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The diagnostic approach to dizziness or true vertigo uses anatomy arthritis in back of leg generic 75mg indocin otc, beginning with the external ear and working inward toward the middle ear rheumatoid arthritis zumba discount indocin amex, labyrinth degenerative arthritis in neck symptoms buy 50 mg indocin fast delivery, auditory artery and nerve, and vestibular nuclei in the brainstem. Otitis media, especially when it invades the mastoid or petrous bone, is the most important cause of vertigo in the middle ear. If the drum is perforated, however, or if there is a perforation into the perilymph system, vertigo will occur, especially when water enters the ear. Drugs such as streptomycin and gentamicin are common causes, but aspirin and quinidine should be considered with a host of other drugs. This can be determined by a good history without looking up the long list of drugs. Perhaps more common and more important from a legal standpoint is traumatic labyrinthitis from head injuries. If the internal auditory artery is obstructed by spasm (as occurs in migraine), basilar artery insufficiency, or thrombosis, vertigo will result. Rarely, an aneurysm of this artery or the basilar artery at its branching may compress or hemorrhage into the vestibular nerve and cause vertigo. Additional neurologic causes of vertigo are acoustic neuromas and other brainstem tumors, petrositis, and vestibular neuronitis, which may involve the vestibular nerve or nucleus. Approach to the Diagnosis 280 the first step is to determine if the patient has true vertigo. True vertigo is the experience of subjective or objective rotation with respect to the environment. The patient who does not experience true vertigo should have a syncope workup (see page 404). Narrowing the differential diagnosis of true vertigo depends on the presence or absence of other symptoms and signs. If there is vertigo without tinnitus, deafness, or focal neurologic signs, the clinician should suspect acute labyrinthitis, vestibular neuronitis, benign positional vertigo, and drug toxicity. If there are rapid respirations during the attack of vertigo, one would consider hyperventilation syndrome. If there are significant findings on otoscopic examination, a diagnosis of otitis media, cholesteatoma, or mastoiditis should be considered. The workup will depend on whether the patient has objective findings on otoscopic or neurologic examination. If local pathology is suspected, perhaps a tympanogram, x-ray of the mastoids and petrous bones, audiogram, or referral to an otolaryngologist are required. There is, however, a history of similar attacks in the past associated with numbness of the left side of the face and weakness of the extremities. Fortunately for us but unfortunately for the patient, double vision is usually binocular and due to paralysis of the extraocular muscles. The causes can be recalled best by anatomically grouping them into those that involve the muscles themselves, the myoneural junction, the peripheral portion of the cranial nerve, and the nucleus of the cranial nerve in the brainstem and supranuclear causes. M-Malformations such as myotonic dystrophy and congenital ophthalmoplegia belong here. I-Inflammatory conditions such as dermatomyositis and orbital cellulitis are considered here.
L1 divides on the posterior abdominal wall to form the iliohypogastric and ilioinguinal nerves rheumatoid arthritis medications order indocin pills in toronto. The former runs deep to the external oblique just above the inguinal canal to supply the suprapubic skin arthritis in knee and torn meniscus buy indocin 25mg low cost, while the latter traverses the inguinal canal in front of the round ligament wear and tear arthritis in feet purchase generic indocin on line. It emerges either through the external inguinal ring or through the adjacent aponeurosis to supply the skin of the anterior part of the labium majus together with the skin of the adjacent upper thigh. Above the umbilicus this is wide, but below this level it becomes narrow and the surgeon may experience some difficulty in finding the exact line of cleavage between the two recti. Being made up of fibrous tissue, it provides an almost bloodless line along which the abdominal wall can be rapidly opened. Deep to the sheath is a variable amount of extraperitoneal fascis, depending on the build of the patient, and then the peritoneum. In a lower (a) Rectus abdominis Xiphoid 6th and 7th costal cartilages Linea alba External oblique muscle (b) External oblique muscle Internal oblique muscle Transversus muscle Transversalis fascia Peritoneum Superior epigastric artery (c) Figure 2. Reproduced from Harold Ellis, Clinical Anatomy, figure 44, Copyright Wiley, 2002, with permission. Inferior epigastric artery the pelvic skeleton the pelvic skeleton is made up of the innominate bones (Figure 2. The pelvis is involved in: walking (through its part in the formation of the hip joint and in its side-to-side swinging action in ambulation) supporting the weight of the body providing attachment for powerful muscles protection of the pelvic viscera. To the obstetrician, its particular interest is in its function as the bony birth canal. The os innominatum this is made up of three separate bones-the ilium, the ischium, and the pubic. In the fetus and child these