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Each mammary gland extends superolaterally around the lower margin of the pectoralis major muscle and enters the axilla best treatment for pain from shingles purchase cheap cafergot on-line. The positions of the nipple and areola vary relative to the chest wall depending on breast size pain treatment a historical overview cafergot 100mg with amex. The mammary gland consists only of small ducts knee pain laser treatment discount cafergot 100 mg amex, often composed of cords of cells midwest pain treatment center ohio cafergot 100mg without a prescription, which normally do not extend beyond the areola. Clinical app Breast cancer Breast cancer is one of the most common malignancies in women. Breast cancer develops in the cells of the acini, lactiferous ducts, and lobules of the breast. Tumor growth and spread depend on the exact cellular site of origin of the cancer. Further subcutaneous spread can induce a rare manifestation of breast cancer that produces a hard, woody texture to the skin (cancer en cuirasse). A Areola Nipple Axillary proces s Muscles of the pectoral region Each pectoral region contains the pectoralis major, pectoralis minor, and subclavius muscles (Table 3. All originate from the anterior thoracic wall and insert into bones of the upper limb. A continuous layer of deep fascia, clavipectoral fascia, encloses the subclavius and pectoralis minor and attaches to the clavicle above and to the oor of the axilla below. The muscles of the pectoral region form the anterior wall of the axilla, a region between the upper limb and the neck through which all major structures pass. Lateral view of the chest wall of a woman showing the axillary process of the breast. Consequently, the plane of the superior thoracic aperture is at an oblique angle, facing somewhat anteriorly. Muscles of the pectoral region Origin Medial half of clavicle and anterior surface of sternum, rst seven costal cartilages, aponeurosis of external oblique Rib I at junction between rib and costal cartilage Anterior surfaces of the third, fourth, and fth ribs, and deep fascia overlying the related intercostal spaces Insertion Lateral lip of intertubercular sulcus of humerus Groove on inferior surface of middle third of clavicle Coracoid process of scapula Innervation Medial and lateral pectoral nerves Function Adduction, medial rotation, and exion of the humerus at the shoulder joint Pulls clavicle medially to stabilize sternoclavicular joint; depresses tip of shoulder Depresses tip of shoulder; protracts scapula Subclavius Nerve to subclavius Pectoralis minor Medial pectoral nerves 61 Thorax At the superior thoracic aperture, the superior aspects of the pleural cavities, which surround the lungs, lie on either side of the entrance to the mediastinum. Structures that pass between the upper limb and thorax pass over rib I and the superior part of the pleural cavity as they enter and leave the mediastinum. Structures that pass between the neck and head and the thorax pass more vertically through the superior thoracic aperture. Thus, the posterior margin of the inferior thoracic aperture is inferior to the anterior margin. Skeletal framework the skeletal elements of the thoracic wall consist of thoracic vertebrae, intervertebral discs, ribs, and sternum. Inferior thoracic aperture the inferior thoracic aperture is large and expandable, and bone, cartilage, and ligaments form its margin. Thoracic vertebrae There are 12 thoracic vertebrae, each of which is characterized by articulations with the ribs. S upe rio r tho rac ic ape rture Es ophagus Brachial plexus Rib I Scapula Axillary inle t Clinical app Thoracic outlet syndrome Clinically, thoracic outlet syndrome is used to describe symptoms resulting from abnormal compression of the brachial plexus of nerves as it passes over the rst rib and through the axillary inlet into the upper limb. The anterior ramus of T1 passes superiorly out of the superior thoracic aperture to join and become part of the brachial plexus. A connective tissue band that can extend from the tip of a cervical rib to rib I is one cause of thoracic outlet syndrome by putting upward stresses on the lower parts of the brachial plexus as they pass over the rst rib. A typical thoracic vertebra A typical thoracic vertebra has a heart-shaped vertebral body, with roughly equal dimensions in the transverse and anteroposterior directions, and a long spinous process. The vertebral foramen is generally circular and the laminae are broad and overlap with those of the vertebra below. The superior articular processes are at, with their