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Associate Professor, Stony Brook University School of Medicine

The straight part symptoms 0f pneumonia purchase cheap panadol line, called the duct treatment goals for ptsd discount 500 mg panadol visa, traverses the dermis and epidermis and opens on the surface of the skin medications order panadol 500 mg visa. The glands are large in the axilla and groin, most numerous in the palms and soles, and least numerous in the neck and back. The glands help in regulation of the body temperature by evaporation of sweat, and also help in excreting the body salts. They develop in close association with hair and their ducts typically open into the distal ends of the hair follicles. Ceruminous glands of the external auditory meatus are modified apocrine sweat glands. The apocrine glands also are merocrine in nature, but are regulated by a dual autonomic control. Some workers are not inclined to call them as sweat glands at all because they do not respond sufficiently to temperature changes. In animals they produce chemical signals or pheromones, which are important in courtship and social behaviour. On an average one litre of sweat is secreted per day; another 400 ml of water is lost through the lungs, and 100 ml through the faeces. This makes a total of about 1500 ml, a rough estimate of the invisible loss of water per day. However, in hot climates the secretion of sweat may amount to 3-10 litres per day, with a maximum of 1-2 litres per hour. Sebaceous Glands Sebaceous glands, producing an oily secretion, are widely distributed all over the dermis of the skin. They are especially abundant in the scalp and face, and are also very numerous around the apertures of the ear, nose, mouth, and anus. Sebaceous glands are small and sacculated in appearance, made up of a cluster of about 2-5 piriform alveoli. Their ducts open into the hair follicles, with the exception of lips, glans penis, inner surface of prepuce, labia minora, nipple and areola of the breast, and tarsal glands of the eyelids, where the ducts open on the surface of the skin. Skin protects the body from mechanical injuries, bacterial infections, heat and cold, wet and drought, acid and alkali, and the actinic rays of the sun. Heat is lost through evaporation of sweat; and heat is conserved by the fat and hair. In the skin, vitamin D is synthesized from ergosterol by the action of ultraviolet rays of the sun. Fat is abundant in the gluteal region (buttocks), lumbar region (flanks), front of the thighs, anterior abdominal wall below the umbilicus, mammary gland. In females fat is in the superficial fascia of the lower abdomen, upper thigh, whereas in males it is inside the abdominal cavity. The cells of brown fat are smaller with several small droplets, and multiple mitochondria. Fat cells are specialised cells, and the size of fat cells increases during accumulation of fat, rather than the number of cells. Any attempt to reduce excessive fat (obesity) must be slow and steady and not drastic, as the latter may cause harm to the body. Superficial fascia is most distinct in the lower part of the anterior abdominal wall, perineum, and the limbs. It is very thin on the dorsal aspect of the hands and feet, sides of the neck, face, and around the anus. Superficial fascia shows stratification (into two layers) in the lower part of anterior abdominal wall, perineum, and uppermost part of the thighs. It contains: (a) Subcutaneous muscles in the face, neck and scrotum (b) Mammary gland (c) Deeply situated sweat glands (d) Localized groups of lymph nodes (e) Cutaneous nerves and vessels. Biceps Skin Superficial fascia (subcutaneous tissue) Deep fascia Brachialis Medial intermuscular septum Brachioradialis Lateral intermuscular septum Triceps Humerus.

