of the sigmoid colon. Obstipation (inability of the stool or flatus to pass) and ischemia (absence of blood flow) of the looped part of the sigmoid colon result. Volvulus is an acute emergency, and unless it resolves spontaneously, necrosis (tissue death) of the involved segment may occur if untreated. Stomach: the stomach is the dilated portion of the alimentary tract between the esophagus and the duodenum, specialized to accumulate ingested food and prepare it chemically and mechanically for digestion. However, the position of the stomach can vary markedly in persons of different body types. Proximal to this point, it is supplied by branches of the celiac trunk; distal to this point, it is supplied by branches of the superior mesenteric artery. The jejunum and ileum make up the convolutions of the small intestine occupying most of the infracolic division of the greater sac of the peritoneal cavity. The orad (proximal relative to the mouth) two fifths is jejunum and the aborad (distal) three fifths is ileum, although there is no clear line of transition. The diameter of the small intestine becomes increasingly smaller as the semifluid chyme progresses through it. Large intestine: the large intestine consists of the cecum; appendix; ascending, transverse, descending, and sigmoid colon; rectum; and anal canal. Most commonly, 1143 the appendix is retrocecal in position, but 32% of the time, it descends into the lesser pelvis. The teniae, haustra, and omental appendices cease at the junction, located anterior to the third sacral segment. The part of large intestine orad (proximal) to the left colic flexure (cecum, appendix, and ascending and transverse colons) is served by branches of the superior mesenteric vessels. Aborad (distal) to the flexure, most of the remainder of the large intestine (descending and sigmoid colons and superior rectum) is served by the inferior mesenteric vessels. Surface anatomy of spleen relative to the rib cage, anterior abdominal organs, and thoracic viscera and costophrenic pleural recess. Surface anatomy of the spleen and pancreas relative to the diaphragm and posterior abdominal viscera. Concavities on the visceral surface are impressions formed by the structures in contact with the spleen. In spite of its size and the many useful and important functions it provides, it is not a vital organ (not necessary to sustain life). To accommodate these functions, the spleen is a soft, vascular (sinusoidal) mass with a relatively delicate fibroelastic capsule. The thin capsule is covered with a layer of visceral peritoneum that entirely surrounds the spleen except at the splenic hilum, where the splenic branches of the splenic artery and vein enter and leave. Consequently, it is capable of marked expansion and some relatively rapid contraction. The spleen is a mobile organ although it normally does not descend inferior to the costal (rib) region; it rests on the left colic flexure. The spleen varies considerably in size, weight, and shape; however, it is usually approximately 12 cm long and 7 cm wide. The close relationship of the spleen to the ribs that normally protect it can be a detrimental one in the presence of rib fractures (see the Clinical Box "Rupture of Spleen," p. The anterior and superior borders of the spleen 1146 are sharp and often notched, whereas its posterior (medial) end and inferior border are rounded. Normally, the spleen does not extend inferior to the left costal margin; thus, it is seldom palpable through the anterolateral abdominal wall unless it is enlarged. When it is hardened and enlarged to approximately three times its normal size, it moves inferior to the left costal margin, and its superior (notched) border lies inferomedially (see the Clinical Box "Splenectomy and Splenomegaly," p. The notched border is helpful when palpating an enlarged spleen because, when the person takes a deep breath, the notches can often be palpated. The spleen normally contains a large quantity of blood that is expelled periodically into the circulation by the action of the smooth muscle in its capsule and trabeculae. The thin fibrous capsule of the spleen is composed of dense, irregular, fibroelastic connective tissue that is thickened at the splenic hilum. Internally, the trabeculae (small fibrous bands), arising from the deep aspect of the capsule, carry blood vessels to and from the parenchyma or splenic pulp, the substance of the spleen. The spleen contacts the posterior wall of the stomach and is connected to its greater curvature by the gastrosplenic ligament and to the left kidney by the splenorenal ligament. These ligaments, containing splenic vessels, are attached to the hilum of the spleen on its medial aspect. The splenic hilum is often in contact with the tail of the pancreas and constitutes the left boundary of the omental bursa. The arterial supply of the spleen is from the splenic artery, the largest branch of the celiac trunk. It follows a tortuous course posterior to the omental bursa, anterior to the left kidney, and along the superior border of the pancreas. Between the layers of the splenorenal ligament, the splenic artery divides into five or more branches that enter the hilum. The lack of anastomosis of these arterial vessels within the spleen results in the formation of vascular segments of the spleen: two in 84% of spleens and three in the others, with relatively avascular planes between them, enabling subtotal splenectomy (see the Clinical Box "Splenectomy and Splenomegaly," p. Relationships of the spleen, pancreas, and extrahepatic biliary ducts to other retroperitoneal viscera. The entry of the bile duct and pancreatic duct into the duodenum through the hepatopancreatic ampulla. The interior of the descending part of the duodenum reveals the major and minor duodenal papillae. The photomicrograph of the pancreas displays secretory acini and a pancreatic islet. Venous drainage from the spleen flows via the splenic vein, formed by several tributaries that emerge from the hilum. Because of the close relationship of the pancreas and 1149 duodenum, their blood vessels are the same in whole or in part. Except for the inferior part of the pancreatic head (including uncinate process), the spleen and pancreas receive blood from the celiac artery.

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Dural border hemorrhage is typically venous in origin and commonly results from tearing a superior cerebral vein as it enters the superior sagittal sinus myofascial pain treatment uk generic ibuprofen 600 mg free shipping. Subarachnoid hemorrhage is an extravasation of blood, usually arterial, into the subarachnoid space. Most of these hemorrhages result from rupture of a saccular aneurysm (sac-like dilation on the side of an artery), such 1993 as an aneurysm of the internal carotid artery (see the clinical box "Strokes"). Some subarachnoid hemorrhages are associated with head trauma involving cranial fractures and cerebral lacerations. Bleeding into the subarachnoid space results in meningeal irritation, severe headache, stiff neck, and often loss of consciousness. Dura mater: the outer (periosteal) lamina of the dura is continuous with the periosteum on the external surface of the cranium and is intimately applied to the internal surface of the cranial cavity. Neurovasculature of meninges: the cranial meninges receive blood primarily from the middle meningeal branches of the maxillary arteries. It is a delicate structure that is enclosed in a rigid cranium; however, it can be damaged by a blow to the head, compressed by a tumor, or deprived of oxygen by a leak or clot of blood in one of the cerebral arteries. Furthermore, 11 of 12 cranial nerves arise from the brain (see Chapter 10, Cranial Nerves). Parts of Brain the brain (contained by the neurocranium) is composed of the cerebrum, cerebellum, and brainstem. Whereas the gyri and sulci demonstrate much variation, the other features of the brain, including overall brain size, are remarkably consistent from individual to individual. The cerebral hemispheres, separated by the falx cerebri within the longitudinal cerebral fissure, are the dominant features of the brain. Each cerebral hemisphere is divided for descriptive purposes into four lobes, each of which is related to , but the boundaries of which do not correspond to , the overlying bones of the same name. From a superior view, the cerebrum is essentially divided into quarters by the median longitudinal cerebral fissure and the coronal central sulcus. The central sulcus separates the frontal lobes (anteriorly) from the parietal lobes 1995 (posteriorly). In a lateral view, these lobes lie superior to the transverse lateral sulcus and the temporal lobe inferior to it. The posteriorly placed occipital lobes are separated from the parietal and temporal lobes by the plane of the parieto-occipital sulcus, visible on the medial surface of the cerebrum in a hemisected brain. The anteriormost points of the anteriorly projecting frontal and temporal lobes are the frontal and temporal poles. The posteriormost point of the posteriorly projecting occipital lobe is the occipital pole. The frontal lobes occupy the anterior cranial fossae, the temporal lobes occupy the lateral parts of the middle cranial fossae, and the occipital lobes extend posteriorly over the tentorium cerebelli. The diencephalon is composed of the epithalamus, thalamus, and hypothalamus and forms the central core of the brain. The midbrain, the rostral part of the brainstem, lies at the junction of the middle and posterior cranial fossae. The pons is the part of the brainstem between the midbrain rostrally and the medulla oblongata caudally. The medulla oblongata (medulla) is the most caudal subdivision of the brainstem that is continuous with the spinal cord. The cerebellum is the large brain mass lying posterior to the pons and medulla and inferior to the posterior part of the cerebrum. It consists of two lateral hemispheres that are united by a narrow middle part, the vermis. Ventricular System of Brain the ventricular