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By K. Angar. Abilene Christian University. 2019.

The face and scalp 151 68 The cranial cavity Cerebral veins Falx cerebri Tentorium cerebelli Endothelium of superior sagittal sinus Diaphragma sellae Emissary vein Fibrous dura Serous dura Fig discount betapace 40 mg mastercard. The cere- also forms two large sheetsathe falx cerebri and the tentorium cere- brospinal fluid is produced in the choroid plexuses of the lateral betapace 40mg on-line, 3rd belli (see below). The subarachnoid space contains the cerebrospinal between the arachnoid and pia and serves to protect the brain and spinal fluid. It tapers to a point anteriorly but pos- which forms a roof over the pituitary fossa and the pituitary gland. Veins from the cerebral hemispheres drain into the superior The cavernous sinus lies on either side of the pituitary fossa and the sagittal sinus or into diverticula from it, the lacunae laterales. Like the other venous sinuses, it is formed by a the underlying arachnoid sends small outgrowths through the serous layer of serous dura lined by endothelium. These are the arachnoid villi and they are dura from the posterior cranial fossa projects forwards into the side of the site of absorption of cerebrospinal fluid into the bloodstream. The cranial cavity 153 69 The orbit and eyeball Frontal Superior oblique Lacrimal Optic nerve Trochlear Central artery of retina Oculomotor Ophthalmic artery Abducent Oculomotor Nasociliary Fibrous ring Inferior oblique Fig. The most important branch of the ophthalmic artery is the central and 6th cranial nerves and the three branches of the ophthalmic division artery of the retina which enters the optic nerve and is the only blood of the trigeminal nerve. The outermost is a tough superior and inferior ophthalmic veins drain it, passing through the fibrous layer, the sclera. Anteriorly, the • The superior orbital fissure: this slit-like opening is divided into sclera is replaced by the transparent cornea, which is devoid of vessels two parts by the fibrous ring that forms the origin of the main muscles or lymphatics and can therefore be transplanted. Behind the cornea, the choroid is replaced by • Above the ringafrontal, lacrimal and trochlear nerves. These, when they contract, • The inferior orbital fissure: transmits the maxillary nerve and some relax the lens capsule and allow the lens to expand; thus they are used in small veins. The lens the levator palpebrae superioris which is inserted into the upper eyelid lies behind the pupil and is enclosed in a delicate capsule. The ciliary body secretes the aqueous humour into the posterior • The medial rectusaturns the eyeball medially. The aqueous then passes • The superior rectusabecause of the different long axes of the orbit through the pupil into the anterior chamber and is reabsorbed into the and of the eyeball, turns the eye upwards and medially. Any interference with this process can give rise • The inferior rectusafor the same reason, turns the eye downwards to a dangerous increase in intra-ocular pressure, a condition known as and medially. It turns the eye down- The retina consists of an inner nervous layer and an outer pigmented wards and laterally. The nervous layer has an innermost layer of ganglion cells whose tract together, the eye turns directly downwards. Outside this is a layer of bipo- • The inferior obliqueaarises from the floor of the orbit, passes lar neurones and then the receptor layer of rods and cones. Near the under the eyeball like a hammock and is inserted into its lateral posterior pole of the eye is the yellowish macula lutea, the receptor area side. Since the subarachnoid space and its contained (the ‘muscle with the pulley’) is supplied by the trochlear nerve. All the cerebrospinal fluid reach to the back of the eyeball, any increase in others, including levator palpebrae superioris, are supplied by the ocu- intracranial pressure can give rise to changes in the optic disc which lomotor nerve. The orbit and eyeball 155 70 The ear, and lymphatics and surface anatomy of the head and neck Ridge produced by lateral semicircular canal Tegmen tympani Stapes Geniculate ganglion Facial nerve Greater petrosal nerve Aditus Incus Lesser petrosal nerve Malleus Auditory tube Tympanic plexus Chorda Promontory tympani Internal carotid artery Tympanic membrane Round window Tympanic branch Internal jugular vein Glossopharyngeal nerve Fig. The inset (right) shows the two major groups into which the others eventually drain 156 Head and neck The ear mandible and also deep to sternomastoid. They drain the head and the The ear is subdivided into the outer ear, the middle ear and the inner ear. The outer ear • The lower deep cervical nodes (): in the The outer third of this is cartilaginous and the inner two-thirds is bony. They drain the lower part of the neck and also receive lymph from the upper deep cervical nodes, from the breast and some of the lymph The middle ear from the thorax and abdomen. The • The runs backwards and then downwards in a bony may be represented on the surface by a pencil placed behind the canal in the medial wall. Its function • The supraorbital, infraorbital and mental nerves: all lie on a ver- is to equalize the pressure between the middle ear and the pharynx. It consists of two • The sternomastoid muscle (with the on its sur- components: face) may be made to contract by asking the patient to turn his head to • The osseous labyrinth: comprises the , the the side against resistance. The labyrinth itself consists of spaces in the • The trunks of the brachial plexus can be palpated in the angle petrous temporal bone and it contains the. The utricle and saccule are con- • The hyoid bone, and the thyroid and cricoid cartilages are easily cerned with the sense of position and the semicircular ducts are con- felt. Abduction of the upper limb (assisted by supraspinatus and • serratus anterior), flexion (anterior fibres) and extension (posterior From the common flexor origin on the medial epicondyle of the fibres) of the arm. Acting together, these muscles maintain the stability of the • shoulder joint as well as having their own individual actions, as From the common flexor origin.

