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Professor, Duquesne University College of Osteopathic Medicine
Which of the following venous structures is most at risk of infection should this abscess erode through the thin bony wall? A hard blow to arrhythmia technology institute south carolina buy cheap triamterene 75 mg the head at the union of the frontal blood pressure up generic triamterene 75 mg fast delivery, parietal blood pressure levels emergency purchase triamterene 75mg, sphenoid, and temporal bones is extremely dangerous; the resulting fracture can lead to an intracranial hemorrhage. Aberrant parathyroid glands are not uncommon; they can be found throughout the lower neck and even in the superior mediastinum, often in association with the thymus gland. Which of the following pharyngeal pouches most likely gives rise to these aberrant parathyroid glands? During the act of swallowing, the tongue is raised and the bolus of food is passed up against the hard palate and then back into the oral pharynx. Which of the following muscles assists the styloglossus muscle in raising the tongue during swallowing? It is innervated by a nerve that also provides taste to the posterior third of the tongue. For each structure described below (42-45), select the name (A-I) on the radiograph of the skull that best fits the description. The retropharyngeal space lies between the buccopharyngeal (visceral) fascia and the prevertebral fascia (specifically the alar layer) and extends from the base of the cranium to the posterior mediastinum. Infections in this space can easily spread superiorly or inferiorly via the contractions of the pharyngeal muscles and esophagus, which can "knead" the bacteria along the space. Fractures in this area can result in the partial herniation of the orbital contents inferiorly, especially the orbital fat (the eye may droop but is tethered by the optic nerve and extraocular muscles). From the inferior ophthalmic veins, the infection could spread in several directions, but to involve the inferior alveolar and lingual nerves, it would need to spread to the pterygoid plexus of veins draining the infratemporal region. The recurrent laryngeal (inferior laryngeal) nerve passes through the neck in the tracheoesophageal groove as it ascends to innervate the muscles of the larynx. If injured, the only pair of abductors of the vocal folds would be compromised ipsilaterally (hemiparalysis of the posterior cricoarytenoids), leading to a hoarse voice. The patient will have difficulty looking inferiorly and medially as she steps down stairs or off curbs and will present with diplopia. The superior tarsal muscle is the only muscle on the list innervated by the sympathetic fibers; when denervated, it will result in a partial ptosis ipsilaterally. Subdural hematomas usually occur from bleeding associated with the bridging veins passing to the superior sagittal dural venous sinus. Epidural bleeds are associated with bleeding from the middle meningeal artery or one of its many branches. The thyroid gland appears healthy, so we can assume that the C cells of the thyroid gland developed normally, along with the superior parathyroid glands of the fourth pouch. The third pharyngeal pouch, however, gives rise to the thymus gland and the inferior parathyroid glands, so this is the pouch most likely affected. The supraorbital nerve is a branch of the ophthalmic division of the trigeminal nerve, and its distribution matches the description of the skin eruptions. The sensory innervation comes from the mandibular division of the trigeminal nerve. Together, this pair of muscles help protrude the mandible and depress the chin in the initial act of opening the jaw. Partial ptosis (denervation of the superior tarsal muscle) and pupillary constriction (absence of pupillary dilation) suggest an injury to the sympathetic system somewhere along its pathway to the head. Of the listed nerves, only the deep petrosal (postganglionic fibers from the superior cervical ganglion) nerve would show exclusively sympathetic involvement as it courses on the intracranial portion of the internal carotid artery. If taste is the only sense affected, the answer is the chorda tympani, which is damaged before joining the lingual nerve (apparently sensation on the anterior tongue is intact). One might also expect that some parasympathetics to the submandibular ganglion would also be affected, but this may not be immediately obvious. In an affected ear (decreased hearing), if the air conduction is still better than bone conduction, it suggests that the hearing loss is caused by sensorineural loss (inner ear problem vs. An ipsilateral asymmetrical elevation of the soft palate and uvula suggests that the levator veli palatini muscle is affected; the muscle is innervated by the vagus nerve. The lesser petrosal nerve is found in this area and carries preganglionic parasympathetic secretory fibers to the otic ganglion, where the fibers synapse. Postganglionic fibers from the otic ganglion then join the auriculotemporal nerve to innervate the parotid gland.