system of the brain consists of two lateral ventricles and the midline 3rd and 4th ventricles connected by the cerebral aqueduct. Each lateral ventricle opens through an interventricular foramen into the 3rd ventricle. The 3rd ventricle, a slit-like cavity between the right and the left halves of the diencephalon. The pyramid-shaped 4th ventricle in the posterior part of the pons and medulla extends inferoposteriorly. Inferiorly, it tapers to a narrow channel that continues into the cervical region of the spinal cord as the central canal. At certain areas on the base of the brain, the arachnoid and pia are widely separated by subarachnoid cisterns. Pontocerebellar cistern (pontine cistern): an extensive space ventral to the pons, continuous inferiorly with the spinal subarachnoid space. Interpeduncular cistern (basal cistern): located in the interpeduncular fossa between the cerebral peduncles of the midbrain. Chiasmatic cistern (cistern of optic chiasma): inferior and anterior to the optic chiasm, the point of crossing or decussation of optic nerve fibers. Quadrigeminal cistern (cistern of great cerebral vein): located between the posterior part of the corpus callosum and the superior surface of the cerebellum; contains parts of the great cerebral vein. Cisterna ambiens (ambient cistern): located on the lateral aspect of the midbrain and continuous posteriorly with the quadrigeminal cistern (not illustrated). The choroid plexuses consist of fringes of vascular pia mater (tela choroidea) covered by cuboidal epithelial cells. They are invaginated into the roofs of the 3rd and 4th ventricles and on the floors of the bodies and inferior horns of the lateral ventricles. In many places at the base of the brain, only the cranial meninges intervene between the brain and cranial bones. Small, rapidly recurring changes take place in intracranial pressure owing to the beating heart; slow recurring changes result from unknown causes. Any change in the volume of the intracranial contents, for example, a brain tumor, an accumulation of ventricular fluid caused by blockage of the cerebral aqueduct. The blood supply to the brain is derived from the internal carotid and vertebral arteries. Venous drainage from the brain occurs via cerebral and cerebellar veins that drain to the adjacent dural venous sinuses. The bilaterally paired internal carotid and vertebral arteries deliver an abundant supply of oxygen-rich blood. The cervical part of each artery ascends vertically through the neck, without branching, to the cranial base. Each internal carotid artery enters the cranial cavity through the carotid canal in the petrous part of the temporal bone. In addition to the carotid arteries, the carotid canals contain venous plexuses and carotid plexuses of sympathetic nerves. The arteries run in the carotid groove located on the side of the body of the sphenoid. The terminal branches of the internal carotid arteries are the anterior and middle cerebral arteries. The orientation drawing (left) indicates the plane of the coronal section that intersects the carotid canal (right). The cervical part of the internal carotid artery ascends vertically in the neck to the entrance of the carotid canal in the petrous temporal bone. The petrous part of the artery turns horizontally and medially in the carotid canal, toward the apex of the petrous temporal bone. It emerges from the canal superior to the foramen lacerum, closed in life by cartilage, and enters the cranial cavity. The artery runs anteriorly across the cartilage; then the cavernous part of the artery runs along the carotid grooves on the lateral side of the body of the sphenoid, traversing the cavernous sinus. Radiopaque dye injected into the carotid arterial system demonstrates unilateral distribution to the brain from the internal carotid artery. A, anterior cerebral artery and its branches; I, the four parts of the 2003 internal carotid artery; M, middle cerebral artery and its branches; O, ophthalmic artery. Armstrong, Associate Professor of Medical Imaging, University of Toronto, Ontario, Canada. The internal carotid and basilar arteries converge, divide, and anastomose to form the cerebral arterial circle (of Willis). The left temporal pole is removed to show the middle cerebral artery in the lateral sulcus of the brain.

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The vocal process provides the posterior attachment for the vocal ligament pain management for my dog purchase 600mg ibuprofen visa, and the muscular process serves as a lever to which the posterior and lateral cricoarytenoid muscles are attached. The crico-arytenoid joints, located between the bases of the arytenoid cartilages and the superolateral surfaces of the lamina of the cricoid cartilage. These movements are important in approximating, tensing, and relaxing the vocal folds. The elastic vocal ligaments extend from the junction of the laminae of the thyroid cartilage anteriorly to the vocal process of the arytenoid cartilage posteriorly. These ligaments are the thickened, free superior border of the conus elasticus or cricovocal membrane. The parts of the membrane extending laterally between the vocal folds and the superior border of the cricoid are the lateral cricothyroid ligaments. The fibro-elastic conus elasticus blends anteriorly with the median cricothyroid ligament. The conus elasticus and overlying mucosa close the tracheal inlet except for the central rima glottidis (opening between the vocal folds). The epiglottic cartilage, consisting of elastic cartilage, gives flexibility to the epiglottis, a heart-shaped cartilage covered with mucous membrane. Situated posterior to the root of the tongue and the hyoid and anterior to the laryngeal inlet, the epiglottic cartilage forms the superior part of the anterior wall and the superior margin of the inlet. Its tapered inferior end, the stalk of the epiglottis, is attached to the angle formed by the thyroid laminae by the thyro-epiglottic ligament. The hyo-epiglottic ligament attaches the anterior surface of the epiglottic cartilage to the hyoid. Its free inferior margin constitutes the vestibular ligament, which is covered loosely by mucosa to form the vestibular fold. This fold lies superior to the vocal fold and extends from the thyroid cartilage to the arytenoid cartilage. The free superior margin of the quadrangular membrane forms the aryepiglottic ligament, which is covered with mucosa to form the aryepiglottic fold. The corniculate and cuneiform cartilages appear as small nodules in the posterior part of the aryepiglottic folds. The corniculate cartilages attach to the apices of the arytenoid cartilages; the cuneiform cartilages do not directly attach to other cartilages. The quadrangular membrane and conus elasticus are the superior and inferior parts of the submucosal fibro-elastic membrane of the larynx. The epiglottis is a leaf-shaped plate of elastic fibrocartilage, which is covered with mucous membrane (pink) and is attached anteriorly to the hyoid by the hyo-epiglottic ligament (gray). The epiglottis serves as a diverter valve over the superior aperture of the larynx during swallowing. The posterior wall of the larynx is split in the median plane, and the two sides are spread apart and held in place by a surgical needle. On the right side, the mucous and submucous coats are peeled off, and the skeletal coat- consisting of cartilages, ligaments, and the fibro-elastic membrane-is uncovered. The laryngeal cavity extends from the laryngeal inlet, through which it communicates with the laryngopharynx, to the level of the inferior border of the cricoid cartilage. This coronal section shows the compartments of the larynx: the vestibule, middle compartment with left and right ventricles, and the infraglottic cavity. The laryngeal inlet is bounded (1) anteriorly by the free curved edge of the epiglottis; (2) posteriorly by the arytenoid cartilages, the corniculate cartilages that cap them, and the interarytenoid fold that unites them; and (3) on each side by the aryepiglottic fold that contains the superior end of the cuneiform cartilage. The planes of these transverse studies, oriented in the same direction as part (C), pass superior (D) and inferior (E) to the rima glottidis. The laryngeal saccule is a blind pocket opening into each ventricle that is lined with mucosal glands. The 2306 shape of the rima glottidis, the aperture between the vocal folds, varies according to the position of the vocal folds. During a deep inhalation, the vocal ligaments are abducted by contraction of the posterior crico-arytenoid muscles, opening the rima glottidis widely into an inverted kite shape. Stronger contraction of the same muscles seals the rima glottidis (Valsalva maneuver). During whispering, the vocal ligaments are strongly adducted by the lateral crico-arytenoid muscles, but the relaxed arytenoid muscles allow air to pass between the arytenoid cartilages (intercartilaginous part of rima glottidis), which is modified into toneless speech. The vocal folds are the sharp-edged folds of mucous membrane overlying and incorporating the vocal ligaments and the thyro-arytenoid muscles. These folds produce audible vibrations when their free margins are closely (but not tightly) apposed during phonation, and air is forcibly expired intermittently. The vocal folds also serve as the main inspiratory sphincter of the larynx when they are tightly closed. Complete adduction of the folds forms an effective sphincter that prevents entry of air. The glottis (the vocal apparatus of the larynx) makes up the vocal folds and processes, together with the rima glottidis, the aperture between the vocal folds 2307. During ordinary breathing, the rima is narrow and wedge shaped; during forced respiration, it is wide and trapezoidal in shape. The rima glottidis is slit-like when the vocal folds are closely approximated during phonation. Variation in the tension and length of the vocal folds, in the width of the rima glottidis, and in the intensity of the expiratory effort produces changes in the