Interestingly purchase 40mg betapace with visa, children have higher melatonin levels than adults order betapace 40mg on line, which may prevent the release of gonadotropins from the anterior pituitary, thereby inhibiting the onset of puberty. Jet lag occurs when a person travels across several time zones and feels sleepy during the day or wakeful at night. Traveling across multiple time zones significantly disturbs the light-dark cycle regulated by melatonin. It can take up to several days for melatonin synthesis to adjust to the light-dark patterns in the new environment, resulting in jet lag. The primary hormone produced by the male testes is testosterone, a steroid hormone important in the development of the male reproductive system, the maturation of sperm cells, and the development of male secondary sex characteristics such as a deepened voice, body hair, and increased muscle mass. The primary hormones produced by the ovaries are estrogens, which include estradiol, estriol, and estrone. Estrogens play an important role in a larger number of physiological processes, including the development of the female reproductive system, regulation of the menstrual cycle, the development of female secondary sex characteristics such as increased adipose tissue and the development of breast tissue, and the maintenance of pregnancy. Another significant ovarian hormone is progesterone, which contributes to regulation of the menstrual cycle and is important in preparing the body for pregnancy as well as maintaining pregnancy. The placenta supplies oxygen and nutrients to the fetus, excretes waste products, and produces and secretes estrogens and progesterone. Commonly used for performance enhancement, anabolic steroids are synthetic versions of the male sex hormone, testosterone. The use of performance-enhancing drugs is banned by all major collegiate and professional sports organizations in the United States because they impart an unfair advantage to athletes who take them. For example, anabolic steroid use can increase cholesterol levels, raise blood pressure, and damage the liver. Altered testosterone levels (both too low or too high) have been implicated in causing structural damage to the heart, and increasing the risk for cardiac arrhythmias, heart attacks, congestive heart failure, and sudden death. Paradoxically, steroids can have a feminizing effect in males, including shriveled testicles and enlarged breast tissue. In females, their use can cause masculinizing effects such as an enlarged clitoris and growth of facial hair. In both sexes, their use can promote increased aggression (commonly known as “roid-rage”), depression, sleep disturbances, severe acne, and infertility. Although it is primarily an exocrine gland, secreting a variety of digestive enzymes, the pancreas has an endocrine function. Its endocrine function involves the secretion of insulin (produced by beta cells) and glucagon (produced by alpha cells) within the pancreatic islets. Cells and Secretions of the Pancreatic Islets The pancreatic islets each contain four varieties of cells: • The alpha cell produces the hormone glucagon and makes up approximately 20 percent of each islet. Glucagon plays an important role in blood glucose regulation; low blood glucose levels stimulate its release. It is thought to play a role in appetite, as well as in the regulation of pancreatic exocrine and endocrine secretions. Pancreatic polypeptide released following a meal may reduce further food consumption; however, it is also released in response to fasting. The body derives glucose from the breakdown of the carbohydrate-containing foods and drinks we consume. Glucose not immediately taken up by cells for fuel can be stored by the liver and muscles as glycogen, or converted to triglycerides and stored in the adipose tissue. Receptors located in the pancreas sense blood glucose levels, and subsequently the pancreatic cells secrete glucagon or insulin to maintain normal levels. Glucagon Receptors in the pancreas can sense the decline in blood glucose levels, such as during periods of fasting or during prolonged labor or exercise (Figure 17. In response, the alpha cells of the pancreas secrete the hormone glucagon, which has several effects: • It stimulates the liver to convert its stores of glycogen back into glucose. Some of the free glycerol released into the bloodstream travels to the liver, which converts it into glucose. The activity of glucagon is regulated through a negative feedback mechanism; rising blood glucose levels inhibit further glucagon production and secretion. If blood glucose concentration rises above this range, insulin is released, which stimulates body cells to remove glucose from the blood. If blood glucose concentration drops below this range, glucagon is released, which stimulates body cells to release glucose into the blood. Red blood cells, as well as cells of the brain, liver, kidneys, and the lining of the small intestine, do not have insulin receptors on their cell membranes and do not require insulin for glucose uptake. Although all other body cells do require insulin if they are to take glucose from the bloodstream, skeletal muscle cells and adipose cells are the primary targets of insulin. The presence of food in the intestine triggers the release of gastrointestinal tract hormones such as glucose-dependent insulinotropic peptide (previously known as gastric inhibitory peptide). This is in turn the initial trigger for insulin production and secretion by the beta cells of the pancreas. Once nutrient absorption occurs, the resulting surge in blood glucose levels further stimulates insulin secretion. However, insulin appears to activate a tyrosine kinase receptor, triggering the phosphorylation of many substrates within the cell.

