Co-Director, University of Tennessee College of Medicine
They contain myofibrils that allow them to contract thereby opening up channels by which blood is discharged into the splenic substance allergy migraine order promethazine in india. Under the stratified squamous epithelium (Ep) that covers the tonsil surface is a profusion of dark-staining allergy shots last how long discount 25 mg promethazine with visa, closely packed lymphocytes allergy symptoms during pregnancy purchase promethazine in india. Tonsillar nodules also contain many macrophages (Ma) allergy forecast ireland purchase promethazine american express, known as tingible (or stainable) macrophages. Their presence among the smaller, darker lymphocytes produces a unique "starry night" pattern in the nodule, which is a useful distinguishing feature of this tonsil. These macrophages phagocytose developing B lymphocytes in the nodule that are either apoptotic or undergoing degeneration. None of the other lymphoid organ show any such epithelium except tonsil, though the other findings may be evident. Lymphatic nodules are present with pale staining germinal centre and dark staining periphery. The surface epithelium (epidermis) is of the keratinized stratified squamous variety. The deeper dermis consists mainly of bundles of collagen fibers together with some elastic tissue, blood vessels, lymphatics Colour of skin is determined by the degree of pigmentation produced by melanocytes in the basal layer of the epidermis. Hair and nails are a hard type of keratin; the keratin of the skin surface is soft keratin. Each hair is formed from the hair Sweat glands are exocrine glands with a small tubular structures of the skin that secrete sweat onto an epithelial surface by way of a duct. Self Assessment and Review of Anatomy They are distributed all over the skin except on the tympanic membranes, lip margins, nipples, inner surface of prepuce, glans penis and labia minora. The greatest concentration is in the thick skin of the palms and soles, and on the face. They are two types: Eccrine and apocrine Eccrine sweat glands are distributed almost all over the human body and has water-based secretion meant primary form of cooling the body. Apocrine sweat glands are rare to find and are mostly limited to axillae, areolae, periumbilical, genital and perianal regions Ceruminous glands (ear wax), mammary glands (milk), and ciliary glands in the eyelids are modified apocrine sweat glands. Sebaceous glands are holocrine glands, small saccular structures in the dermis and open into the side of hair follicles. They also open directly on to the surface of the hairless skin of the lips, nipples, areolae, inner surface of prepuce, glans penis and labia minora. The epidermis of thick skin consists of five layers of cells (keratinocytes): stratum corneum (characterized by dead and dying cells with compacted keratin), stratum lucidum (a translucent layer not obvious in thin skin), stratum granulosum (characterized by keratohyalin granules), stratum spinosum (characterized by tonofibrils and associated desmosomes) and stratum basale (proliferative layer). Langerhans cells are dendritic cells derived from monocyte-phagocyte series in the bone marrow; lack tonofilaments, desmosomes, and melanosomes. They are found principally in the stratum spinosum of the epidermis, but also in lymph nodes, spleen, and thymus. Their surface markers are characteristic of macrophages, and are antigen-presenting cells involved in contact allergic responses and other cell-mediated immune reactions in the skin (delayed hypersensitivity). Langerhans cell histiocytosis is a disease characterized by the excessive proliferation of Langerhans cells, which can manifest as skin or bone lesions. Table 31: Characteristics of thick and thin skin Cellular strata (Superficial to deepest) Epidermis Thick skin Is a stratified squamous keratinized epithelium derived from ectoderm. Cells of the epidermis consist of four cell types: keratinocytes, melanocytes, Langerhans cells and Merkel cells. Composed of several layers of dead, anucleated, flattened Only about five or so layers of keratinocytes keratinocytes (squames) that are being sloughed from the (squames) comprise this layer in the thinnest surface. Poorly stained keratinocytes filled with keratin compose this Layer is absent but individual cells of the layer thin, well-defined layer. Only