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Professor, Louisiana State University School of Medicine in Shreveport

The tumor spread to the brain from the abdomen via the internal vertebral venous plexus (of Batson) symptoms 9 weeks pregnancy buy vesicare on line amex. Arnold-Chiari malformation 50 A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks medications side effects discount vesicare express. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side medications known to cause miscarriage discount vesicare 10 mg visa. Femoral hernia 47 A 26-year-old man painting his house slipped and fell from the ladder symptoms wisdom teeth cheap 5 mg vesicare amex, landing on the pavement below. After initial examination in the emergency department, the patient is sent to the radiology department. Radiographs reveal that the portion of his left scapula that forms the tip, or point, of the shoulder has been fractured. Acromion 48 A 43-year-old male construction worker survived a fall from a two-story building but lost all sensation from his lower limbs and was admitted to the hospital for examination and treatment. Radiographic studies revealed that he crushed his spinal cord at vertebral level C6. Deltoid 49 A maternal serum sample with high alphafetoprotein alerted the obstetrician to a possible neural tube defect. Ultrasound diagnosis revealed a meningo- 51 A 54-year-old woman is admitted to the emergency department due to increasing back pain over the preceding year. It is common for the disks to shrink in people older than 40, and it can result in spinal stenosis and disk herniation. Between the superior and inferior intercostovertebral joints 52 A 37-year-old pregnant woman is administered a caudal epidural block to alleviate pain during delivery. Caudal epidural block involves injection of local anesthetic into the sacral canal. Which of the following landmarks is most commonly used for the caudal epidural block? Her obstetrician decided to perform a caudal epidural block within the sacral canal. What are the most important bony landmarks used for the administration of such anesthesia? Coccyx 54 A 22-year-old man is brought into the emergency department following a brawl in a tavern. A radiograph is ordered and reveals an unusual sagittal fracture through the spine of the left scapula. Suprascapular nerve and thoracodorsal nerve 57 A male newborn infant is brought to the clinic by his mother and diagnosed with a congenital malformation. Tethered cord syndrome 58 A 62-year-old woman is admitted to the hospital because of her severe back pain. Radiographic examination reveals that the L4 vertebral body has slipped anteriorly, with fracture of the zygapophysial joint. Klippel-Feil syndrome 55 A 5-year-old boy is admitted to the hospital because of pain in the upper back. Radiographic examination reveals abnormal fusion of the C5 and C6 vertebrae and a high-riding scapula. Klippel-Feil syndrome 56 A 53-year-old male is admitted to the emergency department due to severe back pain. Anterior tubercle of the atlas 60 A 34-year-old woman is admitted to the emergency department after a car crash. Radiographic examination reveals a whiplash injury in addition to hyperextension of her cervical spine. Interspinous ligament 63 A 45-year-old woman is admitted to the outpatient clinic for shoulder pain. Radiographic examination reveals quadrangular space syndrome, causing weakened shoulder movements. Ulnar 64 A 29-year-old female elite athlete was lifting heavy weights during an intense training session. The athlete felt severe pain radiate suddenly to the posterior aspect of her right thigh and leg.

