Program Director, Midwestern University Arizona College of Osteopathic Medicine
Body of the epididymis: major part consisting of the tightly convoluted duct of the epididymis gastritis symptoms medscape buy genuine renagel line. Tail of the epididymis: tapering continuation with the ductus deferens chronic gastritis support group generic renagel 800mg with visa, the duct that transports the sperms from the epididymis to the ejaculatory duct for expulsion via the urethra during ejaculation (see Chapter 6 symptoms of upper gastritis quality renagel 400mg, Pelvis and 1030 Perineum) gastritis symptoms australia buy renagel with a mastercard. Surface Anatomy of Anterolateral Abdominal Wall the umbilicus is an obvious feature of the anterolateral abdominal wall. It is a vestige of the site of attachment of the umbilical cord and is the reference point for the transumbilical plane. However, its height on the wall varies considerably, and is lower when abdominal subcutaneous fat is abundant. The epigastric fossa (pit of the stomach) is a slight depression in the epigastric region, just inferior to the xiphoid process. This fossa is particularly noticeable when a person is in the supine position because the abdominal organs spread out, drawing the anterolateral abdominal wall posteriorly in this region. The pain caused by pyrosis ("heartburn," resulting from reflux of gastric acid into the esophagus) is often felt at this site. Although the abdominal cavity extends higher, the costal margin is the demarcation between the thoracic and abdominal portions of the body wall. When a person is in the supine position, observe the rise and fall of the abdominal wall with respiration: superiorly with inspiration and inferiorly with expiration. The rectus abdominis muscles can be palpated and observed when a supine person is asked to raise their head and shoulders against resistance. The location of the linea alba is visible in lean individuals because of the vertical skin groove superficial to this raphe. The groove is usually obvious because the linea alba is approximately 1 cm wide between the two parts of the rectus abdominis superior to the umbilicus. Some pregnant women, especially those with dark hair and a dark complexion, have a heavily pigmented line, the linea nigra, in the midline skin external to the linea alba. The upper margins of the pubic bones (pubic crest) and the cartilaginous joint that unite them (pubic symphysis) can be felt at the inferior end of the linea alba. The pubic crest, inguinal folds, and iliac crests demarcate the inferior limit of the anterior abdominal wall, distinguishing it from the perineum centrally and the lower limbs (thighs) laterally. Skin grooves also overlie the tendinous intersections of the rectus abdominis, which are clearly visible in persons with well-developed rectus muscles. The interdigitating bellies of the serratus anterior and external oblique muscles are also visible. The site of the inguinal ligament is indicated by the inguinal groove, a skin crease that is parallel and just inferior to the inguinal ligament. This groove is readily visualized by having the person drop one leg to the floor while lying supine on an examining table. The inguinal groove marks the division between the anterolateral abdominal wall and the thigh. If a testis has not descended or is not retractable (capable of being drawn down), the condition is cryptorchidism (G. The undescended testis usually lies somewhere along the normal path of its prenatal descent, commonly in the inguinal canal. The importance of cryptorchidism is a greatly increased risk for developing malignancy in the undescended testis, particularly problematic because it is not palpable and is not usually detected until cancer has progressed. Because the testis needs a cooler environment for fertility as well, these are typically surgically corrected in childhood. Postnatal Patency of Umbilical Vein Before the birth of a fetus, the umbilical vein carries well-oxygenated, nutrientrich blood from the placenta to the fetus. Although reference is often made to the "occluded" umbilical vein forming the round ligament of the liver, this vein is patent for some time after birth and is used for umbilical vein catheterization for exchange transfusion during early infancy-for example, in infants with erythroblastosis fetalis or hemolytic disease of the neonate (Kliegman et al. This is also true of the uterus, the veins and lymph vessels of which mostly drain via deep routes. However, some lymphatic vessels follow the course of the round ligament through the inguinal canal. Thus, while occurring less often, metastatic uterine cancer cells (especially from tumors adjacent to the proximal attachment of the round ligament) can spread from the uterus to the labium majus (the developmental homolog of the scrotum and site of distal attachment of the round ligament) and from there to the superficial inguinal nodes, which receive lymph from the skin of the perineum (including the labia). These herniations occur in both sexes, but most inguinal hernias (approximately 86%) occur in males because of the passage of the spermatic cord through the inguinal canal. An inguinal hernia is a protrusion of parietal peritoneum and viscera, such as the small intestine, through a normal or abnormal opening from the cavity in which they belong. Most hernias are reducible, meaning they can be returned to their normal place in the peritoneal cavity by appropriate manipulation. Characteristics of direct and indirect inguinal hernias are listed and illustrated in Table B5. Normally, most of the processus vaginalis obliterates before birth, except for the distal part that forms the tunica vaginalis of the testis (see Table 5. The peritoneal part of the hernial sac of an indirect inguinal hernia is formed by the persisting processus vaginalis. If the entire stalk of the processus vaginalis persists, the hernia extends into the scrotum superior to the testis, forming a complete indirect inguinal hernia (Table B5.
