Ectopic Pregnancy and its Types

Ectopic Pregnancy

Is a condition during which fertilized ovum implants outside of the endometrial lining of the uterus. There are many factors which lead to such kinds of implantations amoung which inflammation of pelvic cavity, prior ectopic pregnancy, assisted reproductive techniques such as ovulation induction and in vitro fertilization. It is the leading cause of maternal death. The clinical representation of ectopic pregnancy is non-specific and includes vaginal bleeding, adnexal mass in a patient with positive pregnancy test. In more complicated cases evaluation of intrauterine and extrauterine findings helps sonographers to confirm an ectopic pregnancy.

Intrauterine Findings

An endometrial lining and uterus exhibit a wide variety of appearance in a patient with ectopic pregnancy. An endometrial cavity appears normal, thickened, or heterogeneous and it may contain fluid-filled structures pseudogestational sac or decidual cysts. A pseudogestationl sac is a collection of fluid or other materials due to blood or debris that accumulates in the endometrial cavity in the setting of some ectopic pregnancy. A decidual cyst is a tiny cyst in the endometrium and is associated with higher risk of ectopic pregnancy in the setting of positive pregnancy test and no identifiable intrauterine pregnancy.

Extrauterine Findings

Identification of an embryo with cardiac activity in the extrauterine pseudogestationl sac is the most reliable ultrasound appearance of the ectopic pregnancy. In the appropriate clinical setting of a positive pregnancy test and failure to identify intrauterine, ultrasound identification of an adnexal ring sign, characterized by extraovarian and extrauterine mass with a peripheral hyperechoic rim of trophoblastic tissue and central fluid corresponding to the gestational sac, is highly likely to represent an ectopic pregnancy.  

Unusual Forms of Ectopic Pregnancy

• Interstitial Ectopic Pregnancy

Also known as cornual ectopic pregnancy, is a condition during which a fertilized egg implants in the intermural section of the fallopian tube, that is, in the segment of the fallopian tube that joins the uterine cavity wall. The pregnancy tends to grow larger and ruptures later in pregnancy than ectopic pregnancies in the ampullary or isthmic portion of the tube due to their location and abundant blood supply. In such kind of cases, ultrasound reveals a presence of pseudogestational sac in the superolateral aspect of the uterine fundus. There is absence or asymmetric thinning of the myometrium surrounding the gestational sac.

• Cervical Ectopic Pregnancy

Is a rare form of ectopic pregnancy which involves implantation of the gestation into the cervical tissue. Factors which leads to cervical ectopic pregnancy are more frequent use of assisted reproductive techniques, abortions and cervical instrumentation. In a patient with cervical ectopic pregnancy, ultrasound reveals an embryo with cardiac activity, prominent peri trophoblastic flow on Doppler evaluation, eccentric location of the gestational sac with the visualization of the endocervical canal separate from the pregnancy and lack of endometrial thicking in the upper uterus

• Abdominal Pregnancy

Abdominal pregnancy refers to implantation of the gestation in the abdominal cavity. It is also a rare form of ectopic pregnancy which occurs following tubal abortion, rupture of a tubal pregnancy into the abdomen, and can be found in a wide variety of locations such as the liver, cul-de-sac, and spleen and along the uterine wall, broad ligament or diaphragm. The ultrasound diagnosis of abdominal pregnancy relies on the identification of the uterus separate from the pregnancy.    

            

   

Diagnostic and Concerning Features of Obstetrical Ultrasound

Obstetrical Ultrasound

Is the evaluation of changes and alterations occurring in the fetus and the pelvic cavity of the mother during pregnancy, which includes embryogenesis and structural changes usually of the size of the pelvic cavity. These diagnostic and concerning features are seen during the first trimester of the gestation.

Diagnostic Features that Conforms non-viable Pregnancy

1. Crown to rump length greater than 7mm with no evaluation of embryo confirms non-viable pregnancy.
2. Mean sac diameter greater than 25mm with no visualization of yolk sac and embryo confirms non-viable pregnancy.
3. If the embryo and cardiac activity are not seen after:

•    Two or more weeks of the visualization of the gestational sac
• 9 to 10 days following visualization of gestational and yolk sac

Concerning Features that are not Diagnostic Features of non-viable Pregnancy

1. The crown to rump length less than 7mm favors viable pregnancy.
2. Mean sac diameter less than 25mm will result in viable pregnancy.
3. An empty amnion sign. 
4. Double belb sign.
5. Misshapen gestational sac (irregular, thin hypoechogenic peripheral rim)
6. Large amnion relative to the embryo.
7. Dislocation of the gestational sac.
8. Small gestational sac relative to the embryo, the condition is termed as oligohydramnios
9. Abnormal heartbeat rate, lower than 90bps before 6.3 weeks of gestation and lower than 110bps greater than 7 to 10 weeks of gestation, the condition is termed as bradycardia.
10. No embryo with cardiac activity is seen after 6 weeks of gestation or last menstrual cycle.
11. Chorionic bump.
12. Abnormal appearing  

Endocarditis

Endocarditis is a bacterial or fungal inflammation of the inner layer of the heart, the endocardium, resulting in the formation of an adherent mass of thromboitic debris and organisms, termed as vegetation. It normally involves the coronary heart valves, the interventricular septum, the mural endocardium, cordae tendineae or the surfaces of the intracardiac gadgets. It's miles continually a severe infection and, if left untreated, will result in demise.

What Causes Endocarditis?

Predisposing factors

• Congenital heart disease: Such as bicuspid aortic valve, hypertrophic subaortic stenosis, calcified aortic valve disease, VSD, coarctation of aorta or patent ductus arteriosus
• Rheumatic Coronary disease: So as of sequence mitral regurgitation, mitral stenosis, aortic stenosis, aortic regurgitation
• Prosthetic valves

Organisms

• Enterococcus fecalis is found in perianal and fecal bacterial flora. It can cause infections more commonly in older men with the prostatic disease while in women with genitourinary infections.
• Staphylococcus aureus is responsible for acute endocarditis and originates from skin infections, abscesses or intravenous lines.
• Streptococcus viridians are a common cause of periodontal infections and are commensals in the upper respiratory tract. They may enter the blood stream on chewing, teeth brushing, or dental extraction.
• Postoperative endocarditis follows cardiac surgery and affects native or prosthetic valve. The most common organism is Staphylococcus epidermis.
• Fungal infections ( Aspergillus, Candida ) may attack previously normal or prosthetic valves, usually affects drug addicts and immunosuppressed patients.

