Professor, West Virginia School of Osteopathic Medicine
Over the 9 months of pregnancy treatment tennis elbow 5mg compazine visa, the gravid uterus expands greatly to accommodate the fetus medications similar to cymbalta purchase genuine compazine on line, becoming larger and increasingly thin walled treatment 8th march buy compazine cheap. The uterus becomes nearly membranous, with the fundus dropping below its highest level (achieved in the 9th month), at which time it extends superiorly to the costal margin, occupying most of the abdominopelvic cavity. Immediately after delivery of the fetus, the large uterus becomes thick walled and edematous. The multiparous nongravid uterus has a large and nodular body and usually extends into the lower abdominal cavity, often causing a slight protrusion of the inferior abdominal wall in lean women. Postmenopause, the uterus is involuted and regresses to a markedly smaller size, once again assuming childhood proportions. All these stages represent normal anatomy for the particular age and reproductive status of the woman. Cervical Cancer Screening Until 1940, cervical cancer was the leading cause of death in North American women (Krebs, 2000). The decline in the incidence and number of women dying from cervical cancer is related to the accessibility of the cervix to direct visualization and to cell and tissue study by means of cervical cytology (invented in 1946 by Dr. Cervical cytology allows detection and treatment of premalignant cervical conditions (Hoffman et al. The vagina can be distended with a vaginal speculum to enable inspection of the cervix. The spatula is rotated to scrape cellular material from the mucosa of the vaginal cervix. The cellular material is then placed in a preservative liquid for microscopic examination. Because no peritoneum intervenes between the anterior cervix and the base of the bladder, cervical cancer may spread by contiguity to the bladder. It may also spread by lymphogenous (lymph-borne) metastasis to external or internal iliac or sacral nodes. Hematogenous (bloodborne) metastasis may occur via iliac veins or via the internal vertebral venous plexus. The incidence of hysterectomy for noncancerous reasons has markedly declined in favor of exploring other options. The procedure stops abnormal bleeding but also stops menstrual periods and ends the ability to conceive. The incidence of 1440 hysterectomy for noncancerous reasons has markedly declined in favor of exploring other options. The uterus may be surgically approached and removed through the anterior abdominal wall ("transabdominal approach") or through the vagina ("transvaginal approach"). Depending on the location, extent, and nature of the pathology, a subtotal (supracervical or cervical), total, or radical hysterectomy may be performed, the latter involving removal of the ovaries in addition to the uterus. When cervical or total hysterectomies are performed, the vaginal fornices are incised, encircling the cervix, to separate the uterus from the vagina. Ligation of the uterine artery is performed distal to the vaginal artery and vaginal branches to enable maximal blood flow to the superior end of the vagina to facilitate healing. Distension of Vagina 1441 the vagina can be markedly distended, particularly in the region of the posterior part of the fornix. For example, distension of this part allows palpation of the sacral promontory during a pelvic examination (see the Clinical Box "Pelvic Diameters (Conjugates)").
It extends from the sternal end of one clavicle to the sternal end of the other clavicle medications not to mix buy generic compazine pills. The costoclavicular ligament anchors the inferior surface of the sternal end of the clavicle to the 1st rib and its costal cartilage medications japan travel buy discount compazine 5mg line, limiting elevation of the pectoral girdle treatment 4 hiv order cheap compazine line. When elevation is achieved via flexion, it is accompanied by rotation of the clavicle around its longitudinal axis. Although not a typical movement, except perhaps during calisthenics (systematic body exercises), it is capable of performing these movements sequentially, moving the acromial end along a circular path-a form of circumduction. Range of motion of lateral end of clavicle permitted by movements at the sternoclavicular joint. Circumduction of the upper limb requires coordinated movements of the pectoral girdle and glenohumeral joint. Beginning with extended limb, retracted girdle (B); neutral position (A); flexed limb, protracted girdle (D); and, finally, elevated limb and girdle (E). As long as this ligament is intact with the clavicle tethered to the coronoid process, the acromion of the scapula cannot be driven inferior to the clavicle. Rotation of the scapula at "scapulothoracic joint" is an essential component of abduction of the upper limb. Movements of a similar scale occur during elevation, depression, and rotation of the scapula. The articular surfaces, covered with fibrocartilage, are separated by an incomplete wedge-shaped articular disc. Although relatively weak, the joint capsule is strengthened superiorly by fibers of the trapezius. However, the integrity of the joint is maintained by extrinsic ligaments, distant from the joint itself. The extent of the synovial membrane of the glenohumeral joint is demonstrated in this specimen in which the articular cavity has been injected with purple latex and the fibrous layer of the joint capsule has been removed. The articular cavity has two 655 extensions: one where it forms a synovial sheath for the tendon of the long head of the biceps brachii in the intertubercular sulcus of the humerus and the other inferior to the coracoid