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This pedicled fat is then transposed over the orbital rim medications versed order vesicare 10mg online, resulting in a smooth symptoms 28 weeks pregnant discount vesicare 10 mg with amex, full treatment h pylori buy vesicare 10 mg mastercard, youthful eyelid symptoms women heart attack buy 5 mg vesicare mastercard. The fat may either be sutured into its new position to the maxillary periosteum (skin-muscle approach), to the overlying skin (transconjunctival approach), or simply allowed Figure 73­7. As stated before, the incision does not need to be sutured closed secondary to the tight adherence of the conjunctiva to the tarsal plate. Milia the development of milia is the most common complication of upper blepharoplasty. These arise from trapped epithelium within the epidermis, often at the suture line. This problem can easily be addressed by "unroofing" the lesions with a needle in the office. Pressure dressings are not necessary because they hinder the ability to assess the presence of bleeding or vision changes. Instructions are given to return immediately if there is an onset of pain, bleeding, or visual disturbance. Patients are again reminded to refrain from aspirin or nonsteroidal anti-inflammatory drug use. Lagophthalmos In the initial postoperative period, lagophthalmos is present in many patients secondary to lid edema. If lubrication, massage, and taping of the lid fail to correct the problem, surgical correction is necessary with a full-thickness skin graft. Additional Complications Some other complications of blepharoplasty are scleral show, lid asymmetry, ptosis, corneal injury, and dry eye. The incidence of all these complications can be minimized with careful surgical attention, a preoperative screening, and a detailed anatomic knowledge. Transconjunctival versus transcutaneous approach in upper and lower blepharoplasty. This increases the intraocular pressure and causes an ischemic optic neuropathy, the occlusion of the central retinal artery, or both. Clinically, the patient has a rapid onset of pain and proptosis with associated eyelid ecchymosis. Return to the operating room is mandated with clot evacuation and control of any bleeding sites. With a visual loss, the intravenous administration of mannitol and steroids is recommended to decrease intraocular pressure. Lower Eyelid Malposition & Ectropion Lower eyelid malposition is the most common complication of lower blepharoplasty. It occurs after excessive skin removal or other weakening maneuver on the lower lid. Mild malposition preferentially occurs laterally, resulting in inferior bowing of the lateral lid, called "rounding. It usually requires surgical correction either with horizontal lid shortening, muscle suspension, or full-thickness skin grafting. The upper lateral cartilages are not only juxtaposed to the nasal bones here, but there is actual overlap among them. Unlike the nasion and rhinion, which correspond to exact anatomic landmarks, the radix or the root of the nose refers to a general location. On frontal view, the radix is formed as the space between two gently curving continuous lines from the superior orbital rims to the lateral nasal walls (Figure 74­2). On profile, it is the lowest portion of the nasal dorsum, correlating to the nasofrontal groove or angle (Figure 74­3). Upper Cartilaginous Vault the upper cartilaginous vault comprises the upper lateral cartilages. The cephalic border is relatively immobile because of the fusion of the upper lateral cartilages to the fixed quadrangular cartilage of the septum and the overlap with bone at the keystone area. Laterally, the upper lateral cartilages are fused to the pyriform aperture by dense fibroareolar tissue and are attached to the alar cartilages caudally. The caudal edge of the upper lateral cartilage curves in the same direction as the overlapping cephalic edge of the alar cartilage, creating the scroll. In many ways, the bony pyramid and the upper lateral cartilage act as a single osseocartilaginous unit. The thickened caudal border of the upper lateral cartilage acts as the internal nasal valve and moves with the respiratory cycle in a paradoxical fashion.

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A low level of trauma that produces disarray of both inner and outer hair cell stereocilia proportionally elevates tuning curve thresholds (Figure 44­25A) medicine 2015 lyrics buy cheap vesicare 5 mg on-line. When outer hair cells are lost medicinebg 10 mg vesicare, only the sharp peak of the tuning curve is lost (Figure 44­25B and D) medications related to the lymphatic system buy vesicare 5 mg with visa. Loss of inner hair cells produces a dramatic elevation in tuning curve thresholds (Figure 44­25C) medications kidney patients should avoid buy cheap vesicare 10mg online. Outer hair cell damage blocks the cochlear amplifier, but the passive tuning properties of the cochlea are retained. In summary, outer hair cells are responsible for the cochlear amplifier, whereas inner hair cells provide afferent input. This begins with the conversion of mechanical vibrations of the organ of Corti into changes of inner hair cell membrane potentials. Synaptic transmission to the afferent eighth nerve fibers (the auditory nerve) modulates the ongoing action potential discharge of the fiber. As a result of the faithful link between basilar membrane mechanics and the afferent fiber, each auditory nerve fiber is tuned to a particular characteristic frequency (see Figure 44­25). In this way, the central nervous system knows that there is energy at that specific frequency entering the ear. Electrodes placed on the scalp (similar to those used with an electroencephalogram) can measure the electrical signals being relayed from the cochlea to the auditory cortex. By playing a "click" into the ear, a large number of auditory nerve fibers are excited simultaneously. If delayed, a conduction block can be diagnosed, which may represent brainstem pathology. The most common conduction delays are measured between Waves 1 and 3 and Waves 1 and 5, which may suggest the presence of an acoustic neuroma that is slowing conduction along the eighth cranial nerve. In all sensory systems, an important part of the neural code is determined by what location of the sensory organ is stimulated. In the case of the eye, a spot of light falls on a few photoreceptors and they excite nerves that map a representation of the visual world in the brain. In