By O. Runak. University of Minnesota-Morris.

This is a life-threatening situation that significant structure seen here is a small elevation discount proscar 5 mg mastercard prostate ultrasound images, repre- may cause cardiac or respiratory arrest generic proscar 5 mg on-line prostate ultrasound cpt. Both can be seen in the ventral view of the BRAINSTEM 7 brainstem (see Figure 7). Details of the information car- ried in these pathways will be outlined when the functional aspects of the cerebellum are studied with the motor sys- BRAINSTEM: DORSAL VIEW — CEREBELLUM tems (see Figure 55). The superior cerebellar peduncles REMOVED convey fibers from the cerebellum to the thalamus, passing through the roof of the fourth ventricle and the midbrain This diagram shows the brainstem from the dorsal per- (see Figure 57). This peduncle can only be visualized from spective, with the cerebellum removed. This dorsal perspective is useful (see also Figure 6 and Figure 7). The lower part of the fourth ventricle separates the MIDBRAIN LEVEL medulla from the cerebellum (see Figure 21). The special structures below the fourth ventricle are two large protu- The posterior aspect of the midbrain has the superior and berances on either side of the midline — the gracilis and inferior colliculi, as previously seen, as well as the emerg- cuneatus nuclei, relay nuclei which belong to the ascend- ing fibers of CN IV, the trochlear nerve. The posterior ing somatosensory pathway (discussed with Figure 9B, aspect of the cerebral peduncle is clearly seen. The cranial nerves seen from this view include the PONTINE LEVEL entering nerve CN VIII. More anteriorly, from this oblique Now that the cerebellum has been removed, the dorsal view, are the fibers of the glossopharyngeal (CN IX) and aspect of the pons is seen. The space separating the pons vagus (CN X) nerves, as these emerge from the lateral from the cerebellum is the fourth ventricle — the ventricle aspect of the medulla, behind the inferior olive. The roof of the upper portion of the fourth ventricle is a sheet of nervous tissue and bears the name superior med- ADDITIONAL DETAIL ullary velum; more relevant, it contains an important The acoustic stria (not labeled) shown in the floor of the connection of the cerebellum, the superior cerebellar fourth ventricle are fibers of CN VIII, the auditory portion, peduncles (discussed with Figure 57). The lower half of which take an alternative route to relay in the lower pons, the roof of the fourth ventricle has choroid plexus (see before ascending to the inferior colliculi of the midbrain. Two additional structures are shown in the midbrain As seen from this perspective, the fourth ventricle has — the red nucleus (described with Figure 47 and Figure a “floor”; noteworthy are two large bumps, called the 65A), and the brachium of the inferior colliculus, a con- facial colliculus, where the facial nerve, CN VII, makes necting pathway between the inferior colliculus and the an internal loop (to be discussed with Figure 48 and also medial geniculate body, all part of the auditory system with the pons in Section C of this atlas, see Figure 66C). As the cerebellum has been removed, the cut surfaces The medial and lateral geniculate nuclei belong with of the middle and inferior cerebellar peduncles are seen. The lateral The cerebellar peduncles are the connections between geniculate body (nucleus) is part of the visual system (see the brainstem and the cerebellum, and there are three pairs Figure 41A and Figure 41C). The inferior cerebellar peduncle connects the medulla and the cerebellum, and the prominent middle © 2006 by Taylor & Francis Group, LLC Orientation 35 Red n. Superior colliculus Lateral geniculate Brachium of body inferior colliculus Medial Inferior colliculus geniculate body Cerebral peduncle Trochlear nerve (CN IV) Superior medullary velum Superior cerebellar Trigeminal peduncle nerve (CN V) Middle 4 cerebellar peduncle Facial colliculus Inferior cerebellar peduncle Vestibulocochlear nerve (CN VIII) Glossopharyngeal nerve (CN IX) 4 Vagus nerve (CN X) Cut edge of 4th ventricle Inferior olive Cuneatus n. Cervical spinal cord 4 = Floor of 4th ventricle FIGURE 10: Brainstem 7 — Dorsal View — Cerebellum Removed © 2006 by Taylor & Francis Group, LLC 36 Atlas of Functional Neutoanatomy FIGURE 11 areas of the cortex. In addition, the limbic system has circuits that involve the thalamus. THE DIENCEPHALON: Other thalamic nuclei are related to areas of the cere- bral cortex, which are called association areas, vast areas THALAMUS 1 of the cortex that are not specifically related either to sensory or motor functions. Parts of the thalamus play an THALAMUS: ORIENTATION important role in the maintenance