Fibers of the palpebral portion of the orbicularis oculi (the sphincter of the palpebral fissure) are in the connective tissue superficial to the tarsi and deep to the skin of the eyelids gastritis jello buy generic renagel pills. Embedded in the tarsi are tarsal glands that produce a lipid secretion that lubricates the edges of the eyelids and prevents them from sticking together when they close gastritis symptoms medication buy renagel 400mg otc. The lipid secretion also forms a barrier that lacrimal fluid does not cross when produced in normal amounts gastritis diet vegetables order renagel line. When production is excessive gastritis emedicine buy renagel now, it spills over the barrier onto the cheeks as tears. Their ciliary margins are free; however, they are 2023 attached peripherally to the orbital septum (palpebral fascia in the eyelid). In this dissection of the orbit, the eyelids, orbital septum, levator palpebrae superioris, and some fat have been removed. Part of the lacrimal gland is seen between the bony orbital wall laterally and the eyeball and lateral rectus muscle medially. Structures receiving lacrimal drainage from the conjunctival sac are seen medially. The junctions of the superior and inferior eyelids make up the medial and lateral palpebral commissures, defining the medial and lateral angles of the eye (G. Between the nose and the medial angle of the eye is the medial palpebral ligament, which connects the tarsi to the medial margin of the orbit. A similar lateral palpebral ligament attaches the tarsi to the lateral margin of the orbit, but it does not provide for direct muscle attachment. The orbital septum is a fibrous membrane that spans from the tarsi to the margins of the orbit, where it becomes continuous with the periosteum. It keeps the orbital fat contained and, owing to its continuity with the periorbita, can limit the spread of infection to and from the orbit. The septum constitutes in large part the posterior fascia of the orbicularis oculi muscle. The fluid moistens and lubricates the surfaces of the conjunctiva and cornea and provides some nutrients and dissolved oxygen to the cornea. Excretory ducts of lacrimal gland: convey lacrimal fluid from the lacrimal glands to the conjunctival sac. Nasolacrimal duct: conveys the lacrimal fluid to the inferior nasal meatus (a cavity below the inferior nasal concha, the lowest of three downward-curving ridges on the lateral wall of the nasal cavity). The lacrimal gland, almond shaped and approximately 2 cm long, lies in the fossa for the lacrimal gland in the superolateral part of each orbit. The gland is divided into a superior orbital and inferior palpebral parts by the lateral expansion of the tendon of the levator palpebrae superioris. Accessory lacrimal glands may also be present, sometimes in the middle part of the eyelid, or along the superior or inferior fornices of the conjunctival sac. The eyelids come together in a lateral to medial sequence pushing a film of fluid medially over the cornea, somewhat like windshield wipers. In this way, lacrimal fluid, containing foreign material such as dust, is pushed toward the medial angle of the eye, accumulating in the lacrimal lake. Capillary action drains fluid into the lacrimal canaliculi through the lacrimal puncta. Action of the orbicular oculi muscle, attached in part to the lacrimal sac, assists in pulling fluid into the sac. From this sac, the fluid drains to the inferior nasal meatus of the nasal cavity through the nasolacrimal duct. It then flows posteriorly across the floor of the nasal cavity to the nasopharynx and is eventually swallowed. In addition to cleansing particles and irritants from the conjunctival sac, lacrimal fluid provides the cornea with nutrients and oxygen. The nerve supply of the lacrimal gland is both sympathetic and parasympathetic. The presynaptic parasympathetic secretomotor fibers are conveyed from the facial nerve by the greater petrosal nerve and then 2025 by the nerve of the pterygoid canal to the pterygopalatine ganglion, where they synapse with the cell body of the postsynaptic fiber. Vasoconstrictive, postsynaptic sympathetic fibers, brought from the superior cervical ganglion by the internal carotid