three to five layers thick with polygonal-shaped nucleated Layer is absent but individual cells of the layer keratinocytes with a normal complement of organelles as well are probably present. This thickest layer is composed of mitotically active and the stratum is the same as in thick skin but the maturing polygonal keratinocytes (prickle cells) that number of layers is reduced. The cytoplasm is rich in tonofilaments, organelles, and membranecoating granules, Langerhans cells are present in this layer. Thin skin Stratum conium (Cornified cell layer) Stratum Lucidum (Clear cell layer) Stratum granulosum (Granular cell layer) Stratum spinosum (prickle cell layer) 192 Histology Cellular strata (Superficial to deepest) Stratum basale (stratum germinativum) Thick skin Thin skin this deepest stratum is composed of a single layer of mitotically this layer is the same in thin skin as in thick skin. Keratinocytes of the more superficial strata originate from this layer and eventually migrate to the surface where they are sloughed. Located deep to the epidermis and separated from it by a basement membrane, the dermis is derived from mesoderm and is composed mostly of dense irregular collagenous connective tissue. It contains capillaries, nerves, sensory organs, hair follicles, seat and sebaceous glands, as well as arrector pilli muscles. It is divided into two layers: a superficial papillary layer and a deeper reticular layer.
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Recommended Dietary Allowance (RDA): average daily level of intake that is enough to meet the nutrient needs of nearly all (97 - 98%) healthy people.
Check for swelling, redness, wetness, rashes, cold fingers and toes, twisted arms or legs, folded earlobes, or pinched fingers or toes.
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Growth characteristically slows down till the age of 1 year and there is subsequent gradual involution of the lesion with complete involution in 50% of individuals at 5 years of age and in 90% of individuals at 9 years allergy symptoms aches pains order discount promethazine. Diagnosis is usually made on clinical history and examination findings alone without the need for imaging allergy medicine symptoms purchase 25mg promethazine otc. Infantile haemangiomas with superficial dermal components have a classic strawberry appearance (Figure 13 allergy forecast dc order promethazine toronto. Management of haemangioma is conservative in the majority of cases with even larger lesions naturally involuting over time allergy symptoms in babies purchase generic promethazine line. Recently, treatment with topical beta-blocker has been found to be effective for superficial lesions. High output cardiac failure is a rarely occurring complication of infantile haemangioma requiring medical treatment and embolisation of the capillary bed. Other vascular tumours include congenital haemangioma, present and fully formed at birth, pyogenic granuloma and tufted angioma. Vascular malformations Vascular malformations develop as a result of abnormal vessel angiogenesis. Therefore, unlike vascular tumours, they are dysplastic rather than proliferative. They are always present at birth, although they may not be clinically evident for months or years. These lesions can undergo periods of enlargement particularly during puberty, pregnancy or following trauma and do not spontaneously regress. It is usually possible to differentiate between low- and high-flow malformations on clinical history and examination. Imaging being used to confirm diagnoses and to plan any subsequent treatment (Table 13. They are red macular lesions commonly involving the nape of the neck, the upper eyelids or on the forehead between the eyebrows. They become more prominent when the infant cries or has a fever, and usually disappear by 2 years of age. They are usually dermatomal in distribution and unilateral, growing proportionately over time with the child. This is the association of a capillary vascular malformation affecting one branch of the trigeminal nerve of the face, with a leptomeningeal vascular malformation and vascular malformation of the eye (Figure 13. Local intravascular coagulopathy is a feature, which combined with slow venous flow makes them prone to thrombosis. Vascular Anomalies 83 Mixed malformations There is considerable overlap between venous and lymphatic malformations