the ear, the acoustic world is coded by a one-dimensional representation of frequency. This frequency map then projects to the brain, which reconstructs the three-dimensional acoustic "world. The analysis of speech appears to take place in parts of the brain that are highly developed only in humans. The amazing machinery that accomplishes the reconstruction of the acoustic world relies on the delicate structures of the inner ear that deconstruct the original sounds. Outer hair cell piezoelectricity: frequency response enhancement and resonance behavior. Many of the tests constituting the diagnostic audiologic battery of 20 years ago have now been replaced with newer procedures with greater specificity, sensitivity, and site of lesion accuracy. This is exemplified by the fact that the terms "sensory" or "neural" can now frequently replace the term "sensorineural. The logical extension of this advancement is to provide the audiologist and otolaryngologist with information related to prognosis and rehabilitation. Audiologic tests can be classified according to measures of hearing threshold, suprathreshold recognition of speech, assessment of middle ear function, assessment of cochlear function, determination of neural synchrony and vestibular function. The test correlates associated with these measures are pure-tone audiometry, speech recognition, immittance battery, otoacoustic emissions, electrophysiology (including auditory brainstem, middle latency responses, auditory steady state response, electrocochleography, and evoked cortical potentials), and electronystagmography (discussed in Chapter 46). Audiologic test results should always be interpreted in the context of a battery of tests because no single test can provide a clear picture of a specific patient. In addition, the combination of objective and subjective (behavioral) tests provides a cross-check of the results. It is vital to remember that there are no age restrictions for audiologic testing; it is now possible to test newborns within hours of birth. The typical range of frequencies tested does not cover the entire range of human hearing (20­20,000 Hz). Instead, the range includes the frequencies considered to be essential for understanding speech (250­8000 Hz).

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The nuchal ligament is a longitudinal extension of the supraspinous ligament above the level of C7 symptoms blood clot leg vesicare 10 mg discount. The iliocostalis thoracis muscle is found in the deep back and functions to maintain posture medications prescribed for pain are termed 10 mg vesicare overnight delivery. Rhomboid major and minor are both innervated by the dorsal scapular nerve and serve to adduct the scapulae medications with acetaminophen order generic vesicare line. Teres major is innervated by the lower subscapular nerve and serves to medially rotate and adduct the humerus osteoporosis treatment 10 mg vesicare with visa. The pedicles are bony structures connecting the vertebral arches to the vertebral body. The ligamentum flavum runs on the posterior aspect of the vertebral canal and is more closely associated with the lamina than to the pedicles of the vertebrae. The nuchal ligament is a longitudinal extension of the supraspinous ligament from C7 to the occiput, both running on the most posterior aspect of the vertebrae along the spinous processes. The cruciform (also called cruciate) ligament is a stabilizing ligament found in C1/C2. It attaches to the pedicles and helps anchor the dens in situ, but it has been broken in this case. The posterior longitudinal ligament extends the length of the anterior aspect of the vertebral canal and is anterior to the pedicles. Spondylolysis, also known as "facet jumping," is the anterior displacement of one or more vertebrae. This is most commonly seen with the cervical vertebrae because of their small size and structure and the oblique angle of the articular facets. Lumbar vertebrae are somewhat susceptible to this problem because of the pressures at lower levels of the spine and the sagittal angles of the articular facets. It is much less common in the thoracic vertebrae due to the stabilizing factor of the ribs. The internal vertebral plexus (of Batson) surrounds the dura mater in the epidural space; hence, the bleeding would cause the hematoma in that space. A subarachnoid bleed would most likely result from a ruptured intercerebral aneurysm. A subdural hematoma would result most likely from a venous bleed from a torn cerebral vein as it enters the superior sagittal venous sinus within the skull. The lumbar cistern is an enlargement of the subarachnoid space between the conus medullaris of the spinal cord and the inferior end of the subarachnoid space. In the lumbar region spinal nerves exit the vertebral column below their named vertebrae. In an L4, L5 intervertebral disk herniation, the L5 spinal nerve would be affected as it descends between L4, L5 vertebrae to exit below the L5 level. L2, L3, and L4 spinal nerves have already exited above the level of herniation; therefore, they would not be affected by this herniation. Posterior intercostal arteries supply the deep back muscles that are responsible for extending and laterally bending the trunk. The subscapular supplies subscapularis muscle, the thoracodorsal supplies latissimus dorsi, the anterior intercostal supplies the upper nine intercostal spaces, and the suprascapular supplies supraspinatus and infraspinatus muscles. The atlantoaxial joint is a synovial joint responsible for rotation of the head, not flexion, abduction, extension, or adduction. The atlanto-occipital joint is primarily involved in flexion and extension of the head on the neck. The internal vertebral plexus (of Batson) lies external to the dura mater in the epidural space. To aspirate excess blood, the physician must pass the needle through the ligamentum flavum to reach the epidural space wherein the blood would accumulate. The spinal cord, pia mater, and arachnoid mater are located deep to the epidural space. The rib articulates with the superior facet on the body of its own vertebra (fourth rib articulates with the superior facet T4 vertebra) and with the inferior facet on the body of the vertebra above (fourth rib articulates with the inferior facet of T3 vertebra). Taking the T4 vertebra into consideration, the superior facet of this vertebra articulates with the head of the fourth rib and the inferior facet articulates with the head of the fifth rib.

