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By I. Knut. Bethune-Cookman College. 2017.

The examination reveals that the man has jerky up-down (A) Abducens nucleus movements of his upper extremities especially noticeable in his (B) Edinger-Westphal nucleus hands when his arms are extended cheap ginette-35 2mg visa. Which of the following most (C) Oculomotor nucleus specifically designate this abnormal movement? The examination reveals that (E) Resting tremor muscles around the oral cavity and of the cheek are poorly developed or absent ginette-35 2 mg on-line. His wife states (A) Head mesoderm that he does not seem to understand what she is saying when she (B) Pharyngeal arch 1 talks to him. The examination reveals that the man can speak flu- (C) Pharyngeal arch 2 ently and clearly, can read notes written on paper, can hear noise, (D) Pharyngeal arch 3 but has great difficulty understanding or interpreting sounds. Which of the following neurotransmitters is associated with hy- (A) Agnosia pothalamic fibers that project to the cerebellar cortex (hypothala- (B) Agraphia mocerebellar fibers)? During a busy day in the emergency department, the neurology cal law enforcement personnel. The man is thin, undernourished, resident sees three patients with brainstem lesions. Other indicators, such as a 83-year-old woman with a lesion in the territory of the midbrain lack of personal hygiene, suggest that the man’s condition has been served by the quadrigeminal and lateral posterior choroidal arter- long-term. The second is a 68-year-old man with a posterior inferior cere- he lives the man give a nonsensical response. This man is most bellar artery (lateral medullary or Wallenberg) syndrome. Which of the following would most likely be seen in all three (D) Munchausen syndrome patients assuming a thorough neurologic examination? The history reveals (E) Medial medullary syndrome that the man has had this problem for several weeks. Which of the following structures serves as an important landmark in the placement of the intentional division of the spinal cord 14. Damage to which of the following structures would most likely (myelotomy) in an anterolateral cordotomy? Assuming that the infarcted area in the brain of this man is the re- a high school football game.

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This category of claims will be more carefully examined toward the conclu- sion of this chapter discount ginette-35 2 mg with mastercard. Scarring in General Most surgeons assume the patient understands that healing entails formation of scar trusted 2 mg ginette-35. Unfortunately, it is seldom discussed in the preop- erative consultation. In plastic and reconstructive surgery, the appear- ance of the resulting scar can be the major genesis of dissatisfaction. It is imperative that the plastic surgeon obtains from the patient clear evidence of his or her comprehension that without scarring, there is no healing. The patient must be made to understand that healing qualities Chapter 14 / Plastic and Reconstructive Surgery 191 are as individual as the texture of one’s hair or the color of one’s eyes; it is built into genetic programming. Documentation of such conver- sation in the preoperative chart is most important. Breast Reduction The genesis of dissatisfaction most often involves the following: • Unsatisfactory scar. Approximately 44% of all elective aesthetic surgery claims involve augmentation. Setting aside for the moment breast implants and autoimmune disease, the most frequent causes of dissatisfaction are as follow: • Encapsulation with distortion and firmness. Facelift/Blepharoplasty Facelift and blepharoplasty account for approx 11% of claims. The most common allegations are listed here: • Excessive skin removal, resulting in a “stary” look. The trend toward doing the vast majority of these patients on an outpatient basis deserves some comment. In a survey of blindness after blepharoplasty carried out by the author at The Doctors Company in 1999, it was discovered that the only trait all cases had in common was the fact that they were discharged very shortly after the termination of the outpatient surgery.

