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By H. Kirk. Bacone College. 2018.

With psy- • Psychological/non-pharmacological techniques of chogenic pain the rowing family demonstrated how pain management work well in children 120 mg allegra overnight delivery allergy shots heart palpitations. If a patient is suffering nausea and vomiting then an alternate route of administration may be required 120mg allegra mastercard allergy to beer. This clinically oriented survey of cranial nerve anatomy and function was written for students of medicine allegra 180 mg discount allergy medicine types, dentistry and speech therapy, but will also be useful for postgraduate physicians and general practitioners, and specialists in head and neck healthcare (surgeons, dentists, speech therapists, etc. After an introductory section surveying cranial nerve organization and tricky basics such as ganglia, nuclei and brain stem pathways, the nerves are considered in functional groups: (1) for chewing and facial sensation; (2) for pharynx and larynx, swal- lowing and phonation; (3) autonomic components, taste and smell; (4) vision and eye movements; and (5) hearing and balance. In each chapter, the main anatomical features of each nerve are followed by clinical aspects and details of clinical testing. Stanley Monkhouse is Anatomist at the University of Nottingham at Derby (Graduate Entry Medicine). He has been an examiner at the Royal Colleges of Surgeons of England and Ireland; at the Universities of Nottingham, Leeds, Newcastle-upon-Tyne, London, Belfast, Dublin (Trinity College), National University of Ireland, King AbdulAziz University (Jeddah, Saudi Arabia), Amman (Jordan) and King Faisal University (Dammam, Saudi Arabia). CRANIAL NERVES Functional Anatomy STANLEY MONKHOUSE MA, MB, BChir, PhD University of Nottingham Medical School at Derby Sometime Professor of Anatomy at the Royal College of Surgeons in Ireland; Lecturer in Human Morphology at the University of Nottingham; and Clinical Assistant in Ear Nose and Throat, Queen’s Medical Centre, Nottingham cambridge university press Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge cb2 2ru,UK Published in the United States of America by Cambridge University Press, New York www. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2005 isbn-13 978-0-511-13272-8 eBook (NetLibrary) isbn-10 0-511-13272-7 eBook (NetLibrary) isbn-13 978-0-521-61537-2 paperback isbn-10 0-521-61537-2 paperback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. CONTENTS List ofFigures page vii List of Tables ix Acknowledgements xi A note to the reader xiii Part I Organization of the cranial nerves 1 1 General considerations 3 2 Cranial nerve motor fibres and nuclei 17 3 Cranial nerve motor pathways: upper and lower motor neurons 24 4 Cranial nerve sensory fibres, brain stem sensory nuclei and tracts 31 Parts II–V Individual cranial nerves and functional considerations 39 5 Survey of cranial nerves and introduction to Parts II–V 41 Part II Trigeminal, facial and hypoglossal nerves 45 6 Cutaneous sensation and chewing 47 7 The trigeminal nerve (V) 50 8 The ophthalmic nerve (Va) 52 9 The maxillary nerve (Vb) 56 10 The mandibular nerve (Vc) 60 11 The facial nerve (VII) 66 12 The hypoglossal nerve (XII) 74 vi Contents Part IIIGlossopharyngeal,vagus and accessory nerves 77 13 Swallowing and speaking, bulbar palsy, pseudobulbar palsy, Broca’s area 79 14 The glossopharyngeal nerve (IX) 83 15 The vagus nerve (X) 86 16 The accessory nerve (XI) 92 Part IV Autonomic components of cranial nerves, taste and smell 95 17 Parasympathetic components and taste sensation 97 18 Smell: The olfactory nerve (I) 106 19 The sympathetic nervous system in the head 109 Part V Vision, eye movements, hearing and balance: optic, oculomotor, trochlear, abducens and vestibulocochlear nerves 113 20 The optic nerve (II) 115 21 The oculomotor (III), trochlear (IV) and abducens (VI) nerves 121 22 Visual reflexes: the control of eye movements; clinical testing of II, III, IV and VI 128 23 The vestibulocochlear nerve (VIII) and auditory and vestibular pathways 133 Further reading 140 Index 143 FIGURES 1. Comments from students over the years helped me to modify the text, and I am therefore greatly indebted to those whom I have taught. The notes were condensed for inclusion in my textbook Clinical Anatomy (first published by Churchill Livingstone, 2001), and I acknowledge with thanks the cooperation of staff at Elsevier in allowing the use of the original notes here. The first is Eric Clarke who goaded me into action in 1992 and who has been a constant source of encouragement and practical help. The second is Dr Gordon Wright MA, MD, Fellow of Clare College, Cambridge, who in 1970–1971 taught me neuroanatomy with great wit and style, and who responded to my request for constructive criticism of an earlier version of the text. And finally, I thank Pauline Graham and her colleagues at Cambridge University Press. I would like to think that this book would have met with the approval of Maxwell Marsden Bull MA, MD, sometime Fellow and Senior Tutor of Queens’ College, Cambridge. He had a great gift for expository and analytical teaching, and he showed me that educare and delectare can be synonymous. Stanley Monkhouse Derby 2005 A NOTE TO THE READER For those of you who will become physicians and general practition- ers, cranial nerves are important. Undergraduate anatomy is proba- bly the last time you will study their anatomy, so you need to get the hang of it first time round. It assumes that you will have some understanding