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The maxillary nerve supplies the region over the maxilla order tamoxifen uk women's health center centrastate, inferior to the orbit effective 20mg tamoxifen women's health blood in urine, including the lateral surface of the nose and the upper lip. The mandibular division supplies a band of skin running superiorly over the temporalis muscle. The major branches of the ophthalmic nerve that supply skin are the supraorbital and supratrochlear nerves, which supply skin of the forehead and anterior scalp. The nasociliary nerve supplies skin over the medial nose through the external nasal branch of the anterior ethmoidal nerve. Supraorbital nerve Frontal branch of frontal nerve Mesencephalic nucleus of V Supratrochlear nerve Anterior ethmoidal nerve Main sensory Posterior ethmoidal nerve nucleus of V Nasociliary nerve Main motor Infratrochlear nerve Frontal nerve nucleus of V Ophthalmic nerve Ciliary ganglion Semilunar Nucleus of Internal nasal ganglion spinal tract of V rami Infraorbital nerve Lacrimal a Mandibular nerve External nasal rami Anterior and posterior deep temporal nerves Nasal and labial Pterygopalatine (to temporal muscle) rami of infraorbital ganglion Otic ganglion nerve Auriculotemporal nerve Anterior superior External pterygoid muscle alveolar nerves Chorda tympani nerve Submaxillary Internal pterygoid muscle ganglion Masseter muscle Submaxillary and Mylohyoid nerve sublingual glands Mylohyoid muscle Mental nerve Anterior belly of digastric muscle figure 41-1. More laterally, the zygomaticofacial and zygomaticotemporal nerves also contribute. The branches of the mandibular nerve that innervate the skin are the auriculotemporal superiorly and the mental nerve (a branch of the inferior alveolar) inferiorly. Although its branches pass through the buccinator, they do not provide motor innervation. Among other symptoms, a marked deficit in bite strength was observed on the affected side, indicating weakness in the muscles of mastication. He has no known medical problems, and his headache is slightly improved with ibuprofen. Examination reveals ptosis, dilated pupil, and displacement “down and out” in his left eye The remainder of the exam is normal. The oculomotor nerve is the third of 12 paired cranial nerves and originates from the midbrain. Down-and-out displacement of the eye occurs from the unopposed action of the lateral rectus and superior oblique. An oculomotor nerve palsy may be caused by an aneurysm, compression, infection, infarction, or tumor. Be able to name the seven extraocular eye muscles of each orbit, and also their attachments, actions, and innervation 2. Be able to describe how each of these muscles is optimally tested in a clinical setting 3. All of the extraocular muscles originate from the apex of the pyramidal shaped orbit near the optic canal, except for the inferior oblique muscle, which arises from the anterior orbital floor. The levator superioris attaches directly to the eyelid and controls its movements. Rarely do any of the six muscles attaching directly to the eyeball move the eyeball independently from the other muscles, although their indi- vidual actions are typically described. Their attachments, actions, and innervation are listed in Table 42-1 and illustrated in Figure 42-1. Levator palpebrae (elevated) Superior oblique Superior rectus Medial rectus Lateral rectus Inferior rectus Inferior oblique figure 42-1. It contains smooth muscle fibers forming the superior tarsal muscle that is innervated by sympathetic nerve fibers during fright or startle responses. The superior oblique muscle originates anatomically from the posterior apex of the orbit and passes anteriorly to the trochlea, a pulley like fibrous ring at the super- omedial margin on the orbit. Its tendon passes through the trochlea to insert on posterosuperior portion of the sclera. On contraction, it pulls the posterior portion of the eyeball anteriorly and medially. The inferior oblique muscle originates from the anteromedial floor of the orbit, thus simulating the portion of the superior oblique between the trochlea and insertion. It inserts into the posteroinferior sclera and therefore opposes the action of the superior oblique. The two oblique muscles also produce extorsion or lateral rotation of the eyeball. The four rectus muscles (superior, inferior, lateral, and medial) all originate from a common tendinous ring surrounding the optic canal and a portion of the superior orbital fissure in the posterior orbit. Each inserts on the anterior half of the sclera on that portion of the eyeball according to their name. Note that the superior and inferior rectus muscles will turn the eyeball in or adduct the pupil and will also produce intorsion or medial rotation of the eyeball. For the sake of clarity, the following descriptions for muscle testing are for only the right eye. For optimal testing of the extraocular