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On the right side of the body purchase 80 mg inderal mastercard, the right sides of the head effective inderal 80 mg, thorax, and right upper limb drain lymph fluid into the right subclavian vein via the right lymphatic duct (Figure 21. On the left side of the body, the remaining portions of the body drain into the larger thoracic duct, which drains into the left subclavian vein. The thoracic duct itself begins just beneath the diaphragm in the cisterna chyli, a sac-like chamber that receives lymph from the lower abdomen, pelvis, and lower limbs by way of the left and right lumbar trunks and the intestinal trunk. The lymph from the rest of the body enters the bloodstream through the thoracic duct via all the remaining lymphatic trunks. In general, lymphatic vessels of the subcutaneous tissues of the skin, that is, the superficial lymphatics, follow the same routes as veins, whereas the deep lymphatic vessels of the viscera generally follow the paths of arteries. The Organization of Immune Function The immune system is a collection of barriers, cells, and soluble proteins that interact and communicate with each other in extraordinarily complex ways. The modern model of immune function is organized into three phases based on the timing of their effects. The three temporal phases consist of the following: • Barrier defenses such as the skin and mucous membranes, which act instantaneously to prevent pathogenic invasion into the body tissues • The rapid but nonspecific innate immune response, which consists of a variety of specialized cells and soluble factors • The slower but more specific and effective adaptive immune response, which involves many cell types and soluble factors, but is primarily controlled by white blood cells (leukocytes) known as lymphocytes, which help control immune responses The cells of the blood, including all those involved in the immune response, arise in the bone marrow via various differentiation pathways from hematopoietic stem cells (Figure 21. In contrast with embryonic stem cells, hematopoietic stem cells are present throughout adulthood and allow for the continuous differentiation of blood cells to replace those lost to age or function. These cells can be divided into three classes based on function: • Phagocytic cells, which ingest pathogens to destroy them • Lymphocytes, which specifically coordinate the activities of adaptive immunity • Cells containing cytoplasmic granules, which help mediate immune responses against parasites and intracellular pathogens such as viruses This OpenStax book is available for free at http://cnx. Lymphocytes: B Cells, T Cells, Plasma Cells, and Natural Killer Cells As stated above, lymphocytes are the primary cells of adaptive immune responses (Table 21. The two basic types of lymphocytes, B cells and T cells, are identical morphologically with a large central nucleus surrounded by a thin layer of cytoplasm. They are distinguished from each other by their surface protein markers as well as by the molecules they secrete. While B cells mature in red bone marrow and T cells mature in the thymus, they both initially develop from bone marrow. B cells and T cells are found in many parts of the body, circulating in the bloodstream and lymph, and residing in secondary lymphoid organs, including the spleen and 12 lymph nodes, which will be described later in this section. An antibody is any of the group of proteins that binds specifically to pathogen-associated molecules known as antigens. An antigen is a chemical structure on the surface of a pathogen that binds to T or B lymphocyte antigen receptors. Once activated by binding to antigen, B cells differentiate into cells that secrete a soluble form of their surface antibodies. T Cells The T cell, on the other hand, does not secrete antibody but performs a variety of functions in the adaptive immune response. Different T cell types have the ability to either secrete soluble factors that communicate with other cells of the adaptive immune response or destroy cells infected with intracellular pathogens. The roles of T and B lymphocytes in the adaptive immune response will be discussed further in this chapter. A plasma cell is a B cell that has differentiated in response to antigen binding, and has thereby gained the ability to secrete soluble antibodies. These cells differ in morphology from standard B and T cells in that they contain a large amount of cytoplasm packed with the protein-synthesizing machinery known as rough endoplasmic reticulum. Natural Killer Cells A fourth important lymphocyte is the natural killer cell, a participant in the innate immune response. Primary Lymphoid Organs and Lymphocyte Development Understanding the differentiation and development of B and T cells is critical to the understanding of the adaptive immune response. It is through this process that the body (ideally) learns to destroy only pathogens and leaves the body’s own cells relatively intact. The lymphoid organs are where lymphocytes mature, proliferate, and are selected, which enables them to attack pathogens without harming the cells of the body. Later, the bone marrow takes over most hematopoietic functions, although the final stages of the differentiation of some cells may take place in other organs. The red bone marrow is a loose collection of cells where hematopoiesis occurs, and the yellow bone marrow is a site of energy storage, which consists largely of fat cells (Figure 21. The B cell undergoes nearly all of its development in the red bone marrow, whereas the immature T cell, called a thymocyte, leaves the bone marrow and matures largely in the thymus gland. Thymus The thymus gland is a bilobed organ found in the space between the sternum and the aorta of the heart (Figure 21. The trabeculae and lobules, including the darkly staining cortex and the lighter staining medulla of each lobule, are clearly visible in the light micrograph of the thymus of a newborn. The connective tissue capsule further divides the thymus into lobules via extensions called trabeculae. The outer region of the organ is known as the cortex and contains large numbers of thymocytes with some epithelial cells, macrophages, and dendritic cells (two types of phagocytic cells that are derived from monocytes). The medulla, where thymocytes migrate before leaving the thymus, contains a less dense collection of thymocytes, epithelial cells, and dendritic cells. Immune System By the year 2050, 25 percent of the population of the United States will be 60 years of age or older. One major cause of age-related immune deficiencies is thymic involution, the shrinking of the thymus gland that begins at birth, at a rate of about three percent tissue loss per year, and continues until 35–45 years of age, when the rate declines to about one percent loss per year for the rest of one’s life.