process where it is continuous with the subscapular bursa between the subscapularis tendon and the margin of the glenoid cavity. In this radiograph, the head of the humerus and the glenoid cavity overlap, obscuring the joint plane because the scapula does not lie in the coronal plane (therefore, the glenoid cavity is oblique, not in a sagittal plane. The coracoclavicular ligament consists of two ligaments, the conoid and trapezoid ligaments, which are often separated by a bursa related to the lateral end of the subclavius muscle. The more vertical and medially placed conoid ligament is an inverted triangle (cone), which has its apex inferiorly where it is attached to the root of the coracoid process. Its wide attachment (base of the triangle) is to the conoid tubercle on the inferior surface of the clavicle. The nearly horizontal trapezoid ligament is attached to the superior surface of the coracoid process and extends laterally to the trapezoid line on the inferior surface of the clavicle. These movements are associated with motion at the physiological scapulothoracic joint. Glenohumeral Joint the glenohumeral (shoulder) joint is a ball-and-socket type of synovial joint that permits a wide range of movement; however, its mobility makes the joint relatively unstable. Dissection of the glenohumeral joint in which the joint capsule was sectioned and the joint opened from its posterior aspect as if it were a book. The anterior, internal surface demonstrates the glenohumeral ligaments, which were incised to open the joint.
The loss of tonus of the orbicularis oculi causes the inferior eyelid to evert (fall 1953 away from the surface of the eyeball) medicine man generic 5 mg compazine mastercard. Thus medicine qvar inhaler purchase generic compazine line, lacrimal fluid is not spread over the cornea medications on nclex rn purchase compazine no prescription, preventing adequate lubrication, hydration, and flushing of the surface of the cornea. If the injury weakens or paralyzes the buccinator and orbicularis oris, food will accumulate in the oral vestibule during chewing, usually requiring continual removal with a finger. When the sphincters or dilators of the mouth are affected, displacement of the mouth (drooping of its corner) is produced by contraction of unopposed contralateral facial muscles and gravity, resulting in food and saliva dribbling out of the side of the mouth. Weakened lip muscles affect speech as a result of an impaired ability to produce labial (B, M, P, or W) sounds. They frequently dab their eyes and mouth with a handkerchief to wipe the fluid 1954 (tears and saliva), which runs from the drooping lid and mouth. Infra-Orbital Nerve Block For treating wounds of the upper lip and cheek or, more commonly, for repairing the maxillary incisor teeth, local anesthesia of the inferior part of the face is achieved by infiltration of the infra-orbital nerve with an anesthetic agent. The injection is made in the region of the infra-orbital foramen, by elevating the upper lip and passing the needle through the junction of the oral mucosa and gingiva at the superior aspect of the oral vestibule. To determine where the infra-orbital nerve emerges, pressure is exerted on the maxilla in the region of the infra-orbital foramen. Because companion infra-orbital vessels leave the infra-orbital foramen with the nerve, aspiration of the syringe during injection prevents inadvertent injection of anesthetic fluid into a blood vessel. Because the orbit is located just superior to the injection site, a careless injection could result in passage of anesthetic fluid into the orbit, causing temporary paralysis of the extra-ocular muscles. Mental and Incisive Nerve Blocks Occasionally, it is desirable to anesthetize one side of the skin and mucous membrane of the lower lip and the skin of the chin. Injection of an anesthetic agent into the mental foramen blocks the mental nerve that supplies the skin and mucous membrane of the lower lip from the mental foramen to the midline, including the skin of the chin. Buccal Nerve Block 1955 To anesthetize the skin and mucous membrane of the cheek. It is characterized by sudden attacks of excruciating, lightening-like jabs of facial pain. The pain may be so intense that the person winces, thus the common term tic (twitch). In some cases, the pain may be so severe that psychological changes occur, leading to depression and even suicide attempts. The paroxysms are often set off by touching the face, brushing the teeth, shaving, drinking, or chewing. The pain is often initiated by touching an especially sensitive trigger zone, frequently located around the tip of the nose or the cheek (Haines, 2013). In most cases, this is caused by pressure of a small aberrant artery (Kiernan, 2013). Other scientists believe the condition is caused by a pathological process affecting neurons in the trigeminal ganglion. The simplest surgical procedure is avulsion or cutting of the branches of the nerve at the infra-orbital foramen. Other treatments have used radiofrequency selective ablation of parts of the trigeminal ganglion by a needle electrode passing through the cheek and foramen ovale. In some cases, it is necessary to section the sensory root for relief of the pain. To prevent regeneration of nerve fibers, the sensory root of the trigeminal nerve may be partially cut between the ganglion and the brainstem (rhizotomy). This loss of sensation may annoy the patient, who may not recognize the presence of food on the lip and cheek or feel it within the mouth on the side of the nerve section. Lesions of Trigeminal Nerve Lesions of the entire trigeminal nerve cause widespread anesthesia involving the: Corresponding anterior half of the scalp.