muscles, the axis of the muscle is placed parallel with the axis of muscle pull. With the eyeball (pupil) abducted, the superior and inferior recti are in line with their pull, and their action on the eyeball is almost purely elevation and depression, respectively. For the superior and inferior oblique muscles, adduction of the eyeball (pupil) places the axis of the muscle in line with its pull (remember that the functional origin of the superior oblique is the trochlea). The lateral and medial recti are tested by simply adducting or abducting the eyeball (pupil) (see Figure 42-2). The pupil will also be dilated because of loss of the parasympathetic innervation to the constrictor muscle of the pupil. Loss of the trochlear nerve, although rare, results in slight adduction of the affected eye, weakness of downward gaze due to paralysis of the superior oblique, and head tilting to eliminate diplopia (double vision). You would test the function of the superior oblique muscle by having the patient do which of the following? Ptosis or drooping of the eyelid is due to paralysis of the levator palpebrae muscle. Turning the eyeball inward places the portion of the superior oblique between the trochleae, and its insertion places the axis of the muscle in line with its axis of muscle pull. Because the muscle’s insertion is on the posterior portion of the sclera, it will then turn the eye (pupil) down (depress). Turning the eyeball out places the axis of the superior rectus muscle paral- lel to its pull, and the muscle will then turn the eyeball upward (elevate). The previous day, the infant was delivered vaginally by vacuum-assisted extraction because there were severe fetal heart rate decelerations. The infant’s scalp has a 5-cm dis- colored soft tissue swelling that seems to be contained by and does not cross the sagittal or lambdoidal sutures. The infant appears icteric, and his scalp has a 5-cm hematoma that is contained by and does not cross the sagittal or lambdoidal sutures. The more common caput succeda- neum, which is swelling of the scalp soft tissue, is a normal response of the fetal head to the birth process. When a soft tissue mass seems contained by suture lines, subgaleal cephalohematoma is suspected. The hemoglobin deposited in the hematoma becomes bilirubin, which is the reason for the infant’s icterus. The lambdoidal suture runs left to right posteriorly and separates the two parietal bones from the occipital bone. The coronal suture has the same course anteriorly and separates the frontal bone from the two parietal bones. It usually accumulates in the gallbladder and is excreted into the small bowel to facilitate digestion.

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Macrophage Mast cell Stabilize lysosomal Low-Potency tamoxifen 20mg without prescription the women's health big book of yoga pdf download, Short-Acting Glucocorticoids membranes Decrease activation Inhibit release of Cortisol cheap tamoxifen 20mg otc menstruation 10, the major glucocorticoid in humans, is called Prevent release of Decrease cytokine histamine, catabolic enzymes hydrocortisone when used as a pharmaceutical. Cortisone synthesis and release prostaglandins, is rapidly metabolized to hydrocortisone by the liver after leukotrienes oral administration. Hydrocortisone has a duration of action Increase transcription of of 8 to 12 hours, with equal glucocorticoid and mineralo- annexin-1 Glucocorticoids corticoid effects. Hydrocortisone and cortisone are the pre- ferred glucocorticoids when replacement therapy is needed for patients with adrenal insuffciency. These drugs are also Eosinophil T-cell used as antiinfammatory agents, but more potent glucocor- ticoids are often preferred for treating most infammatory, allergic, and autoimmune disorders. Inhibit relase of Suppress activation histamine, Decrease cytokine prostaglandins, synthesis and release Medium-Potency, Intermediate-Acting leukotrienes Glucocorticoids Increase Prednisone, prednisolone, methylprednisolone, and tri- transcription of annexin-1 amcinolone are the glucocorticoids used most often for systemic treatment. Glucocorti- coids act by suppressing T-cell activation, decreasing cytokine production verted to prednisolone, a substance that is itself available as and release, and preventing mast cells and eosinophils from releasing a drug. The intermediate-acting glucocorticoids have a dura- various chemical mediators of infammation, including histamine, prosta- tion of action of 12 to 36 hours and are often used to treat glandins, leukotrienes, and other substances that cause tissue damage, vaso- cancer, infammation, allergy, and autoimmune disorders. They also have a number of actions on neutrophils and macrophages that reduce the chemical mediators of infammation. Gluco- corticoids have additional antiinfammatory effects that are described in the text. High-Potency, Long-Acting Glucocorticoids Betamethasone and dexamethasone