Types of Endocarditis

   There are several ways to classify endocarditis. The simplest classification is based on the cause: either infective or non-infective, depending on whether the microorganism is the source of inflammation or not. The infective endocarditis is further subdivided into following subtypes:

Acute infective endocarditis

A highly virulent organism such as Staphylococcus aureus is responsible for causing an acute infective endocarditis. They can cause severe destruction of valve resulting in acute valvular regurgitation. Intravenous drug users are at very risk of endocarditis because numerous needle punctures give aggressive staph bacteria many opportunities to enter. If untreated this form of endocarditis can be fatal in less than six weeks.

Subacute infective endocarditis

Subacute infective endocarditis is caused by organisms of low virulence such as Streptococcus viridian and Streptococcus epidermidis that normally live in mouth and throat and almost always occur in patients with a pre-existing valvular abnormality. This condition has more chronic course, the resultant infection tends to progress somewhat more slowly and it usually is less likely to cause septic emboli than acute endocarditis. If untreated, it can worsen for as long as one year before it is fatal. 

Prosthetic Endocarditis

Prosthetic endocarditis is a serious infection with potentially fatal consequences, it can arise early or late after surgery. The timing of the infection reflects a different pathogenic mechanism that, in turn, influence the pathology and clinical manifestation of the infection. The common organism responsible for the prosthetic endocarditis is Staphylococcus epidermidis. This produces myocardial abscesses and damage to the conduction system.

Medical features of infective endocarditis 

• Features of contamination: Fever, night time sweats, fatigue, arthralgia, myalgia, weight reduction.
• Cardiac capabilities: Signs and symptoms of an underlying heart ailment, a cardiac failure because of valvular destruction, new or converting murmur.
• Functions of embolism: First time may additionally gift with embolic functions including stroke, pulmonary or myocardial infarction, extreme limb ache.
• Functions of immune vasculitis: Splinter hemorrhage, petechial hemorrhage, clubbing, janeway lesion.

Inspections of infective endocarditis

Following are a number of the powerful investigations to diagnose infective endocarditis:

1. Blood culture: It's far positive in approximately 95% of instances and negative in 5% cases.
2. ECG: This will display myocardial infarction or conduction defects,
3. Echocardiography: Is the important thing research for the detection of vegetations, valve harm, and the abscess formation.
4. Chest X-ray: This can indicate cardiac failure or pulmonary embolism in right-sided failure.
5. Serological assessments: It may include tests for immune complexes. 
6. Urine evaluation: Proteinuria may also occur and microscopic hematuria is constantly gifted.

Thalassemia

Thalassemia is a group of a genetic disorder of hemoglobin synthesis characterized by a decreased synthesis of globin chain. It is a type of microcytic anemia which affects blood functioning. Two alpha and two beta chains of globin polypeptide combine with haem to form hemoglobin. If synthesis of globin is reduced it will lead to decreased hemoglobin (anemia). Anemia is a condition in which body does not have enough normal, healthy red blood cells due to the destruction of erythrocytes at the massive rate. It is inherited meaning that at least one of your parents must be a carrier of the diseases. If both of your parents are carriers of thalassemia, you have a greater chance of inheriting a more serious form of thalassemia.
Several types and subtypes of the thalassemia exist, and symptoms depend on the type of disorder.

Types of thalassemia

• In normal (homozygote) both polypeptide genes are normal and produce normal beta polypeptide chains in normal quantity.
• In heterozygote conditions, one gene is abnormal and fails to perform its function but the normal gene produces enough beta chain to maintain hemoglobin level about normal. Such condition is referred to as Beta-thalassemia minor. 
• In thalassemia conditions a patient's blood contains abnormal homozygote-beta chain, both genes are abnormal and do not produce beta polypeptide chain. Such condition is called Beta thalassemia major. 
• Decreased beta chain results in unbalanced polypeptide chain production. Beta chain production is impaired or stopped while alpha chain production is normal. Alpha chain will combine with any beta chain available while remaining alpha chains combine with gamma chains to form hemoglobin F ( Fetal hemoglobin). The free alpha chains precipitate within the red cells resulting in the damage of the cell membrane and making them susceptible to phagocytosis by the reticuloendothelial system.

Beta thalassemia

Some of the most common subtypes of the Beta thalassemia are:

• Silent carrier, which usually does not cause symptoms
• A beta thalassemia trait, which causes mild anemia
• Thalassemia major ( cooley's anemia) which causes severe anemia, stunted growth, and an abnormally large spleen (splenomegaly)

Beta thalassemia major

It is a subtype of Beta-thalassemia and much more diverse than the alpha-thalassemia syndromes due to the diversity of the mutations that produce the defects in the beta globin gene. Individuals who have beta thalassemia major are usually homozygous for one of the common mutations or heterozygous for one of the common mutations. Both lead to an absence of beta globin chain production.

Symptoms of Beta-thalassemia major

Children affected by the Beta thalassemia major have following common symptoms:

1. Growth retardation
2. Intermittent infection
3. Severe anemia
4. Bone marrow hyperplasia causing bossing of skull
5. Hepatosplenomegaly

Investigations

Investigations are involved:

1. Blood picture
2. Serum ferritin high serum iron binding capacity saturated
3. X-ray of cranium: Indicates hair on end look.
4. Hemoglobin electrophoresis: Indicates a boom in fetal hemoglobin (HbF) 

Treatment

Following are some of the effective treatments for the Beta-thalassemia major.

1. Splenectomy
2. Bone marrow transplantation
3. Blood transfusion every 4-6 weeks

Alpha thalassemia

Some of the most common subtypes of the alpha-thalassemia are:

• Silent carrier, which does not cause symptoms
• An alpha thalassemia trait that can cause mild anemia
• Alpha-Thalassemia major is the most severe type. A developing fetus with this type of thalassemia needs a blood transfusion while still in the womb to survive.
• Hb H disease, which causes mild to moderately severe anemia, and an enlarge spleen ( the organ that removes worn-out old red blood cells )

Alpha thalassemia

It is characterized by an inactivation of alpha globin genes, which results in a relative increase in nonfunctional beta globin or gamma globin tetramers and subsequent cell damage. There are four alpha genes. If one gene is deleted there is no clinical effect and if two alpha genes are deleted there is mild hypochromic anemia. If all four are deleted, the baby is stillborn ( hydrops fetalis ).