Tandem gait is when the patient places the heel of one foot against the toe of the other foot and walks in a straight line in that manner quality 40mg betapace. Ataxia can also refer to sensory deficits that cause balance problems betapace 40 mg low price, primarily in proprioception and equilibrium. Hereditary conditions can lead to degeneration of the cerebellum or spinal cord, as well as malformation of the brain, or the abnormal accumulation of copper seen in Wilson’s disease. The examiner would look for issues with balance, which coordinates proprioceptive, vestibular, and visual information in the cerebellum. To test the ability of a subject to maintain balance, asking them to stand or hop on one foot can be more demanding. The cerebellum is crucial for coordinated movements such as keeping balance while walking, or moving appendicular musculature on the basis of proprioceptive feedback. The cerebellum is also very sensitive to ethanol, the particular type of alcohol found in beer, wine, and liquor. Walking in a straight line involves comparing the motor command from the primary motor cortex to the proprioceptive and vestibular sensory feedback, as well as following the visual guide of the white line on the side of the road. When the cerebellum is compromised by alcohol, the cerebellum cannot coordinate these movements effectively, and maintaining balance becomes difficult. The point of this is to remove the visual feedback for the movement and force the driver to rely just on proprioceptive information about the movement and position of their fingertip relative to their nose. With eyes open, the corrections to the movement of the arm might be so small as to be hard to see, but proprioceptive feedback is not as immediate and broader movements of the arm will probably be needed, particularly if the cerebellum is affected by alcohol. The speech rapid alternating movement subtest is specifically using the consonant changes of “lah-kah-pah” to assess coordinated movements of the lips, tongue, pharynx, and palate. But the entire alphabet, especially in the nonrehearsed backwards order, pushes this type of coordinated movement quite far. The mental status exam is concerned with the cerebrum and assesses higher functions such as memory, language, and emotion. The sensory and motor exams assess those functions as they relate to the spinal cord, as well as the combination of the functions in spinal reflexes. The coordination exam targets cerebellar function in coordinated movements, including those functions associated with gait. The location of the injury will correspond to the functional loss, as suggested by the principle of localization of function. The neurological exam provides the opportunity for a clinician to determine where damage has occurred on the basis of the function that is lost. Damage from acute injuries such as strokes may result in specific functions being lost, whereas broader effects in infection or developmental disorders may result in general losses across an entire section of the neurological exam. Sensory functions are associated with the dorsal regions of the spinal cord, whereas motor function is associated with the ventral side. Localizing damage to the spinal cord is related to assessments of the peripheral projections mapped to dermatomes. Sensory tests address the various submodalities of the somatic senses: touch, temperature, vibration, pain, and proprioception. Results of the subtests can point to trauma in the spinal cord gray matter, white matter, or even in connections to the cerebral cortex. Input to the muscles comes from the descending cortical input of upper motor neurons and the direct innervation of lower motor neurons. The presence of reflexive contractions helps to differentiate motor disorders between the upper and lower motor neurons. The specific signs associated with motor disorders can establish the difference further, based on the type of paralysis, the state of muscle tone, and specific indicators such as pronator drift or the Babinski sign. It apparently plays a role in procedural learning, which would include motor skills such as riding a bike or throwing a football. The basis for these roles is likely to be tied into the role the cerebellum plays as a comparator for voluntary movement. The motor commands from the cerebral hemispheres travel along the corticospinal pathway, which passes through the pons. Collateral branches of these fibers synapse on neurons in the pons, which then project into the cerebellar cortex through the middle cerebellar peduncles. Ascending sensory feedback, entering through the inferior cerebellar peduncles, provides information about motor performance. The cerebellar cortex compares the command to the actual performance and can adjust the descending input to compensate for any mismatch. The output from deep cerebellar nuclei projects through the superior cerebellar peduncles to initiate descending signals from the red nucleus to the spinal cord. The primary role of the cerebellum in relation to the spinal cord is through the spinocerebellum; it controls posture and gait with significant input from the vestibular system. The root cause of the ataxia may be the sensory input—either the proprioceptive input from the spinal cord or the equilibrium input from the vestibular system, or direct damage to the cerebellum by stroke, trauma, hereditary factors, or toxins.