pitch of the voice. The lower range of pitch of the voice of postpubertal males results from the greater length of the vocal folds. They consist of two thick folds of mucous membrane enclosing the vestibular ligaments. The lateral recesses between the vocal and the vestibular folds are the laryngeal ventricles. The laryngeal muscles are divided into extrinsic and intrinsic groups: Extrinsic laryngeal muscles move the larynx as a whole. The infrahyoid muscles are depressors of the hyoid and larynx, whereas the suprahyoid muscles (and the stylopharyngeus, a pharyngeal muscle discussed later in this chapter) are elevators of the hyoid and larynx. Intrinsic laryngeal muscles move the laryngeal components, altering the length and tension of the vocal folds and the size and shape of the rima glottidis. All but one of the intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve. The cricothyroid is supplied by the external laryngeal nerve, one of the two terminal branches of the superior laryngeal nerve. The cricothyroid joint is disarticulated, and the right lamina of the thyroid cartilage is turned anteriorly (like opening a book), stripping the cricothyroid muscles off the arch of the cricoid cartilage. The actions of the intrinsic laryngeal muscles are easiest to understand when they are considered as functional groups: adductors and abductors, sphincters, and tensors and relaxers. These fibers constitute the thyro-epiglottic muscle, which widens the laryngeal inlet. Adductors and abductors: these muscles move the vocal folds to open and close the rima glottidis. The principal adductors are the lateral crico2310 arytenoid muscles, which pull the muscular processes anteriorly, rotating the arytenoid cartilages so that their vocal processes swing medially. When this action is combined with that of the transverse and oblique arytenoid muscles, which pull the arytenoid cartilages together, air pushed through the rima glottidis causes vibrations of the vocal ligaments (phonation). When the vocal ligaments are adducted, but the transverse arytenoid muscles do not act, the arytenoid cartilages remain apart and air may bypass the ligaments. This is the position of whispering when the breath is modified into voice in the absence of tone. Sphincters: the combined actions of most of the muscles of the laryngeal inlet result in a sphincteric action that closes the laryngeal inlet as a protective mechanism during swallowing. Contraction of the lateral cricoarytenoids, transverse and oblique arytenoids, and aryepiglottic muscles brings the aryepiglottic folds together and pulls the arytenoid cartilages toward the epiglottis. This action occurs reflexively in response to the presence of liquid or particles approaching or within the laryngeal vestibule. It is perhaps our strongest reflex, diminishing only after loss of consciousness, as in drowning. Tensors: the principal tensors are the cricothyroid muscles, which tilt or pull the prominence or angle of the thyroid cartilage anteriorly and inferiorly toward the arch of the cricoid cartilage. This increases the distance between the thyroid prominence and the arytenoid cartilages.

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Glossopharyngeal Neuralgia Glossopharyngeal neuralgia (glossopharyngeal tic) is uncommon and its cause is unknown heel pain treatment yahoo discount ibuprofen 400mg overnight delivery. These paroxysms (spasms or sudden attacks) of pain are often initiated by swallowing, protruding the tongue, talking, or touching the palatine tonsil (Yugrakh et al. Lesions of the superior laryngeal nerve produce anesthesia of the superior part of the larynx and paralysis of the cricothyroid muscle. Injury of a recurrent laryngeal nerve may be caused by aneurysms of the arch of the aorta and may occur during neck operations. Injury of the recurrent laryngeal nerve causes dysphonia (hoarseness or weakness of voice) because of paralysis of the vocal folds (cords). Paralysis of both recurrent laryngeal nerves causes aphonia (loss of voice) and inspiratory stridor (a harsh, high-pitched respiratory sound). Paralysis of recurrent laryngeal nerves usually results from cancer of the larynx and thyroid gland and/or from injury during surgery on the thyroid gland, neck, esophagus, heart, and lungs. Because of its longer course, lesions of the left recurrent laryngeal nerve are more common than those of the right. After some time, the tongue atrophies, making it appear shrunken and wrinkled (Russo et al. When the tongue is protruded, its apex deviates toward the paralyzed side because of the unopposed action of the genioglossus muscle on the normal side of the tongue. International Federation of Anatomical Associations/Federative International Programme on Anatomical Terminologies: Terminologia Anatomica: International Anatomical Nomenclature. Maklad A, Quinn T, Fritsch B: Intracranial distribution of the sympathetic system in mice: Dil tracing and immunocytochemical labeling. This tiny, flat, plaque-like, subdural-based lesion, seen on a whole mount section, was found in an older woman with multiple sclerosis and was too small to be responsible for any of her symptomatology. This represented the only site of Rosenthal fibre deposition in the brain of this elderly woman. Note the concentration of these massive vacuoles in deeper brain areas where the formalin fixative used in autopsy preservation of tissues has not penetrated. The brain was immersed in formalin at the time of autopsy and the formalin penetrated a few centimetres into the tissues and killed the post-mortem overgrowth of micro-organisms in the more superficial areas. On microscopic inspection, no host inflammatory reaction is present around these vacuoles, but numerous bacteria can often be found. This artefactual occurrence is particularly likely if the cord is already fragile and damaged by infarction or tumour. Distinguishing Pathological Abnormalities from Artefacts and Incidentals (a) (b) (c) 37 1 (d) (e) 1. The latter are also of unknown significance and are not associated with any specific disease. However, in acute demyelinating lesions that prompt biopsy (as illustrated here) they diffusely permeate a neuropil that is largely intact except for the loss of myelin. Their admixture with reactive astrocytes further adds to the diagnostic difficulty; some examples are misdiagnosed as mixed oligoastrocytomas. Although metastatic neoplasms, including hematopoietic neoplasms, often involve the dura, this granulation tissue response should not be interpreted as neoplastic, or even abnormal. Continued 38 (f) Chapter 1 General Pathology of the Central Nervous System (g) (h) (i) (j) (k) 1. The identity of the entrapped cells can be proven by immunostaining for epithelial membrane antigen (h). More commonly, corpora amylacea can also become encompassed by an infiltrating glioma; this usually occurs in an older adult whose brain contains numerous corpora amylacea as part of normal ageing. This 23-year-old woman had undergone a posterior cervical spinal cord untethering procedure several months previously and had had Bioglue placed over her dural suture as a sealant for a cerebrospinal fluid leak. She then developed a fluid collection in the posterior cervical tissue and aseptic meningitis, prompting wound revision and removal of the soft tissue and Bioglue. This specimen shows the granulomatous foreign-body type response and the macrophages containing tiny droplets of eosinophilic Bioglue (arrow); the large central inert blob of Bioglue was homogeneously densely eosinophilic, and visually uninteresting. The material can cause vessel wall necrosis, neutrophilic infiltrates that simulate an acute infection, and a foreign body giant cell reaction. Both the anoxia, sepsis or acidosis that was part of the original injury and the bilirubin itself may injure the brain. Free (unconjugated to albumin) bilirubin is reported to bind to phospholipids and gangliosides in cell membranes and to interfere with neuronal oxygen consumption and oxidative phosphorylation. Neural stem cells from the adult mammalian central nervous system were first confidently isolated in 1992. As noted earlier, although the presence of these stem cells is now undisputed, their innate ability effectively to replenish injured or dead neurons is highly limited. Nevertheless, overwhelming interest has been 40 (a) Chapter 1 General Pathology of the Central Nervous System (b) (c) (d) (e) (f) 1. This is an example of active central pontine myelinolysis, characterized by its typical triangular midline location in the basis pontis at the level of the 5th cranial nerve, occurring in a typical patient with severe concomitant liver failure and bilirubin elevation. Note how the greenish discolouration extends beyond the immediate nidus of the tissue injury. This non-iron-containing pigment forms when erythrocytes are disrupted within the ingesting macrophage; the iron in haemoglobin is then oxidized to the trivalent state, forming methaemoglobin. The haem and globin then dissociate and the iron is liberated from hemin by the microsomal enzyme, haem oxygenase, yielding iron and biliverdin. Xanthogranulomas of the choroid plexus are incidental findings usually in aged individuals, but the cholesterol clefts illustrated here are seen in a pathological lesion, a cholesterol granuloma of temporal bone. Any successful use of stem cells as therapy requires an understanding of how neurons differentiate and commit to lineage during normal embryology. This material is Fontana-positive, bleaches with potassium permanganate and is thought to be composed of sulphur. It is probably artefactual, may represent melanization of lipofuscin and is almost never associated with cerebellar symptomatology. The black pigment is usually found in joints, the cardiovascular system, kidney and skin, but in this reportable example it was found in the dura mater. Gross photograph of lateral surface of formalin-fixed brain with attached, reflected dura mater. The localized microenvironment into which neural stem