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At the wrist uremic gastritis definition generic pyridium 200 mg buy on line, the nerve is vulnerable in the ulnar tunnel, where it passes deep to the palmaris brevis muscle and palmar (volar) carpal ligament, just lateral to the pisiform bone (Clinical Focus 7-24). Abductor pollicis brevis Opponens pollicis Superficial head of flexor pollicis brevis (deep head often supplied by ulnar n. Repetitive forearm pronation and finger flexion, especially against resistance, can cause muscle hypertrophy and entrap the nerve. Pronator syndrome Hypesthesia and activity-induced paresthesias Pain location Provocative maneuvers Compression by flexor digitorum superficialis m. Pronation against resistance Compression by bicipital aponeurosis Flexion of wrist against resistance Supracondylar process Lig. Anterior interosseous syndrome Normal Abnormal Hand posture in anterior interosseous syndrome due to paresis of flexor digitorum profundis and flexor pollicis longus muscles Chapter 7 Upper Limb 423 7 Clinical Focus 7-24 Ulnar Tunnel Syndrome the ulnar tunnel exists at the wrist where the ulnar nerve and artery pass deep to the palmaris brevis muscle and palmar (volar) carpal ligament, just lateral to the pisiform bone. Within the tunnel, the nerve divides into the superficial sensory and deep motor branches. Injury may result from trauma, ulnar artery thrombosis, fractures (hook of the hamate), dislocations (ulnar head, pisiform), arthritis, and repetitive movements. A review of the applied anatomy and clinical presentation of several common neuropathies is shown in this illustration. Refer to the muscle tables presented in this chapter for a review of the muscle actions and anticipated functional weaknesses. Cubital tunnel Radial tunnel High compression in arm Ulnar nerve C7T1 Compression sites Thoracic outlet Radial nerve C5T1 Flexor digitorum superficialis arch Carpal tunnel Ulnar tunnel Wrist Sensory distribution Sensory distribution Sensory distribution Motor and sensory functions of each nerve assessed individually throughout entire upper extremity to delineate level of compression or entrapment Testing techniques Sensory threshold tested with tuning fork Pinch strength Paresthesias may be induced by tapping over n. Grip strength Two-point discrimination Median nerve Ulnar nerve Radial nerve Chapter 7 Upper Limb 425 7 Clinical Focus 7-26 Ulnar Nerve Compression in Cubital Tunnel Cubital tunnel syndrome results from compression of the ulnar nerve as it passes beneath the ulnar collateral ligament and between the two heads of the flexor carpi ulnaris muscle. This syndrome is the second most common compression neuropathy after carpal tunnel syndrome. The tunnel space is significantly reduced with elbow flexion, which compresses and stretches the ulnar nerve. The nerve also may be injured by direct trauma to the subcutaneous portion as it passes around the medial epicondyle. Cubital tunnel Tunnel narrows, stretching nerve Elbow flexion Elbow extension Medial intermuscular septum Flexor carpi ulnaris aponeurosis Common flexor aponeurosis Flexor digitorum superficialis m. Cubital tunnel wide Compression Cubital tunnel Olecranon Sensory distribution Ulnar tunnel Motor branch to intrinsic mm. Upper (and lower) limb bones then develop by endochondral ossiication from the cartilaginous precursors, except the clavicle, which develops largely by intramembranous ossiication. Neuromuscular Development Segmental somites give rise to myotomes that form collections of mesoderm dorsally called epimeres (which give rise to epaxial muscles). Ventral mesodermal collections form the hypomeres (which give rise to hypaxial muscles), which are innervated by the anterior rami of spinal nerves. Hypaxial muscles in the upper limbs divide into anterior (lexor) and posterior (extensor) muscles. Limb Bud Rotation and Dermatomes Initially, as the limb buds grow out from the embryonic trunk, the anterior muscle mass (future lexors) faces medially and the posterior mass (future extensors) faces laterally.
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Sagittal section Pharynx Buccopharyngeal fascia Retropharyngeal space Prevertebral fascia Pretracheal fascia Trachea Esophagus Pericardium Thyroid gland Manubrium of sternum Superficial layer of (deep) cervical fascia Fascia of infrahyoid mm gastritis symptoms spanish order pyridium 200 mg with visa. Thyroid and Parathyroid Glands he thyroid gland lies at the C5-T1 vertebral level, anterior to the trachea, and is a ductless endocrine gland that weighs about 20 grams. In about 50% of cases, a pyramidal lobe may extend superiorly from the isthmus, demarcating the embryonic migratory pathway of the thyroid from the base of the tongue (see Clinical Focus 8-49). Increases the deposition of calcium and phosphate in bones (via the hormone calcitonin). Additionally, the scalene muscles (posterior, middle, and anterior muscles) help elevate the rib cage and laterally flex the neck (see Table 8. Pyramidal lobe (often absent or small) Right lobe Left lobe Isthmus Thyroid gland Right lateral view Superior thyroid a. Excess synthesis and release of thyroid hormone (T3 and T4) result in thyrotoxicosis, which upregulates tissue metabolism and leads to symptoms, indicating increased metabolism. In addition to the autoimmune form of the disease, hypothyroidism also may occur from thyroidectomy and radiation-related damage. It extends from the base of the skull to the cricoid cartilage, where it is continuous with the esophagus. Oropharynx: extends from the soft palate to the superior tip of the epiglottis; it is the region that lies posterior to the oral cavity. Laryngopharynx: extends from the tip of the epiglottis to the inferior aspect of the cricoid cartilage; also known clinically as the hypopharynx. Chapter 8 Head and Neck 519 8 Clinical Focus 8-43 Manifestations of Primary Hyperparathyroidism Kidney Nephrocalcinosis Nephrocalcinosis "Codfishing" of vertebrae Nephrolithiasis Absence of lamina dura (broken line indicates normal contour) Bone biopsy (focal