Symptoms of Alpha thalassemia

Patients with the more severe type of alpha thalassemia can have:

1. Slight to extremely pale skin, slight jaundice, a swollen or large abdomen
2. Nerve problems or paralysis
3. Exercise intolerance
4. Coronary heart murmur (atypical sounds inside the heart)
5. Enlarged organs
6. Frequent infections

Treatments

• Hydrops fetalis - none
• Hemoglobin H - as for thalassemia major
• Avoid iron therapy
• Folic acid if required 

Functions of Kidneys

Kidneys are two bean-shaped organs that perform several vital functions besides formation of urine. By excreting urine, kidney plays the principal role in homeostasis.
They reside against the back muscles in the upper abdominal cavity. They reside in opposite to each other on both aspects of the backbone. The right kidney sits a little bit lower than the left to accommodate the liver.
The kidneys are multi-functional powerhouses of activity when it comes to components of the urinary system. Some of the core functions of the kidneys are detailed below.

ROLE IN HOMEOSTASIS

The primary function of the kidney is homeostasis. Homeostasis is the maintenance of internal environment from the harms of fluctuations in the external environment. Kidney accomplished this by the formation of urine, kidneys regulate various activities in the body, which are concerned with homeostasis such as.

• Excretion of waste products. Kidneys excrete the unwanted waste products, which are formed during metabolic activities:

1. Urea (cease manufactured form of amino acid metabolism)
2. Uric acid (cease manufactured form  of nucleic acid metabolism)
3. Creatinin (cease manufactured form  of metabolism in muscles)
4. Bilirubin (cease manufactured form of hemoglobin degradation)

Kidneys additionally excrete harmful overseas chemical materials which include toxins, drugs, heavy metals, pesticides and many others.

• Maintenance of Electrolyte Balance. Preservation of electrolyte balance, mainly sodium is in relation to water balance. Kidneys reserve sodium if the osmolarity of body water decreases and do away with sodium when osmolarity increases. It does this via lively shipping of sodium from the proximal tubule of the nephron.
• Preservation of Water Balance. Kidneys hold the water stability in the body via conserving water, whilst it is reduced and excreting water while it is far in extra in the body. This is a crucial process for homeostasis in the body.
• Maintenance of Acid-Base Balance. The pH of blood and body fluids must be maintained within a narrow variety for a healthful dwelling. It is achieved with the aid of the characteristic of kidneys. A pair of the kidneys prevents the body from developing acidosis via disposing of certain metabolic acids like sulphuric acid and phosphoric acid.

REGULATION OF BLOOD CALCIUM LEVEL

Kidneys play a position inside the regulation of blood calcium degree via activating 1,25-dihydroxycholecalciferol into vitamin D. Vitamin D is essential for the absorption of calcium from the intestine.

HEMATOPOIETIC FUNCTIONS

Kidneys stimulate the production of the erythrocytes by secreting erythropoietin. Erythropoietin is the important stimulating factor for erythropoiesis. Kidney also secrets another factor called thrombopoietin, which stimulates the production of thrombocytes.

REGULATION OF BLOOD PRESSURE

Kidneys play an important role in long-term regulation of arterial blood pressure by two ways:

1. With the aid of regulating the quantity of extracellular fluid.
2. Through renin-angiotensin mechanism. 

Renin-angiotensin system

Renin is secreted by the juxtaglomerular apparatus of the nephron. when released into the blood it acts on the plasma protein called angiotensinogen or renin substrate. By a series of complex reactions, it converts renin substrate into the angiotensin 2. The actions of angiotensin 2 in maintaining blood pressure are:

1. On Blood Vessels:

It increases atrial blood pressure by directly acting on the blood vessels and causing vasoconstriction. It does this also indirectly by increasing the release of noradrenaline from postganglionic sympathetic fibers.

2. On Adrenal Cortex:

It stimulates adrenal cortex to secrete aldosterone. It acts on renal tubules and increases retention of sodium, which is also responsible for the elevation of blood pressure.

3. On Kidneys:

It constricts the efferent arteriole of the glomerulus to regulate glomerular filtration rate, which causes a decrease in filtration after an initial increase.

ENDOCRINE FUNCTIONS

 Kidneys secrete many hormonal substances in addition to erythropoietin and thrombopoietin. Some of the main hormones are listed below:

1. Renin
2. Prostaglandins
3. Erythropoietin
4. 1,25-dihydroxycholecalcifeferol
5. Thrombopoietin

Congestive Heart Failure

Congestive heart disease is a clinical condition which results from deficient cardiac stroke volume, relative to body need, with the inability of the cardiac output to keep pace with the venous return i-e, the heart is unable to pump all the blood coming to it. Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal. About 670,000 people are diagnosed with heart failure each year. It is the leading cause of hospitalization in people older than age 65.

Etiology

Left Ventricular Failure

Volume overload

• Aortic regurgitation
• Mitral regurgitation
• Patent ductus arteriosus

Pressure overload

• Systemic hypertension
• Aortic stenosis

Myocardial diseases

• Ischemic heart disease
• Dilated cardiomyopathy
• Cardiomyopathy coronary artery disease

Right Ventricular Failure

Volume overload

• Atrial septal defect
• Tricuspid regurgitation

Pressure overload

• Pulmonary hypertension
• Pulmonary stenosis

Myocardial disease

• Cardiomyopathy (dysfunction of left and right ventricles)

Causes of Heart Failure

•  Coronary heart disease. A disease of the arteries that supply blood and oxygen to the heart, causes decreased blood flow to the heart muscle. If the arteries emerge as blocked or critically narrowed, the heart turns into starved for oxygen and vitamins.
• Cardiomyopathy. Damage to the heart muscle from causes other than artery or blood flow problem, such as from infections or alcohol or drug abuse.
• Decreased cardiac output ( Forward failure ). Decreased cardiac output due to decreased heart function results in diminished filling of the arterial tree. Therefore blood supply of the organs is reduced which may lead to ischemia.
• Damming of blood ( backward failure ). Heart fails to pump the whole blood coming to it resulting in blood damming back into the venous system. Accumulation of deoxygenated blood in the tissue venous system may produce disturbed organ function.
• Other conditions. Conditions including high blood pressure, valve disease, thyroid ailment, kidney ailment, diabetes, or coronary heart defects present at birth can all reason coronary heart failure. In addition, heart failure can occur when several disease or conditions are present at once.