are stereoisomers that differ only in the confguration of a methyl group. Beta- methasone is available for systemic use, and it is also used in the topical treatment of a number of skin disorders, lipocortin-1), which inhibits phospholipase A, the frst step including psoriasis, seborrheic or atopic dermatitis, and neu- in the eicosanoid pathway (see Chapter 26). Dexamethasone is used in diagnostic dexa- Fourth, glucocorticoids stabilize lysosomal membranes methasone suppression tests and in the treatment of a of neutrophils and prevent the release of catabolic enzymes variety of neoplastic, infectious, and other infammatory (e. Budesonide is a long-acting glucocorticoid that is cause vasoconstriction and decrease capillary permeability by administered by inhalation. They also decrease the synthesis of proinfammatory cytokines and Antiinfammatory Effects other substances released from eosinophils in blood vessels The antiinfammatory effects of glucocorticoids are primar- as noted previously, and both actions reduce the vaso- ily attributable to their multiple actions on several types of dilation and plasma extravasation that are the signs of leukocytes (Fig. Second, they suppress the produc- Glucocorticoids also have multiple effects on circulating tion of cytokines by activated helper T cells. Pharmacologic doses of glucocorticoids sup- a major role in infammation by recruiting and activating press lymphoid tissue and reduce the number of circulating eosinophils and by stimulating antibody production by B lymphocytes. Third, glucocorticoids decrease the release of various chemical mediators of infammation, including histamine, prostaglandins, leukotrienes, and other substances from mast Indications cells, eosinophils, and infamed tissue. They decrease the Glucocorticoids are used for the diagnosis and treatment of synthesis of prostaglandins and leukotrienes by increas- adrenal diseases and for the treatment of a diverse group of ing the transcription of annexin-1 (previously named nonadrenal disorders. Chapter 33 y Adrenal Steroids and Related Drugs 347 Infammation, Allergy, and one third given in the evening. If hyperkalemia is still present Autoimmune Disorders after the oral hydrocortisone dose is stabilized, the addition The glucocorticoids are frequently used to suppress infam- of a mineralocorticoid to the treatment regimen is usually mation and immune dysfunction associated with diseases required. A single daily dose, given in the morning, of affecting almost every organ in the body. Examples of diseases treated with corticoste- the synthesis of cortisol and aldosterone. Impaired synthe- roids include systemic lupus erythematosus, autoimmune sis leads to a compensatory increase in corticotropin secre- thrombocytopenia purpura, polyarteritis nodosa, multiple tion by the pituitary and results in adrenal hyperplasia. Because of the enzyme defciencies, the steroid biosynthetic Several glucocorticoids, including beclomethasone and pathway shifts to the production of adrenal androgens, mometasone, are available for nasal insuffation or oral thereby resulting in virilization (masculinization) and pseu- inhalation to treat allergic rhinitis or asthma, respectively. Ciclesonide is a newer agent also indicated for 21-hydroxylase defciency, which accounts for 90% of cases hay fever or allergic rhinitis. The second most common defect is11β-hydroxylase For corneal infammation and keratitis, many glucocorti- defciency, which accounts for 9% of cases. Fludrocortisone can be given to provide luprednate is a new eyedrop formulation indicated for the additional mineralocorticoid activity for salt-losing patients infammation and pain associated with ocular surgery. Adrenocortical hyperfunction (Cushing syndrome), which is caused by excessive levels of circulating corticotropin, is Cancer treated with surgery, irradiation, and adrenal steroid inhibi- Because of their lymphotoxic effects, glucocorticoids are tors (Box 33-1). Cushing syndrome most often results from used in the treatment of lymphocytic leukemias and lym- a pituitary adenoma that produces excessive quantities of phomas (see Chapter 45). Dexamethasone is a long-acting corticotropin, leading to adrenal hyperplasia and excessive glucocorticoid used in combination with other drugs to cortisol production. Respiratory Distress Syndrome The diagnosis of Cushing syndrome is often based on the Betamethasone is used to prevent respiratory distress syn- free cortisol level in urine samples and on the results of drome in premature infants. In the low-dose dexametha- maturation in the same manner as endogenous cortisol does. In healthy individuals, dexamethasone will suppress corticotropin Adrenal Insuffciency secretion by the pituitary and cause plasma cortisol levels to In primary adrenal insuffciency (Addison disease), all be under 5 mcg/dL. This gives rise dexamethasone will not suppress corticotropin secretion, to defciencies