of the functional anatomy of the spinal cord, spinal nerves, trunk and limbs. If you want to jump straight to the main business of cranial nerves, skip Part I which deals with their organization. I advise you to try reading it sometime, though, because it covers topics that students find troublesome but which aid understanding if properly appreciated. If you persevere with Part I you might be rewarded with, at the very least, a warm inward glow when the light finally dawns on some previously murky corner. Rather than work through them from first to twelfth, the book con- siders them according to function. There are several approaches to cranial nerves: the embryological and evolutionary, the analytical, and that which numbs the senses with topographical detail. The principal emphasis of this book is on clinically useful information, but because understanding is aided by some analysis and embryology, the book is more than just a list of xiv A note to the reader points for cramming. I hope that the inclusion of some explanatory material will stimulate you whilst not obscuring the basics. It is by no means the last word on the subject, and I expect that research neuroanatomists will throw up their hands in horror at some of the generalizations it contains. It is unavoidable that some material appears more than once, but I hope that this repetition will reinforce rather than bore.

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Notations in a patients do not maintain temperature as well as young medical chart indicating that a patient should undergo patients purchase allegra 120 mg visa allergy treatment alternative, and the mechanisms used to increase body tem- one or the other type of anesthesia are inappropriate and perature buy allegra 180mg with amex allergy testing dayton ohio, such as shivering 180 mg allegra amex allergy shots sore arm, can require excessive portions place the practitioner in the unfortunate position of con- of a patient’s oxygen consumption. Convection warming systems safer for elderly patients than general anesthetics, most operate like a large hair dryer, inflating a blanket that major studies fail to support this idea. Intravenous analysis, not focused on elderly patients, concluded that, fluids can be warmed, the operating room can be main- "Neuraxial blockade reduces postoperative mortality tained at a reasonable ambient temperature, the abdomi- and other serious complications. The size of some of nal viscera can be maintained in the abdominal cavity as these benefits remains uncertain, and further research long as possible, and lavage fluids can be warmed. In spite is required to determine whether these effects are due of these attempts, patients may lose significant body heat. End-tidal carbon opposed to the choice of anesthetic technique, is more dioxide measurement is used to evaluate ventilation and likely to have a positive impact on the elderly surgical should be used whenever intubation is required. Continuous peripheral arterial blood pressure measurement may be taken by placing an Indications for Intraoperative intra-arterial catheter in the radial artery and connecting Monitoring it to a transducer. Both radial arteries should be pal- Blood pressure, ECG, and oxygen saturation should be pated before selecting a cannulation site to be sure that monitored in all elderly patients undergoing any proce- they are equal. Automated blood pressure cuffs are common and the arterial monitor should be placed elsewhere. The measurement should be made at least every advantages of continuous monitoring include beat- 5 min. Accurate reading may be difficult in patients with to-beat blood pressure information and the ability to highly irregular cardiac rhythms. Application of the cuff acquire multiple blood samples without further should be done with care in frail individuals, who may venipuncture. Central venous pressures can be monitored with a The ECG should be configured to observe both p waves catheter placed in an intrathoracic vein, such as the and the lateral wall of the left ventricle (i. The pulse oximeter measures oxygen satura- reflect intravascular volume,which is very important when tion of arterial blood using a probe that is typically placed the cardiovascular system responds primarily to Starling on the finger. Frequently, signal quality is inadequate due forces,rather than altering heart rate and contractility (see to a decrease in pulsatile flow. Lower tioned, or other forms of probes can be used on other pressures generally indicate the need for blood or fluid 21. Anesthesia for the Geriatric Patient 237 replacement;elevated pressures may occur with right ven- associated with anesthetic care of the elderly. Pulmonary arterial readers are referred to a number of recent publications hypertension secondary to pulmonary disease, high that expand greatly on the knowledge presented here. References Such an elevation suggests adequate blood volume when, in fact, blood volume is inadequate. Is a cardiac risk assessment paradigm possi- tachycardia (which may not occur), hypotension, or ble? Klopfenstein CE, Herrmann FR, Michel JP, Clergue F, tered in bolus form (250–500 ml in £10 min, as tolerated). The influence of an aging surgical population on If signs fail to resolve with one or two bolus infusions, the anesthesia workload: a ten-year survey. Prediction of outcome of The next level of monitoring is the use of balloon- surgery and anesthesia in patients over 80. Prospective mul- Occluding a small pulmonary artery with the flotation ticentre trial of mortality following general or spinal anaes- balloon allows measurement of the pulmonary capillary thesia for hip fracture surgery in the elderly. PACs also allow measurement of cardiac associated with anaesthesia—a prospective survey in output and mixed venous blood gas analysis, which can France. An introductory perspective on the study of failure, wedge pressures may rise to 40 mmHg or more. In: Yaksh TL, Lynch C III, These measurements are particularly valuable guides to Zapol WA, Maze M, Biebuyck JF, Saidman LJ, eds. Anes- intraoperative management of fluid replacement therapy thesia: Biologic Foundations.

