By S. Frithjof. Santa Clara University. 2019.
The falciform ligament (with the round ligament of the liver order bupron sr 150 mg with visa, the adult remnant of the umbilical vein order 150 mg bupron sr fast delivery, in its free margin) is reflected onto the anterior abdominal wall and divides the liver into apparent right and left anatomical lobes. As the falciform ligament passes onto the superior surface of the liver, the two layers of peritoneum diverge to the right and to the left, creating the anterior layers of the coronary ligaments. These pass to the right and to the left to the extremes of the superior liver surface, turn back on themselves (creating the triangular ligaments), and turn posteriorly to form the posterior layers of the coronary ligaments. In this manner, an area devoid of visceral peritoneum is created, the bare area of the liver. The posterior layers of the coro- nary ligaments converge to form the lesser omentum, which passes from the visceral surface of the liver to the lesser curvature of the stomach (hepatogastric ligament) and the first part of the duodenum (hepatoduodenal ligament). The liver is divided anatomically into four lobes by external landmarks and is delineated on the visceral surface by fissures and fossae, which form the letter H (see Figure 23-1). The left side of the H is formed by the fissure for the round ligament and the ligamentum venosum (adult remnant of the ductus venosus); the left lobe is to the left of this fissure. The crossbar of the H is the porta hepatis, through which the hepatic artery, portal vein, and nerves enter the liver and the bile ducts and lymphatics exit. Appendix fibrosa Inferior vena cava Esophageal impression Bare area of the liver Caudate lobe Coronary ligament Gastric impression Portal vein Suprarenal impression Hepatic artery Renal impression Porta hepatis Common hepatic duct Cystic duct Edge of lesser omentum Duodenal impression Quadrate lobe Round ligament Colic impression Gallbladder figure 23-1. The left portal lobe is the left anatomical lobe, quadrate lobe, and the remainder of the caudate lobe. The portal lobes are supplied by lobar branches of the hepatic artery, portal vein, and bile ducts. Although lacking external landmarks, the portal lobes are further divided functionally into hepatic segments. The liver receives a dual blood supply; approximately 30 percent of the blood entering the organ is from the hepatic artery, and 70 percent is from the portal vein. The proper hepatic artery is a branch of the common hepatic artery, one of the three major branches of the celiac artery. As it approaches the liver, it divides into right and left hepatic branches that enter the liver and divide into lobar, seg- mental, and smaller branches.
Each examination diet is blueprinted to ensure that all areas of the syllabus are covered order 150mg bupron sr mastercard, so the best advice is to ensure that you have covered the whole syl- labus in your reading and revision purchase bupron sr 150 mg mastercard, rather than trying to ‘spot’ questions. In addition to the textbooks you used as an undergraduate, there are sev- eral books on the market covering issues relevant to women’s health in general practice, and we suggest that you also access specifc texts on contraception and genitourinary medicine. We have provided a list of websites where you will fnd helpful information about some topics that could come up in the examina- tion, and although this list is not exhaustive, we think you will fnd that the websites contain interesting revision material. Doing exam questions is a very good way to revise, and it is highly recom- mended that you re-read a topic where your score is disappointing – you will be even more disappointed if it comes up in the examination and you have neglected to revisit that topic and top up your knowledge. Whilst you are revising, don’t forget to eat, sleep, and relax too – all these things will improve your performance! To pass the exam reading and revision is required, but understanding the style of questions and practising questions will improve your chance of success. Learning Outcomes This module covers history taking; clinical examination and investigation; note keeping; legal issues relating to medical certifcation; time management and decision making; communication; and ethics and legal issues. It is easy to set clinical questions on history, examination, or investigation, but quite a challenge to set written questions to test the other areas. We have also tried to look at attitudes and behaviour using written ques- tions concentrating on issues such as consent, domestic violence, and con- fdentiality. When tak- ing a history, which of the following symptoms suggests that the diagnosis might be endometriosis? There is a linear burn across the patient’s abdomen that occurred during ironing E. The woman seems unsure about her request for termination of unwanted pregnancy Answer [ ] 1. When they suffer an early pregnancy complication, which one of these non- sensitised, rhesus negative women does not need anti-D immunoglobulin? Miscarriage less than 12 weeks when the uterus is evacuated surgically or medically B.
