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Color Code Important Doctors Notes Notes/Extra explanation Objectives At the end of the lecture pregnancy mood swings generic cabergoline 0.25 mg overnight delivery, the students should be able to: Explain the cerebral meninges & compare between the main dural folds menstrual 3 times in 1 month cheap 0.5mg cabergoline otc. Identify the spinal meninges & locate the level of the termination of each of them women's health kate beckinsale buy cabergoline 0.5 mg visa. The delicate arachnoid layer is attached to the inside of the dur and surrounds the brain and spinal cord women's breast health issues discount 0.5 mg cabergoline otc. This allows the pia mater to enclose csf) Meninges 1- Dura Matter o the cranial dura is a two layered tough, fibrous, thick membrane that surrounds the brain. Falx cerebri; o It is a vertical sickle shaped sheet of dura, in the midline o Extends from the cranial roof into the great longitudinal fissure between the two cerebral hemispheres. Tentorium cerebelli; o A horizontal shelf of dura, lies between the posterior part of the cerebral hemispheres and the cerebellum. Meninges 2- Arachnoid Mater o is a soft, translucent membrane loosely envelops the brain. Meninges Subarachnoid Space the subarachnoid space is varied in depth forming; subarachnoid cisterns. Spinal Meninges the spinal meninges are very similar to the cranial meninges with 2 differences: 1) the epidural space and 2) denticulate ligament Just like the brain the spinal cord, is invested by three meningeal coverings: the pia mater, arachnoid mater and dura mater. Pia mater, o Innermost covering, a delicate membrane closely envelops the cord and nerve roots. The central canal of the spinal cord is continuous upwards to the fourth ventricle. On each side of the fourth ventricle laterally, lateral recess extend to open into lateral aperture opening (foramen of Luscka), central defect in its roof (foramen of Magendie)* the forth ventricle is continuous up with the cerebral aqueduct, that opens in the third ventricle. The third ventricle is continuous with the lateral ventricle through the interventricular foramen (foramen of monro). Central Canal Fourth Ventricle Cerebral Aqueduct Third Ventricle Interventricular Foramen (foramen of monro) o o o o Lateral Ventricles *in the fourth ventricle there are 2 lateral recess which have an opening called foramen of luscka, there is another opening on the wall called foramen of magendie. Older people may have headaches, double vision, poor balance, urinary incontinence, personality changes, or mental impairment. Other symptoms may include vomiting, sleepiness, seizures, and downward pointing of the eyes. Summary o the brain & spinal cord are covered by 3 layers of meninges: (1) dura, (2) arachnoid & (3) pia mater. The ventricular system in the spinal cord is represented by: a) Lateral ventricle b) 3rd ventricle c) 4th ventricle d) Central canal 2. The lateral ventricle opens into the 3rd ventricle through: a) Foramen of luscka b) Foramen of magendie c) Foramen of Monroe d) Cerebral aqueduct 7. Cerebrospinal fluid circulates in: a) Ventricles b) Subarachnoid space c) Dural venous sinuses d) Epidural space 3. It flows from lateral ventricle to 3rd ventricle through interventricular foramen and then goes to 4th ventricle through cerebral aqueduct. Decompress the dilated ventricles by inserting a shunt connecting the ventricle to the jugular veins or abdominal peritoneum. Although many of these disorders are isolated phenomena that affect only a single structure, others are systemic disorders that involve various other organs in the body. In many patients with visual loss, an abnormal pupillary response is the only objective sign of organic visual dysfunction. In patients with diplopia, an impaired pupil can signal the presence of an acute or enlarging intracranial mass. An adequate clinical examination of the pupils requires little time and can be meaningful when approached with a sound understanding of the principles of pupillary innervation and function. In most cases, one needs only a hand light with a bright, even beam, a device for measuring pupillary size (preferably in half-millimeter steps), a few pharmacologic agents, and an examination room that permits easy control of the background illumination. This section commences with an overview of congenital and acquired diseases of the iris that affect pupil size, shape, and reactivity because these structural defects may be the cause of ``abnormal pupils' and often are easy to diagnose at the slit lamp. Furthermore, if a preexisting structural iris defect is present, it may confound interpretation of the neurologic evaluation of pupillary function; at the very least, it should be kept in consideration during such evaluation. Patients with aniridia initially may be thought to have fixed, dilated pupils until a more careful examination is performed. The iris is only minimally developed, and the iris musculature usually is hypoplastic. Patients with aniridia often have photophobia, poor visual acuity, and other ocular defects, including glaucoma, cataracts, ectopia lentis, corneal opacification, ciliary body hypoplasia, optic nerve hypoplasia, foveal hypoplasia, strabismus, and nystagmus (3).