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The divided by blood flow () (see Chapter 12): first mechanism is known as capillary recruitment generic ginette-35 2mg amex. Under ˙ normal conditions purchase ginette-35 2 mg on-line, some capillaries are partially or com- R P/Q (1) pletely closed in the top part of the lungs because of the Pulmonary vascular resistance is extremely low; about low perfusion pressure. As blood flow increases, the pres- one-tenth that of systemic vascular resistance. The differ- sure rises and these collapsed vessels are opened, lowering ence in resistances is a result, in part, of the enormous num- overall resistance. This process of opening capillaries is the ber of small pulmonary resistance vessels that are dilated. The fall in pulmonary vascular resistance with increased With Increased Cardiac Output cardiac output has two beneficial effects. It opposes the Another unique feature of the pulmonary circulation is the tendency of blood velocity to speed up with increased flow ability to decrease resistance when pulmonary arterial pres- rate, maintaining adequate time for pulmonary capillary sure rises, as seen with an increase in cardiac output. It pressure rises, there is a marked decrease in pulmonary vas- also results in an increase in capillary surface area, which 340 PART V RESPIRATORY PHYSIOLOGY FIGURE 20. A catheter is threaded through a peripheral vein in the systemic circulation, through the right heart, and into the pulmonary artery. The wedged catheter temporarily occludes blood flow in a part of the vascular bed. Pulmonary circulation is characterized as normally dilated, while the systemic circulation is characterized as nor- mally constricted. Pressures are given in mm Hg; a bar over the number indicates mean pressure. High capillary pressure is a major threat to the lungs and can cause pulmonary edema, an abnormal accumulation of fluid, which can flood the alveoli and im- pair gas exchange. When cardiac output increases from a resting level of 5 L/min to 25 L/min with vigorous exercise, the decrease in pulmonary vascular resistance not only min- imizes the load on the right heart but also keeps the capil- lary pressure low and prevents excess fluid from leaking out of the pulmonary capillaries. Pulmonary vascular resist- Pulmonary vascular resistance is also significantly affected ance falls as cardiac output increases. Because pulmonary capillaries have little rial pressure rises, pulmonary vascular resistance decreases. CHAPTER 20 Pulmonary Circulation and the Ventilation-Perfusion Ratio 341 FIGURE 20. These two mechanisms are responsible for decreasing pulmonary vascular resistance when arterial pressure in- creases.

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The majority of eral view should include all seven cervical vertebrae cord injuries are in the lower cervical spine and at the cer- along with the upper half of the T1 vertebra purchase 2mg ginette-35 mastercard. Patients with a neurological deficit are best studied with MRI discount 2mg ginette-35 otc, which is capable of demonstrating cord in- juries (Fig. Bony abnormalities and facet joint dislocations are best seen with plain radiographs supple- mented with MDCT. The standard axial CT views help in visualizing the spinal canal, facet joints, and spinous Fig. Bony fragments within the spinal canal can al- Traumas of the Axial Skeleton 113 Table 1. Systematic inspection of the images in cervical spine trauma Alignment Subluxation/ Radiographs MRI dislocation and CT Spinal cord Edema + Swelling + Hemorrhage + + Compression + Dissection + Epidural space Disk herniation + + Bone fragment + Hematoma + + Spinal column Vertebral body fracture + Posterior element fracture + Dislocation + Bony edema + Spondylosis + Ligaments Anterior longitudinal + ligament-rupture Posterior longitudinal + ligament-rupture Interlaminar ligament + (flava)-rupture Supra- or interspinous + ligament-rupture Fig. Parallel lines are drawn occlusion/dissection along the anterior vertebral Fig. Drawing of the AP cer- bodies, posterior vertebral bod- vical spine: a line through the ies, and connecting the spino- spinous processes should be laminar lines fairly straight Table 2. Imaging protocol Question Image procedure ♦ Trauma with spinal involvement? Dynamic views (flexion and exten- spine (sagittal, T2-weighted): anterior subluxation of C on sion) are contraindicated in the acutely traumatized spine. MRI of cervical spine C3 with disc herniation and In the unconscious patient, all three imaging modalities, (sagittal, T2-weighted): hyper- cord compression. In addition, 2D sagittal and coronal reformations are an essential part of the CT Cervical Spine Instability examination. When CT and MRI are available, we do not recom- The statement made by Denis more than 20 years ago, mend open-mouth views or oblique views of the spine. El-Khoury abnormalities, or both, is considered stable, is still valid Table 6. After the initial emergency treatment, the long- dislocations term survival and quality of life of the patient depend on Mechansim Type Stable Unstable the stability of the injury. Signs of instability on plain ra- of injury diographs are presented in Table 3. The three-column concept was originally intended for Hyperflexion Anterior subluxation (sprain) + the thoraco-lumbar spine, but it can be used, with some Bilateral interfacetal dislocation + Simple wedge fracture + modifications, in the lower cervical spine (Table 4). Clay-shoveler’s fracture + According to this concept, fractures affecting both the ante- Tear-drop fracture + rior and middle columns or all three columns are considered Odontoid fracture + + unstable.

By I. Knut. Bethune-Cookman College. 2017.