with many lesions having various different tissue morphologies within different areas of the same malformation. The blue papular parts of the lesion can be emptied with compression and spontaneously refill. The lesions are non-pulsatile, often with associated swelling and blue discolouration of the skin, and can be tender (Figure 13. They classically distend when dependent and empty on elevation of the lesion, depending on the number and integrity of the venous channels. Pain, bleeding and ulceration are common presenting symptoms: high output cardiac failure is rare. Clinical examination usually reveals a warm, pulsatile mass with skin discolouration. Limb overgrowth may be noted due to hypertrophy or venous hypertension (Figure 13. Imaging vascular malformations the diagnosis of vascular anomalies is mostly through clinical assessment, but a handheld Doppler ultrasound is a useful adjunct to gauge the presence of arterial flow. Duplex ultrasound is an accessible, non-invasive first-line investigation that can give more specific information regarding exact location, presence of vascular spaces and flow characteristics. Detailed information regarding the anatomical extent, and vascular supply, can be obtained as a prelude to treatment (Figure 13. Catheter venography/angiography is essential for treatment planning of both low- and high-flow malformations, providing detailed Lymphatic malformations Lymphatic malformations are the second most common vascular malformation. Arising from lymphatic vessels, the majority are present at birth with 90% seen at 2 years of age. Lymphatic malformations are most commonly located in the neck, where they are often known as cystic hygromas (Figure 13. Note the skin changes secondary to venous hypertension as well as small ulcers (arrows) that presented periodically with life-threatening haemorrhage. The use of cosmetics and camouflage creams, analgesia for episodes of pain, venous compression stockings and antibiotics for infections associated with lymphatic malformations has a role. Avoidance of the combined oral contraceptive to reduce thrombotic risk may be appropriate. Venous malformations Percutaneous sclerotherapy is the primary treatment if conservative measures have failed to manage symptoms, in particular pain. Following direct puncture of the venous channels using ultrasound and fluoroscopic guidance, agents such as ethanol, bleomycin or sodium tetradecyl sulphate are injected (Figure 13. Swelling and pain in the region of the malformation generally increases in the first 2 weeks post procedure, and patients must (c) Figure 13. Approximately 20% of the patients can expect to have complete relief of symptoms after one course of treatment, 60% should have a decrease in symptoms, while 20% receive no therapeutic benefit.
The aortic and pulmonary artery valves have three leaflets and resemble one another except for the fact that the coronary arteries originate from behind the cusps in the aorta allergy medicine dry eyes order 25 mg promethazine with visa. An action potential (yellow arrows) starts at the sinoatrial node and travels through atrial muscle cells to the atrioventricular node allergy testing dayton ohio purchase promethazine once a day. After a short delay at the atrioventricular node allergy medicine philippines purchase promethazine 25 mg mastercard, the action potential spreads through the interventricular septum in modified cardiac muscle cells allergy testing frequency generic 25mg promethazine mastercard, called Purkinje fibers, and then through muscle cells to the whole ventricle. The right and left coronary arteries can be seen coming off the aortic valve cusps. The right coronary artery supplies the sinoatrial node and most often the posterior aspect of the heart; the left coronary artery divides into the left anterior descending and the circumflex arteries. The three tunics are homologous to those of blood vessels: endocardium = tunica intima; myocardium = tunica media; and epicardium = tunica adventitia. The pericardium is composed of two layers: the outer parietal pericardium and the epicardium, or visceral pericardium, which is in contact with the heart and roots of the great vessels. The parietal pericardium has two regions: a serosa facing the pericardial cavity and, peripheral to that, a fibrosa. This causes moving columns of blood to abruptly decelerate, which sets