cells are transplanted has a strong influence on the stem cells and provides the signals that influence the cells to form the correct synapses and chemical phenotype 42 (a) Chapter 1 General Pathology of the Central Nervous System (b) (c) (d) (f) (e) 1. Although melanocytic melanin pigment is commonly found at the base of the brain at autopsy, particularly around the ventral medulla or hypothalamus, and especially in dark-skinned individuals, visible melanocytic accumulation elsewhere is rare. This example from the temporal lobe of a young Hispanic girl was mistaken by the referring coroner for an area of remote haemorrhage. Although the coeliac ganglion is illustrated here, more commonly observed sites include neurons of the dorsal root ganglia, the dentate nucleus of the cerebellum and the inferior olivary nucleus. Note the satellite Schwann cells surrounding the neurons and the fact that the Nissl substance is arranged at the periphery in this type of neuron. Note the displacement of the basophilic Nissl substance in this neuron from the anterior horn cell region, as well as the artefactual perineuronal space. Young children do not start to manifest either gross or significant microscopic accumulation of neuromelanin pigment in these neurons until about the age of 7 years. The amyloid in blood vessels of the cortical grey matter and leptomeninges is quite obvious on Congo red staining. The amyloid core in the centre of neuritic plaques can also be visualized with Congo red stain (arrow) but is better highlighted with thioflavin-S staining (inset). The amyloid appears to be formed focally and locally for unknown reasons, but has the staining characteristics of all amyloids. These appear to be large conglomerates of proteinaceous material and lack the affinity for Congo red dye or the thioflavin-S immunofluorescence of true amyloid. In animal models, highly proliferative stem cells within the subventricular zone show the highest degree of susceptibility to chemical or viral oncogenesis. In a tumour model in which avian sarcoma 44 Chapter 1 General Pathology of the Central Nervous System virus was injected into neonatal dog brains, gliomas initially developed in the periventricular regions, but as the tumours increased in size, their relationship with the subventricular zone diminished until they were found at day 10 deep within the white matter, unconnected to the subventricular zone. Further evidence in support of the concept that human gliomas may arise from neural stem cells is the fact that neural stem cells share many properties with gliomas (see earlier). Various developmentally regulated genes that are important in normal brain development and the evolution of neoplasia.

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Most lymph (>75%) pain management in uti ibuprofen 400 mg low price, especially from the lateral breast quadrants, drains to the axillary lymph nodes, initially to the anterior or pectoral nodes for the most part. However, some lymph may drain directly to other axillary nodes or even to interpectoral, deltopectoral, supraclavicular, or inferior deep cervical nodes. Lymph from the skin of the breast, except the nipple and areola, drains into the ipsilateral axillary, inferior deep cervical, and infraclavicular lymph nodes and into the parasternal lymph nodes of both sides. Lymph from the axillary nodes drains into clavicular (infraclavicular and supraclavicular) lymph nodes and from them into the subclavian lymphatic trunk, which also drains lymph from the upper limb. Lymph from the parasternal nodes enters the bronchomediastinal lymphatic trunks, which also drain lymph from the thoracic viscera. The termination of the lymphatic trunks varies; traditionally, these trunks are described as merging with each other and with the jugular lymphatic trunk, draining the head and neck to form a short right lymphatic duct on the right side or entering the termination at the thoracic duct on the left side. However, in many (perhaps most) cases, the trunks open independently into the junction of the internal jugular and subclavian veins, the right or left venous angles, that form the right and left brachiocephalic veins. In some cases, they open into both contributing veins immediately prior to the angle. The branches of the intercostal nerves pass through the pectoral fascia covering the pectoralis major to reach overlying subcutaneous tissue and skin of the breast. The branches of the 779 intercostal nerves convey sensory fibers from the skin of the breast and sympathetic fibers to the blood vessels in the breasts and smooth muscle in the overlying skin and nipple. Surface Anatomy of Thoracic Wall the clavicles (collar bones) lie subcutaneously, forming bony ridges at the junction of the thorax and neck. They can be palpated easily throughout their length, especially where their medial ends articulate with the manubrium of the sternum. The clavicles demarcate the superior division between zones of lymphatic drainage: above the clavicles, lymph flows ultimately to inferior jugular lymph nodes; below them, parietal lymph (that from the body wall and upper limbs) flows to the axillary lymph nodes. Between the prominences of the medial ends of the clavicles at the sternoclavicular joints, the jugular notch in the manubrium can be palpated between the prominent medial ends of the clavicles. The notch lies at the level of the inferior border of the body of T2 vertebra and the space between the 1st and 2nd thoracic spinous processes. The manubrium, approximately 4 cm long, lies at the level of the bodies of T3 and T4 vertebrae. The sternal angle is palpable and often visible in young people because of the slight movement that occurs at the manubriosternal joint during forced respiration. The intermammary cleft (midline depression or cleavage between the mature female breasts) overlies the sternal body. The xiphisternal joint is palpable and is often seen as a ridge, at the level of the inferior border of T9 vertebra. The ribs and intercostal spaces provide a basis for locating or describing the position of structures or sites of trauma or pathology on or deep to the thoracic wall. To count the ribs and intercostal spaces anteriorly, slide the fingers (digits) laterally from the sternal angle onto the 2nd costal cartilage and begin counting the ribs and spaces by moving the fingers from here. The 1st intercostal space is that superior to the 2nd costal cartilage-that is, intercostal spaces are numbered according to the rib forming their superior boundary. Generally, it is more reliable to count intercostal spaces, since the fingertip tends to rest in (slip into) the gaps between the ribs. If the fingers are removed from the thoracic wall while counting spaces, the finger may easily be returned to the same space, mistaking it for the one below. While the ribs and/or intercostal spaces provide the "latitude" for navigation and localization on the thoracic wall, several imaginary lines facilitate anatomical and clinical descriptions by providing "longitude. Additional lines (not illustrated) are extrapolated along the borders of palpable bony formations, such as the parasternal and paravertebral lines (G. Breasts are the most prominent surface features of the anterior thoracic wall, especially in women. In moderately athletic individuals, the contour of the pectoralis major muscles is apparent, separated in the midline by the intermammary cleft overlying the sternum, with the lateral border forming the anterior axillary fold. Inferolaterally, finger-like slips, or digitations of the serratus anterior, have a serrated (sawtooth) appearance as they attach to the ribs and interdigitate with the external oblique. The inferior ribs and costal margins are often apparent, especially when the abdominal muscles are contracted. The intercostal musculature is not normally evident; however, in (rare) cases in which there is an absence or atrophy of the intercostal musculature, the intercostal spaces become apparent with respiration: during inspiration, they are concave; during expiration, they protrude. Their flattened superior surfaces show no sharp demarcation from the anterior surface of the thoracic wall, but laterally and inferiorly, their borders are well defined. The areola usually darkens during pregnancy and retains the darkened pigmentation thereafter. The areola is normally dotted with the papular (small elevated) openings of the areolar glands (sebaceous glands in the skin of the areola). On occasion, one or both nipples are inverted (retracted); this minor congenital anomaly may make breastfeeding difficult. Usually, however, the position of nipples varies considerably with breast size, especially in multiparous women- those who have given birth to two or more children. Consequently, because of variations in size and shape, the nipples are not a reliable guide to the 4th intercostal spaces in adult females. Although mammary glands are prepared for secretion by midpregnancy, they do not produce milk until shortly after the baby is born. Colostrum, a creamy white to yellowish premilk fluid, may secrete from the nipples during the last trimester of pregnancy and during initial episodes of nursing. In multiparous women (those who have given birth two or more times), the breasts often become large and pendulous. The breasts in elderly women are usually small because of the decrease in fat and the atrophy of glandular tissue. Breast Quadrants For the anatomical location and description of tumors and cysts, the surface of the breast is divided into four quadrants. Carcinoma of the Breast Understanding the lymphatic drainage of the breasts is of practical importance in predicting the metastases (dispersal) of cancer cells from a carcinoma of the breast (breast cancer). Carcinomas of the breast are malignant tumors, usually adenocarcinomas (glandular cancer) arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules. Metastatic cancer cells that enter a lymphatic vessel usually pass through two or three groups of lymph nodes. Interference