in cortisol and aldosterone and to a reduction so the cortisol level will usually exceed 10 mcg/dL. Secondary adrenal insuffciency has high-dose dexamethasone suppression test can be used several causes, but it most commonly results when steroid to differentiate adrenal hyperplasia from other causes of drugs are used for a prolonged time, thereby suppressing the hyperadrenocorticism. Secondary disease is Cushing syndrome is usually treated by surgical excision characterized by low levels of cortisol and androgens but of the pituitary adenoma or the hyperplastic adrenal glands. Patients must receive hydrocortisone parenterally in large Acute adrenal insuffciency (adrenal crisis, addisonian doses during the surgical procedure. The dose is then gradu- crisis) is a medical emergency that must be treated promptly ally tapered to normal replacement levels. Once the patient’s condition is stabilized, long-term Dermatologic Conditions oral hydrocortisone treatment can be instituted. Corticosteroids are often used to treat a wide range of der- In the treatment of chronic adrenal insuffciency, hydro- matologic conditions, including atopic (contact) and sebor- cortisone is administered orally in a manner that mimics the rheic dermatitis, pruritus (itching) from various causes, circadian secretion of cortisol by the normal adrenal gland, psoriasis, sunburn, and a number of other conditions. Desoximetasone and fuocinonide are high- A 49-year-old man with a history of cigarette smoking notices recent weight gain of about 15 pounds in the last potency steroids, whereas betamethasone dipropionate and few months. He is puzzled by this as he watches his diet clobetasol are very-high-potency steroids. His wife says that his face looks “puffy” and he Other Disorders has stretch marks on his stomach. On questioning by his Glucocorticoids are used to treat hypercalcemia, and they physician, he admits to having felt tired lately, and physical are the drugs of choice for managing sarcoidosis (a systemic examination reveals a small fatty hump on his back. Glucocorticoids are also used as physician orders a low-dose dexamethasone suppression immunosuppressant drugs to prevent organ graft rejection test, which results in no change of the man’s elevated levels (see Chapter 45). In the circulation the treat Cushing syndrome and is told he has less than a year glucocorticoids are highly bound to corticosteroid-binding to live. Pituitary adenomas, which are benign tumors of the pitu- Glucocorticoids are administered orally to treat allergic itary gland, are the cause of most cases of non-iatrogenic reactions, autoimmune disorders, neoplastic diseases, and Cushing syndrome. For acute disorders, glucocorticoids as Cushing disease, affects women fve times more fre- quently than men. For severe autoimmune and infam- than in women, small oat cell lung tumors are the cause.

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Screening is not indicated unless early therapy fr the screened condition is more efective than late therapy or no therapy buy generic tamoxifen 20 mg on-line menopause or pregnant. Preventve services fr the elderly include as goals the optmizaton of quality of life tamoxifen 20mg online breast cancer vaccine cleveland clinic, satsfcton with life, and maintenance of independence and productivity. Most recommenda­ tions fr patients older than age 65 overlap with recommendations fr the general adult population. Certain categories are unique to older patients, including sensory perception and fall. The primary care physician can perfrm efective health screen­ ing using simple and relatively easily administered assessment tools (Figure 18-1). Vision Screening Visual impairment is an independent risk fctor fr flls, which has a signifcant impact on quality of lif. The majority of conditions leading to vision loss in the elderly are presbyopia, macular degeneration, glaucoma, cataract, and diabetic reti­ nopathy. Patients have difculty fcusing on near objects while their distant vision remains intact. Glaucoma is characterized by a group of optic neuropathies that can occur in all ages. Although glaucoma is most ofen associated with elevated intraocular pressure, it is the optic neuropathy that defnes the disease. However, fr elderly patients with risk fctors including increased intraoc­ ular pressure, fmily history, vision changes, or Afican-American race, screening would be of beneft. Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. Hearing Screening More than one-third of persons older than age 65 and half of those older than age 85 have some hearing loss. The whispered voice test has sensitivities and specifcities ranging fom 70% to 100%. Limited ofce-based pure-tone audiometry is more accurate in identifying patients who would beneft fom a more frmal audiometry. The majority of patients with hearing impairment will present with complaints unrelated to their sensory defcit. In a quiet examination room with fce-to-fce conversation, patients can overcome signifcant hearing loss and avoid detection fom a physician. Common causes ofgeriatric hearing impairments are presbycu­ sis, noise-induced hearing loss, cerumen impacton, otosclerosis, and central auditory processing disorder. Presbycusis is age-related sensorineural hearing loss usually associated with both selective high-fequency loss and difculty with speech dis­ crimination. Noise-induced hearing loss is essentially a wear and tear phenomenon that can occur with either industrial or recreational noise exposure. Patients will typically present with tinnitus, difculty with speech discrimination, and problems hearing background noise. Cerumen impaction in the external auditory canal is a common, fequently overlooked problem in the elderly that may produce a tran­ sient, mild conductive hearing loss. It is estimated that 25% to 35% of institution­ alized or hospitalized elderly are afected by impacted cerumen. It results in progres­ sive conductive hearing loss with onset most commonly in the late twenties to the early frties. Geriatric patients with hearing loss may have otosclerosis complicating their presentation. Since the last recommendation, evidence of routine screening has become available that shows that the widespread use of hearing aids afer objective hearing loss was identifed via in-ofce tests did not beneft those who did not self-report hearing loss. However, this recommendation does not apply to elderly patients with symptoms of hearing loss, cognitive impairment, or psychosocial complaints indicating other diagnoses. The associated com­ plications are the leading cause of death fom injury in those older than age 65. Hip factures are common precursors to fnctional impairment and nursing home placement. Factors contributing to flls include age-related postural changes, alterations in visual abil­ ity, certain medications, and diseases afecting muscle strength and coordination. Due to the fr-reaching consequences that flls have on both the patient and the health-care system, the American Geriatric Society recommends that physicians ask their elderly patients about history of falls and balance problems. Cognitive Screening The prevalence of dementia doubles every 5 years afer age 60, so that by age 85 approximately 30% to 50% of individuals have some degree of impairment. Patients with mild or early dementia fequently remain undiagnosed because their social graces are retained. The combinaton of the "cock draw" and the "three-item recall" is a rapid and firly reliable ofce-based screening fr dementia. When patients fil either of these screening tests, frther testing with the Folstein Mini-Mental State questionnaire should be perfrmed. Incontinence is estimated to afect 11% to 34% of elderly men and 17% to 55% of elderly women. Continence problems are fequently treatable, have major social and emotional consequences, but are ofen not raised by patients as a concern. Depression Screening Depressive symptoms are more common in the elderly despite major depressive disorder being slightly lower in prevalence when compared with younger popu­ lations. Depression signifcantly increases morbidity and mortality, and is ofen overlooked by physicians. A simple two-question screen (Have youfelt down/depressed/hopeless in the last 2 weeks? Posi­ tive responses can be fllowed up with a Geriatric Depression Scale, a 30-question instrument that is sensitive, specifc, and reliable fr the diagnosis of depression in the elderly. A combinaton of serial weigt measurements obtined in the ofce and inquiry about changng appette is likely the most usefl method of assessing nutri­ tonal status in the elderly. Supple­ mentation with a multivitamin frmulated at about 100% daily value can decrease the prevalence of suboptimal vitamin status in older adults and improve their micro­ nutrient status to levels associated with reduced risk fr several chronic diseases. Malnutrition is common in nursing homes, and protein undernutrition has a preva­ lence of 17% to 56% in this setting. Protein undernutrition is associated with an increased risk of infctions, anemia, orthostatic hypotension, and decubitus ulcers. Hypertension Screening Treatment of hypertension is of substantial beneft in the elderly. Heart disease and cerebrovascular disease are leading causes of death in the elderly. Treatment of hypertension has contributed to a reduction in mortality fom both stroke and coronary artery disease. Tiazides are the drugs of choice unless a comorbid condition makes another choice prefrable. Stroke Prevention The incidence of stroke in older adults roughly doubles with each 10 years of age. Anticoagula­ tion with warfrin or newer agents, including dabigatran and apixaban, reduces the risk of strokes in people with atrial fbrillation. However, many elderly patients are not anticoagulated because of the fear of injuries fom falls.