Signs and Symptoms of Heart Failure

The symptoms can include:

• Congested lungs. Fluids amassed in the lungs can purpose shortness of breath with a workout or difficulty breathing at rest or whilst mendacity flat in bed. Lung congestion can also purpose a dry, hacking cough or wheeze.
• Dyspnea. A sense of breathlessness, initially on exertion than on rest also. The dyspnea is maximal when congestion of lung is greatest as in exercise.
• Orthopnea. Dyspnea on lying flat is called orthopnea. It results from increased amount of venous return to thorax from lower extremities when the patient is in lying position. 
• Paroxysmal nocturnal dyspnea. Dyspnea during sleep which awakens the patient with severe breathlessness, accompanied by a choking sensation and coughing is called paroxysmal nocturnal dyspnea.  

Signs

• Tachycardia. cardiomegaly, third heart sound, and fine crepts at the lung bases. 
• Chronic dilation of the left atrium may also occur which may be associated with atrial fibrillation.   

Types of Heart Failure

The coronary heart failure may be categorized in several approaches.

1. Chronic heart failure versus Acute heart failure 
2.  Biventricular failure, left as opposed to right ventricular failure
3. Forward as opposed to backward failure
4. Systolic as opposed to diastolic failure
5. Low output versus excessive output failure  

Investigations

ECG
ECG may show:

• Right or left ventricular hypertrophy
• Myocardial ischemia or infarction
• Arrhythmia

Echocardiography
Echocardiography is a very important tool for the diagnosis and cause of heart failure, it may demonstrate:

• Systolic or diastolic ailment of left or right ventricle
• Valve disease
• Local wall motion abnormalities in ischemic heart disease
• Cardiomyopathy
• Ejection fraction
• Intracardiac thrombus 

X-Ray Chest

It may show:

• Hilar congestion
• Cardiomegaly
• Evidence of pulmonary hypertension
• Pleural effusion

  

Stomach and its Structure

The stomach is a muscular, hollow pouch like structure situated on the left side of the abdomen, thus helping in the digestion of the food. It is present nearly in every animal which chews food. In humans, it is located between the esophagus and the small intestine, from esophagus it enters stomach through a narrow section called esophageal sphincter. On the entrance of the food, it releases a large number of enzymes which combines with food, making chyme, thus helping in the digestion, usually 2nd step of digestion occurs here and useful contents get absorb into the blood for further processing. In adults, it has a capacity to store about 1500ml of the chyme.
The stomach is relatively fixed at both ends but very mobile in between. It tends to be high and transversely arranged in the short, obese person ( steer-horn ) and elongated vertically in tall, thin person ( J-shaped stomach ). Its shape undergoes considerable variation in the same person and depends on the volume of contents, the position of the body and the phase of respiration.

Structure of the Stomach

In humans, the stomach is divided into following parts:

Fundus: It is a dome-shaped structure, located left side of the cardiac orifice projecting upward and full of gas.

Body: It extends from the cardiac orifice to the incisura angularis, a constant notch in the lesser curvature of the stomach.

Pyloric antrum: This extends from the incisura angularis to the pylorus. 

Pylorus: This is the tubular structure of the stomach. The thick muscular wall is called the pyloric sphincter, and the cavity of the pylorus is called pyloric canal. 

Openings: The stomach has two openings the cardiac orifice and the pyloric orifice. The cardiac orifice is the region where the esophagus enters the stomach, that prevents the regurgitation of the stomach contents into the esophagus. The pyloric orifice is formed by the pyloric canal, which is about a 2.5cm long tube. The pylorus is located in the transpyloric plane, which can be recognized by the presence of the slight constriction on the surface of the stomach.

Lesser and greater Curvature: It extends from the cardiac orifice to the pylorus, forming right border of the stomach, which is suspended from the liver by the lesser omentum, The greater curvature is longer than the lesser curvature, which extends from the left of the cardiac orifice, over the dome of the fundus, and along the left border of the stomach to the pylorus.

Function

In addition to the secretion of the enzymes, it performs following functions too:

1. It stores meals (within the grown up it has an ability of approximately 1500ml ).
2. It mixes the meals with gastric secretions to shape semi-fluid chyme.
3. It controls the rate of transport of the chyme to the small gut in order that efficient digestion and absorption can take place.

Layers of the Stomach 

As we discussed earlier that the human stomach is hollow, muscular organ, which is consist of the layers packed on each other, providing strength to the stomach. It is consist of the following layers:

• Mucosa

This is the innermost structure of the stomach and has three layers the mucosal epithelium, the lamina propria, and the muscularis mucosa, collectively called lumen of the stomach.

• Submucosa

This surrounds the mucosa and contains loose connective tissue, blood vessels, and the nerves.

• Muscularis Externa

It consists of the connective tissues whose fibers move in a different direction from each other to strengthen the stomach, which is as follow, the oblique, circular and the longitudinal muscle.

• Serosa

It lies next to the muscularis externa and includes a dense network of the blood vessels.

Anatomical Relation

Anteriorly: Anterior to the stomach, the anterior abdominal wall, the left costal margin, the left pleura and lung, the diaphragm, and the left lobe of the liver are located.

Posteriorly: The lesser sac, the diaphragm, the spleen, the left suprarenal gland, the superior part od the kidney, the splenic artery, the pancreas, the transverses mese-colon, and the transverses colon.

Blood Supply

• Arteries

The arteries are derived from the celiac artery and supply blood to the stomach.

The left gastric artery: It supplies the lower third of the esophagus and the upper right part of the stomach.

The right gastric artery: It supplies the lower right part of the stomach.

The short gastric artery: It supplies blood to the fundus of the stomach.

The left gastroepiploic artery: It supplies blood to an upper part of the greater curvature.

The right gastroepiploic artery: It supplies blood to the lower part of the greater curvature of the stomach.

• Veins

The veins drain into the portal circulate, The left and right gastric veins drain at once into the portal vein. The short gastric veins and the left gastroepiploic veins be a part of the splenic vein. The right gastroepiploic artery then joins the superior mesenteric vein. 

    

The Inguinal Canal

The inguinal canal is the tubular structure that is located in the inguinal region, the lower portion of the anterior abdominal wall, with the pubic tubercle medially, the thigh inferiorly, and the anterior superior iliac spine superolaterally. It is about the 4cm long tube in the adult and extends from the deep inguinal ring to the superficial inguinal ring, which is a hole in the fascia transversalis downward to the superficial inguinal ring, a hole in the aponeurosis of the external oblique.