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Sesamoid bones: these are bony nodules found embedded in the tendons or joint capsules treatment jerawat di palembang buy panadol 500mg lowest price. They are related to medications54583 generic 500 mg panadol amex an articular or nonarticular bony surface symptoms 8 dpo bfp buy panadol 500mg with amex, and the surfaces of contact are covered with hyaline cartilage and lubricated by a bursa or synovial membrane. Functions of the sesamoid bones are: (a) to resist pressure; (b) to minimise friction; (c) to alter the direction of pull of the muscle; and (d) to maintain the local circulation. Skeleton I 33 Head Greater tubercle Lesser tubercle Anterior border Deltoid tuberosity Lateral supracondylar ridge Lateral epicondyle Capitulum Medial supracondylar ridge Medial epicondyle Trochlea Lunate Capitate Carpal bones Scaphoid and its tubercle Trapezium and its crest Triquetral Pisiform 0) c 2 to C L Trapezoid First metacarpal Hamate and its hook Fifth metacarpal 2nd, 3rd and 4th metacarpals Phalanges (b) Trapezius Lateral end Sternocleidomastoid Medial end Capsule of sternoclavicular joint Pectoralis major Deltoid (c). These may occur as ununited epiphyses developed from extra centres of ossification. Examples: sutural bones, os trigonum (lateral tubercle of talus), os vesalianum (tuberosity of 5th metatarsal), etc. This is an adaptation to bending and twisting forces (a combination of compression, tension and shear). Cancellous or spongy, or trabecular bone is open in texture, and is made up of a meshwork of trabeculae (rods and plates) between which are marrow containing spaces. The trabecular meshworks are of three primary types, namely: (a) meshwork of rods, Filled with marrow 38 I Handbook of General Anatomy (b) meshwork of rods and plates, and (c) meshwork of plates (Singh, 1978). Bones are marvellously constructed to combine strength, elasticity and lightness in weight. Though the architecture of bone may be modified by mechanical forces, the form of the bone is primarily determined by heredity. Both the tensile and compressive forces can stimulate bone formation in proper conditions. The architecture of cancellous bone is often interpreted in terms of the trajectorial theory. Thus the arrangement of bony trabeculae (lamellae) is governed by the lines of maximal internal stress in the bone. Pressure lamellae are arranged parallel to the line of weight transmission, whereas tension lamellae are arranged at right angles to pressure lamellae. The compact arrangement of pressure lamellae forms bony buttress, for additional support, like calcar femorale. Compression lamellae from upper part of the head resist compression forces Tension lamellae from lower part of the head resist bending forces in the neck Calcar femorale resists shearing stresses between the neck and shaft Compression lamellae resist shearing stresses due to pull of muscles attached to greater trochanter. Microscopically, the bone is of five types, namely lamellar (including both compact and cancellous), woven, fibrous, dentine and cement. Lamellar bone: Most of the mature human bones, whether compact or cancellous, are composed of thin plates of bony tissue called lamellae. These are arranged in piles in a cancellous bone, but in concentric cylinders (Haversian system or secondary osteon) in a compact bone. Fibrous bone is found in young foetal bones, but are common in reptiles and amphibia. Shaft: From without inwards, it is composed of periosteum, cortex and medullary cavity. It is made up of an outer fibrous layer, and an inner cellular layer which is osteogenic in nature. At the articular margin the periosteum is continuous with the capsule of the joint. The abundant periosteal arteries nourish the outer part of the underlying cortex also. Periosteum has a rich nerve supply which makes it the most sensitive part of the bone. As the age advances, the red marrow at many places atrophies and is replaced by yellow, fatty marrow, with no power of haemopoiesis. In the sternum ribs, iliac crest, vertebrae and skull bones the red marrow is found throughout life. The two ends of a long bone are made up of cancellous bone covered with hyaline (articular) cartilage.

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Enzymes released along this border by exocytosis are called "brush border enzymes" medications on nclex rn order panadol pills in toronto. Structure and functions of the small intestine: the small intestine stretches nearly 20 feet medicine versed discount 500 mg panadol with visa, including the duodenum symptoms norovirus cheap 500 mg panadol with amex, jejunum and ileum. The surface area is increased by circular folds (the plicae circularis), finger-like villi, and the presence of microvilli (brush border) on the cell surfaces. At the base of the villi are the intestinal crypts, also called the intestinal glands because they are the source of the secretory cells of the mucosa. These cells are constantly renewed by mitosis and push up along the villi until they exfoliate from the surface. Intestinal enzymes are released from the surface of the mucosal cells by exocytosis. These enzymes are called brush border enzymes because they cling to the microvilli. The villi possess a lamina propria beneath the epithelial lining which contains both blood and lymph capillaries for the absorption of materials. The muscularis mucosae contracts to move the villi and increase their exposure to the contents of the lumen. Goblet cells are progressively more abundant the further one travels along the intestine. Virtually all remaining digestion occurs in the small intestine as well as all absorption of the digestive endproducts. Segmentation and peristalsis propel materials through the small intestine in 4 to 6 hours. The alkaline mucus produced by these glands helps neutralize the acid from the stomach. They are sometimes called intestinal glands because the cells they produce are the secretory cells for enzymes and other substances. The longitudinal muscle of the colon is arranged into three distinct bands, the taenia coli, which cause the colon to buckle producing the haustra. These are pouches which increase the surface area of the colon for absorption of water and electrolytes. Attached to the cecum is the vermiform (wormlike) appendix, a vestigial remnant of the larger cecum seen in other mammals. The appendix has a concentration of lymph tissue and is filled with lymphocytes, but its removal has not been demonstrated to have any negative effect on the immune system. The cecum leads in sequence to the ascending colon, then the transverse colon, the descending colon, and the sigmoid colon before entering the rectum. The rectum possesses skeletal muscle which functions during the defecation reflex. Unlike the nearly constant propulsion in the small intestine, in the large intestine materials move at intervals by mass peristalsis. In between these intervals segmentation, called haustral churning, stirs the contents so that water can be absorbed more efficiently and bacteria, an important component in fecal processing, can be mixed with the contents. The Colon Taenia coli Descending colon Haustra Sigmoid colon Rectum Ascending colon Ileocecal valve Cecum Vermiform appendix the colon absorbs the remaining water and produces the feces. Liquid chyle enters the colon through the ileocecal sphincter, whose pursed lips protrude into the cecum to help prevent backflow of chyme under pressure. Muscle movements in the colon consist of: 1) minor peristaltic waves, 2) haustral churning, and 3) mass peristalsis. Haustral churning is produced by segmentation contractions which serve to mix the contents to enhance absorption. Mass peristalsis consists of large movements which occur at intervals, usually associated with meals. These movements are often initiated by the gastrocolic reflex (or gastroileal or duodenocolic reflexes) which stimulates the colon in response to food entering the stomach. It causes mass peristalsis in about 15 minutes which continues for about 30 minutes.