resorption) "Salt and pepper" skull Epulis (giant cell tumor) Bone rarefaction; cysts, fractures Subperiosteal resorption Strong nails, pseudoclubbing Limbus keratopathy Increased flexibility of joints Peptic ulcer Pancreatitis Nephrolithiasis Multiple adenomas (pituitary, thyroid, pancreas, adrenals) Calcium deposits in blood vessels; hypertension; heart failure Characteristic Description Etiology Presentation Prevalence Management Hypertrophy of parathyroid glands (>85% are solitary benign adenomas), which leads to secretion of excess parathyroid hormone that causes increased calcium levels Mild or nonspecific symptoms including fatigue, constipation, polyuria, polydipsia, depression, skeletal pain, and nausea Approximately 100,000 new cases/year in the United States; 2:1 prevalence in women, which increases with age Surgical removal of parathyroid glands 520 Chapter 8 Head and Neck Basilar part of occipital bone Rectus capitis anterior m. Middle Posterior Posterior tubercle of transverse process of C7 vertebra Occipital condyle Transverse process of atlas (C1) Anterior Posterior Tubercles of transverse process of C3 vertebra Phrenic n. Epiglottis Hyoid bone Laryngopharynx Laryngeal inlet (aditus) Thyroid cartilage Vocal fold Cricoid cartilage Trachea Esophagus Thyroid gland C4 C2 C3 Pharyngeal opening of auditory (eustachian) tube Pharyngeal tonsil Anterior arch of atlas (C1 vertebra) Dens of axis (C2 vertebra) C1 Pharyngeal constrictor mm. Cartilaginous part of auditory (eustachian) tube Pharyngobasilar fascia Levator veli palatini m. The tip of the tongue contacts the anterior part of palate while the bolus is pushed posteriorly in a groove between tongue and palate. When the bolus has reached the vallecula, the hyoid and larynx move superiorly and anteriorly, while the epiglottis is tipped inferiorly. A receptive space is created in the oropharynx as the root of the tongue moves slightly anteriorly. The soft palate is pulled inferiorly and approximated to the root of tongue by contraction of the palatopharyngeus and pressure of the descending "stripping wave. The cricopharyngeus remains relaxed and the bolus has largely passed into the esophagus. All structures of the pharynx return to their resting positions as the "stripping wave" passes into the esophagus, pushing the bolus before it. Venous drainage is via the pharyngeal venous plexus, the pterygoid plexus of veins, and the facial, lingual, and superior thyroid veins, all of which drain primarily into the internal jugular vein.
The sural nerve is a cutaneous nerve (contains only somatic afferent fibers and postganglionic sympathetic fibers) and lies subcutaneously along the posterior aspect of the leg and close to the small saphenous vein gastritis histology 200 mg pyridium order with amex. Since the man can evert and invert but cannot fully dorsiflex at the ankle, he most likely has injured his deep fibular nerve. If he had lost eversion alone, he would have injured the superficial fibular nerve and if dorsiflexion and eversion were weakened, then one would suspect an injury of the common fibular nerve. The dorsalis pedis pulse can be reliably and most easily found just lateral to the extensor hallucis longus tendon (points the big toe up), where this artery can be palpated by pressing it against the underlying navicular or intermediate cuneiform bone. Bunions result from a medial angling of the distal first metatarsal (varus) coupled with a subluxation and proximal lateral displacement (valgus) of the first phalanx (big toe). The prepatellar bursa lies right over the lower aspect of the patella and the patellar ligament when the knee is flexed. Thus, it is in the perfect position to bear the brunt of the pressure on the bended knee. The iliotibial tract (often called "band" by clinicians) is the lower extension and insertion of the tensor fasciae latae muscle on the lateral condyle of the tibia. The gluteus medius muscle is a powerful abductor of the femur at the hip and maintains a relatively stable pelvis when the opposite foot is off the ground. The "gluteal dip" or lurch is seen when the patient stands on the injured limb and the pelvis dips on the other side when that limb is off the ground (a positive Trendelenburg sign). The gluteus medius (and minimus) cannot abduct the hip on the affected side (stance side) to prevent the dip. Usually, this denotes an injury to the superior gluteal nerves innervating the medius and minimus. The biceps femoris (short head) is a muscle of the posterior compartment of the thigh but only flexes the leg at the knee and does not cross the hip joint and extend the thigh at the hip, like the other three "hamstring" muscles. This is a positive Trendelenburg sign and indicates paralysis (usually from polio or a pelvic fracture) of the hip adductors (gluteus medius and minimus muscles) innervated by the superior gluteal nerves on the side of the limb that is weight-bearing, in this case, the right lower limb. The opposite hip "dips," and the patient may actually lurch to the weakened side to maintain a level pelvis when walking. Thus, when one is standing on the right leg and the left pelvis dips or drops, a positive right Trendelenburg sign is present. The arch is stabilized by several ligaments and muscle tendons, but the most important support for the medial arch is the plantar calcaneonavicular (spring) ligament. Footdrop and weakened eversion of the foot are associated with weakness of the anterior and lateral compartment muscles of the leg, all innervated by the common fibular nerve. Tapping the calcaneal tendon elicits the reflex contraction of the gastrocnemius and soleus muscles, and is associated with the S1-S2 nerve roots.
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Gonzales, 28 years: In most patients, the femoral vein lies medial to the femoral artery and inferior to the inguinal ligament.
Tukash, 36 years: To aspirate the pneumothorax, attach a three-way stopcock to the catheter and slowly aspirate air with a 60-mL syringe until resistance is felt.
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