The examination reveals that the man has jerky up-down (A) Abducens nucleus movements of his upper extremities especially noticeable in his (B) Edinger-Westphal nucleus hands when his arms are extended cheap ginette-35 2mg visa. Which of the following most (C) Oculomotor nucleus specifically designate this abnormal movement? The examination reveals that (E) Resting tremor muscles around the oral cavity and of the cheek are poorly developed or absent ginette-35 2 mg on-line. His wife states (A) Head mesoderm that he does not seem to understand what she is saying when she (B) Pharyngeal arch 1 talks to him. The examination reveals that the man can speak flu- (C) Pharyngeal arch 2 ently and clearly, can read notes written on paper, can hear noise, (D) Pharyngeal arch 3 but has great difficulty understanding or interpreting sounds. Which of the following neurotransmitters is associated with hy- (A) Agnosia pothalamic fibers that project to the cerebellar cortex (hypothala- (B) Agraphia mocerebellar fibers)? During a busy day in the emergency department, the neurology cal law enforcement personnel. The man is thin, undernourished, resident sees three patients with brainstem lesions. Other indicators, such as a 83-year-old woman with a lesion in the territory of the midbrain lack of personal hygiene, suggest that the man’s condition has been served by the quadrigeminal and lateral posterior choroidal arter- long-term. The second is a 68-year-old man with a posterior inferior cere- he lives the man give a nonsensical response. This man is most bellar artery (lateral medullary or Wallenberg) syndrome. Which of the following would most likely be seen in all three (D) Munchausen syndrome patients assuming a thorough neurologic examination? The history reveals (E) Medial medullary syndrome that the man has had this problem for several weeks. Which of the following structures serves as an important landmark in the placement of the intentional division of the spinal cord 14. Damage to which of the following structures would most likely (myelotomy) in an anterolateral cordotomy? Assuming that the infarcted area in the brain of this man is the re- a high school football game.

purchase ginette-35 2mg with amex

This category of claims will be more carefully examined toward the conclu- sion of this chapter discount ginette-35 2 mg with mastercard. Scarring in General Most surgeons assume the patient understands that healing entails formation of scar trusted 2 mg ginette-35. Unfortunately, it is seldom discussed in the preop- erative consultation. In plastic and reconstructive surgery, the appear- ance of the resulting scar can be the major genesis of dissatisfaction. It is imperative that the plastic surgeon obtains from the patient clear evidence of his or her comprehension that without scarring, there is no healing. The patient must be made to understand that healing qualities Chapter 14 / Plastic and Reconstructive Surgery 191 are as individual as the texture of one’s hair or the color of one’s eyes; it is built into genetic programming. Documentation of such conver- sation in the preoperative chart is most important. Breast Reduction The genesis of dissatisfaction most often involves the following: • Unsatisfactory scar. Approximately 44% of all elective aesthetic surgery claims involve augmentation. Setting aside for the moment breast implants and autoimmune disease, the most frequent causes of dissatisfaction are as follow: • Encapsulation with distortion and firmness. Facelift/Blepharoplasty Facelift and blepharoplasty account for approx 11% of claims. The most common allegations are listed here: • Excessive skin removal, resulting in a “stary” look. The trend toward doing the vast majority of these patients on an outpatient basis deserves some comment. In a survey of blindness after blepharoplasty carried out by the author at The Doctors Company in 1999, it was discovered that the only trait all cases had in common was the fact that they were discharged very shortly after the termination of the outpatient surgery.