are separate and connected to each other by cartilage. It runs between the anterior and posterior superior iliac spines, below which are the corresponding inferior spines. The inner aspect bears a large auricular (ear-shaped) surface, which forms the synovial sacroiliac joint with the corresponding auricular surface on the lateral aspect of the sacrum. The iliopectineal line runs forwards from the apex of the auricular surface and clearly demarcates the true from the false pelvis. This is easily palpated through the buttock when the hip is flexed and it is this on which you sit. From the tuberosity projects the ischial ramus, which passes forwards to join the inferior pubic ramus. The obturator foramen is the opening, which is bounded by the body and rami of the pubis and the body and ramus of the ischium. This forms the deep socket for the femoral head, for which it bears a large, smooth, crescentic articular surface. The pelvis tilts forwards in the erect posture so that the plane of its inlet is at an angle, of 60 degrees to the horizontal. To place the articulated pelvis in the position it adopts in standing, position it against a wall so that the anterior superior iliac spine and the top of the body of the pubis touch it. Reproduced from Harold Ellis, Clinical Anatomy: Applied Anatomy for Students and Junior Doctors, figure 92, Copyright Wiley, 2010, with permission. Chapter 2 Anatomy midline incision, the peritoneum should be opened at the upper end of the wound to ensure that bladder injury is avoided. The Pfannensteil incision: A curving interspinous skin crease incision is made about 5 cm above the pubis just inferior to the margin of the pubic hair line.
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Case Presentation #36 A 38-year-old carpenter complained of intermittent pain in his right groin for several months arthritis in feet and toes treatment order indocin 25 mg with amex. Physical examination failed to disclose a mass in his right groin arthritis in the knee cap symptoms cheap 25 mg indocin with visa, but there was slight tenderness on palpation arthritis questions to ask your doctor order indocin without a prescription. Neurologic examination reveals diminished sensation to touch, pain in the right L1 dermatome, and precipitation of the pain by coughing or sneezing. Intake: Obviously if one takes estrogen or other feminizing hormones, gynecomastia may result. Not so obvious is the gynecomastia resulting from ingestion of methyl testosterone and desoxycorticosterone. Taking drugs such as amphetamines, tricyclic antidepressants, methadone, and isoniazid may also cause this disorder. Production: the production of estrogen or estrogen-like substances is increased in testicular tumors such as seminomas, Sertoli cell tumors, and adrenal tumors. Several drugs including phenothiazines, marijuana, reserpines, and methyldopa increase prolactin production. Production of testosterone and other androgens or androgen-producing substances is decreased in Klinefelter syndrome, advancing age, mumps orchitis, hypothalamic lesions, liver disease, and neurologic disorders such as myotonic dystrophy, syringomyelia, and 399 Friedreich ataxia. Testosterone production is also reduced in pseudohermaphroditism and congenital adrenal hyperplasia. Transport: Plasma proteins that carry hormones are reduced in starvation, and many debilitating states reduce testosterone activity and availability leading to gynecomastia. Regulation: the regulation of the ratio of circulating estrogen and androgen may be affected in hyperthyroidism, hypothyroidism, renal failure, and dialysis. Drugs such as spironolactone, digitalis, griseofulvin, cimetidine, and cannabis antagonize androgens causing gynecomastia. Destruction: In liver diseases such as hemochromatosis, cirrhosis, carcinoma, and hepatitis there may be increased conversion of testosterone to estrogen. Approach to the Diagnosis It is important to find out if the patient has been taking alcohol or drugs of any kind. On physical examination, the physician may find bronze skin (a sign of hemochromatosis), a testicular mass, neurologic signs (suggesting. Anyone who has a friend with large tonsils knows that this is a frequent cause, especially when the tonsils become infected. Proceeding down the esophagus to the stomach, one should recall the accumulation of food in diverticula, cardiospasm of the esophagus, and the frequent foul odor of chronic membranous or granulomatous esophagitis associated with a hiatal hernia. Carcinoma of the esophagus may also cause obstruction and allow putrefaction of food that accumulates there. Uremia will often present with an ammoniac and urinous odor to the breath, whereas the breath of hepatic coma may be fishy (fetor hepaticus). The feculent odor of a gastrocolic fistula and late states of intestinal obstructions should also be recalled. Approach to the Diagnosis the workup of bad breath involves a careful examination of the mouth and nasal passages. Appropriate liver and renal function tests will be ordered when uremia or hepatic coma is suspected. Auditory hallucinations without evidence of mental deterioration usually indicate schizophrenia, but epilepsy, drug toxicity, and brain tumors must be excluded. Visual hallucinations are often the sign of drug or alcohol intoxication, but occasionally they occur in schizophrenia.