with dermal lymphatics by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue) in the skin of the breast, which in turn may result in deviation of the nipple and a thickened, leather-like appearance of the skin. Larger dimples (fingertip size or bigger) result from cancerous invasion of the glandular tissue and fibrosis (fibrous degeneration), which causes shortening or places traction on the suspensory ligaments. Subareolar breast cancer may cause retraction of the nipple by a similar mechanism involving the lactiferous ducts. Breast cancer typically spreads from the breast by means of lymphatic vessels (lymphogenic metastasis), which carry cancer cells from the breast to the lymph nodes, chiefly those in the axilla. Abundant communications among lymphatic pathways and among axillary, cervical, and parasternal nodes may also cause metastases from the breast to develop in the supraclavicular lymph nodes, the opposite breast, or the abdomen. Because most of lymphatic drainage of the breast is to the axillary lymph nodes, they are the most common site of metastasis from a breast cancer. Enlargement of these palpable nodes suggests the possibility of breast cancer and may be key to early detection. However, the absence of enlarged axillary lymph nodes is no guarantee that metastasis from a breast cancer has not occurred; the malignant cells may have passed to other nodes, such as the infraclavicular and 788 supraclavicular lymph nodes or directly into the systemic circulation. Surgical removal of axillary nodes to which breast cancer has metastasized, or damage to the axillary lymph nodes and vessels by radiation therapy for cancer treatment, may result in lymphedema in the ipsilateral upper limb, which also drains through the axillary nodes (see the Clinical Box "Dissection of Axillary Lymph Nodes" in Chapter 3, Upper Limb). The posterior intercostal veins drain into the azygos/hemi-azygos system of veins alongside the bodies of the vertebrae. Cancer cells can also spread from the breast by these venous routes to the vertebrae and from there to the cranium and brain.

Syndromes

• Collapse of the lung (pneumothorax)
• Rescue breathing, which provides oxygen to the lungs.
• Inflammation or edema
• Hematoma (blood accumulating under the skin)
• Resin
• Rapid heart rate
• Increased potassium
• If the prescription was prescribed for the person
• Slurred speech

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The anterior thigh muscles include the pectineus pain medication for dogs with lymphoma buy 600mg ibuprofen mastercard, iliopsoas, sartorius, and quadriceps femoris. Damage to one or more of the listed spinal cord segments, or to the motor nerve roots arising from them, results in paralysis of the muscles concerned. The major muscles of the anterior compartment tend to atrophy (diminish) rapidly with disease, and physical therapy is often necessary to restore strength, tone, and symmetry with the opposite limb after immobilization of the thigh or leg. It often appears to be composed of two layers, superficial and deep, and these are generally innervated by two different nerves. Its broad lateral part, the iliacus, and its long medial part, the psoas major, arise from the iliac fossa and lumbar vertebrae, respectively. It is in a unique position not only to produce movement but to stabilize (fixate). However, it can also perpetuate and even contribute to deformity and disability when it is malformed (especially if it is shortened), dysfunctional, or diseased. Concentric contraction of the iliopsoas typically moves the free limb, producing flexion at the hip to lift the limb and initiate its forward swing during walking. Bilateral contraction of the iliopsoas muscles initiates flexion of the trunk at the hip on the fixed thigh-as when 1615 (incorrectly) doing sit-ups-and decreases the lumbar lordosis (curvature) of the vertebral column. It is active during walking downhill, its eccentric contraction resisting acceleration. The iliopsoas is also a postural muscle, active during standing in maintaining normal lumbar lordosis (and indirectly the compensatory thoracic kyphosis; see Chapter 2, Back) and resisting hyperextension of the hip joint. The sartorius lies superficially in the anterior compartment, within its own relatively distinct fascial sheath. The actions of both sartorius muscles bring the lower limbs into the cross-legged sitting position. None of the actions of the sartorius is strong; therefore, it is mainly a synergist, acting with other thigh muscles that produce these movements. The quadriceps femoris (usually shortened to quadriceps) consists of four parts: (1) rectus femoris, (2) vastus lateralis, (3) vastus intermedius, and (4) vastus medialis. Collectively, the quadriceps is a two-joint muscle capable of producing action at both the hip and knee. Consequently, it may be three times stronger than its antagonistic muscle group, the hamstrings. In level walking, the quadriceps muscles become active during the 1616 termination of the swing phase, preparing the knee to accept weight. The quadriceps is primarily responsible for absorbing the jarring shock of heel strike, and its activity continues as the weight is assumed during the early stance phase (loading response). It also functions as a fixator during bent-knee sports, such as skiing and tennis, and contracts eccentrically during downhill walking and descending stairs. The tendons of the four parts of the quadriceps unite in the distal portion of the thigh to form a single, strong, broad quadriceps tendon. The medial and lateral vasti muscles also attach independently to the patella and form aponeuroses, the medial and lateral patellar retinacula, which reinforce the joint capsule of the knee joint on each side of the patella en route to attachment to the anterior border of the tibial plateau. The retinacula also play a role in keeping the patella aligned over the patellar surface of the femur. The patella provides a bony surface that is able to withstand the compression placed on the quadriceps tendon during kneeling and the friction occurring when the knee is flexed and extended during running. The inferiorly directed apex of the patella indicates the level of the joint plane of the knee when the leg is extended and the patellar ligament is taut. In 1617 (A) and (B), the suprapatellar bursa, normally a potential space extending between the quadriceps and the femur (exaggerated for schematic purposes in C), is depicted as if injected with latex. Testing the quadriceps2 is performed with the person in the supine position with the knee partly flexed. During the test, contraction of the rectus femoris should be observable and palpable if the muscle is acting normally, indicating that its nerve supply is intact. We are providing only a few important examples useful to primary care health professionals. The rectus femoris is the only part of the quadriceps that crosses the hip joint, and as a hip flexor, it acts with and like the iliopsoas during the preswing and initial swing phases of walking. The ability of the rectus femoris to extend the knee is compromised during hip flexion, but it does contribute to the extension force during the toe off phase of walking, when the thigh is extended. It is particularly efficient in movements combining knee extension and hip flexion from a position of hip hyperextension and knee flexion, as in the preparatory position for kicking a soccer ball. The rectus femoris is susceptible to injury and avulsion from the anterior inferior iliac spine during kicking, hence the name "kicking muscle. Vastus intermedius lies deep to the rectus femoris, between the vastus medialis and vastus lateralis. The small, flat articularis genu (articular muscle of the knee), a derivative of the vastus intermedius, usually consists of a variable number of muscular slips that attach superiorly to the inferior part of the anterior aspect of the femur and inferiorly to the synovial membrane of the knee joint and the wall of the suprapatellar bursa. The articularis genu muscle pulls the synovial membrane superiorly during extension of the leg, thereby preventing folds of the membrane from being compressed between the femur and the patella within the knee joint. Medial Thigh Muscles the muscles of the medial compartment of the thigh comprise the adductor group, consisting of the adductor longus, adductor brevis, adductor magnus, gracilis, and obturator externus. In general, they attach proximally to the antero-inferior external surface of the bony pelvis (pubic bone, ischiopubic ramus, and ischial tuberosity), and adjacent obturator membrane, and distally to the linea aspera of the femur. The hamstring part of the adductor magnus is supplied by the tibial part of the sciatic nerve (L4). The details of their attachments, nerve supply, and actions of the muscles are provided in Table 7. The triangular long adductor arises by a strong tendon from the anterior aspect of the body of the pubis, just inferior to the pubic tubercle (apex of triangle), and expands to attach to the linea aspera of the femur (base of triangle). It widens as it passes distally to attach to the superior part of the linea aspera. As the obturator nerve emerges from the obturator canal to enter the medial compartment of the thigh, it splits into an anterior and a posterior division. This unique relationship is useful in identifying the muscle during dissection and in anatomical cross-sections. The two parts differ in their attachments, nerve supply, and main actions (Table 7. The gracilis joins with two other two-joint muscles from the other two compartments (the sartorius and semitendinosus muscles). The gracilis is a synergist in adducting the thigh, flexing the knee, and rotating the leg medially when the knee is flexed. It acts with the other two "pes anserinus" muscles to add stability to the medial aspect of the extended knee, much as the gluteus maximus and tensor fasciae latae do via the iliotibial tract on the lateral side. It extends from the external surface of the obturator membrane and surrounding bone of the pelvis to the posterior aspect of the greater trochanter, passing directly under the acetabulum and neck of the femur. They are also used to stabilize the stance when standing on both feet, to correct a lateral sway of the trunk, or when there is a side-to-side shift of the surface on which one is standing (rocking a boat, standing on a balance board). These muscles are also used in kicking with the medial side of the foot in soccer and in swimming. Finally, they contribute to flexion of the extended thigh and extension of the flexed thigh when running or against resistance. Although they are important in many activities, it has been shown that a reduction of as much as 70% in their function will result in only a slight to moderate impairment of hip function (Markhede and Stener, 1981). Testing of the medial thigh muscles is performed while the person is lying supine with the knee straight. The individual adducts the thigh against resistance, and if the adductors are normal, the proximal ends of the gracilis and adductor longus can easily be palpated. The adductor hiatus transmits the femoral artery and vein from the adductor canal in the thigh to the popliteal fossa posterior to the knee. The opening is located just lateral and superior to the adductor tubercle of the femur.