Apply firm pressure to the template while introducing the blade at a right angle on the upper portion of the template slot cheap betapace 40mg online. After the test buy generic betapace 40mg, the template and gauge must be washed thouroughly with surgical soap then rinsed well with water and autoclaved or sterilized by a gas such as ethylene chloride. Interpretation Prolonged bleeding times are demonstrable in patients with: • Thrombocytopenia with a platelet count of < 50 x 109/l. Whole Blood Coagulation Time Method of Lee and White Principle: Whole blood is delivered using carefully controlled venipuncture and collection process into standardized glass tubes. It is prolonged in defects of intrinsic and extrinsic coagulation and in the presence of certain pathological anticoagulants and heparin. Venous blood is withdrawn using normal precautions and a stop watch is started the moment blood appears in the syringe. Deliver 1ml of blood into each of four 10 x 1cm dry, chemically clean glass tubes which have previously been placed in a water bath maintained at 37oC. After 3 minutes have elapsed, keeping the tubes out of the water bath for as short time as possible, tilt them individually every 30 seconds. The clotting time of each tube is recorded separately and the coagulation time is reported as an average of the four tubes. Clot Retraction: Classic Method Principle: Clot retraction is a measure of: (1) the amount of fibrin formed and its subsequent contraction, (2) the number and quality of platelets, since platelets have a protein that causes clot retraction. Since the fibrin clot enmeshes the cellular elements of the blood, a limit is set to the extent fibrin contracts by the volume of red blood cells (the hematocrit). Clot retraction is directly proportional to the number of platelets and inversely proportional to the hematocrit. Normal Values: 48-64% (average 55%) Observation of the Clot Examination of a clot in a tube gives information on: • The concentration of fibrinogen • The number and function of platelets, and • The activity of the fibrinolytic system Result 1. Measurement of the Extrinsic System Prothrombin Time (One stage) Principle: The prothrombin is the time required for plasma to clot after tissue thromboplastin and an optimal amount of calcium chloride have been added. Prewarm sufficient partial thromboplastin and CaCl2 solution in separate tubes in a water bath at 37oC. Briefly mix and allow to stand for about 40 seconds undisturbed in the water bath, then remove from the bath and tilt back and forth until fibrin clot forms. The test is repeated with both control and test plasmas; the duplicate times should be within 5 seconds. Normal Range It is largely dependent on the activity of the partial thromboplastin but should be in the order of 45-70 seconds. Each laboratory should determine its own normal range using a series of plasmas from healthy subjects. Each laboratory should determine its own normal range with the reagent in use and the selected activation period. How do the components of normal hemostasis integrate to maintain blood flow within the vascular system? Laboratory testing of these miscellaneous body fluids is usually done to aid in the diagnosis of specific conditions of disease. Depending of the nature of the tests to be done, various divisions of the laboratory are involved in handling the specimens. From these, 120-150ml of the fluid is required to fill the arachnoid space between the brain and the spinal cord. It acts as a mechanical buffer to prevent trauma, to regulate the volume of intracranial pressure, to circulate nutrients, to remove metabolic waste products from the central nervous system, and to generally act as a lubricant for the system. The most important indication for doing the lumbar puncture is to diagnose meningitis of bacterial, fungal, mycobacterial, and amebic origin. The tubes that are sequentially collected and labeled in order of collection are generally dispersed and utilized for analysis (after gross examination of all tubes) as follows: 420 Hematology 1. Color and clarity are noted by holding the sample beside a tube of water against a clean white paper or a printed page. Turbidity Slight haziness in the specimen indicates a white cell count of 200 to 500/µl, and turbidity indicates a white cell count of over 500/µl. Turbidity in spinal fluid may result form the presence of large numbers of leucocytes, or from bacteria, increased protein, or lipid. Clots 421 Hematology In addition to the gross observation of turbidity and color, the spinal fluid should be examined for clotting. Color (traumatic gap versus hemorrhage) Bloody fluid can result from a traumatic tap or from subarachnoid hemorrhage. If blood in a specimen results from a traumatic tap (inclusion of blood in the specimen from the puncture itself), the successive collection tubes will show less bloody fluid, eventually becoming clear. If blood in a specimen is caused by a subarachnoid hemorrhage, the color of the fluid will look the same in all the collection tubes.