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The axillary nerve also arises from cervical spinal nerves 5 and 6 and innervates the deltoid and teres minor muscles treatment urinary retention buy generic vesicare 10mg on-line. The deltoid muscle is large and covers the entire surface of the shoulder medicine 95a buy 10mg vesicare, and contributes to arm movement in any plane medicine lyrics discount vesicare 10mg otc. The teres minor is a lateral rotator and a member of the rotator cuff group of muscles medications joint pain order vesicare once a day. It is the largest branch, and it innervates the triceps brachii and anconeus in the arm. The carpal tunnel is formed anteriorly by the flexor retinaculum and posteriorly by the carpal bones. Carpal tunnel syndrome is caused by a compression of the median nerve, due to reduced space in the carpal tunnel. The carpal tunnel contains the tendons of flexor pollicis longus, flexor digitorum profundus, and flexor digitorum superficialis muscles. Fracture of the medial epicondyle often causes damage to the ulnar nerve due to its position in the groove behind the epicondyle. The ulnar nerve innervates one and a half muscles in the forearm-the flexor carpi ulnaris and the medial half of the flexor digitorum profundus. The flexor digitorum superficialis is innervated by the median nerve and the biceps brachii by the musculocutaneous. A midshaft humeral fracture can result in injury to the radial nerve and deep brachial artery because they lie in the spiral groove located in the midshaft. Injury to the median nerve and brachial artery can be caused by a supracondylar fracture that occurs by falling on an outstretched hand and partially flexed elbow. A fracture of the surgical neck of the humerus can injure the axillary nerve and posterior humeral circumflex artery. The long thoracic nerve and lateral thoracic artery may be damaged during a mastectomy procedure. The course of the median nerve is anterolateral, and at the elbow it lies medial to the brachial artery on the brachialis muscle. The axillary nerve passes posteriorly through the quadrangular space, accompanied by the posterior circumflex humeral artery, and winds around the surgical neck of the humerus. The musculocutaneous nerve pierces the coracobrachialis muscle and descends between the biceps and brachialis muscle. The ulnar nerve descends behind the medial epicondyle in its groove and is easily injured and produces "funny bone" symptoms. The radial nerve descends posteriorly between the long and lateral heads of the triceps and passes inferolaterally on the back of the humerus between the medial and lateral heads of the triceps. It eventually enters the anterior compartment and descends to enter the cubital fossa, where it divides into superficial and deep branches. The deep branch of the radial nerve winds laterally around the radius and runs between the two heads of the supinator and continues as the posterior interosseous nerve, innervating extensor muscles of the forearm. Because this injury does not result in loss of sensation over the skin of the upper limb, it is likely that the superficial branch of the radial nerve is not injured. If the radial nerve were injured very proximally, the woman would not have extension of her elbow. The branches of the radial nerve to the triceps arise proximal to where the nerve runs in the spiral groove. The anterior interosseous nerve arises from the median nerve and supplies the flexor digitorum profundus, flexor pollicis longus, and pronator quadratus, none of which seem to be injured in this example. Injury to the median nerve causes a characteristic flattening (atrophy) of the thenar eminence. The musculocutaneous nerve supplies the biceps brachii and brachialis, which are the flexors of the forearm at the elbow. The musculocutaneous nerve continues as the lateral antebrachial cutaneous nerve, which supplies sensation to the lateral side of the forearm (with the forearm in the anatomic position). Injury to this nerve would result in weakness of supination and forearm flexion and lateral forearm sensory loss.

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