up vibrations of the chordae tendineae, ventricles, and blood as a unit. The aortic component (A2) normally precedes the pulmonary component (P2) of the S2 heart sound. As the diaphragm descends, it causes a further decrease in intrathoracic pressure, which increases the flow of blood out of the vena cava into the right side of the heart. A2 and P2 become a single sound on expiration as intrathoracic pressure becomes less negative. An accentuated A2 is heard in primary hypertension (increased pressure causes it to snap shut), and an accentuated P2 is heard in pulmonary hypertension (increased pressure causes it to snap shut). It may be a normal finding in children and young adults, in whom it reflects a more energetic expansion and filling of the left ventricle; however, it is considered a pathologic finding after 40 years of age. It is thought to be caused by a sudden rush of blood entering a volume-overloaded left or right ventricle (stiff ventricle). The S3 heart sound is best heard at the apex with the patient in the left lateral decubitus position. It is never a normal finding and is caused by increased resistance to filling (decreased compliance) in the left or the right heart after a vigorous atrial contraction. Causes of decreased ventricular compliance include concentric ventricular hypertrophy (left/right) and a volume overloaded ventricle (no more room to expand). In a volume-overloaded left or right ventricle, it is commonly present along with an S3 heart sound. The presence of an S3 and S4 heart sound is called a summation gallop (see schematic) and sounds like a galloping horse. Grade 1 and 2 murmurs are very hard to hear, but grade 3 murmurs are easy to hear. Right-sided murmurs and abnormal heart sounds have increased intensity when the patient takes a deep inspiration and holds the breath for 3 to 5 seconds. This occurs as the intrathoracic pressure becomes increasingly negative, essentially drawing blood out of the venous system into the right side of the heart, hence accentuating the murmur and abnormal heart sound on that side. In contradistinction, left-sided heart murmurs and abnormal heart sounds do not change their intensity with deep held inspiration. The most common cause of a continuous murmur in children is a cervical venous hum. They produce an ejection type of murmur (schematic A), which has a diamondshaped (crescendo-decrescendo) configuration. Regurgitation (insufficiency) murmurs occur when there is defective valve closure. They are even-intensity pansystolic murmurs (schematic C) that often obliterate the S1 and S2 heart sounds. A giant a wave occurs when there is restricted filling of the right side of the heart. The heart on the left (A) has concentric hypertrophy of the left ventricle that is related to an increase in afterload, and the heart on the right (B) has eccentric hypertrophy of the left ventricle that is related to an increase in preload. In addition, there is usually an S4 atrial gallop because of increased resistance to filling in late diastole. Pulmonary congestion commonly occurs when the heart cannot meet the metabolic demands of peripheral tissue. F F A B C D E 11-2: A, Pulmonary edema (F) showing pink fluid (transudate) completely filling the alveoli. Note the fluffy alveolar infiltrates ("bat-wing" or "angel wing" configuration) throughout both lung fields. Careful observation in the opaque fluffy infiltrates shows air bronchograms (lucent areas around opaque regions). D, Kerley B lines (septal edema; circles) in both lower lobes in a patient with pulmonary edema. Chronic passive venous congestion of the liver causes dark areas where centrilobular zones are congested by blood, contrasting with pale periportal areas. This appearance is similar to that of the cut surface of a nutmeg, hence the term "nutmeg liver. A, the distribution of an infarction in a left anterior descending coronary artery thrombosis. C, the distribution of an infarction in a left circumflex coronary artery occlusion. Clinicalfindings e (1) Exercise-inducedsubsternalchestpainlasting30secondsto30minutes (2) Otherprecipitatingeventsincludesexualintercourse,climbingstairs,eatingaheavy meal,emotionalstress,andcoldtemperature. The common denominator in each of these syndromes is rupture of an atherosclerotic plaque leading to platelet aggregation and the formation of an intracoronary thrombosis (Link 11-18, bottom).
