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It is essential to review the nurses’ notes to ascertain their concor- dance with your own notes on clinical events order glycomet 500mg with mastercard. For example, it is not uncommon for the nurse’s notes to reflect the use of fundal pressure rather than suprapubic pressure. Although there are no data to support the use of one maneuver over another, the McRobert’s patient posi- tioning is simple and resolves about 50% of the cases of anterior shoul- der impaction. Fundal pressure prior to the diagnosis of shoulder dystocia is not a standard-of-care issue. Cervical plexus injury has been reported without documented shoulder dystocia at the time of vaginal birth (9) as well as at the time of planned C-section (10). There is no scientific basis that all or even most brachial plexus injuries result from inappropriate maneuvers at deliv- ery (11). Newborn seizure activity is so rare following delivery with shoul- der dystocia that intracerebral hemorrhage must be ruled out. HIE with mental retardation and/or cerebral palsy is also rare (<1%), unless the time from diagnosis of dystocia at delivery of the head to resuscitation exceeds 10 minutes. Video recording during periods of obstetric emer- gencies should not be allowed. Although the severity of the dystocia cannot be defined as mild, moderate, or severe, a videotape is often very revealing as to the twists and turns exerted on the baby’s neck. Documentation of the sequence and timing of the maneuvers is critical as are APGAR scores, need for resuscitation, and evident plexus in- jury. Obstetric hemorrhage is the most common cause of maternal death when associated complications are included. Death secondary to hem- orrhage would be most unusual in a modern obstetric service in the United States. Accepted risk factors include delays in identification of the site of the bleeding and in volume resuscitation with appropriate blood products. This often follows a failure to appreciate the quantity of blood the obstetric patient can lose before exhibiting shock fol- lowed rapidly by cardiovascular collapse and the morbidity of associ- ated organ injury.

Lancon There are two essential goals of a student studying human neu- cise generic glycomet 500mg on line, some answers may contain additional relevant informa- robiology, or, for that matter, the student of any of the medical tion to extend the educational process. The first is to gain the knowledge base and diagnostic In general, the questions are organized by individual chapters, skills to become a competent health care professional. Ref- ing the medical needs of the patient with insight, skill, and com- erence to the page (or pages) containing the correct answer are passion is paramount. The second is to successfully negotiate usually to the chapter(s) from which the question originated. However, recognizing that neuroscience is dynamic and three-di- These may be standard class examinations, Subject National mensional, some answers contain references to chapters other Board Examination (now used/required in many courses), the than that from which the question originated. Correct diagnosis of the neurologically compromised patient The questions in this chapter are prepared in two general not only requires integration of information contained in differ- styles. First, there are study or review questions that test gen- ent chapters but may also require inclusion of concepts gained in eral knowledge concerning the structure of the central ner- other basic science courses. These ques- sampling that covers a wide variety of neuroanatomical and tions have been carefully reviewed for clinical accuracy and clinically relevant points. There is certainly a much larger va- relevance as used in these examples. At the end of each ex- riety of questions that could be developed from the topics cov- plained answer, page numbers appear in parentheses that ered in this atlas. It is hoped that this sample will give the user specify where the correct answer, be it in a figure or in the text, a good idea of how basic neuroscience information correlates may be found. In order to make this a fruitful learning exer- with a range of clinically relevant topics. In addition to the vestibulocochlear nerve, which of the following structures would most likely also be affected by the tumor in this Chapters 1 and 2 man? A 71-year-old man complains to his family physician that his face (B) Facial nerve “feels funny. MRI shows a lesion in the cerebral (D) Posterior inferior cerebellar artery cortex.

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Between the spinal cord’s The cell bodies of the spinal cord motor neurons are dorsal and ventral horns lies the intermediate zone discount 500mg glycomet with mastercard, which grouped into pools in the ventral horns. A pool consists of contains an extensive network of interneurons that inter- the motor neurons that serve a particular muscle. Some interneu- ber of motor neurons that control a muscle varies in direct rons make connections in their own cord segment; others proportion to the delicacy of control required. The motor have longer axon projections that travel in the white mat- neurons are organized so that those innervating the axial ter to terminate in other segments of the spinal cord. These muscles are grouped medially and those innervating the longer axon interneurons, termed propriospinal cells, carry limbs are located laterally (Fig. The impor- neuron areas are further organized so that proximal actions, tance of spinal cord interneurons is reflected in the fact that such as girdle movements, are controlled from relatively they comprise the majority of neurons in the spinal cord medial locations, while distal actions, such as finger move- and provide the majority of the motor neuron synapses. A motor neuron The Spinal Cord Mediates Reflex Activity pool may extend over several spinal segments in the form of a column of motor neurons. This is mirrored by the in- The spinal cord contains neural circuitry to generate re- nervation serving a single muscle emerging from the spinal flexes, stereotypical actions produced in response to a pe- cord in two or even three adjacent spinal nerve root levels. One function of a reflex is to A physiological advantage to such an arrangement is that generate a rapid response. A familiar example is the rapid, injury to a single nerve root, as could be produced by her- involuntary withdrawal of a hand after touching a danger- 96 PART II NEUROPHYSIOLOGY ously hot object well before the heat or pain is perceived. Dorsal root This type of reflex protects the organism before higher ganglion cell CNS levels identify the problem. Even the simplest requires co- ordinated action in which the agonist contracts while the antagonist relaxes. The functional unit of a reflex consists of a sensor, an afferent pathway, an integrating center, an Muscle efferent pathway, and an effector. The sensory receptors spindle for spinal reflexes are the proprioceptors and cutaneous re- ceptors.