Case 05: Hypochromic Microcytic Anaemia A 29-year-old woman presented with weakness bupron sr 150 mg online, palpitation and shortness of breath on exertion discount bupron sr 150 mg visa. Microcytic hypochromic blood profle with a history of blood loss suggests iron-defciency anaemia. Treatment includes correction of anaemia by blood transfusion, iron therapy for 3–6 months (to replenish the store) and treatment of primary cause. Case 06: b-Thalassaemia Major A 15-year-old girl presented with weakness, abdominal distension and loss of appetite. A: Anaemia, jaundice, frontal and parietal bossing, mongoloid facies and splenomegaly. Presence of microcytic hypochromic anaemia with a high reticulocyte count, jaundice and splenomegaly in a young patient indicates hereditary haemolytic anaemia, most commonly b-thalassaemia major. Other common hereditary haemolytic anaemia—HbE disease, thalassaemia E disease (double heterozygous). Case 07: Macrocytic Anaemia A 50-year-old woman presented with weakness and anorexia for 3 months. A: As follows: • Megaloblastic anaemia (as a result of vitamin B12 or folic acid defciency). A: As follows: • If macrocytosis is associated with megaloblasts in bone marrow: The diagnosis is megaloblas- tic anaemia. Most common cause is megaloblastic anaemia as a result of vitamin B12 or folic acid defciency. Case 08: Leukemoid Reaction A 60-year-old woman presented with fever, cough and weight loss. She was suffering from breast cancer, which was treated by mastectomy and chemotherapy. Leukemoid reaction means that the peripheral blood profle resembles leukaemia, but there is no leukaemia. Causes of lymphatic leukemoid reaction are viral (infectious mononucleosis, cytomegalovirus infection, measles, chickenpox), whooping cough and, rarely, tuberculosis and carcinoma.
It is important to distinguish Prior to excision of the cartilages 150mg bupron sr fast delivery, the natural dome is identified caudal septal deflection from footplate flare generic 150 mg bupron sr visa, which can be and marked. When overlapping cartilages, precise amount of done easily by palpation on physical exam. The overlap takes place with footplate is often associated with a deflection of the caudal septum. The suture will reinforce the medial crus, providing strength to stabilize and sometimes increase projection. For medialization to last, the soft tissue from the footplate and the posterior septum is divided, creating a potential space into which the footplates can be sutured. Guyuron found that divergent footplates were often associated with retracted columellar base and spine and that approximation without resection of soft tissue led to narrowing of the columella base with caudal advancement. The divided footplate then may be reconfigured with a suture across the columella or completely removed. The horizontal mat- tress suture should be placed so that the overlapping cartilagi- nous segments act as a fortified singular unit of cartilage, free from any interfragmentary motion. The cartilage should be separated from the underlying vestibular mucosa and the knot should be tied away from the vestibular skin and cut without a tail to minimize the risk of suture extrusion. Identifying patients with specific var- iant anatomy (for example, “hooked nose” or flared footplate) will allow an appropriate surgical solution to take place. Cartilage-splitting techniques can be performed with either an open or endonasal technique. However, open techniques maximize visualization and allow easy exposure for these techniques. Division of the lower lateral cartilages requires precision and introduces another variability of healing in the patient’s surgi- cal outcome. However, in the patient with the overly long lat- eral, medial, or intermediate crura, it is a powerful technique that eﬀectively and reproducibly corrects aesthetic flaws. Cartilage-splitting techniques, maligned for many years, are now a necessary tool in the successful rhi- noplasty surgeon’s armamentarium. These The nasal tip refers to the paired lower lateral cartilages, mechanisms are described as major and minor. The caudal aspect of the nasal septum that is principally relevant to tip projection is the anterior septal angle.