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There is a time to concentrate and a time to look around; a time to make a judgment and a time to withhold one order allegra 180mg visa allergy forecast pleasanton ca. Bayesian reasoning quality allegra 180mg allergy symptoms rash on face, with its controversial concept of prior probability is one attempt to assess generic allegra 180mg amex allergy testing queenstown, semi-formally, the importance of context. In a nutshell, it offers a method for weighting the significance of an individual piece of data given certain aspects of the context in which it occurs. Informally, we do this all the time, for example when we decide to double check a laboratory value which makes no sense in light of what we know already about a case. When studies come out "proving" that penicillin does not shorten the course of streptococcal pharyngitis, that antibiotics do not help cat scratch disease, that triglycerides do not affect heart disease, that ibuprofen is as safe as acetaminophen in children over six months and that post-menopausal estrogen causes breast cancer (or does not), that a high fiber diet can (or cannot) prevent colon cancer or that personality does or does not affect heart attack risk, we take all with "a grain of salt. No matter how compelling the statistical evidence internal to one study may be, it does not exist in a contextual vacuum. For example, suppose that a serologic test for HIV is positive in 95% of people actually infected with HIV and in 1% of people who are not infected. When such a test is used in a population "previously known" to have a low incidence of HIV infection, say "worried well college students" who havea1in1,000 chance of being infected, a positive test has much less predictive value than it does in a population of 1,000 prisoners whose "prior probability" of being infected is, say, 10%. When prior probabilities are actually applicable to the group being tested, and in this lies the controversy, the predictive value of the test comes out as follows: For the 1,000 college students 92 CHAPTER 3 there is one who will likely have a true positive test result and there are 10 who will have false positive tests. After the test, the probability of anyone testing positive actually being infected is about. The predictive value of a negative test only improves the odds that one is not infected in this group from. In contrast, for the prisoners, out of the 100 actually infected, 95 will test positive and out of the 900 not infected, 9 will test positive. A test is most useful when it most strongly changes the odds that a disease is present, and that depends on the setting in which it is used. Bayesian theory is a wonderful way to improve the precision of informal reasoning about some contextual questions. But, as Dewey has shown, informal reasoning deals with much more than just weighing the significance of prior probabilities. Informal reasoning even includes deciding when to use a more formal decision process. CONCLUSION Dewey’s claims about natural and interactional values, real qualities, situated reason and the importance of context provide the groundwork for understanding what he means by a "situation. After the discussion of "situations," a fairly comprehensive and direct presentation of his theory of means and ends can be made. I have saved discussion of the difficulties and problems with this theory, some of which I think are major, until the end of that chapter. Dewey appears to be overconfident that "situations" and "problems" are self-evident; that if there is no worry, there is no problem. However, modifications which might be required regarding certain of his claims do not render his insights useless. Already, in this chapter, we can see how his considerations make it totally inappropriate to put on blinders when making medical decisions, and how they show that common assumptions about "costs" and "benefits" misrepresent the nature of means, ends and values. Dewey’s work on means and ends reasoning dovetails with the discoveries of cognitive psychology and linguistics in showing us how our reasoning in many practical domains both is, and cannot escape being, informal. Chapter IV gives more detail of how Dewey thinks engaged judgment can grapple with amorphous and shifting circumstance. Dewey often failed to note that there have been many philosophers of process whose views should have been quite sympathetic to his own. For example, Heraclitus, whose words as reported by Plato this passage echoes: "Heraclitus somewhere says that all things are in process and nothing stays still, and likening existing things to the stream of a river he says that you would not step twice into the same river. Kant elaborates on the meaning of an end in itself in the following several pages. It signifies the order, perspective, proportion which is achieved, during deliberation, out of a diversity of earlier incompatible preferences.