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The epithelium lining the walls of the pericardioperitoneal canals forms the parietal pleura active pain treatment knoxville order ibuprofen 400 mg overnight delivery. During embryogenesis, the pleural cavities become separated from the pericardial and peritoneal cavities. The pleural cavity-the potential space between the layers of pleura- contains a capillary layer of serous pleural fluid, which lubricates the pleural surfaces and allows the layers of pleura to slide smoothly over each other during respiration. The surface tension of the pleural fluid provides the cohesion that keeps the lung surface in contact with the thoracic wall; consequently, the lung expands and fills with air when the thorax expands while still allowing sliding to occur, much like a film of water between two glass plates. The visceral pleura (pulmonary pleura) closely covers the lung and adheres to all its surfaces, including those within the horizontal and oblique fissures. In cadaver dissection, the visceral pleura cannot usually be dissected from the surface of the lung. It provides the lung with a smooth slippery surface, enabling it to move freely on the parietal pleura. The visceral pleura is continuous with the parietal pleura at the hilum of the lung, where structures making up the root of the lung. The left sternal reflection of parietal pleura and anterior border of the left lung deviate from the median plane, circumventing the area where the heart is, lies adjacent to the anterior thoracic wall. In this "bare area" the pericardial sac is accessible for needle puncture with less risk of puncturing the pleural cavity or lung. The shapes of the lungs and the larger pleural sacs that surround them during quiet respiration are demonstrated. The costodiaphragmatic recesses, not 798 occupied by lung, are where pleural exudate accumulates when the body is erect. The outline of the horizontal fissure of the right lung clearly parallels the 4th rib. The parietal pleura lines the pulmonary cavities, thereby adhering to the thoracic wall, mediastinum, and diaphragm. It is thicker than the visceral pleura, and during surgery and cadaver dissections, it may be separated from the surfaces it covers. The parietal pleura consists of three parts-costal, mediastinal, and diaphragmatic-and the cervical pleura. The costal part of the parietal pleura (costovertebral or costal pleura) covers the internal surfaces of the thoracic wall. It is separated from the internal surface of the thoracic wall (sternum, ribs and costal cartilages, intercostal muscles and membranes, and sides of thoracic vertebrae) by endothoracic fascia. This thin, extrapleural layer of loose connective tissue forms a natural cleavage plane for surgical separation of the costal pleura from the thoracic wall (see the Clinical Box "Extrapleural Intrathoracic Surgical Access"). At this level, the 799 mediastinum consists of the pericardial sac (middle mediastinum) and the posterior mediastinum, mainly containing the esophagus and aorta. The deep groove surrounding the convexity of the diaphragm is the costodiaphragmatic recess, lined with parietal pleura. Anteriorly at this level, the pericardium and costomediastinal recesses and, between the sternal reflections of pleura, an area of pericardium only (the bare area) lie between the heart and the thoracic wall. The mediastinal part of the parietal pleura (mediastinal pleura) covers the lateral aspects of the mediastinum, the partition of tissues and organs separating the pulmonary cavities and their pleural sacs. It is continuous with costal pleura anteriorly and posteriorly and with the diaphragmatic pleura inferiorly. Superior to the root of the lung, the mediastinal pleura is a continuous sheet passing anteroposteriorly between the sternum and the vertebral column. At the hilum of the lung, it is the mediastinal pleura that reflects laterally onto the root of the lung to become continuous with the visceral pleura the diaphragmatic part of the parietal pleura (diaphragmatic pleura) covers the superior (thoracic) surface of the diaphragm on each side of the mediastinum, except along its costal attachments (origins) and where the diaphragm is fused to the pericardium, the fibroserous membrane surrounding the heart. A thin, more elastic layer of endothoracic fascia, the phrenicopleural fascia, connects the diaphragmatic pleura with the muscular fibers of the diaphragm. The cervical pleura covers the apex of the lung (the part of the lung extending superiorly through the superior thoracic aperture into the root of the neck;. It is a superior continuation of the costal and mediastinal parts of the parietal pleura. The cervical pleura is reinforced by a fibrous extension of the endothoracic fascia, the suprapleural membrane (Sibson fascia). The membrane attaches to the internal border of the 1st rib and the transverse process of C7 vertebra. The relatively abrupt lines along which the parietal pleura changes direction 800 as it passes (reflects) from one wall of the pleural cavity to another are the lines of pleural reflection. Three lines of pleural reflection outline the extent of the pulmonary cavities on each side: sternal, costal, and diaphragmatic. Deviation of the heart to the left side primarily affects the right and left sternal lines of pleural reflection, which are asymmetrical. The sternal lines are sharp or abrupt and occur where the costal pleura is continuous with the mediastinal pleura anteriorly. Here it passes to the left margin of the sternum and continues inferiorly to the 6th costal cartilage, creating a shallow notch as it runs lateral to an area of direct contact between the pericardium (heart sac) and the anterior thoracic wall. This shallow notch in the pleural sac, and the "bare area" of pericardial contact with the anterior wall. The costal lines of pleural reflection are sharp continuations of the sternal lines, occurring where the costal pleura becomes continuous with diaphragmatic pleura inferiorly. The vertebral lines of pleural reflection are much rounder, gradual 801 reflections and occur where the costal pleura becomes continuous with the mediastinal pleura posteriorly. The vertebral lines of pleural reflection parallel the vertebral column, running in the paravertebral planes from vertebral level T1 through T12, where they become continuous with the costal lines. The lungs do not fully occupy the pulmonary cavities during expiration; thus, the peripheral diaphragmatic pleura is in contact with the lowermost parts of the costal pleura. The potential pleural spaces here are the costodiaphragmatic recesses, pleura-lined "gutters," which surround the upward convexity of the diaphragm inside the thoracic wall. The left recess is larger (less occupied) because the cardiac notch in the left lung is more pronounced than the corresponding notch in the pleural sac. The inferior borders of the lungs move farther into the pleural recesses during deep inspiration and retreat from them during expiration. The lungs are shown in isolation in anterior (A) and lateral views (B), demonstrating lobes and fissures. The superior lobe of the left lung in C is a variation that has neither a marked cardiac notch nor a lingula. Their main function is to oxygenate the blood by bringing inspired air into close relation with the venous blood in the pulmonary capillaries. Although cadaveric lungs may be shrunken, firm or hard, and discolored, healthy lungs in living people are normally light, soft, and spongy and fully occupy the pulmonary cavities. At the hilum (B and D), the root of each lung is surrounded by a pleural sleeve that descends inferior to the root as the pulmonary ligament. The pulmonary veins are the most anterior and inferior in the root, with the bronchi central and posteriorly placed. The right lung features right oblique and horizontal fissures that divide it into three right lobes: superior, middle, and inferior. The right lung is larger and heavier than the left, but it is shorter and wider because the right dome of the diaphragm is higher and the heart and pericardium bulge more to the left. The left lung has a single left oblique fissure dividing it into two left lobes, superior and inferior. The anterior border of the left lung has a deep cardiac notch, an indentation consequent to the deviation of the apex of the heart to the left side. This indentation often shapes the most inferior and anterior part of the superior lobe into a thin, tongue-like process, the lingula (L. These markings provide clues to the relationships of the lungs; however, only the cardiac impressions are evident during surgery or in fresh cadaveric or postmortem specimens.