The paired bulbs of the vestibule lie on each side deep to the bulbospongiosus muscle psoriatic arthritis diet gluten order 75 mg indocin. Anteriorly each continues as a thin band of erectile tissue into the clitoris arthritis in low back and hip order cheap indocin line, uniting into a strand that expands into the glans at its tip arthritis exercises for seniors buy indocin 50mg free shipping. At puberty it becomes covered with hair that has a horizontal upper limit, in contrast to the male, where the pubic hair extends upwards towards the umbilicus in and adjacent to the median line. The labia majora and minora the labia major are two folds of skin that meet anteriorly at the mons and posteriorly in the midline anterior to the anal orifice. Within the cleft lie the thin, vascular folds of skin, the labia minora, which lack both hair and sebaceous glands. The space between these folds is termed the vestibule, into which opens the urethral orifice, 2. The bulbospongiosus muscle runs on either side from its attachment to the perineal body in front of the anal canal beneath the skin of the vestibule to insert into the clitoris. Laterally, the ischiocavernosus muscle runs from the medial surface of the ramus of the ischium forward and medially to insert into the clitoris. The superficial transverse perineal muscles run laterally from the perineal body to the ischial ramus (Figure 2. Perineal branch of pudendal nerve Ischiocavernosus Perineal membrane Glans clitoris Corpus cavernosum Deep artery of clitoris Dorsal artery of clitoris Artery of the bulb Bulb of the vestibule Greater vestibular gland Internal pudendal artery Inferior rectal artery Bulbospongiosus Inferior rectal nerve Pudendal nerve Posterior cutaneous nerve of thigh the clitoris this is the female equivalent of the penis (Figure 2. It consists, like the penis, of three columns of erectile tissue but, unlike the penis, of course, it does not transmit the urethra, which opens behind it. The erectile tissue comprises the corpora cavernosa and the bulbs of the vestibule. The superficial muscles have been removed on the left to show the bulb of the vestibule and the greater vestibular glands. The greater vestibular glands of Bartholin these comprise a pair of lobulated, pea-shaped, mucussecreting glands that lie deep to the posterior parts of the labia majora. Posterior labial branches-which supply the labia and the superficial perineal muscles. The artery and vein of the bulb-supplying the bulb of the vestibule, the greater vestibular glands, and the clitoris, and contributing to the supply of the terminal part of the vagina. These branches of the internal pudendal vessels anastomose with terminal branches of the superficial external pudendal vessels of the femoral artery and vein. Nerve supply the skin of the mons pubis and the adjacent anterolateral parts of the labia majora are supplied by spinal segment L1 through the ilioinguinal and genitofemoral nerves. The rest of the external genitalia are supplied by S3 via the pudendal nerve via its perineal branch (Figure 2. All four tubes lie close together caudally and project into the anterior part of the cloaca (Figure 2. The paramesonephric ducts in the male and the mesonephric ducts in the female all but disappear, leaving behind congenital remnants that are of clinical interest. In the male the paramesonephric duct disappears, apart from the appendix testis (a tiny cystic structure perched on the upper pole of the testis, which may undergo torsion) and the prostatic utricle (a short sinus leading into the posterior aspect of the prostatic urethra). Chapter 2 Anatomy the bulbs of the vestibule, together with the glans of the clitoris, are equivalent to the corpus spongiosum and glans of the male. The anterior ends of the labia minora split to surround the clitoris, providing it with a prepuce. These vessels are: 34 tract termed the epoophoron, mesoophoron, and the ducts of Gartner. More caudally, they sweep together and fuse in the midline to become the epithelium of the body of the uterus, the cervix, and the upper third of the vagina-at first a solid cord that then canalizes.