It lies immediately above and parallels to the inguinal ligament. In the newborn child's the deep inguinal ring lies posterior to the superficial ring but later it comes to the lateral side due to the growth. The inguinal canal is made up of:

1. Superficial and deep rings ( openings )
2. Anterior and superior walls
3. Floor and Roof ( inferior and superior walls )

• Deep Inguinal Ring: The deep inguinal ring is an oval opening that is present in the fascia transversalis, it lies about 1.3cm above inguinal ligament midway between the anterior superior iliac spine and the symphysis pubis. The inferior epigastric vessels are present medial to it, which pass upward from the external iliac vessels. The margins of the deep inguinal ring give attachment to the internal covering of the spermatic fascia.

• Superficial Ring: The superficial ring is a triangular shaped ring situated in the aponeurosis of the external oblique muscle that lies immediately above and medial to the pubic tubercle. The margins of the external oblique are called crura, which give attachment to the external covering of the spermatic cord.

Walls of the Inguinal Canal

• Anterior Wall: The anterior wall of the inguinal canal is formed by the aponeurosis of the external oblique muscle, which is reinforced laterally with the aid of the internal muscle. It lies opposite to the weakest part of the posterior wall, specifically, the deep inguinal ring.
• Posterior Wall:  It is formed by the conjoint tendon, and strengthen by the fascia transversalis laterally.
• Superior Wall:  Also known as the roof of the inguinal canal, it is formed by the transversalis fascia, internal oblique, and the transversus abdominis.
• Inferior Wall:    Also called floor of the inguinal canal, it is formed by the inguinal ligament and thickened by the lacunar ligament.

Functions of the Inguinal Canal

The inguinal canal permits structures of the spermatic cord to bypass to and away from the testes to the abdomen in the males, at the same time as in the females it acts as a passageway to pass the round ligament of the uterus from the uterus to the labium majus.

Nerve Supply

The inguinal canal is innervated by the ilioinguinal nerve a branch of the first lumbar nerve (L1). Note that the ilioinguinal nerve does no longer pass via the deep inguinal ring, and therefore it only travels through a part of the inguinal canal. 

 

 

Muscles of the Abdominal Wall

The abdomen is the region of trunk situated between diaphragm below and the inlet of the pelvis below. It accommodates a large number of organs and its muscles strengthen or give proper shape to the human skeleton.
From exterior to interior the muscles of the anterior abdominal wall are the external oblique, internal oblique, and transversus abdominis, which are aponeurotic in front. In addition to these, it also contains a wide vertical thin sheet called rectus abdominis, which is separated from its compartments by means of linea alba. The posterior abdominal wall consists of psoas major, quadratus lumborum and iliacus muscle.

Anterior Abdominal Wall

As we discuss earlier the anterior abdominal wall consist of the external oblique, internal oblique, and the transversus abdominis. Their details are as follow:

• External Oblique

It's miles a skinny, wide muscular sheet, arise from the outer surfaces of the lower eight ribs, which fans ahead laterally to be inserted into the xiphoid process,  pubic crest (bone), pubic tubercle (bone), linea alba and anterior half of the iliac crest. The aponeurosis of the external oblique incorporates superficial inguinal ring and additionally forms the inguinal ligament, pectineal ligament and the lacunar ligament (connects inguinal ligament to the pectineal ligament).

Nerve supply: It is innervated by lower six thoracic and lumbar nerves.

Action: It compresses abdominal contents and helps in micturition, defecation, and parturition.

• Internal Oblique

It is also a thin muscular sheet, which lies deep to the external oblique, its fibers fan perpendicular to that of external oblique. Internal oblique arises from the lumbar fascia, anterior two third of the iliac crest, lateral two third of the inguinal ligament. They move upward and forward to be inserted into the lower borders of the lower three ribs and their intercostal cartilages, xiphoid process, linea alba and pubic symphysis.

Nerve supply: It is innervated by lower six thoracic and lumbar vertebrae.

Action: Similar as external oblique.

• Transversus Abdominis

It is the deepest muscle among all, which arise from the costal cartilages of the lower six ribs, lumbar fascia, iliac crest and lateral two third of the inguinal ligament, which is inserted into the xiphoid process, linea alba, and pubic symphysis. Its fibers move forward horizontally and contain the deep inguinal ring.

Nerve supply: Lower six thoracic and lumbar nerves.

Action: Similar as external and internal oblique.

• Rectus Abdominis

The rectus abdominis is long strap muscle that arises from the front of the pubic crest and pubic symphysis. It is inserted into the fifth, sixth, and seventh costal cartilages and the xiphoid process. It is divided into three distinct segments by three transverse tendinous intersections: one at the level of xiphoid process, one at the level of the umbilicus and another halfway between these two. These intersections are strongly attached to the anterior wall of the rectus sheath.

Nerve supply: It is innervated by lower six thoracic nerves.

Action: It pulls the ribs and the pelvis in and curves back.

Posterior Abdominal Wall

The posterior abdominal wall consist of following muscles:

• Psoas Major

The psoas major arises from the transverse processes, bodies, and intervertebral discs of 12th thoracic to 5th lumbar vertebrae. Its fibers move downward laterally to be inserted into the lesser trochanter of the femur, It is enclosed in a fibrous sheath that is derived from the lumbar fascia, it forms medial arcuate ligament superiorly.

Nerve supply: It is innervated by the lumbar plexus.

Action: It flexes the thigh on the trunk and if thigh is fixed flexes trunk on the thigh.

• Quadratus lumborum

  It is quadrilateral shaped, flat muscle that lies obliquely with vertebral column. It arises from the iliolumbar ligament, which is the adjoining part of the iliac crest and the transverse process of the lower lumbar vertebrae. It moves upward medially to be embedded into the 12th rib and upper four lumbar vertebrae.

Nerve supply:  It is innervated by the lumbar plexus.

Action: It boosts or recessed the 12th rib for the duration of respiration and laterally flexes the vertebral column to the same side.

• Iliacus 

It is fan-shaped muscle which arises from the upper surface of the iliac fossa. The fibers of iliac fossa join the lateral side of the psoas tendon to be inserted into the lesser trochanter of the femur, which is commonly called iliopsoas muscles.

Nerve supply: This muscle is supplied by femoral nerve, a branch of the lumbar nerve.