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The visceral afferent innervation of the superior (intraperitoneal; fundus and body) and inferior (subperitoneal; cervical) parts of the uterus and vagina differs in terms of course and destination monterey pain treatment medical center buy ibuprofen cheap online. The two different routes followed by visceral pain fibers is clinically significant in that it offers mothers a variety of types of anesthesia for childbirth (see the Clinical Box "Anesthesia for Childbirth"). All visceral afferent fibers from the uterus and vagina not concerned with pain (those conveying unconscious sensations) also follow the latter route. Conversely, inflammation of a tube (salpingitis) may result from infections that spread from the peritoneal cavity. A major cause of infertility in women is blockage of the uterine tubes, often the result of salpingitis. Accumulation of radiopaque fluid or the appearance of gas bubbles in the pararectal fossae (pouch) region of the peritoneal cavity indicates that the tubes are patent. Oocytes released from the ovaries that enter the tubes of these patients degenerate and are soon absorbed. Surgical tubal sterilizations are performed using either an abdominal or laparoscopic approach. Open abdominal tubal sterilization is 1431 usually performed through a short suprapubic incision made at the pubic hairline and involves removal of a segment or all of the uterine tube. Laparoscopic tubal sterilization is done with a fiberoptic laparoscope inserted through a small incision, usually near the umbilicus. A hysterosalpingography is performed after 3 months to ensure that the uterine tubes are completely occluded. Ectopic Tubal Pregnancy Tubal pregnancy is the most common type of ectopic gestation (embryonic implantation and initiation of gestational development outside of the body of the uterus); it occurs in approximately 1 of every 250 pregnancies in North America (Moore et al. If not diagnosed early, ectopic tubal pregnancies may result in rupture of the uterine tube and severe hemorrhage into the abdominopelvic cavity during the first 8 weeks of gestation. In some women, collections of pus may develop in a uterine tube (pyosalpinx) and the tube may be partly occluded by adhesions. In these cases, the morula (early embryo) may not be able to pass along the tube to the uterus, although sperms have obviously done so. When the blastocyst forms, it may implant in the mucosa of the uterine tube, producing an ectopic tubal pregnancy. Although ectopic implantation may occur in any part of the tube, the common site is in the ampulla. Ectopic pregnancies also occur idiopathically (without demonstrable or understood reason) in women, and there is increased risk in cases of faulty tubal sterilization. This relationship explains why a ruptured tubal pregnancy and the resulting peritonitis may be misdiagnosed as acute appendicitis. In both cases, the parietal peritoneum is inflamed in the same general area, and the pain is referred to the right lower quadrant of the abdomen. Remnants of Embryonic Ducts Occasionally, the mesosalpinx between the uterine tube and the ovary contains embryonic remnants. The epoophoron forms from remnants of the mesonephric tubules of the mesonephros, the transitory embryonic kidney (Moore et al. There may also be a persistent duct of the epoophoron (duct of Gartner), a remnant of the mesonephric duct that forms the ductus deferens and ejaculatory duct in the male. It lies between layers of the broad ligament along each side of the uterus and/or vagina. A vesicular appendage is 1434 sometimes attached to the infundibulum of the uterine tube. It is the remains of the cranial end of the mesonephric duct that forms the ductus epididymis. Although these vestigial structures are mostly of embryological and morphological interest, they occasionally accumulate fluid and form cysts. Bicornate Uterus Incomplete fusion of the embryonic paramesonephric ducts, from which the uterus is formed, results in a variety of congenital anomalies, ranging from formation of a unicornuate uterus (receiving a uterine duct only from the right or left) to duplication in the form of a bicornate uterus. Disposition of Uterus Normally, the uterus is anteverted and anteflexed, so that the body of the uterus rests upon the empty bladder, one of several means by which passive support for the uterus may be provided. However, the uterus may assume other dispositions, including excessive anteflexion. Once marked, retroversion and/or retroversion was thought to be a potential predisposing factor in uterine prolapse or to present a potential complication in pregnancy; however, this has proven to be unjustified. Manual Examination of Uterus the size and disposition of the uterus may be examined by bimanual palpation. When softening of the uterine isthmus occurs (Hegar sign), the cervix feels as though it were separated from the body of the 1436 uterus. The uterus can be further stabilized through rectovaginal examination, which is used if examination via the vagina alone does not yield clear findings. Lifetime Changes in Anatomy of Uterus 1437 the uterus is possibly the most dynamic structure in human anatomy. At birth, the uterus is relatively large and has adult proportions (body to cervical ratio = 2:1) due to the prepartum (before childbirth) influence of the maternal hormones. Several weeks postpartum (after childbirth), childhood dimensions and proportions are obtained: the body and cervix are approximately of equal length (body to cervical ratio = 1:1), with the cervix being of greater diameter (thickness). Because of the small size of the pelvic cavity during infancy, the uterus is mainly an abdominal organ. The cervix remains relatively large (approximately 50% of total uterus) throughout childhood. During puberty, the uterus (especially its body) grows rapidly in size, once again assuming adult proportions. In the postpubertal, premenopausal, nonpregnant woman, the body of the uterus is pear shaped; the thick-walled superior two thirds of the uterus lies within the pelvic cavity. During this phase of life, the uterus undergoes monthly changes in size, weight, and density in relation to the menstrual cycle. Over the 9 months of pregnancy, the gravid uterus expands greatly to accommodate the fetus, becoming larger and increasingly thin walled. The uterus becomes nearly membranous, with the fundus dropping below its highest level (achieved in the 9th month), at which time it extends superiorly to the costal margin, occupying most of the abdominopelvic cavity. Immediately after delivery of the fetus, the large uterus becomes thick walled and edematous. The multiparous nongravid uterus has a large and nodular body and usually extends into the lower abdominal cavity, often causing a slight protrusion of the inferior abdominal wall in lean women. All these stages represent normal anatomy for the particular age and reproductive status of the woman. Cervical Cancer Screening Until 1940, cervical cancer was the leading cause of death in North American women (Krebs, 2000). The decline in the incidence and number of women dying from cervical cancer is related to the accessibility of the cervix to direct visualization and to cell and tissue study by means of cervical cytology (invented in 1946 by Dr. Cervical cytology allows detection and treatment of premalignant cervical conditions (Hoffman et al. The vagina can be distended with a vaginal speculum to enable inspection of the cervix. The spatula is rotated to scrape cellular material from the mucosa of the vaginal cervix. The cellular material is then placed in a preservative liquid for microscopic examination. Because no peritoneum intervenes between the anterior cervix and the base of the bladder, cervical cancer may spread by contiguity to the bladder. The incidence of hysterectomy for noncancerous reasons has markedly declined in favor of exploring other options. The procedure stops abnormal bleeding but also stops menstrual periods and ends the ability to conceive.