plexus and deep petrosal nerve, join the parasympathetic fibers to form the nerve of the pterygoid canal and traverse the pterygopalatine ganglion. The maxillary, infra-orbital, zygomatic, and lacrimal nerves convey the postsynaptic fibers to the gland. It occupies most of the anterior portion of the orbit, suspended by six extrinsic 2026 muscles that control its movement, and a fascial suspensory apparatus. All anatomical structures within the eyeball have a circular or spherical arrangement. The eyeball proper has three layers; however, there is an additional connective tissue layer that surrounds the eyeball, supporting it within the orbit. The connective tissue layer is composed posteriorly of the fascial sheath of the eyeball (bulbar fascia or Tenon capsule), which forms the actual socket for the eyeball, and anteriorly of bulbar conjunctiva. A very loose connective tissue layer, the episcleral space (a potential space) lies between the fascial sheath and the outer layer of the eyeball, facilitating movements of the eyeball within the fascial sheath. Inner layer (inner coat), consisting of the retina, which has both optic and nonvisual parts.
The fan-like parts of the collateral ligaments cause the palmar ligaments to move like a visor over the underlying metacarpal or phalangeal heads gastroenteritis flu purchase renagel visa. The interphalangeal joints have corresponding ligaments gastritis diet колеса cheap renagel 400 mg with mastercard, but the distal ends of the proximal and middle phalanges gastritis pdf generic 400mg renagel free shipping, being flattened anteroposteriorly and having two small condyles gastritis diet барбоскины buy 800mg renagel overnight delivery, permit neither adduction or abduction. When a blow is received to the acromion of the scapula, or when a force is transmitted to the pectoral girdle during a fall on the outstretched hand, the force of the blow is usually transmitted along the length of the clavicle, that is, along its long axis. When ankylosis (stiffening or fixation) of the joint occurs, or is necessary surgically, a section of the center of the clavicle is removed, creating a pseudojoint or "flail" joint to permit scapular movement. When the coracoclavicular ligament tears, the shoulder separates from the clavicle and falls because of the weight of the upper limb. Rupture of the coracoclavicular ligament allows the fibrous layer of the joint capsule to be torn so that the acromion can pass inferior to the acromial end of the clavicle. Calcific Tendinitis of Shoulder Inflammation and calcification of the subacromial bursa result in pain, tenderness, and limitation of movement of the glenohumeral joint. This causes increased local pressure that often causes excruciating pain during abduction of the arm; the pain may radiate as far as the hand. The calcium deposit may irritate the 696 overlying subacromial bursa, producing an inflammatory reaction known as subacromial bursitis. As long as the glenohumeral joint is adducted, no pain usually results because in this position the painful lesion is away from the inferior surface of the acromion. The pain usually develops in males 50 years of age and older after unusual or excessive use of the glenohumeral joint. Recurrent inflammation of the rotator cuff, especially the relatively avascular area of the supraspinatus tendon, is a common cause of shoulder pain and results in tears of the musculotendinous rotator cuff. To test for degenerative tendonitis/tendinosis of the rotator cuff, the person is asked to lower the fully abducted limb slowly and smoothly. Rotator cuff injuries may also occur during a sudden strain of the muscles, for example, when an older person strains to lift something, such as a window that is stuck. Often the intracapsular part of the tendon of the long head of the biceps brachii becomes frayed (even worn away), leaving it adherent to the intertubercular sulcus. Because they fuse, the integrity of the fibrous layer of the joint capsule of the glenohumeral joint is usually compromised when the rotator cuff is injured. Because the supraspinatus muscle is no longer functional with a complete tear of the rotator cuff, the person cannot initiate abduction of the upper