Action: It flexes the thigh on the trunk at the hip joint and if thigh is fixed then flexes trunk on the thigh.

 

      

Necrosis and its Types

Necrosis is the type of cell injury, which results in premature death of cells in living tissue, in response to non-stop physiological stress by means of autolysis. It is far an unprogrammed cell loss of life and may be due to factors external to the cell or tissue, together with infection, toxins, or trauma which bring about the unregulated digestion of cell components.

Types of Necrosis

There are six types of necrosis:

• Coagulative Necrosis

It is an accidental cell death typically caused by ischemia or infarction, which is characterized by the formation of a gelatinous substance in dead tissue and can be observed by light microscope. During coagulation protein ( albumin ) transform into a firm and opaque state, which can be seen in hypoxic conditions. It occurs primarily in tissues such as kidney, adrenal glands, and heart. 

• Liquefactive Necrosis

It is a type of necrosis, during which the affected cell is completely digested by hydrolytic enzymes, resulting in soft, circumscribed lesion consisting of pus and fluid remains of necrotic tissue. The necrotic fluid is creamy yellowish in appearance, due to the presence of dead leukocytes and commonly known as pus.

• Gangrenous Necrosis

It is a not communicable disease, caused by a critically an insufficient blood supply.  Smoking and diabetes may increase the risk of gangrenous necrosis. Types of gangrene necrosis may differ in symptoms which include

1. Dry gangrene
2. Wet gangrene
3. Gas gangrene
4. Internal gangrene

• Caseous Necrosis

It can be considered a combination of a coagulative and liquefactive necrosis. Typically caused by bacteria, fungi, and some foreign substances. During caseous necrosis, dead cells disintegrate but not completely digested, and a tissue maintains a cheese- like an appearance. 

• Fat Necrosis

It is a benign condition which is characterized by action upon fat by fat digesting enzymes. During which lipases splits fat into glycerol and fatty acids. Which then combines with alkali metals to form soap, called saponification, which can cause critical conditions.

• Fibrinoid Necrosis

It is miles a form of necrosis, which is resulting from immune-mediated vascular damage. It's far marked by means of complexes of antigens and antibodies, on occasion known as ''immune complexes'' deposited inside arterial walls together with fibrin.

Cellular Changes during Necrosis

The cellular changes can be classified into following stages.

• Karyolysis

During which nucleus fades due to loss of DNA by degradation.

• Pyknosis

The nucleus shrinks and chromatin condensed.

• Karyorrhexis

The shrunken nucleus fragments to finish dispersal. 

Peptic Ulcer

Peptic ulcer disease refers to the destruction of the inner lining of the stomach and upper portion of the small intestine, called duodenum. An ulcer in the stomach is known as gastric ulcer and while that in the first part of the stomach is known as the duodenal ulcer.

Causes of the Ulcers

There is no any single factor which causes the ulcer. But following are some of the major factors which can cause an ulcer.

Infections

The major causative factor is chronic inflammation due to Helicobacter pylori, that destroys internal mucosa. In response to the presence of the bacteria, parietal cells secrete gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation.

NSAIDS

Excessive usage of the painkillers called non-steroidal anti-inflammatory drugs, such as aspirin, naproxen, and ibuprofen can also cause ulcers. 

Diet

Dietary factors such as spice consumption were hypothesized to cause the ulcer. Caffeine and coffee, additionally commonly concept to cause or exacerbate ulcers, seem to have little impact.

Tumors in Acid Producing Cells

In Zollinger-Ellison Syndrome, the acid producing cells become inflamed and cause gastrinomas, tumors of the acid-producing cells of the stomach that increases acid output.

Stress

Stress due to serious health problems and chronic life stress can also cause ulcers, known as stress ulcers. Although some studies have found correlations between drinking, smoking, and ulcer formation.

Signs and Symptoms

The most common symptom of a peptic ulcer is burning abdominal pain that extends from navel to the chest. Other common signs of a peptic ulcer include:

• Abdominal pain
• Bloating and abdominal fullness 
• Loss of appetite and weight loss
• Hematemesis ( vomiting of blood ), this can occur due to bleeding directly from a gastric ulcer,
• Melena ( tarry, foul-smelling feces due to presence of the oxidized iron from hemoglobin )
• Nausea and copious vomiting
• Waterbrush ( rush of saliva after an episode of regurgitation to dilute the acid in esophagus, although this is more associated with gastroesophageal disease )    

       

  

The Pericardium

The pericardium is a fibro serous sac that encloses heart and blood vessels originating from the base of the heart. It is located in the middle mediastinum, posterior to the body of the sternum and the second to sixth costal cartilages and anterior to the fifth to eighth thoracic vertebrae. It serves as a lubricant container in which different parts of the heart can contract and restrict excessive movement of the heart. It has two main layers the fibrous and serous pericardium.

Fibrous pericardium

It is a thin elastic layer and the outermost layer of the pericardium which is firmly attached below to the central tendon of the diaphragm and in front to the sternum by the Sterno pericardial ligaments. It lines anterior section of the vertebral column of the thoracic wall posteriorly and pleural sac anteriorly.

Serous pericardium

It is situated next to the fibrous pericardium and dived into parietal and cervical serous pericardium. The parietal pericardium strains fibrous layer externally and contemplated around the roots of the great vessels to grown to be non-stop with the visceral layer of the serous pericardium. The inner layer of the serous pericardium covers the walls of coronary heart intently and is frequently referred to as the pericardium. 

There is a small slit like space between the parietal and visceral layer, containing fluid which serves as a lubricant and reduces friction during the heart beat. In normal condition, it contains nearly 50ml of fluid. On the posterior surface of the heart, the reflection of serous pericardium around the large veins forms a recess called oblique sinus and reflection around the aorta and pulmonary trunk forms a transverse sinus. 

Nerve Supply

The visceral layer of the serous pericardium is innervated by sympathetic nerve and the vagus nerves. The fibrous and parietal layer of the pericardium is innervated by phrenic nerves.

Pericarditis

In inflammation of the serous pericardium ( pericarditis ) pericardial fluid may accumulate excessively, which can compress the thin-walled atria and interfere with the filling of the heart during diastole. This compression of the heart is referred as cardiac tamponade, which can also occur secondary to the stab and gunshot wounds when the chambers of the heart have been penetrated.