Even though the device appears undamaged hypertension case study buy triamterene mastercard, it may have small defects and internal stress patterns which could lead to arrhythmia course certification triamterene 75mg cheap breakage arteria fibrillation order 75mg triamterene overnight delivery. For optimal implant performance, surgeons should consider the levels of implantation, patient weight, patient activity level, other patients conditions, etc. These patients should be skeletally mature and have had at least six (6) months of non-operative treatment. In addition, these patients may have up to Grade 1 spondylolisthesis or retrolisthesis at the involved level(s). Hyperlordotic implants (25° lordosis) are intended for use with supplemental fixation. Active systemic infection, infection localized to the site of the proposed implantation, or when the patient has demonstrated allergy or foreign body sensitivity to any of the implant materials. Conditions that may place excessive stresses on bone and implants, such as severe obesity or degenerative diseases, are relative contraindications. The decision whether to use these devices in such conditions must be made by the physician taking into account the risks versus the benefits to the patient. Patients whose activity, mental capacity, mental illness, alcoholism, drug abuse, occupation, or lifestyle may interfere with their ability to follow postoperative restrictions and who may place undue stresses on the implant during bony healing and may be at a higher risk of implant failure. Other potential risks which may require additional surgery, include: device component fracture; loss of fixation; non-union; fracture of the vertebrae; neurological injury; and vascular or visceral injury. Certain degenerative diseases or underlying physiological conditions such as diabetes, rheumatoid arthritis, or osteoporosis may alter the healing process, thereby increasing the risk of implant breakage or spinal fracture. Patients with previous spinal surgery at the involved level(s) to be treated may have different clinical outcomes compared to those without previous surgery. Patients with a known hereditary or acquired bone friability or calcification problem should not be considered for this type of surgery. These devices must not be used for pediatric cases, nor where the patient still has general skeletal growth. Any case where the implant components selected for use would be too large or too small to achieve a successful result. Any patient having inadequate tissue coverage at the operative site or inadequate bone stock or quality. Any patient in which implant utilization would interfere with anatomical structures or expected physiological performance. During surgery, after the correct size has been determined, remove the products from the packaging using aseptic technique. Products should be checked to ensure that they are in working order prior to surgery. All products should be inspected prior to use to ensure that there is no unacceptable deterioration such as corrosion. Non-working or damaged instruments should not be used, and should be returned to Globus Medical. Re-cleaning of single use implants might lead to mechanical failure and/or material degradation. The instruments should be cleaned using neutral cleaners before sterilization and introduction into a sterile surgical field or (if applicable) return of the product to Globus Medical. Cleaning and disinfecting of instruments can be performed with aldehydefree solvents at higher temperatures. The following cleaning methods should be observed when cleaning instruments after use or exposure to soil, and prior to sterilization: 1. Immediately following use, ensure that the instruments are wiped down to remove all visible soil and kept from drying by submerging or covering with a wet towel. Immerse the instruments in the detergent and allow them to soak for a minimum of 2 minutes. Remove the instruments from the detergent and rinse them in running warm tap water.