Severance of the common fibular nerve results in flaccid paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors of ankle and evertors of foot) medicine 44-527 order generic compazine on line. The loss of dorsiflexion of the ankle causes footdrop medicine 8 letters buy discount compazine 5mg on-line, which is further exacerbated by unopposed inversion of the foot medications 5 rights generic compazine 5 mg fast delivery. This has the effect of making the limb "too long": the toes do not clear the ground during the swing phase of walking. There are several other conditions that may result in a lower limb that is "too long" functionally, for example, pelvic tilt. A waddling gait, in which the individual leans to the side opposite the long limb, "hiking" the hip. A swing-out gait, in which the long limb is swung out laterally (abducted) to allow the toes to clear the ground. A high-stepping steppage gait, in which extra flexion is employed at the hip and knee to raise the foot as high as necessary to keep the toes from hitting the ground. Because the dropped foot makes it difficult to make the heel strike the ground first as in a normal gait, a steppage gait is commonly employed in the case of flaccid paralysis. Sometimes, an extra "kick" is added as the free limb swings forward in an attempt to flip the forefoot upward just before setting the foot down. The braking action normally produced by eccentric contraction of the dorsiflexors is also lost in flaccid paralysis footdrop. Therefore, the foot is not lowered to the ground in a controlled manner after heel strike; instead, the foot slaps the ground suddenly, producing a distinctive "clop" and greatly increasing the shock both received by the forefoot and transmitted up the tibia to the knee. Individuals with a common fibular nerve injury may also experience a variable loss of sensation on the anterolateral aspect of the leg and the dorsum of the foot. This entrapment may cause compression of the deep fibular nerve and pain in the anterior compartment. Compression of the deep fibular nerve by tight-fitting ski boots, for example, may occur where the nerve passes deep to the inferior extensor retinaculum and the extensor hallucis brevis. Pain occurs in the dorsum of the foot and usually radiates to the web space between the 1st and 2nd toes. Because ski boots are a common cause of this type of nerve entrapment, this condition has been called the "ski boot syndrome"; however, the syndrome also occurs in soccer players and runners and can also result from tight shoes. Superficial Fibular Nerve Entrapment Chronic ankle sprains may produce recurrent stretching of the superficial fibular nerve, which may cause pain along the lateral side of the leg and the dorsum of the ankle and foot. Numbness and paresthesia (tickling or tingling) may be present and increase with activity. Fabella in Gastrocnemius Close to its proximal attachment, the lateral head of the gastrocnemius may contain a sesamoid bone, the fabella (L. Microscopic tears of collagen fibers in the tendon, particularly just superior to its attachment to the calcaneus, result in tendinitis, which causes pain during walking, especially when wearing rigid-soled shoes. Calcaneal tendinitis often occurs during repetitive activities, especially in individuals who take up running after prolonged inactivity, or suddenly increase the intensity of their training, but it may also result from poor footwear or training surfaces. Ruptured Calcaneal Tendon 1742 Rupture of the calcaneal tendon is often sustained by poorly conditioned people with a history of calcaneal tendinitis. The injury is typically experienced as an audible snap during a forceful push off (plantarflexion with the knee extended) followed immediately by sudden calf pain and sudden dorsiflexion of the plantarflexed foot.
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