Blood Supply and Venous Drainage

The fibrous and parietal pericardium is supplied with an internal thoracic artery, and descending thoracic aorta. Coronary arteries supply blood to the visceral serous pericardium. Azygos and internal thoracic vein drain venous blood from the fibrous and parietal pericardium. Visceral serous pericardium - drain into the coronary sinus.`  

    

Arteries of the Thoracic Cacity

As we know that arteries incorporate oxygenated blood, except pulmonary artery and that they pass away from the heart to deliver blood all over the body. Following are a number of the primary and huge arteries of the thoracic cavity.

Aorta

Aorta is the main section of human blood circulatory system, which is situated at the base of the heart and delivers blood to all over the body from the left ventricle. For purposes of description, it is mile's divided into following parts:

• Ascending aorta

It lies within the fibrous pericardium and is enclosed with the pulmonary trunk in a sheath of serous pericardium. The ascending aorta originates at the bottom of the left ventricle and runs upward to come to lie in the back of the right half of the sternum, at a level of the sternal angle, it possesses three bulges. Its branches are right coronary artery and left coronary artery, which assists blood to the cardiac tissues.

• Descending aorta 

It lies within the posterior mediastinum and starts of evolved as a continuation of the arch of the aorta at a level to the 4th thoracic vertebrae, it runs all the way down to the diaphragm and at a degree of the 12th thoracic vertebrae it enters diaphragm through the aortic opening and becomes continuous with the abdominal aorta. Its branches are posterior intercostal arteries, subcostal arteries, pericardial arteries, esophageal arteries, and the bronchial arteries.

• Arch of the aorta 

It begins as a continuation of the ascending aorta and lies behind the manubrium sterni and moves upward to the left in front of the trachea, it then passes down to the left of the trachea and at a stage of the sternal angle, becomes continuous with descending aorta. Its principal branches are the brachiocephalic artery, left common carotid artery and the left subclavian artery.

1.  Brachiocephalic artery: It arises from the convex segment of the aortic arch and runs all the way down to the right of the trachea where it divides into the right subclavian artery and right common carotid artery at a level to the right sternoclavicular joint.
2. Left common carotid artery: It additionally arises from the convex floor of the aortic arch, lies left to the brachiocephalic artery and at a stage, to the left sternoclavicular joint it enters neck area.
3. Left subclavian artery: It arises from the aortic arch in the back of the left common carotid artery and arches over the apex of the left lung and enters root of the neck.

• Pulmonary trunk

The pulmonary trunk conveys deoxygenated blood from the left ventricle to the lungs. Collectively with ascending aorta, it is far enclosed within the fibrous pericardium and the sheath of the serous pericardium. Its branches are left and right pulmonary artery.

Veins Of the Thoracic Cavity

The thoracic cavity is the region from where all blood vessels originate and terminate. Following are some of the blood vessels of the thoracic cavity carrying deoxygenated blood.

Veins of the Thoracic Cavity

• Brachiocephalic Vein

The brachiocephalic veins are vessels of mediastinum that carries deoxygenated blood from the superior portion of the human body ( arms, neck, and head ) to the right atrium. The right brachiocephalic vein is formed by the union of the right internal jugular veins and right subclavian artery, at the root of the neck. The left brachiocephalic vein has also the same origin, it descends to the right behind the manubrium sterni and in front of the large branches of the aortic arch. The right and left brachiocephalic vein combine to form superior vena cava.

• Superior Vena Cava

The superior vena cava drains all the venous blood from the head and neck both upper limbs and passes downward to end in the right atrium of the heart. It is formed by the union of the right and left brachiocephalic vein. The azygous vein joins the posterior aspect of the superior vena cava.

• Azygos Veins

The azygos veins collect blood from the posterior abdominal wall, posterior intercostal spaces, the pericardium, the bronchi, the esophagus and the diaphragm. They are consist of the main azygos vein, the inferior azygos vein, and the superior azygos vein. 

1. Azygos vein: The main azygos vein is formed by the union of the right ascending lumbar vein and the right subcostal vein, at the fifth thoracic vertebrae it arches forward to empty into the posterior surface of the superior vena cava. Its tributaries are mediastinal veins, eight lower right intercostal veins, the right superior intercostal vein, and the superior and inferior hemiazygos veins.
2. Superior hemiazygos vein: It is formed by the union of the fourth to the eighth intercostal veins, at 7th T vertebrae it joins the azygos vein.
3. Inferior hemiazygos vein: The inferior hemiazygos vein is formed by the union of the left ascending lumbar vein and the left subcostal vein. Its tributaries are lower left intercostal veins and mediastinal veins.

• Inferior vena cava

The inferior vena cava resources blood from the inferior segment of the human body, it enters mediastinum via the central tendon of the diaphragm, at the level of the eighth thoracic vertebrae and enters the bottom part of the right atrium. 

The Pleura

The pleura is a thin membrane of connective tissue, lie on the either side of the mediastinum within the chest cavity. Each pleura has two layers parietal pleura and the cervical pleura.

Parietal pleura

The parietal pleura, which lines the thoracic wall, covers the thoracic layer of the diaphragm, and the lateral aspect of the mediastinum, and extends into the root of the neck to line the undersurface of the supra-pleural membrane at the thoracic outlet. 

Cervical pleura

The cervical layer of the mediastinum covers outer surfaces of the lungs and extends deep into the depths of the interlobar fissures.

The two layers of the pleura become continuous with each other forming cuff of the pleura, near to the hilum of the lung. The cuff of pleura hangs down to allow movement of the blood vessels and bronchi during respiration, this structure is referred to as pulmonary ligament.

Between these two layers, a small space is situated called pleural cavity. To avoid confusion with thorax cavity it is referred to as pleural space. Pleural space contains a fluid, usually 5 to 10ml in normal conditions. It acts as the lubricant between two layers. 

Nerve supply of the pleura

The pleura is innervated by both sensory nerves and autonomic nerves, depending on the surface which it covers.

The parietal pleura is sensitive to pain, temperature, touch and pressure and is supplied as follow:

The mediastinal pleura is supplied by the phrenic nerves.

The costal pleura is segmentally supplied with intercostal nerves.

The mediastinal pleura is supplied over the domes by the phrenic nerves and around the periphery by lower six intercostal nerves.

The cervical pleura is insensitive to the pain, touch, and pressure but is sensitive to the stretch. It receives autonomic nerve supply from the pulmonary plexus.