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Slide 31 Swelling of the optic disc with hemorrhages discount inderal 40 mg otc, exudates purchase inderal 40mg with amex, and vascular distension can be marked as in this obese 12-year-old boy with idiopathic intracranial hypertension. Slide 32 In addition to elevated intracranial pressure, swelling of the optic discs occurs in the presence of inflammatory, ischemic, thrombotic, infiltrative, and hypertensive diseases. There are also normal variants of optic disc structure that create the appearance called pseudo-papilledema. Slide 33 The remaining types of visual field loss as illustrated in figures B-H can now be understood with knowledge of visual system anatomy from optic chiasm to visual cortices. Each example has temporal arcuate field loss due to involvement of nasal retinal axons that cross the midline in the chiasm. Figure B occurs when a single lesion involves all of the superior fibers of the right intracranial optic nerve and its inferior nasal fibers that begin to cross the midline just as they enter the chiasm. Figure C, bitemporal hemianopia, occurs when the nasal crossing fibers in the chiasm are asymmetrically involved. Inflammatory disease such as sarcoidosis can also cause isolated chiasmal syndromes. Slide 35 Optic tract syndromes and lesions downstream along the visual pathway cause homonymous hemianopia, visual field loss through each eye restricted to the same side of the visual world. For example, complete congenital absence of an optic tract causes 150 completely congruous homonymous hemianopia. Acquired homonymous hemianopic field loss due to optic tract disease is usually grossly incongruous. For example, a left optic tract syndrome typically can cause nearly complete right-sided homonymous visual field loss through the right eye with incomplete right-sided homonymous field loss through the left eye. This pattern of field loss is termed incongruous and results because axons forming the optic tract are still relatively spatially segregated according to right and left eyes, hence a small lesion can affect axons from one eye more than axons from the other eye. Because of this spatial segregation of visual information, optic tract lesions can be associated with mild asymmetry in pupillary responses to light. Etiologies are usually structural or vascular, most commonly neoplasia in children and vascular compromise in adults. Slide 36 We can now appreciate that the completely congruous homonymous hemianopic visual field loss in figure D has limited localizing value. This pattern can result from large optic tract lesions that encompass all axons from each eye as well as from smaller lesions in the optic radiations where there is homogeneous mixing of axons carrying information from each eye to the level of individual ocular dominance columns. Localization in the presence of such congruity is accomplished by combining the pattern of visual loss with other deficits such as somatosensory or motor loss. Figures F-H are typical of lesions affecting the temporal, parietal, and occipital lobes. The lesion in Figure F involves the right optic radiation beneath the temporal lobe. The lesion in Figure G is due to watershed infarction following cardiac arrest at the right parietal- occipital junction with sparing of the macular representation. The lesion in Figure H is bilateral, asymmetric homonymous hemianopia with central macular preservation following bilateral infarction in the posterior cerebral artery circulations. Copper released from liver associated with Wilson’s disease does not only end up in peripheral Descemet’s membrane as Kayser-Fleischer rings. It becomes deposited throughout the body with early symptoms usually associated with predilection for deposition in basal ganglia. Slide 38 The description “cherry red spot” is not specific for acute retinal infarction immediately following central retinal artery obstruction. Storage material accumulates within retinal ganglion cell bodies in several metabolic lysosomal disorders. Because the ganglion cell layer is normally thickened in the macula, these distended cell bodies create a visible perifoveal opacification of the otherwise transparent retina. The prominence of the normal choroidal vasculature beneath the fovea is also described as a cherry red spot. Slides 39-40 Diseases causing pigmentary retinal degeneration share the disturbance of pigment within retinal pigment epithelium cells as well as migration of pigment from devitalized cells into the retina. Microaneurysms, tiny ectasias in capillary walls that develop after pericyte death, are the earliest clinical sign. Exudation of serum proteins and hemorrhage occur with moderately advanced disease. Ischemic retina produces angiogenic factors that promote growth of fragile neovascular tissue that bleeds, scars, and disturbs ocular anatomy and function. Similar compromise of the optic disc called diabetic papillitis results in swelling of the optic disc. Neovascular glaucoma develops when peripheral iris becomes scarred to peripheral cornea thereby blocking access of aqueous humor to the trabecular meshwork. Fluctuating serum glucose levels cause similar fluctuations in aqueous humor with correspond swelling and shrinkage of the crystalline lens leading to cataract formation.