articular surfaces facing almost directly posteriorly, whereas the inferior articular processes project from the laminae and their articular facets face anteriorly. Ribs There are 12 pairs of ribs, each terminating anteriorly in a costal cartilage. Although all ribs articulate with the vertebral column, only the costal cartilages of the upper seven ribs, known as true ribs, articulate directly with the sternum. The posterior end articulates with the vertebral column and is characterized by a head, neck, and tubercle. The head is somewhat expanded and typically presents two articular surfaces separated by a crest. The smaller superior surface articulates with the inferior costal facet on the body of the vertebra above, whereas the larger inferior facet articulates with the superior costal facet of its own vertebra. The tubercle projects posteriorly from the junction of the neck with the shaft and consists of two regions, an articular part and a nonarticular part: the articular part is medial and has an oval facet for articulation with a corresponding facet on the transverse process of the associated vertebra. The shaft bends forward just Articulation with ribs A typical thoracic vertebra has three sites for articulations with ribs on each side. The superior costal facet articulates with part of the head of its own rib, and the inferior costal facet articulates with part of the head of the rib below. An oval facet (transverse costal facet) at the end of the transverse process articulates with the tubercle of its own rib. It also has a gentle twist around its longitudinal axis so that the external surface of the anterior part of the shaft faces somewhat superiorly relative to the posterior part. The inferior margin of the internal surface is marked by a distinct costal groove. The anterior groove is caused by the subclavian vein, and the posterior groove is caused by the subclavian artery.
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A disc may protrude posteriorly to directly impinge on the cord or the roots of the lumbar nerves best pain medication for shingles purchase cheapest cafergot and cafergot, depending on the level knee pain treatment running buy cheap cafergot 100 mg on line, or may protrude posterolaterally adjacent to the pedicle and impinge on the descending root pain treatment center hattiesburg ms 100mg cafergot for sale. In cervical regions of the vertebral column knee pain treatment physiotherapy discount 100 mg cafergot free shipping, cervical disc protrusions often become ossi ed and are termed disc osteophyte bars. Anterior and posterior longitudinal ligaments the anterior and posterior longitudinal ligaments are on the anterior and posterior surfaces of the vertebral bodies and extend along most of the vertebral column. The anterior longitudinal ligament is attached superiorly to the base of the skull and extends inferiorly to attach to the anterior surface of the sacrum. Along its length, it is attached to the vertebral bodies and intervertebral discs. The posterior longitudinal ligament is on the posterior surfaces of the vertebral bodies and lines the anterior surface of the vertebral canal. Like the anterior longitudinal ligament, it is attached along its length to the vertebral bodies and intervertebral discs. Clinical app Joint diseases Some diseases have a predilection for synovial joints rather than symphyses. A typical example is rheumatoid arthritis, which primarily affects synovial joints and synovial bursae, resulting in destruction of the joint and its lining. Ligamenta ava the ligamenta ava, on each side, pass between the laminae of adjacent vertebrae. These thin, broad ligaments consist predominantly of elastic tissue and form part of the posterior surface of the vertebral canal. Each ligamentum avum runs between the posterior surface of the lamina on the vertebra below to the anterior surface of the lamina of the vertebra above. The ligamenta ava resist separation of the laminae in exion and assist in extension back to the anatomical position. The ligamentum nuchae is a triangular, sheetlike structure in the median sagittal plane: the base of the triangle is attached to the skull, from the external occipital protuberance to the foramen magnum. The broad lateral surfaces and the posterior edge of the ligament provide attachment for adjacent muscles. Clinical app Ligamenta ava In degenerative conditions of the vertebral column, the ligamenta ava may hypertrophy. This is often associated with hypertrophy and arthritic change of the zygapophysial joints. In combination, zygapophysial joint hypertrophy, ligamenta ava hypertrophy, and