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Through the education program and psychotherapy she became aware of these repressed feelings and the pain gradually disappeared generic allegra 120 mg visa allergy medicine 018. The process was not without psychological trauma discount allegra 120mg visa allergy rash on baby, for now she was faced with the disapproval of her family and friends and her own deeply ingrained attitudes cheap allegra 120mg otc allergy medicine and pregnancy. But this was appropriate and vastly preferable to the physical pain, of which she had been a helpless victim. Though we love them, they may burden us in many ways and the resultant anger is internalized. A good example: A man in his forties went to visit his elderly parents in another city. Before the weekend was over he had a recurrence of back pain, the first since successfully completing the TMS therapeutic program a year before. When I suggested that the return of pain meant that something was bothering him subconsciously, he said the weekend had been pleasant. But then he revealed that his mother was feeble, that he had spent most of the weekend ministering to her needs, and that both of his parents were a worry to him. So his natural (intrinsic, unconscious, narcissistically inspired) annoyance (anger, resentment) was completely repressed and, for reasons which shall be clarified shortly, gave rise to the recurrence of back pain. Or take the case of the young father whose first-born turns out to be a nonsleeper. Not only does he lose sleep but his wife is pretty much tied up with baby around the clock. He has to pitch in during his free time, their social life is much curtailed and what was a long honeymoon before baby came is now a grind. He develops back pain because he’s mad at the baby (ridiculous), and angry at his wife because she can no longer minister to his emotional and physical needs as she had before (absurd). But he doesn’t know about any of these feelings—they are deeply buried in his unconscious; and to make sure they stay there he gets back pain—TMS. There is a large group of psychologists and doctors who would put a different interpretation on the young father’s plight. They The Psychology of TMS 41 would say his back hurts from lifting the baby and not getting enough sleep; and that the pain is very bad because he’s trying to get out of doing his part with the baby—now he has a good excuse. The trouble with it is that it presupposes a structural reason for the pain, which is usually untenable (this baby’s father played high school and college football); and, secondly, it elevates to preeminence a feeling that is either minor or non-existent, that the person is deriving some benefit from the pain. Behavioral psychologists like it, however, because it’s simple and all you have to do is reward “non-pain behavior” and punish its opposite. There is no getting involved with messy unconscious feeings like anxiety and anger. Years ago, before I knew about TMS, I tried this approach and found it singularly ineffective. It is one of the first things to be considered when someone has an attack of TMS that seems to come out of nowhere. The combination of real concern and love for the family member and inner resentment of the duties and responsibilities associated with the relationship are a source of deep conflict, the stuff of which TMS is made. Here is a classic story with some interesting sidelights about the natural history of TMS. The patient was a thirty-nine-year-old married man who ran a family business originally started by his father. He told me that his father was still active in the business but that he had become a hindrance rather than a help. He admitted to conflict with his father over this and to feeling guilty about the whole thing. The pain syndrome had begun about two and a half years before, and about four months into the experience he read my first book. He decided it was hogwash and proceeded to make his way through the medical system, determined to get rid of the pain. He said he saw many doctors and tried virtually every available treatment, with no success. Two years later he was still in pain, 42 Healing Back Pain was rapidly becoming obsessed with it, and was extremely limited physically. At that point he read the book again and reported with incredulity, “It had a totally different effect on me.

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