Lentiform nucleus the basal ganglia (basal nuclei) provide subconscious control of skeletal muscle tone and coordination of learned movements blood pressure 6040 buy triamterene 75 mg without a prescription. Once a voluntary movement is initiated cortically heart attack in spanish discount 75 mg triamterene free shipping, the natural rhythm and patterns that we take for granted in walking or reaching for objects are controlled subconsciously by the basal ganglia blood pressure medication urination purchase generic triamterene from india. While it is probably not important to memorize this schematic diagram, it does illustrate the complexity of interconnections in this network. The basal ganglia (nuclei) include the: Caudate nucleus: descriptively, it has a large head and a slender tail, which arches over the diencephalon Putamen: the putamen and globus pallidus together form the lentiform nucleus Globus pallidus: the putamen and globus pallidus together form the lentiform nucleus Clinical Note: Disorders affecting the basal ganglia involve either defects that result in too much movement or not enough movement. The jerky movements of this disease almost resemble a dancer out of control, and the term chorea ("dance") aptly characterizes this fatal condition. Resulting from the degeneration of dopamine-secreting neurons of the substantia nigra, this progressive disease results in bradykinesia (slow movements), resting rhythmic muscular tremor, muscular rigidity, stooped posture, a masked or expressionless face, and a shuffling gait. Schema Amygdaloid body Lateral ventricle Corpus callosum 1 Insula Lentiform nucleus 2 3 Amygdaloid body C. The limbic system participates in emotional behaviors (fear, rage, pleasure, and sexual arousal) and the interpretation of internal and external stimuli (linking conscious functions with autonomic functions, and aspects of memory and retrieval). Structural components of the limbic system (classification of which structures are part of the system or simply communicate with it vary) typically include the: Cingulate gyrus Parahippocampal gyrus Hippocampus (memory) Amygdala (and its axonal projection called the stria terminalis, which projects to the hypothalamus and basal forebrain structures) Septal nuclei: lies just rostral to the hippocampus; regulates emotions Hypothalamus (autonomic and neuroendocrine functions) Olfactory area (smell) the limbic system forms extensive connections with cortical regions and the brainstem, allowing for extensive integration of stimuli, emotional states, and conscious behaviors linked to these stimuli and emotions. Olfactory tract Clinical Note: the hypothalamus, as a center for neuroendocrine and autonomic functioning, and as a processing center for smell and emotions along with other limbic structures, plays a key role in psychosomatic illness. Stress and its accompanying emotions can trigger autonomic visceral reactions that are the hallmark of psychosomatic, or emotion-driven, illnesses. Plate 4-8 Nervous System Limbic System 4 1 Stria terminalis 2 Amygdaloid body Mamillary body A. Anterolateral schematic Anterior nucleus of thalamus Fornix 1 3 1 Corpus callosum 4 Hypothalamus 5 3 2 Fimbria of hippocampus Parahippocampal gyrus B. The neuronal degeneration leads to atrophy of the brain resulting in narrowed cerebral gyri and widening of the sulci of the cortex. The presence of neurofibrillary tangles (filamentous aggregates in the cytoplasm of neurons) is common in the cortex, hippocampus, basal forebrain, and some regions of the brainstem. Memory loss and cognitive impairments lead to progressive loss of orientation, language, and other higher cortical functions. The hippocampus extends from the amygdala and arches up and forward into the diencephalon in close association with the dentate gyrus. Its appearance resembles a sea horse (in coronal sections), which is what the term hippocampus actually means. It occupies a portion of the medial temporal lobes, lying just medial to the temporal pole of the lateral ventricles. The efferent fiber tract of the hippocampus is the fornix, which arches forward under the corpus callosum and toward the mammillary bodies of the hypothalamus, where many of its fibers terminate. The hippocampal formation (dentate gyrus, hippocampus proper, and subiculum) has many interconnections with the limbic system and cortical association areas. Functionally, the hippocampus and amygdala are important in memory consolidation and access. Moreover, the hippocampus plays a role in spatial relationships, whereas the amygdala associates a variety of sensory memories and links them to our emotional responses, especially fear and aversion. Hippocampus Plate 4-9 See Netter: Atlas of Human Anatomy, 6th Edition, Plate 113 Nervous System Hippocampus 4 Genu of corpus callosum Head of caudate nucleus Columns of fornix Stria terminalis 1 Thalamus 2 Parahippocampal gyrus 3 Fimbria of hippocampus 4 Commissure of fornix Lateral ventricle Splenium of corpus callosum Posterior (occipital) horn of lateral ventricle A. The thalamic nuclei are consolidated into an ovoid mass and divided into three major groups: Anterior Medial Lateral the central location of the thalamus is representative of its importance; essentially, no sensory information, except olfactory information, passes to the higher cortical regions without synapsing in the thalamus. Thus the thalamus has been characterized as the "executive secretary" of the brain because it sorts and edits information. Sensory, motor, and autonomic information from the spinal cord and brainstem is conveyed to the cortex via the thalamus. A white matter tract, the medullary laminae, runs through the thalamus and relays information to the cortex.