limb. Because the presence of the coraco-acromial arch and support of the rotator cuff are effective in preventing upward dislocation, most dislocations of the humeral head occur in the downward (inferior) direction. However, they are described clinically as anterior or (more rarely) posterior dislocations, indicating whether the humeral head has descended anterior or posterior to the infraglenoid tubercle and long head of the triceps. Anterior dislocation of the glenohumeral joint occurs most often in young adults, particularly athletes. It is usually caused by excessive extension and lateral rotation of the humerus. The head of the humerus is driven infero-anteriorly, and the fibrous layer of the joint capsule and glenoid labrum may be stripped from the anterior aspect of the glenoid cavity in the process. A hard blow to the humerus when the glenohumeral joint is fully abducted tilts the head of the humerus inferiorly onto the inferior weak part of the joint capsule. This may tear the capsule and dislocate the shoulder so that the humeral head comes to lie inferior to the glenoid cavity and anterior to the infraglenoid tubercle. The strong flexor and adductor muscles of the glenohumeral joint usually subsequently pull the humeral head anterosuperiorly into a subcoracoid position. Inferior dislocation of the glenohumeral joint often occurs after an avulsion fracture of the greater tubercle of the humerus, owing to the absence of the upward and medial pull produced by muscles attaching to the tubercle. The axillary nerve may be injured when the glenohumeral joint dislocates because of its close relation to the inferior part of the joint capsule. Glenoid Labrum Tears 701 Tearing of the fibrocartilaginous glenoid labrum commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation (partial dislocation) of the glenohumeral joint. The tear often results from sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. The typical symptom is pain while throwing, especially during the acceleration phase. A sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm. Injuries that may initiate acute capsulitis are glenohumeral dislocations, calcific supraspinatus tendinitis, partial tearing of the rotator cuff, and bicipital tendinitis (Salter, 1999). Repeated excessive pressure and friction, as occurs in wrestling, for example, may cause this bursa to become inflamed, producing a friction subcutaneous olecranon bursitis.
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Masses in the anterior segment of the right upper lobe of two different patients showing invasion of the pleural surface of the lung (A) and of the superior mediastinum (B) gastritis nursing care plan 800mg renagel mastercard. Lung Cancer and Mediastinal Nerves Lung cancer involving a phrenic nerve may result in paralysis of one half of the diaphragm (hemidiaphragm) gastritis location discount renagel uk. Because of the intimate relationship of the recurrent laryngeal nerve to the apex of the lung gastritis diet игри purchase renagel with visa. This involvement usually results in hoarseness owing to paralysis of a vocal fold (cord) because the recurrent laryngeal nerve supplies all but one of the laryngeal muscles gastritis diet list purchase cheap renagel. Pleural Pain the visceral pleura is insensitive to pain because it receives no nerves of general sensation. The parietal pleura (particularly the costal part) is extremely sensitive to pain. The parietal pleura is richly supplied by branches of the intercostal and phrenic nerves. Irritation of the parietal pleura may produce local pain or referred pain projected to dermatomes supplied by the same spinal (posterior root) ganglia and segments of the spinal cord. Irritation of the costal and peripheral parts of the diaphragmatic pleura results in local pain and referred pain to the dermatomes of the thoracic and abdominal walls. The deep inspiration causes the diaphragmatic domes to descend, filling the lungs with air (increasing their radiolucency) and moving the inferior margins of the lungs into the costodiaphragmatic recesses. Pleural effusions accumulating here do not allow the inferior margin to descend into the recess, and the usual radiolucent air density