Mild motor delays undetected at the 9-month screening visit may be apparent at 18 months menstrual flooding cabergoline 0.25mg fast delivery. In the absence of established risk factors or parent or provider concerns menstrual cramps 7 weeks pregnant purchase cabergoline 0.5mg visa, completion of a general developmental screening test is recommended at the 9- women's health clinic kingswood cheap cabergoline 0.25 mg, 18- pregnancy halloween costumes 0.25mg cabergoline visa, and 30month visits. These ages were selected, in part, on the basis of critical observations of motor skills development. At the recommended screening visits, the following motor skills should be observed in the young child. These skills are typically acquired at earlier ages, and their absence at these ages signifies delay: 30-month visit: Most motor delays will have already been identified during previous visits. However, more subtle gross motor, fine motor, speech, and oral motor impairments may emerge at this visit. Progressive neuromuscular disorders may begin to emerge at this time and manifest as a loss of previously attained gross or fine motor skills. An additional general screening test is recommended at the 48-month visit to identify problems in coordination, fine motor, and graphomotor skills before a child enters kindergarten. Preschool or child care staff concerns about motor development should be addressed. Loss of skills should alert the examiner to the possibility of a progressive disorder. Continuous developmental surveillance should also occur throughout childhood, with additional screenings performed whenever concerns are raised by parents, child health professionals, or others involved in the care of the child. Marked delay beyond these ages warrants attention but does not necessarily signify a neuromotor disease. Perform Developmental Surveillance As the 2006 policy states, "Developmental surveillance is a flexible, longitudinal, continuous and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems. Surveillance can be useful for determining appropriate referrals, providing patient education and familycentered care in support of healthy development, and monitoring the effects of developmental health promotion through early intervention and therapy. Normal gross motor development: the influences of race, sex and socioeconomic status. A great breadth and depth of information is considered in comprehensive developmental surveillance. Administer Screening Tool Developmental screening involves the administration of a brief standardized tool that aids in the identification of children at risk for a developmental disorder. Many screening tools can be completed by parents and scored by nonphysician personnel; pediatric providers interpret the screening results. The aforementioned 2006 policy statement on developmental surveillance and screening provides a list of developmental screening tools and a discussion of how to choose an appropriate screening tool. Consider Administering Screening Tool if Not Already Done the concerns of both parents and child health professionals should be included in determining whether surveillance suggests that the child may be at risk for developmental problems. It is essential to ask parents broad, open-ended questions and listen carefully for any concerns. To broaden historical perspectives, clinicians can ask if extended family members, educators, or others who know the child well express any concerns about motor development. When children are tired or stressed, direct observation of motor skills may not be possible, and full reliance on historical information is needed. Children with increased tone may attain motor milestones early, asymmetrically, or "out of order. Is there anything your child used to be able to do that he or she can no longer do? Physical Examination the examination maneuvers described here are focused on medical home visits of children in the ambulatory setting. Children with motor delays related to systemic illness often show alterations in their level of interaction with their environment and general arousal. Careful assessments of head circumference, weight, and length/height with interpretation of percentiles according to Centers for Disease Control and Prevention or World Health Organization growth curves are essential and may facilitate early identification of children with microcephaly, macrocephaly, and growth impairments.

The three half-circle semicircular canals are oriented at right angles to one another (Figure 7-16) menstruation gassy cheap cabergoline 0.5mg free shipping. Within each canal is a specialized receptor called a crista ampullaris menstrual cycle at age 5 buy cheap cabergoline on-line, which generates a nerve impulse when you move your head women's health clinic kamloops cabergoline 0.5 mg low price. The sensory cells in the cristae ampullares have hair like extensions that are suspended in the endolymph menstrual relief pills discount cabergoline 0.5 mg line. The sensory cells are stimulated when movement of the head causes the endolymph to move, thus causing the hairs to bend. Eventually, nervous impulses passing through this nerve reach the cerebellum and medulla. Other connections from these areas result in impulses reaching the cerebral cortex. The organ of hearing, which lies in the snail shaped cochlea, is the organ of Corti. It is surrounded by endolymph filling the membranous cochlea or cochlear duct, which is the membranous tube within the bony cochlea. Specialized hair cells on the organ of Corti generate nerve impulses when they are bent by the movement or endolymph set in motion by sound waves (Figures 7-16 and 7-17). The Taste Receptors the chemical receptors that generate nervous impulses resulting in the sense of taste are called taste buds. About 10,000 of these microscopic receptors are found on the sides of much larger structure on the tongue called papillae and also as portions of other tissues in the mouth and throat. Nervous impulses are generated by specialized cells in taste buds, called gustatory cells. They respond to dissolved chemicals in the saliva that bathe the tongue and mouth 194 Human Anatomy and Physiology Figure 7-18. All other flavors result from a combination of taste bud and olfacctory receptor stimulation. In other words, the myriads of tastes recognized are not tastes alone but tastes plus odors. For this reason a cold that interferes with the