It inserts on the posterior surface of the tibia allergy testing zyrtec purchase 25 mg promethazine fast delivery, just proximal to the soleal line allergy medicine impotence order 25 mg promethazine amex. Ligaments Ligaments are fibrous bands that connect bones to bones or cartilage or are folds of peritoneum serving to support visceral structures allergy medicine phenylephrine discount promethazine 25 mg fast delivery. They are composed of dense connective tissue allergy shots sore arm buy cheap promethazine 25mg online, mainly collagen fibres, the direction of the fibres being related to the stresses which they undergo. A few ligaments, such as the ligamenta flava between vertebral lamina and the ligamentum nuchae at the back of the neck, are made of elastic fibres, which enables them to stretch and regain their original length thereafter. They have a similar structure to collagenous ligaments, and attach muscle to bone. Tendons have a blood supply from vessels which descend from the muscle belly and anastomose with periosteal vessels at the bony attachment. Synovial sheaths Where tendons bear heavily on adjacent structures, and especially where they pass around loops or pulleys of fibrous tissue or bone and change the direction of their pull, they are lubricated by being provided with a synovial sheath. The parietal layer of the sheath is attached to the surrounding structures, the visceral layer is fixed to the tendon, and the two layers glide on each other, lubricated by a thin film of synovial fluid secreted by the lining cells of the sheath. Usually they do not enclose the tendon cylindrically; it is as though the tendon was pushed into the double layers of the closed sheath from one side. In this way blood vessels can enter the tendon to reinforce the longitudinal anastomosis. In other cases blood vessels perforate the sheath and raise up a synovial fold like a little mesentery-a vinculum-as in the flexor tendons of the digits. Aponeuroses are flat fibrous sheets or expanded broad tendons that attach to muscles and serve as the means of origin or insertion of a flat muscle. Retinaculum Is a fibrous band that holds a structure in place in the region of joints. Bursae Are fluid-filled flattened sacs of synovial membrane that facilitate movement by minimizing friction. Synovial tendon sheaths Are synovial fluid-filled tubular sacs around muscle tendons that facilitate movement by reducing friction. Fascia Is a fibrous sheet that envelops the body under the skin and invests the muscles and may limit the spread of pus and extravasated fluids such as urine and blood. Superficial fascia Is a loose connective tissue between the dermis and the deep (investing) fascia and has a fatty superficial layer (fat, cutaneous vessels, nerves, lymphatics, and glands) and a membranous deep layer. The skin is connected to the underlying bones or deep fascia by a layer of loose areolar connective tissue. This layer, usually referred to as superficial fascia, is of variable thickness and fat content. These include both skeletal muscles (platysma, palmaris brevis) and smooth muscles (subareolar muscle of the nipple, dartos, corrugator cutis ani). The superficial fascia is most distinct on the lower abdominal wall where it differentiates into two layers. Strong connective tissue bands traverse the superficial fascia binding the skin to the underlying aponeurosis of the scalp, palm and sole. Deep Fascia Is a sheet of fibrous tissue that invests the muscles and helps support them by serving as an elastic sheath or stocking. Provides origins or insertions for muscles, forms fibrous sheaths or retinacula for tendons, and forms potential pathways the limbs and body wall are wrapped in deep fascia. In the iliotibial tract of the fascia lata, for example, it is very well developed, while over the rectus sheath and external for infection or extravasation of fluids. Where deep fascia passes directly over bone it is always anchored firmly to the periosteum and the underlying bone is described as being subcutaneous. In the neck, as well as the investing layer of deep fascia, there are other deeper fascial layers enclosing neurovascular structures, glands and muscles. Intermuscular septa are laminae of deep fascia which extend between muscle groups. Transverse thickenings of deep fascia over tendons, attached at their margins to bones, form retinaculae at the wrists and ankles and fibrous sheaths on the fingers and toes. Retinacula at the joints 14 In the vicinity of the joints, the tendons of the muscles of the leg are bound down by localized, band-shaped thickenings of the deep fascia termed retinacula, which collectively serve to prevent bowstringing of the underlying tendons during muscle contraction. General Anatomy Portal Venous Circulation Portal circulation is a capillary network that lies between two veins. Blood supplying the organ thus passes through two sets In hepatic portal system blood supplying the abdominal organs passes through two sets of capillaries before it returns to A portal circulation also connects the median eminence and infundibulum of the hypothalamus with the adenohypophysis.
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