and regulation of the state of consciousness, and also possibly attention, as part The diencephalon, which translates as “between brain,” is of the ascending reticular activating system (ARAS, see the next region of the brain to consider. It will be discussed with the the cerebral hemispheres in the human brain has virtually limbic system in Section D of this atlas (see hidden or “buried” the diencephalon (somewhat like a Figure 78A). This itary stalk and mammillary bodies in Figure 15A and gland is thought to be involved with the regu- Figure 15B, which are part of the hypothalamus). Many people In this section of the atlas, we will consider the thal- now take melatonin, which is produced by the amus, which makes up the bulk of the diencephalon. It is pineal, to regulate their sleep cycle and to over- important to note that there are two thalami, one for each come jetlag. As has been noted, the third ventricle is situated between the two thalami (see Figure 9 and ADDITIONAL DETAIL Figure 20B). The thalamus is usually described as the gateway to As shown in the diagram, the diencephalon is situated the cerebral cortex (see Figure 63). This description leaves within the brain below the level of the body of the lateral out an important principle of thalamic function, namely ventricles (see also Figure 17, Figure 18, and Figure 19A).

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Definitive diagnosis is made by throat culture proscar 5 mg low cost prostate oncology 2017, rapid strep trusted 5mg proscar man health 1, and/or monospot test. See Figures 5-14 (enlarged tonsils) and 5-15 (exudative tonsillitis). PERITONSILLAR ABSCESS Peritonsillar abscesses may occur at any age, although most cases involve adults. Many cases evolve as a complication of tonsillitis, yet others develop as peritonsillar abscess with- out a history of tonsillitis. The condition involves infection of the peritonsillar space. A number of pathogens cause peritonsillar abscesses, although the most common cause is GABHS. The patient describes onset over several days of sore throat, fever, and malaise. Over time, the sore throat becomes very severe and localized to one side. It becomes increasingly difficult to move the neck, speak, and to swallow. The patient’s breath is fetid and the patient is often drooling, unable to swallow saliva. Fever is present and respiratory distress Figure 5-15. Nursing health assessment: A critical thinking, case studies approach. Pharyngeal examination can be very difficult, as the patient may have trismus, an inability to move the jaw due to the swelling. On examination of the pharynx, the area adjacent to the tonsil is swollen and the tonsil is often displaced and the uvula is devi- ated away from the site. There may be signs consistent with dehydration, including dry skin and tachy- cardia. The patient should be referred to a specialist, who may aspirate the abscess to obtain a culture or obtain a culture at the time of therapeutic incision and drainage. An ultrasound or CT scan are used to confirm diagnosis. EPIGLOTTITIS Epiglottitis is rare, but it carries the potential for causing significant respiratory obstruc- tion and death. The patient presents with the complaint of rapidly developing sore throat, fever, cough, and difficulty swallowing. The patient’s voice is muffled and there is drooling. Stridor and/or varying signs of respiratory distress may be evident. The patient often assumes a posture of sitting while leaning forward, to maximize airway opening. The patient has a very ill appearance and gentle palpation over the larynx causes significant pain. The patient should be closely monitored for complete airway obstruction, but urgent referral for emergency care via an ambulance is indicated prior to performing any diagnos- tic evaluation, as the potential exists for sudden loss of airway. An ENT specialist should be informed to meet the patient at the emergency department. THYROIDITIS Painful subacute thyroiditis involves inflammation of the thyroid gland. The condition includes a hyperthyroid phase, followed by a period of hypothyroidism, before the patient regains a euthyroid state. A variant, called postpartum thyroiditis occurs within six months of giving birth, is generally not associated with pain. Although the etiology of the painful subacute thy- roiditis is not clear, it may have viral trigger. Patients commonly complain of pain in the throat and/or neck, with radiation to an ear. Onset is described as relatively sudden and associated symptoms include fever, malaise, and achiness. The patient may not complain of symptoms of hyper- or hypothyroidism during those phases; however, the severity of metabolic symptoms is quite variable.