stimulation of the olfactory receptors by odors from foods in the mouth markedly dulls taste sensations. The Smell Receptors the chemical receptors responsible for the sense of smell are located in a small area of epithelial tissue in the upper part o the nasal cavity (Figure 7-19). The location of the olfactory receptors is somewhat hidden, and we are often forced to forcefully sniff air to smell delicate odors. Each olfactory cell has a number of specialized cilia that sense different chemicals and cause the cell to respond by generating a nervous impulse. To be detected by olfactory receptors, chemicals must be dissolved in the watery mucus that lines the nasal cavity. After the olfactory cells are stimulated by odor-causing chemicals, the resulting nerve impulse travels through the olfactory nerves in the olfactory bulb and tract and then enters the thalamic and olfactory centers of the brain, where the nervous impulses are 197 Human Anatomy and Physiology interpreted as specific odors. The pathways taken by olfactory nerve impulses and the area where these impulses are interpreted are closely associated with areas of the brain important in memory and emotion. For this reason, we may retain vivid and long-lasting memories of particular smells and odors. Temporary reduction of sensitivity to smells often results from colds and other nasal infections. Progressive reduction of the sense of smells often seen in smokers because of the damaging effects the pollutants in tobacco smoke. In olfaction, as with all the special senses, advancing age often brings a structural degeneration that result in reduced function. It is no wonder that many older adults become isolated and depressed when their contact with the outside world, the special senses, is gradually lost. Caring health professionals recognize these signs of aging and provide assistance needed by their aged patients to enjoy life. General Sense Organs Groups of highly specialized and localized receptors are typically associated with the special senses. In the sense organs, however, receptors are found in almost every part of the body. To demonstrate this fact, try touching any point pf your skin with the tip of a toothpick.

In a hypotensive patient with normal cardiac function women's health center san bernardino purchase online cabergoline, which of the following could indicate the need for fluid therapy? Its safety and portability allow for rapid noninvasive bedside assessment to aid diagnosis and management of critically ill patients pregnancy urinary tract infection cheap cabergoline 0.5 mg overnight delivery. Bedside cardiac ultrasound is particularly useful in determining the cause of undifferentiated shock in medically complex patients women's health clinic overland park ks discount cabergoline 0.25mg without a prescription. The American College of Chest Physicians and Society of Critical Care Medicine have now made recommendations on critical care ultrasound competencies menstruation fatigue purchase cabergoline us. Interventions initiated include: fluid boluses, norepinephrine and epinephrine infusions. He remains tachycardic (123 bpm), hypotensive (87/50), with increasing oxygen requirements. Central venous pressure is estimated at 18 mmHg and pulmonary pressures are estimated at 65/34 with a pulmonary artery occlusion pressure of 30 mmHg. Lung ultrasound has made great advances over the past 10 years, particularly in the evaluation of causes of respiratory distress. As both the clinician managing the patient and ultrasound operator, the intensivist has the advantage of making immediate decisions that impact patient care. Although central venous and pulmonary catheter data are available, the diagnosis remains unclear. The clinical picture could be consistent with ventricular failure (right or left), sepsis, or hemorrhage. Bedside cardiac ultrasound can provide real time images to distinguish between these etiologies. The outline below simply aims to provide a basic understanding of the potential uses of ultrasonography in the critically ill patient and therefore cannot substitute for formal training in critical care ultrasound. Please refer to the following website to obtain more comprehensive resources and discussions on each individual topic listed. Cardiac Critical Care Ultrasound Examinations the case presentation above illustrates the difficulty that can be encountered when treating hemodynamic instability. Hemodynamic instability 85 a) Ventricular failure b) Hypovolemia c) Pulmonary embolism d) Acute valvular dysfunction e) Cardiac tamponade 2. Complications after Cardiothoracic Surgery a) Infective endocarditis b) Suspected aortic dissection or rupture c) Respiratory distress 3. Absolute a) Esophageal pathology ­ tear, mass, stricture b) Dysphagia/odynophagia unevaluated c) Cervical spine Instability 2. Hypovolemic shock a) Decreased end-diastolic area b) "Kissing" papillary muscle c) Hyperdynamic function 2. Valvular pathology a) Mitral regurgitation or stenosis b) Aortic regurgitation or stenosis 4. In each of these cases, decision making was altered through the use of ultrasound. Areas investigated include hepatorenal, splenorenal, pericardial space, and bladder (posterior to bladder for fluid). Mayo P, Beaulieu Y, Doelken P, et al: American College of Chest Physicians/La Societe de Reanimation de Langue Francaise Statement on Competence in Critical Care Ultrasonography. Neri L; Storti E; Lichtenstein D: Toward an ultrasound curriculum for critical care medicine. Anesthesiology 2012; 117:801-809 Free fluid in abdomen is shown in a patient who was taken to the operating room for hypotension. This was a trauma patient who had no other obvious cause of bleeding and was found to have a liver laceration. The most important quality of bedside/ portable/point of care ultrasound is reproducibility. Real-time diagnosis based-on images obtained still require proper clinical context in order to make expedient and correct interventions without delay. Improvements in image quality and acquisition allows further developments for new applications in ultrasonography. Volpicelli G, et al: International evidence-based recommendations for point-of-care lung ultrasound. This involves a multistep process in which tests are ordered, samples are drawn, labeled, and transported to the laboratory. There, they are analyzed and the results then communicated back to the requesting unit/physician (Figure 1).