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The circular muscle is poorly developed around the orifice; therefore myofascial pain treatment center virginia ibuprofen 400mg without a prescription, the valve is unlikely to have any sphincteric action that controls passage of the intestinal contents from the ileum into the cecum. The orifice is usually closed by tonic contraction, however, appearing as an ileal papilla on the cecal side. The papilla probably serves as a relatively passive flap valve, preventing reflux from the cecum into the ileum as contractions occur to propel contents up the ascending colon and into the transverse colon (Magee and Dalley, 1986). It arises from the posteromedial aspect of the cecum inferior to the ileocecal junction. The appendix has a short triangular mesentery, the mesoappendix, which derives from the posterior side of the mesentery of the terminal ileum. Radiopaque dye was injected into the bloodstream by means of the catheter introduced into the femoral artery and advanced through the iliac arteries and aorta to the opening of the superior mesenteric artery. Venous drainage by the superior mesenteric vein and inferior mesenteric vein corresponds to the pattern of the superior mesenteric artery and inferior mesenteric artery. Lymph from the large intestine flows sequentially to epicolic nodes (on the gut), paracolic nodes (along mesenteric border), intermediate colic nodes (along the colic arteries), and then to the superior or inferior mesenteric nodes and the intestinal trunks. Innervation of the colon occurs by means of mixed peri-arterial plexuses extending from the superior and inferior mesenteric ganglia along the respective arteries. Parasympathetic fibers from S2 to S4 spinal cord levels ascend independently from the inferior hypogastric (pelvic) plexuses to reach the sigmoid colon, descending colon, and distal transverse colon. Lymphatic drainage of the cecum and appendix passes to lymph nodes in the meso-appendix and to the ileocolic lymph nodes that lie along the ileocolic artery. The nerve supply to the cecum and appendix derives from the sympathetic and parasympathetic nerves from the superior mesenteric plexus. The sympathetic nerve fibers originate in the lower thoracic part of the spinal cord, and the parasympathetic nerve fibers derive from the vagus nerves. Afferent nerve fibers from the appendix accompany the sympathetic nerves to the T10 segment of the spinal cord (see also "Summary of Innervation of Abdominal Viscera," p. The colon encircles the small intestine, the ascending colon lying to the right of the small intestine, the transverse colon superior and/or anterior to it, the descending colon to the left of it, and the sigmoid colon inferior to it. It passes superiorly on the right side of the abdominal cavity from the cecum to the right lobe of the liver, where it turns to the left at the right colic flexure (hepatic flexure). This flexure lies deep to the 9th and 10th ribs and is overlapped by the inferior part of the liver. The ascending colon is narrower than the cecum and is secondarily retroperitoneal along the right side of the posterior abdominal wall. The ascending colon is usually covered by peritoneum anteriorly and on its sides; however, in approximately 25% of people, it has a short mesentery. The ascending colon is separated from the anterolateral abdominal wall by the greater omentum. A deep vertical groove lined with parietal peritoneum, the right paracolic gutter, lies between the lateral aspect of the ascending colon and the adjacent abdominal wall. These arteries anastomose with each other and with the right branch of the middle colic artery, the first of a series of anastomotic arcades that is continued by the left colic and sigmoid arteries to form a continuous arterial channel, the marginal artery (juxtacolic artery). This artery parallels and extends the length of the colon close to its mesenteric border. The lymphatic drainage passes first to the epicolic and paracolic lymph nodes, next to the ileocolic and intermediate right colic lymph nodes, and from them to the superior mesenteric lymph nodes. The nerve supply to the ascending colon is derived from the superior mesenteric nerve plexus. The transverse colon is the third, longest, and most mobile part of the large intestine. It crosses the abdomen from the right colic flexure to the left colic flexure, where it turns inferiorly to become the descending colon. The left colic flexure (splenic flexure) is usually more superior, more acute, and less mobile than the right colic flexure. It lies anterior to the inferior part of the left kidney and attaches to the diaphragm through the phrenicocolic ligament. The transverse colon and its mesentery, the transverse mesocolon, loop down, often inferior to the level of the iliac crests. The mesentery is adherent to or fused with the posterior wall of the omental bursa. The arterial supply of the transverse colon is mainly from the middle colic artery. However, the transverse colon may also receive arterial blood from the right and left colic arteries via anastomoses, part of the series of anastomotic arcades that collectively form the marginal artery (of Drummond, juxtacolic artery). The lymphatic drainage of the transverse colon is to the middle colic lymph nodes, which in turn drain to the superior mesenteric lymph nodes. These nerves transmit sympathetic, parasympathetic (vagal), and visceral afferent nerve fibers (see also "Summary of Innervation of Abdominal Viscera," p. The descending colon occupies a secondarily retroperitoneal position between the left colic flexure and the left iliac fossa, where it is continuous with the sigmoid colon. Although retroperitoneal, the descending colon, especially in the iliac fossa, has a short mesentery in approximately 33% of people; however, it is usually not long enough to cause volvulus (twisting) of the colon. As it descends, the colon passes anterior to the lateral border of the left kidney. As with the ascending colon, the descending colon has a paracolic gutter (the left one) on its lateral aspect. The sigmoid colon, characterized by its S-shaped loop of variable length, links the descending colon and the rectum. The sigmoid colon extends from the iliac fossa to the third sacral (S3) vertebra, where it joins the rectum. The termination of the teniae coli, approximately 15 cm from the anus, indicates the rectosigmoid junction. The sigmoid colon usually has a long mesentery-the sigmoid mesocolon- and therefore has considerable freedom of movement, especially its middle part (see the Clinical Box "Volvulus of Sigmoid Colon," p. The root of the sigmoid mesocolon has an inverted V-shaped attachment, extending first medially and superiorly along the external iliac vessels and then medially and inferiorly from the bifurcation of the common iliac vessels to the anterior aspect of the sacrum. The left ureter and the division of the left common iliac artery lie retroperitoneally, posterior to the apex of the root of the sigmoid mesocolon. The teniae coli also disappear as the longitudinal muscle in the wall of the colon broadens to form a complete layer in the rectum. The arterial supply of the descending and sigmoid colon is from the left colic and sigmoid arteries, branches of the inferior mesenteric artery. The sigmoid arteries descend obliquely to the left, where they divide into ascending and descending branches. The superior branch of the most superior sigmoid artery anastomoses with the descending branch of the left colic artery, thereby forming a part of the marginal artery. Venous drainage from the descending colon and sigmoid colon is provided by the inferior mesenteric vein, flowing usually into the splenic vein and then the hepatic portal vein on its way to the liver. Lymphatic drainage from the descending colon and sigmoid colon is conducted through vessels passing to the epicolic and paracolic nodes and then through the intermediate colic lymph nodes along the left colic artery. However, lymph from the left colic flexure may also drain to the superior mesenteric lymph nodes. Orad (toward the mouth, or proximal) to the left colic flexure, sympathetic and parasympathetic fibers travel together from the abdominal aortic plexus via peri-arterial plexuses to reach the abdominal part of the alimentary tract. The sympathetic nerve supply of the descending and sigmoid colon is from the lumbar part of the sympathetic trunk via lumbar (abdominopelvic) splanchnic nerves, the superior mesenteric plexus, and the peri-arterial plexuses following the inferior mesenteric artery and its branches. The parasympathetic nerve supply is from the pelvic splanchnic nerves via the inferior hypogastric (pelvic) plexus and nerves, which ascend retroperitoneally from the plexus, mostly independent of the arterial supply to this part of the gastrointestinal tract. Orad to the middle of the sigmoid colon, visceral afferents conveying pain sensation pass retrogradely with sympathetic fibers to thoracolumbar spinal sensory ganglia, whereas those carrying reflex information travel with the parasympathetic fibers to vagal sensory ganglia. These parts of the large intestine are described with the pelvis in Chapter 6, Pelvis and Perineum.