Meningeal inflammation is manifested as severe neck pain that is made profoundly worse with neck flexion (meningismus) symptoms torn rotator cuff proven 500mg panadol. The Brudzinski sign (spontaneous flexion of the legs at the hips and knees following neck flexion) and the Kernig sign (resistance to medicine urology best order for panadol knee extension when the hips are flexed) are two other signs indicative of meningeal inflammation symptoms high blood sugar buy generic panadol 500 mg on line, and are often helpful in evaluating for meningismus. As noted above, neck stiffness due to meningeal inflammation should be 11 differentiated from limited neck range of motion in all directions which can be seen with degenerative arthritis of the cervical spine or with increased muscular tone as is seen with paratonic muscle rigidity. This distinction is not difficult to make, since meningeal inflammation primarily limits neck range of motion with flexion only. Olfactory Nerve this nerve is tested by occluding one nostril and presenting a non-volatile stimulus. Smell should always be evaluated after head trauma, because the olfactory nerve may be sheared off as it penetrates the cribriform plate. Basal meningiomas also cause neurologic loss of smell by invading the cribriform plate. Remember that the most common cause of loss of smell is non-neurologic, and is due to inflammation of the nasal mucosa as seen with upper respiratory infections. Optic Nerve Three components of the optic nerve are typically evaluated: visual acuity, visual fields and the funduscopic examination. Visual Acuity For neurologic purposes, corrected visual acuity is tested (with eyeglasses or contact lenses). Distance vision is checked by means of the Snellen chart, and near vision is tested by means of the Jeager chart. Visual acuity is a reflection of the integrity of the entire visual system, including the refractile components (cornea, lens, vitreous humor, retina, optic nerve, optic chiasm, optic tract, lateral geniculate nucleus, optic radiations and the occipital cortex). In this method, the examiner stands directly in front of the patient, usually 2-3 feet away. The examiner then presents bilateral simultaneous stimuli and the patient is asked to localize the stimuli. Various visual field defects can be seen, depending on the location of the lesion within the visual pathway. In addition, by changing the plane of focus on the ophthalmoscope, one can visualize the cornea and lens. With this technique, one can see evidence for optic disk swelling (papilledema), optic disk atrophy, retinal hemorrhages, retinal vascular changes of hypertension and diabetes, as well as corneal scarring and cataracts. The ophthalmoscopic examination is difficult and requires many years of practice, but, once mastered, can provide a great deal of information about the central nervous system. Oculomotor, Trochlear, and Abducens Nerves these nerves are examined together since they have similar functions. There are three parts to the examination of these nerves: pupillary light response, ocular movements and ptosis. To test this reflex, a bright light is shone on each eye individually, and the pupils are examined for direct and consensual pupillary constriction. In addition to constricting to light, pupils also constrict when shifting from far to near gaze, and this response is known as accommodation. Convergence is a normal dysconjugate eye movement that is part of the near response. Two of these fixate the image on the retina (one of these with respect to head and neck motion, and the other with respect to image motion), and one redirects the line of sight. Head rotation is a form of angular acceleration that stimulates the semicircular canals in the inner ear. Visual Pursuit: this reflex fixates the image on the retina with respect to image motion. Visual Saccade: the stimulus for this ocular movement originates in the frontal eye fields located in the frontal lobes of the cerebral hemispheres. These directions correspond to the directions of action of the extraocular muscles, and are detailed in figure 4.

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