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He is referred for an upper GI series and is found to have a recurrent duodenal ulcer purchase proscar 5 mg line prostate cancer on t2 mri. The patient’s fasting gastrin level is 500 pg/ml (normal value order proscar 5mg amex prostate oncology marina del rey, < 100 pg/ml). For this patient, which of the following statements is true? An upper GI series that is diagnostic of a bulbar duodenal ulcer will preclude endoscopy B. Treatment failure with clarithromycin-based regimens occurs in approximately 30% of cases of H. A positive serum antibody test (sensitivity and specificity > 90%) would indicate persistent infection and require retreatment with metronidazole, tetracycline, and bismuth, as well as continuation of a proton pump inhibitor D. Ulcers refractory to pharmacotherapy are seen in acid hypersecretory states; this patient’s fasting gastrin level is diagnostic of the Zollinger- Ellison syndrome Key Concept/Objective: To understand the diagnostic modalities used in peptic ulcer disease Despite having a lower sensitivity and specificity than endoscopy, an upper GI series using barium and air (double contrast) may be favored by primary care physicians and patients over referral for endoscopy for suspected uncomplicated ulcer. An upper GI series offers lower cost, wider availability, and fewer complications. However, for troublesome and undiagnosed dyspepsia, an upper GI series may be superfluous, because a normal result will often necessitate endoscopy (endoscopy is more sensitive than radiography) and because an upper GI series showing a gastric ulcer will also necessitate endoscopy and biopsy to exclude gastric malignancy. In many patients, only a finding of a duodenal bul- 4 BOARD REVIEW bar ulcer on an upper GI series will preclude endoscopy. A 2-week course of a three-drug regimen that includes a proton pump inhibitor, clarithromycin, and amoxicillin has a success rate approaching 90%. The major causes of treatment failure are poor compliance with the reg- imen and clarithromycin resistance; the latter occurs in around 10% of current strains and is increasing with increased macrolide use in the population. Breath testing is more useful than serology in diagnosing failure of eradication of H. A fasting serum gastrin concentration can be used to screen for an acid hypersecretory state resulting from Zollinger-Ellison syndrome. Antisecretory drugs (especially proton pump inhibitors) can also raise serum gastrin levels modestly (to 150 to 600 pg/ml). Definitive documentation of an acid hypersecretory state requires quantitative gastric acid measurement (gastric analysis). A 54-year-old man with a history of COPD and tobacco abuse presents for evaluation of burning epi- gastric pain and melena. The epigastric pain has persisted for several weeks; the melena began several hours ago. His current medical regimen includes albuterol and ipratropium bromide nebulizers, long- term oral steroids, and theophylline. He also reports that he recently used an NSAID for joint pain. On physical examination, the patient’s heart rate is 115 beats/min and his blood pressure is 98/45 mm Hg. Abdominal examination does not demonstrate tenderness, rebound, or rigidity. A complete blood count is significant for a hematocrit of 39%; serum electrolytes are within nor- mal limits. EGD is performed, and the patient is found to have a gastric ulcer with a visible vessel. For this patient, which of the following statements is true? Corticosteroids not only are ulcerogenic but also impair healing of pre- existing ulcers B. The patient’s hemoglobin concentration makes a significant GI bleed unlikely C. To exclude a diagnosis of ulcerated gastric cancer, gastric ulcers should be followed endoscopically until they are completely healed D. Corticosteroids, which block cyclooxygenase-2 (COX-2) but not COX-1, are not ulcerogenic when used alone, though they impair healing of preexisting ulcers. However, when corticosteroids are used in combination with NSAIDs, the risk of ulcer formation is much greater than when NSAIDs are used alone. In the first several hours after an episode of acute ulcer bleeding, the hemoglobin concentration will not completely reflect the severity of the blood loss until compensatory hemodilution occurs or until intravenous fluids such as isotonic saline are administered.

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