a mild disc protrusion can reduce the dimensions of the vertebral canal. Interspinous ligaments Interspinous ligaments pass between adjacent vertebral spinous processes. They attach from the base to the apex of each spinous process and blend with the supraspinous ligament posteriorly and the ligamenta ava anteriorly on each side. Destruction of one of the clinical columns is usually a stable injury requiring little more than rest and appropriate analgesia. Disruption of two columns is likely to be unstable and requires xation and immobilization. A three-column spinal injury usually results in a signi cant neurological event and requires xation to prevent further extension of the neurological defect and to create vertebral column stability. Indications are varied, although they include stabilization after fracture, stabilization related to tumor in ltration, and stabilization when mechanical pain is produced either from the disc or from the posterior elements. Muscles in the super cial and intermediate groups are extrinsic muscles because they originate embryologically from locations other than the back. They are innervated by anterior rami of spinal nerves: the super cial group consists of muscles related to and involved in movements of the upper limb. The intermediate group consists of muscles attached to the ribs and may serve a respiratory function. They are innervated by posterior rami of spinal nerves and are directly related to movements of the vertebral column and head. Clinical app Pars interarticularis fractures the pars interarticularis is a clinical term used to describe the speci c region of a vertebra between the superior and inferior facet (zygapophysial) joints. If a fracture occurs around the pars interarticularis, the vertebral body may slip anteriorly and compress the vertebral canal. It is possible for a vertebra to slip anteriorly on its inferior counterpart without a pars interarticularis fracture. Usually this is related to abnormal anatomy of the facet joints: facet joint degenerative change. Super cial group of back muscles the muscles in the super cial group are immediately deep to the skin and super cial fascia. They attach the superior part of the appendicular skeleton (clavicle, scapula, and humerus) to the axial skeleton (skull, ribs, and vertebral column). Because these muscles are primarily involved with movements of this part of the appendicular skeleton, they are sometimes referred to as the appendicular group. Muscles in the super cial group include the trapezius, latissimus dorsi, rhomboid major, rhomboid minor, and levator scapulae. Rhomboid major, rhomboid minor, and levator scapulae are located deep to the trapezius in the superior part of the back. Proprioceptive bers from trapezius pass in the branches of the cervical plexus and enter the spinal cord at spinal cord levels C3 and C4. The blood supply to trapezius is from the super cial branch of the transverse cervical artery. Clinical app Surgical procedures on the back Discectomy A prolapsed intervertebral disc may impinge on the meningeal (thecal) sac, cord, and most commonly the nerve root, producing symptoms attributable to that level. In some instances the disc protrusion will undergo a degree of involution that may allow symptoms to resolve without intervention. In some instances, pain, loss of function, and failure to resolve may require surgery to remove the disc protrusion.
Ancillary Fetal Testing High-risk fetuses or pregnancies sometimes require closer monitoring or additional testing to assess fetal status prescription pain medication for shingles discount cafergot 100 mg otc. Lower scores are indications for admission and continuous monitoring and sometimes delivery pain medication for dogs cancer purchase 100mg cafergot mastercard. The ratio of flow in systole versus diastole is measured treating pain in dogs with aspirin order cafergot with a mastercard, and a score over 3 is concerning pain treatment center in hattiesburg ms cheap cafergot on line. The Apgar score is a global assessment of neonatal status immediately after birth. Neonatal breathing, heart rate, reaction to stimulus, tone, and color are each assessed at 1, 5, and sometimes 10 minutes postnatal and given a score of 0 to 2 per category. Elevated blood pressure in pregnancy is pathologic and associated with fetal and maternal morbidity and mortality. Preeclampsia can be further categorized as having severe features if any of the following conditions are met: blood pressure elevated over 160 mm Hg systolic or 110 mm Hg diastolic, or end-organ dysfunction, which can manifest as severe headache, vision or cerebral disturbance, pulmonary edema or cyanosis, oliguria or renal failure, liver dysfunction, or severe epigastric pain. Severe proteinuria and fetal growth restriction are no longer used as indicators of severe features but do frequently occur with the disorder (12). The etiology of preeclampsia is still being studied, but abnormalities in placental implantation and placental production of thromboxane and prostacyclin may play a role. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Platelet aggregation occurs at sites of endothelial injury, resulting in coagulopathy. Severe hypertension can cause focal cerebral ischemia, cerebral edema, or hemorrhage, leading to eclampsia or seizures and death or major disability. Intravenous labetalol and hydralazine are most commonly used, and direct arterial pressure monitoring may be necessary. Sedation, decreased reflexes, muscle weakness and potentiation of neuromuscular blockade, and respiratory and cardiovascular depression or arrest are associated with magnesium overdose, which occurs more frequently in patients with renal dysfunction. Intravenous calcium is the primary treatment for arrest related to magnesium overdose. Ultimately, treatment of preeclampsia requires delivery and removal of the placenta. Early preeclampsia without severe features can be managed expectantly with careful maternal and fetal monitoring and antihypertensives in order to prevent preterm birth. Preeclampsia with severe features usually represents an indication for delivery once the patient is stabilized and steroids have been administered to hasten fetal lung maturity. If general anesthesia is necessary for cesarean delivery, laryngoscopy and intubation may be difficult due to systemic and airway edema, and short-acting intravenous antihypertensives should be used to prevent severe hypertension during airway management. Diabetes Mellitus Pregnancy is a diabetogenic state, and women can develop diabetes related to pregnancy (gestational diabetes mellitus). Blood glucose control is very important during pregnancy to avoid fetal central nervous system and cardiovascular malformations and fetal morbidity and mortality. Babies born to diabetic women with poor glucose control have higher rates of macrosomia, shoulder dystocia, respiratory distress, cardiomyopathy, polycythemia and persistent pulmonary hypertension, and term neonatal intensive care unit admission. Many of the physiologic implications of obesity mirror those of pregnancy and the two may combine to produce exaggerated untoward effects. In particular, obese patients have increased cardiac output, increased work of breathing, increased oxygen consumption, decreased lung volumes, and more redundant tissue, making them prone to complications during induction and airway management. Obese parturients exhibit exaggerated aortocaval compression when in the supine position. Obesity worsens obstetric and neonatal outcomes, increasing the rates of dysfunctional labor and cesarean delivery, hypertensive diseases of pregnancy, diabetes, fetal macrosomia, shoulder dystocia, and intrauterine fetal demise. Postoperatively these patients demonstrate increased rates of infection, wound disruption, and thromboembolic disease. Neuraxial anesthetic techniques are fraught with difficulty, and ultrasound guidance may facilitate block placement. Airway management during administration of general anesthesia should cause concern for failure to ventilate, failure to intubate, and aspiration of gastric contents. Obese parturients should be evaluated soon after admission to the labor and delivery unit and 31 Obstetric Anesthesia 595 early neuraxial analgesia is encouraged to decrease the risk of general anesthesia being required should an emergency cesarean delivery become necessary. Fever and Infection Pregnancy is an immunosuppressed state, and systemic infection is poorly tolerated. Chorioamnionitis is a common severe infection in pregnant patients that can lead to preterm labor, atony, hemorrhage, and sepsis. Urinary tract infections are also frequent and can lead to ascending infection and pyelonephritis due to poor ureteral valve function in pregnancy. Systemic inflammatory response syndrome and sepsis are treated in the same manner as for nonpregnant patients, but mortality rates are higher in pregnant patients. Primary herpes infection is associated with flu-like symptoms and genital lesions. Secondary infections are not considered a contraindication to neuraxial techniques. The etiology of the recrudescence is unclear and may be related to immunomodulation or to facial pruritus and scratching.