here is replaced with a hazy radiopacity. Lobar disease, such as pneumonia, appears as localized, relatively radiodense areas that contrast with the 839 radiolucency of the remainder of the lung. Soft tissues, including those of the breasts, cast shadows of varying density, depending on their composition and thickness. Paralleling the superior margins of the clavicles are shadows cast by the skin and subcutaneous tissues covering these bones. The clavicles, ribs, and inferior cervical and superior thoracic vertebrae are visible. The inferior ribs tend to be obscured by the diaphragm and the superior contents of the abdomen. The lower thoracic vertebrae are more or less obscured by the sternum and mediastinum. Occasionally, the costal cartilages are calcified in older people (especially the inferior cartilages). The right dome of the diaphragm, formed by the underlying liver, is usually approximately half an 840 intercostal space higher than the left dome. The lungs, because of their low density, are relatively lucent compared with surrounding structures. The lungs exhibit a radiodensity similar to that of air and, therefore, produce paired radiolucent areas. In lateral projections, the middle and inferior thoracic vertebrae are visible, although they are partially obscured by the ribs. Lateral radiographs allow better viewing of a lesion or anomaly confined to one side of the thorax. In a lateral projection, both domes of the diaphragm are often visible as they arch superiorly from the sternum. A lateral radiograph is made using a lateral projection, with the side of the thorax against the film cassette or X-ray detector and the upper limbs elevated over the head. The pleural fluid prevents the lungs from collapse and causes the lungs to expand when the thorax expands for inhalation. Lungs: the lungs are the vital organs of respiration in which venous blood exchanges oxygen and carbon dioxide with a tidal airflow. Tracheobronchial tree: the tracheobronchial tree is distinguished grossly by cartilage in its walls. However, most of the drainage from the left inferior lobe passes to the right pathway. Nerve fibers of the pulmonary plexuses are autonomic (bronchoconstrictive and secretomotor vagal parasympathetic fibers; inhibitory and vasoconstrictive sympathetic fibers) and visceral afferent (reflex and pain). It is covered on each side by mediastinal pleura and contains all the thoracic viscera and structures except the lungs. The mediastinum extends from the superior thoracic aperture to the diaphragm inferiorly and from the 842 sternum and costal cartilages anteriorly to the bodies of the thoracic vertebrae posteriorly. Unlike the rigid structure observed in an embalmed cadaver, the mediastinum in living people is a highly mobile region because it consists primarily of hollow (liquid- or air-filled) visceral structures united only by loose connective tissue, often infiltrated with fat. The major structures in the mediastinum are also surrounded by blood and lymphatic vessels, lymph nodes, nerves, and fat. The subdivisions of the mediastinum are demonstrated as if the person were in the supine position. The looseness of the connective tissue and the elasticity of the lungs and parietal pleura on each side of the mediastinum enable it to accommodate movement as well as volume and pressure changes in the thoracic cavity, for example, those resulting from movements of the diaphragm, thoracic wall, and tracheobronchial tree during respiration, contraction (beating) of the heart and pulsations of the great arteries, and passage of ingested substances through the esophagus. The connective tissue becomes more fibrous and rigid with age; hence, the mediastinal structures become less mobile. The mediastinum is divided into superior and inferior parts for descriptive purposes. The inferior mediastinum-between the transverse thoracic plane and the diaphragm-is further subdivided by the pericardium into anterior, middle, and posterior parts. The pericardium and its contents (heart and roots of its great vessels) constitute the middle mediastinum. Some structures, such as the esophagus, pass vertically through the mediastinum and therefore lie in more than one mediastinal compartment.