discount ginette-35 2mg online

The divided by blood flow () (see Chapter 12): first mechanism is known as capillary recruitment generic ginette-35 2mg amex. Under ˙ normal conditions purchase ginette-35 2 mg on-line, some capillaries are partially or com- R P/Q (1) pletely closed in the top part of the lungs because of the Pulmonary vascular resistance is extremely low; about low perfusion pressure. As blood flow increases, the pres- one-tenth that of systemic vascular resistance. The differ- sure rises and these collapsed vessels are opened, lowering ence in resistances is a result, in part, of the enormous num- overall resistance. This process of opening capillaries is the ber of small pulmonary resistance vessels that are dilated. The fall in pulmonary vascular resistance with increased With Increased Cardiac Output cardiac output has two beneficial effects. It opposes the Another unique feature of the pulmonary circulation is the tendency of blood velocity to speed up with increased flow ability to decrease resistance when pulmonary arterial pres- rate, maintaining adequate time for pulmonary capillary sure rises, as seen with an increase in cardiac output. It pressure rises, there is a marked decrease in pulmonary vas- also results in an increase in capillary surface area, which 340 PART V RESPIRATORY PHYSIOLOGY FIGURE 20. A catheter is threaded through a peripheral vein in the systemic circulation, through the right heart, and into the pulmonary artery. The wedged catheter temporarily occludes blood flow in a part of the vascular bed. Pulmonary circulation is characterized as normally dilated, while the systemic circulation is characterized as nor- mally constricted. Pressures are given in mm Hg; a bar over the number indicates mean pressure. High capillary pressure is a major threat to the lungs and can cause pulmonary edema, an abnormal accumulation of fluid, which can flood the alveoli and im- pair gas exchange. When cardiac output increases from a resting level of 5 L/min to 25 L/min with vigorous exercise, the decrease in pulmonary vascular resistance not only min- imizes the load on the right heart but also keeps the capil- lary pressure low and prevents excess fluid from leaking out of the pulmonary capillaries. Pulmonary vascular resist- Pulmonary vascular resistance is also significantly affected ance falls as cardiac output increases. Because pulmonary capillaries have little rial pressure rises, pulmonary vascular resistance decreases. CHAPTER 20 Pulmonary Circulation and the Ventilation-Perfusion Ratio 341 FIGURE 20. These two mechanisms are responsible for decreasing pulmonary vascular resistance when arterial pressure in- creases.

cheap ginette-35 2 mg on line

The majority of eral view should include all seven cervical vertebrae cord injuries are in the lower cervical spine and at the cer- along with the upper half of the T1 vertebra purchase 2mg ginette-35 mastercard. Patients with a neurological deficit are best studied with MRI discount 2mg ginette-35 otc, which is capable of demonstrating cord in- juries (Fig. Bony abnormalities and facet joint dislocations are best seen with plain radiographs supple- mented with MDCT. The standard axial CT views help in visualizing the spinal canal, facet joints, and spinous Fig. Bony fragments within the spinal canal can al- Traumas of the Axial Skeleton 113 Table 1. Systematic inspection of the images in cervical spine trauma Alignment Subluxation/ Radiographs MRI dislocation and CT Spinal cord Edema + Swelling + Hemorrhage + + Compression + Dissection + Epidural space Disk herniation + + Bone fragment + Hematoma + + Spinal column Vertebral body fracture + Posterior element fracture + Dislocation + Bony edema + Spondylosis + Ligaments Anterior longitudinal + ligament-rupture Posterior longitudinal + ligament-rupture Interlaminar ligament + (flava)-rupture Supra- or interspinous + ligament-rupture Fig. Parallel lines are drawn occlusion/dissection along the anterior vertebral Fig. Drawing of the AP cer- bodies, posterior vertebral bod- vical spine: a line through the ies, and connecting the spino- spinous processes should be laminar lines fairly straight Table 2. Imaging protocol Question Image procedure ♦ Trauma with spinal involvement? Dynamic views (flexion and exten- spine (sagittal, T2-weighted): anterior subluxation of C on sion) are contraindicated in the acutely traumatized spine. MRI of cervical spine C3 with disc herniation and In the unconscious patient, all three imaging modalities, (sagittal, T2-weighted): hyper- cord compression. In addition, 2D sagittal and coronal reformations are an essential part of the CT Cervical Spine Instability examination. When CT and MRI are available, we do not recom- The statement made by Denis more than 20 years ago, mend open-mouth views or oblique views of the spine. El-Khoury abnormalities, or both, is considered stable, is still valid Table 6. After the initial emergency treatment, the long- dislocations term survival and quality of life of the patient depend on Mechansim Type Stable Unstable the stability of the injury. Signs of instability on plain ra- of injury diographs are presented in Table 3. The three-column concept was originally intended for Hyperflexion Anterior subluxation (sprain) + the thoraco-lumbar spine, but it can be used, with some Bilateral interfacetal dislocation + Simple wedge fracture + modifications, in the lower cervical spine (Table 4). Clay-shoveler’s fracture + According to this concept, fractures affecting both the ante- Tear-drop fracture + rior and middle columns or all three columns are considered Odontoid fracture + + unstable.