An elevation in serum alkaline phosphatase suggests biliary tract obstruction because an isoenzyme of alkaline phosphatase is produced in bile ductular epithelium and in hepatocyte canalicular membranes jaw pain treatment medications cafergot 100mg with amex. Figure 8-9 Kernicterus myofascial pain treatment center springfield va generic cafergot 100 mg on line, gross Unconjugated bilirubin is tightly bound to circulating albumin and is not excreted in urine; in premature newborns without the mature hepatic capacity to clear bilirubin pain treatment spa cafergot 100 mg, blood levels increase pain medication for dogs metacam order discount cafergot on-line, and bilirubin accumulates in the brain to cause neurologic damage. Coronal sections of medulla in the left panel and cerebral hemisphere in the right panel show kernicterus in deep gray matter. Increased unconjugated bilirubin, which accounts for the kernicterus, is toxic to brain tissue. Kernicterus is more likely to occur with prematurity, low birth weight, and increased bilirubin levels. Intrahepatic cholestasis can result from hepatocyte dysfunction or biliary tract obstruction. In addition to intrahepatic bile stasis, intracanalicular bile stasis is present, shown here. The continuing biliary obstruction can also lead to bile duct proliferation, shown on the left. The catabolism of heme derived from developing, damaged, and senescent erythrocytes produces bilirubin loosely bound to albumin in the blood. Bilirubin is taken up into hepatocytes, bound to cytosolic glutathione-S-transferases, conjugated with glucuronic acid by uridine diphosphate-glucuronyl transferase, and excreted into the bile canaliculus. Figure 8-11 Cholestasis, microscopic the yellowish green accumulations of pigment shown here in liver are bile. Obstruction of the biliary tree leads to intrahepatic biliary stasis and formation of bile lakes. Bile acts as an emulsifier and is an important component of lipid digestion in the small intestine. Lack of bile secretion into the duodenum leads to acholic (clay-colored) stools and possible steatorrhea with increased stool fat. Figure 8-12 Hepatic necrosis, gross Necrosis and hepatic lobular collapse are visible here as areas of hemorrhage with irregular furrows and granularity on the cut surface. The normal vascular inflow and outflow patterns are disrupted, with development of portal hypertension. Fibrous septa surround regenerative hepatocyte nodules averaging less than 3 mm in size. Cirrhosis requires at least a decade to develop from chronic liver injury, and a cirrhotic lever tends to decrease in size. Here, hepatic failure is marked by hyperbilirubinemia with green-tinged appearance of some nodules after formalin fixation (with oxidation of bilirubin to biliverdin). Figure 8-14 Cirrhosis, gross In micronodular cirrhosis, the regenerative nodules average 3 mm or less in size. The yellowbrown appearance of these nodules is caused by concomitant hepatic steatosis. The most common cause of micronodular cirrhosis and steatosis is chronic alcohol abuse. Cirrhosis may remain clinically silent for many years until complications of portal hypertension, such as esophageal varices or ascites, develop or there is significant loss of liver parenchyma with diminished metabolic function. Figure 8-15 Cirrhosis, gross Macronodular cirrhosis shown here from the inferior hepatic surface has multiple nodules greater than 3 mm in size with extensive deposition of tan-appearing collagen surrounding these regenerative nodules. This is end-stage decompensated cirrhosis; some cases remain wellcompensated (no metabolic derangements) or partially compensated. Most causes of cirrhosis can produce both patterns and a mixed micronodular and macronodular cirrhosis; the nodular pattern provides no reliable clue to the underlying cause. The abnormal blood flow through cirrhotic liver leads to an elevation in portal venous pressure. Increased collateral venous blood flow may also lead to formation of esophageal varices, dilated superficial abdominal veins (caput medusae), and hemorrhoids. The spleen is larger than normal from portal hypertension and can reach 1 kg in size. Transudation from the intravascular compartment producing an ascites often accompanies cirrhosis. This ascites results from multiple mechanisms, including hepatic sinusoidal hypertension, hypoalbuminemia, increased lymph drainage into the peritoneal cavity, leakage from intestinal capillaries, and secondary hyperaldosteronism with renal sodium and water retention. In addition, "hepatorenal syndrome" occurs with decreased renal function caused by diminished renal perfusion coupled with renal afferent arteriolar vasoconstriction. Figure 8-18 Cirrhosis, microscopic Micronodular hepatic cirrhosis is shown at low power, with regenerative nodules of hepatocytes ringed by thick bands of collagenous fibrosis. Within the fibrous bands are lymphocytic infiltrates and a proliferation of bile ductules. The increased hepatocyte proliferation from nodular regeneration increases the risk for hepatocellular and (to a lesser extent) cholangiolar carcinoma. The cirrhotic liver has diminished protein synthetic function, leading to hypoalbuminemia and diminished intravascular oncotic pressure. This is combined with increased sodium and water retention by the kidneys and increased hydrostatic pressure in veins and capillaries to promote this extravascular fluid collection. The patient may note increasing abdominal girth, and a fluid wave may be observed on physical examination. Figure 8-20 Caput medusae, gross Portal hypertension results from the abnormal hepatic blood flow pattern created by cirrhosis.
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