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You don’t need to give a detailed neurologic exam every day you present a patient who is admitted for asthma generic inderal 40 mg fast delivery. Always inform your fellow students the day before about what you will be talking about so they can read up on the subject inderal 80mg mastercard. An attending (or sometimes a resident) may assign or suggest topics and/or days for you to present, but sometimes you can pick your own topics/days. Again, keep in mind that sometimes the specialist attendings do not evaluate you—so you may want to stick to general peds topics. It is often intimidating to approach your residents and attendings to get constructive criticism, but it is an important part of being a successful student. You are not expected to know the answer to every question, so it is ok to say “I don’t know” if you really have no idea. But you should go home that night and learn about the issue so if you are ever asked again, you will know the answer. Your experience will vary greatly depending on your site, so this guide gives a general overview of the rotation. The Team: • Interns: first year residents who are responsible for the majority of the daily work on all of the inpatients. At some sites you will work with private attendings, who are doctors in the community who admit patients at that hospital. You may have the opportunity to write the history and physical exam for patients when they are admitted in labor. You will follow the progress of laboring patients by doing frequent cervical checks (or at least accompanying a resident who will do the checks) and writing progress notes. You will assist the attending and/or resident in the actual delivery 43 (you will often be in charge of delivering the placenta, but will get to deliver some babies as well) and then may be asked to write a delivery note. Maxwell’s has a good outline of a delivery note, but you can also find an outline on page 22 of this packet. At most sights, you will pre-round and write progress notes every day for the moms you deliver until they are discharged. Maxwell’s has a great outline of a post-partum note as well, but there is also an example post-partum note in this packet on page 22. To prepare for your first day, read about normal labor—know the stages, how long is normal for each stage, etc. Generally you will see the patient first, perform a history and physical exam, and then present your assessment and plan to the attending. You will assist in surgeries like hysterectomies, and tubal ligations, as well as oncology cases (at some sites, there is the possibility of being assigned to the Gyn/Onc service, in which case you will only see oncology cases). Your resident will probably tell you which cases you should “scrub in” on but if he/she doesn’t, ask the senior resident. Sterile technique and scrubbing will also be reviewed during orientation on the first day of the course, and you will have a chance to participate in simulation sessions for Foley insertion and suturing over the course of the six weeks. Potential pimping topics: pelvic anatomy (make sure you know the vessels and the ligaments they run in), complications of various surgeries, cancer staging/treatments/etc. This means that when you are on L and D, you will spend one week on day shifts and another week on night shifts. Typically, however, while at the hospital on night float, you are not permitted to sleep and should not sleep, even if suggested by a resident. Your final grade will be a combination of your shelf score and evaluations from all of your residents and attendings. Tips for Studying for the Shelf: Your first shelf will the hardest because it takes a little time and practice to master shelf studying. Everyone has their own style, but general tips for success are to start reading early in the rotation—don’t wait until the last week to buy your books, and do a lot of practice questions. The shelf exams usually test detailed knowledge, so it is usually not enough to only know general principles or basics. But if you get rave reviews from your attendings and only do decently well on the shelf, you will probably still do very well overall. What to put in your white coat: - Stethoscope - Pocket pharmacopeia/epocrates - Maxwell’s cards (have a great outline of a postpartum note, etc. Before you jump in on a delivery, you should get to know the patient by going in throughout her labor, performing exams, and talking to her and her family. How would you feel if you had been laboring for 10 hours and then just as your are about to deliver, some med student who hasn’t even introduced her/himself jumps in and pulls out your baby??? And don’t turn down a chance to do a speculum exam or cervical check—even if you don’t feel totally comfortable, the only way you will get better is by practicing (and it’s very low-risk for the patients even if you are inexperienced).

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