This occurs from just making a tiny incision with the aid of a microscope into the spinal cord to place the shunt tube (often less than 1/10 of an inch in diameter) menstruation lupus buy cabergoline. However menopause zaps purchase cabergoline 0.25 mg on line, when one realizes that the spinal cord is like an electrical cable with millions of wires or fibers going through it menstrual and ovulation calculator purchase cabergoline 0.25 mg visa, it becomes understandable how even the smallest incision can cause temporary or permanent damage menopause kit gag gift purchase cabergoline without a prescription. For these reasons, shunts are usually placed in the back of the spinal cord where one is less likely to lose motor strength or pain and temperature sensation. The loss of crude touch-type sensation or position sense are more likely to be experienced. Depending on which surgeon you talk to or which article you read, failure of these operations may result in patients requiring re-operation or losing function permanently. It is imperative that every patient feels comfortable with their surgeon and his/her credentials and experience in this area so that the surgical procedure becomes a team effort. The patients and their families or significant others should have full knowledge and understanding of all the pros and cons, alternatives and risks. When surgery is performed with the surgeon and patient working together as a team in every sense, it can result in the best possible outcome for everyone involved. They, as well, are associated with significant overlap regarding both symptoms and surgery. In order to understand what an individual undergoing surgery for either or both of these entities can expect, it behooves us to divide the surgical process into: (1) the events that occur before surgery, (2) the surgery itself, and (3) the events that occur following surgery. First and foremost, it should not be assumed that the presence of either a Chiari malformation or the presence of syrinx constitutes, in and of itself, an indication for surgery. The progression of a syrinx on imaging studies, significant symptoms, or progression of symptoms, in the presence of the anatomical findings consistent with a Chiari malformation and/or syrinx constitute the indication constellation for surgery. Patients should understand this concept and should "interrogate" their surgeon regarding this decision-making process. Realistic expectations regarding outcome, weighed against risk, can then be understood and considered preoperatively. Assuming that no neurological complications of surgery ensue, the other major risks of surgery include leakage of spinal fluid, pseudomeningocele formation (spinal fluid that has leaked from the spinal sac but is contained under the skin), bleeding and infection. Almost all (but not all) surgical procedures for Chiari malformation and syringomyelia are performed in the prone (face down) position. Most surgeons use skull fixation during Chiari surgery in order to immobilize the operative site. This may cause the patient to have some pain at sites (usually three) where the pins of the skull fixation device have penetrated the skin and attach to the skull during surgery. The patient can expect to be unaware of this device, since it is applied after the patient is asleep and is removed before the patient emerges or awakens from general anesthesia. The incision for the Chiari malformation is usually located in the lower part of the back of the skull and the upper part of the neck in the midline. The incision for a syrinx can be located at any point in the posterior neck or upper back, depending on the location of the syrinx cavity. Although both operations may be painful, Chiari malformation surgery is usually associated with a greater amount of pain due to muscle retraction and the dissection required to perform the surgery. After Surgery and the Postoperative Period the postoperative period can be divided into several phases: (1) hospital phase, (2) the first months after surgery, and (3) the long-term period. Neurological complications obviously may ensue, as well as spinal fluid leakage, bleeding and infection. Most other complications are relatively infrequent and are usually unique to the specific situation at hand. As stated in the previous paragraphs, pain is the most significant issue during the first several days following surgery. The patient and family must understand that the surgeon or other physicians caring for the patient cannot overmedicate for fear of complications. A drowsy patient who is over sedated with pain medication is at risk for developing pneumonia, and does not get out of bed and walk. It is imperative that family, friends and the patient understand and appreciate the balancing act that the physician must perform. The First Month Following Surgery During the first month following surgery, the patient is still in the initial phase of recovery.

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