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These present as a contralateral hemiplegia of the tor neurons are influenced by corticospinal fibers either directly or in- upper and lower extremities cheap glycomet 500 mg with visa, coupled with an ipsilateral paralysis of directly via interneurons. Acetylcholine and calcitonin gene-related the tongue (medulla), facial muscles or lateral rectus muscle (pons), peptides are present in these large motor cells and in their endings in and most eye movements (midbrain). Lesions in the internal capsule (lacu- Clinical Correlations: Myasthenia gravis, a disease characterized nar strokes) produce contralateral hemiparesis sometimes coupled with by moderate to profound weakness of skeletal muscles, is caused by various cranial nerve signs due to corticonuclear (corticobulbar) fiber circulating antibodies that react with postsynaptic nicotinic acetyl- involvement. Bilateral weakness, indicative of corticospinal involve- choline receptors. Progressive muscle fatigability throughout the day ment, is also present in amyotrophic lateral sclerosis. Abbreviations ACSp Anterior corticospinal tract LCSp Lateral corticospinal tract Somatotopy of CSp Fibers ALS Anterolateral system ML Medial lemniscus A Position of fibers coursing to APGy Anterior paracentral gyrus MLF Medial longitudinal fasciculus upper extremity regions of BP Basilar pons PO Principal olivary nucleus spinal cord CC Crus cerebri PrCGy Precentral gyrus L Position of fibers coursing to CNu Corticonuclear (corticobulbar) Py Pyramid lower extremity regions of fibers RB Restiform body spinal cord CSp Corticospinal fibers RNu Red nucleus T Position of fibers coursing to IC Internal capsule SN Substantia nigra thoracic regions of spinal cord Review of Blood Supply to Corticospinal Fibers STRUCTURES ARTERIES Posterior Limb of IC lateral striate branches of middle cerebral (see Figure 5–38) Crus Cerebri in paramedian and short circumferential Midbrain branches of basilar and posterior communicating (see Figure 5–27) CSp in BP paramedian branches of basilar (see Figure 5–21) Py in Medulla anterior spinal (see Figure 5–14) LCSp in Spinal Cord penetrating branches of arterial vasocorona (leg fibers), branches of central artery (arm fibers) (See Figure 5–6) Motor Pathways 191 Corticospinal Tracts Thigh Somatomotor cortex Leg APGy Foot Somatotopy of CSp Post. These fibers influence—ei- lesioned side and away from the side of the hemiplegia. In addition to ther directly or through neurons in the immediately adjacent reticular a contralateral hemiplegia, common cranial nerve findings in capsular le- formation—the motor nuclei of oculomotor, trochlear, trigeminal, ab- sions may include 1) deviation of the tongue toward the side of the ducens, facial, glossopharyngeal and vagus (both via nucleus ambiguus), weakness and away from the side of the lesion when protruded and 2) spinal accessory, and hypoglossal nerves. This reflects the fact that corticonuclear (cortico- eas 6 and 8 in caudal portions of the middle frontal gyrus), the precen- bulbar) fibers to genioglossus motor neurons and to facial motor neu- tral gyrus (somatomotor cortex, area 4), and some originate from the rons serving the lower face are primarily crossed. Fibers from area 4 occupy the genu of ticonuclear fibers to the nucleus ambiguus may result in weakness of the internal capsule, but those from the frontal eye fields (areas 8,6) may palatal muscles contralateral to the lesion; the uvula will deviate to- traverse caudal portions of the anterior limb, and some (from areas wards the ipsilateral (lesioned) side on attempted phonation. In addi- 3,1,2), may occupy the most rostral portions of the posterior limb. In contrast to from area 4 terminate in, or adjacent to, cranial nerve motor nuclei ex- the alternating hemiplegia seen in some brainstem lesions, hemisphere cluding those of III, IV, and VI. In addition, it is important to note the following: 1) vertical gaze palsies (midbrain), 2) the Parinaud syn- that descending cortical fibers (many arising in areas 3, 1, 2) project to drome—paralysis of upward gaze (tumors in area of pineal), 3) internu- sensory relay nuclei of some cranial nerves and to other sensory relay clear ophthalmoplegia (lesion in MLF between motor nuclei of III and nuclei in the brainstem, such as those of the posterior column system.