It forms a strong loop around the tendons of the fibularis tertius and the extensor digitorum longus muscles gastritis diet авториа buy renagel on line amex. These muscles pass and insert anterior to the transversely oriented axis of the ankle (talocrural) joint and gastritis symptoms and home remedies buy renagel 400 mg with mastercard, therefore gastritis diet symptoms renagel 400mg visa, are dorsiflexors of the ankle joint erythematous gastritis diet renagel 800mg on-line, elevating the forefoot and depressing the heel. The long extensors also pass along and attach to the dorsal aspect of the digits and are thus extensors (elevators) of the toes. Immediately after, in the stance phase, eccentric contraction of the tibialis anterior controls the lowering of the forefoot to the floor following heel strike. The latter is important to a smooth gait and is important to deceleration (braking) relative to running and walking downhill. During standing, the dorsiflexors reflexively pull the leg (and thus the center of gravity) anteriorly on the fixed foot when the body starts to lean (the center of gravity begins to shift too far) posteriorly. Its tendon passes within its own synovial sheath deep to the superior and inferior extensor retinacula. In so doing, its tendon is located farthest from the axis of the ankle joint, giving it the most mechanical advantage and making it the strongest dorsiflexor. This dissection shows the muscles of the anterolateral leg and dorsum of the foot. The common fibular nerve, coursing subcutaneously across the lateral aspect of the head and neck of the fibula, is the most commonly injured peripheral nerve. In this deeper dissection of the anterior compartment, the muscles and inferior extensor retinaculum are retracted to display the arteries and nerves. A small part of the proximal attachment of the muscle is to the lateral tibial condyle; however, most of it attaches to the medial surface of the fibula and the superior part of the anterior surface of the interosseous membrane. The central band inserts into the base of the middle phalanx, and the lateral slips converge to insert into the base of the distal phalanx. It may play a special proprioceptive role in sensing sudden inversion and then contracting reflexively to protect the anterior tibiofibular ligament, the most commonly sprained ligament of the body. It is one of the two terminal branches of the common fibular nerve, arising between the fibularis longus muscle and the neck of the fibula. The deep fibular nerve then exits the compartment, continuing across the ankle joint to supply intrinsic muscles (extensors digitorum and hallucis brevis), and a small area of the skin of the foot. The smaller terminal branch of the popliteal artery, the anterior tibial artery, begins at the inferior border of the popliteus muscle. At the ankle joint, midway between the malleoli, the anterior tibial artery changes names, becoming the dorsalis pedis artery (dorsal artery of the foot). The popliteal artery begins at the site of the adductor hiatus (where it may be compressed) and then lies successively on the distal end of the femur, joint capsule of the knee joint, and popliteus muscle (not visible) before dividing into the anterior and posterior tibial arteries at the inferior angle of the popliteus fossa. Here, it is subject to entrapment as it passes beneath the tendinous arch of the soleus muscle. Sniderman, Associate Professor of Medical Imaging, University of Toronto, Toronto, Ontario, Canada. It is bounded by the lateral surface of the fibula, the anterior and posterior intermuscular septa, and the deep fascia of the leg. The lateral compartment ends inferiorly at the superior fibular retinaculum, which spans between the distal tip of the fibula and the calcaneus. Here, the tendons of the two muscles of the lateral compartment (fibularis longus and brevis) enter a common synovial sheath to accommodate their passage between the superior fibular retinaculum and the lateral malleolus, using the latter as a trochlea as they cross the ankle joint. These muscles have their fleshy bellies in the lateral compartment but are tendinous as they exit the compartment within the common synovial sheath deep to the superior fibular retinaculum. Developmentally, the fibularis muscles are postaxial muscles, receiving innervation from the posterior divisions of the spinal nerves, which contribute to the sciatic nerve. However, because the fibularis longus and brevis pass posterior to the transverse axis of the ankle (talocrural) joint, they contribute to plantarflexion at the ankle-unlike the 1716 postaxial muscles of the anterior compartment (including the fibularis tertius), which are dorsiflexors. As evertors, the fibularis muscles act at the subtalar and transverse tarsal joints. In practice, the primary function of the evertors of the foot is not to elevate the lateral margin of the foot (the common description of eversion) but to depress or fix the medial margin of the foot in support of the toe off phase of walking and, especially, running and to resist inadvertent or excessive inversion of the plantarflexed foot (the position in which the ankle is most vulnerable to injury). When standing (and particularly when balancing on one foot), the fibularis muscles contract to resist medial sway (to recenter a line of gravity, which has shifted medially) by pulling laterally on the leg while depressing the medial margin of the foot. To test the fibularis longus and brevis, the foot is everted strongly against resistance; if acting normally, the muscle tendons can be seen and palpated inferior to the lateral malleolus. Its tendon can be palpated and observed proximal and posterior to the lateral malleolus. Distal to the superior fibular retinaculum, the common sheath shared by the fibular muscles splits to extend through separate compartments deep to the inferior fibular retinaculum. It then crosses the sole of the foot, running obliquely and distally to reach its attachment to the 1st metatarsal and 1st (medial) cuneiform bones. Its broad tendon grooves the posterior aspect of the lateral malleolus and can be palpated inferior to it. Occasionally, however, the fibularis tertius passes anteriorly to attach directly to the proximal phalanx of the 5th digit. Instead, perforating branches and accompanying veins supply blood to and drain blood from the compartment.