Pleural effusion

It is a condition during which the fluid in the pleural cavity increases abnormally due to any inflammation and malignancy or impairs the drainage of the fluid, resulting in decreased lung expansion, sound and dullness on percussion over the effusion. 

The presence of 300ml of fluid in the costodiaphragmatic recess in an adult is sufficient to enable its clinical detection.

Pleurisy

Inflammation of the pleura secondary to the inflammation of the lung results in the pleural surface becoming coated with inflammatory exudate, causing the surfaces to be roughened. This roughening produce friction, resulting in severe pain, this medical condition is referred to as pleurisy.    

About Myself

Hey, this is my homepage, so I have to say about myself. Sometimes it is hard to introduce yourself because you know yourself so well that you do not know where to start with. Let me give a try to see what kind of image you have about me through my self-description. Here it goes.
I am a person who is positive about every aspect of life. There are many things I like to do and to experience. I like to think, I like to dream, I like to talk, I like to listen, I like to do thought experiment when I can not sleep in the middle of the night, I like to be alone and I like to laugh.
I always wanted to be a great social worker. I also wanted to be a great psychologist, like William James, who could read people's mind. Of course, I am nowhere close to these people, yet. But my dream is still alive.
This is a brief description of myself. If you are interested in knowing more, take a look at my blog http://howcanidoit999.blogspot.com.
Thant You for being on my blog.   

Ribs their Structure and Types

In humans, there are 12 pairs of ribs, all of which are attached posteriorly to the lateral border of the sternum, giving rise to the cage like structure. This structure protects covers and protects most of the body organs situated in the chest cavity. Ribs are of three types, depending on the ways by which they articulate with the sternum.

1. True ribs: which articulate with sternum directly.
2. False ribs: which articulate with sternum indirectly.
3. Floating ribs: neither directly nor indirectly articulate with the sternum.

The ribs ranging from 1st to 7th are true ribs, while the 8th, 9th and 10th are false ribs. The last two ribs are floating ribs.

Structure of the Typical Rib

A typical rib is a flat, twisted and long bone, having round superior border and sharp, thin inferior border. Its main parts are head, neck, tubercle, shaft and angle. First and the last three ribs have single facet, while the ribs ranging from 2nd to 9th have two facets, by means of which they articulate with the thoracic part of the vertebral column. The neck of the rib is constricted portion between head and tubercle of the rib. A typical rib has two tubercles, articulated and non-articulated. Articulated tubercle articulates with the transverse process of the corresponding thoracic vertebral column. The shaft is the thin, twisted and long portion of the rib, which at its inferior side bends to form the costal groove. Costal groove accommodates intercostal arteries, veins, and nerves. The angle is where the shaft of the rib bends sharply forward.

Cervical Rib

It is an extra rib, which arises from the anterior tubercle of the transverse process of the 7th cervical vertebra. It occurs only in 0.5 % of humans. It may have a free anterior end, may be connected to the first rib by a fibrous band, or may articulate with the first rib.

The thoracic Outlet Syndrome

It is a condition in which an extra rib arises from the 7th cervical vertebra and compresses brachial plexus of nerves and the subclavian artery and the vein, which are closely related to the upper surface of the first rib and the clavicles, causing severe pain medially downward the forearm and the hand. Most of the symptoms are caused by pressure on the plexus nerves.

Rib Excision

It is mostly performed by the rib surgeons, wishing to gain an easy access to the thoracic cavity.

During which two incisions are made to remove large surface, A longitudinal incision is made through the periosteum on the outer surface of the rib and a segment of the rib is removed. A second longitudinal incision is then made through the bed of the rib, which is the inner covering of the periosteum. After the operation, the rib regenerates from the osteogenetic layer of the rib.

            

Thoracic Cavity and its Structure

The thoracic cavity is the region between the root of neck and diaphragm, which separate it from the abdominal cavity. It is also known as chest cavity and thorax. It contains large nimber of body organs and its associated structures, which leads into the cavity through the oblique opening, situated anterior to the body of 1st thoracic vertebra and leaves by a large opening, which is situated inferior to the xiphoid process and anterior to the body of the 12th thoracic vertebra.

The Structure of Thoracic Wall

 Wall of the thoracic cavity, externally covered with skin and muscles which connect shoulder girdle to the trunk. The thoracic wall is formed posteriorly by the thoracic part of the vertebral column, anteriorly by the sternum and costal cartilages, laterally by the ribs and intercostal spaces, superiorly by the supra-pleural membrane and inferiorly by the diaphragm, which separates it from the abdominal cavity. In addition to these following are some of the main structures of the rib cage.

Sternum

It is a flat bone, situated in the midline of the anterior chest wall. In addition to supporting rib cage, it has a dominant role in the formation of red blood cells ( hematopoiesis ). Sternum has three main structures, which are given below.

• Manubrium

It is the superior structure of the sternum, which articulate with the body of sternum and forms manubriosternal joint with it, which lies anterior to the body of the 3rd thoracic vertebra. Manubrium provides a site for articulation to the clavicles, first rib and an upper portion of the 2nd rib.

• Body of the sternum

The body of the sternum articulates above with manubrium and below with xiphoid process, giving rise to the xiphisternal joint. It also provides a site for articulation to the ribs ranging from 2nd to 7th.

• Xiphoid Process

It is the inferior structure of the sternum, it articulates above with the body of sternum and forms xiphisternal joint ( cartilaginous joint ), which lies anterior to the body of the 12th thoracic vertebra.

Ribs

 In humans, chest cavity has 12 pairs of ribs, which articulates anteriorly with the lateral body of the sternum and posteriorly with the numerically corresponding vertebra of the thoracic part of the vertebral column. Ribs are of three types, true ribs, false ribs and floating ribs.

Sternum and Bone marrow Biopsy

Sternum provides support and protection to the internal organs, situated in the chest cavity. Since it contains red hemopoietic marrow throughout life, it is the common site for marrow biopsy. During red bone marrow biopsy, a wide, bore needle is introduced into the cavity through the anterior surface of the bone.

Thoracic Outlet

In humans, chest cavity communicates with the root of the neck through a small opening called thoracic outlet. This is the region through which most parts of the body organs and the other structures ( blood vessels and nerves ) leads to or away from thorax cavity, therefore it's named as an outlet. 

The upper opening is bounded posteriorly by the first thoracic vertebra, laterally by the medial parts of the first ribs and their costal cartilages. It is an anteriorly bounded with superior part of the sternum (manubrium). The opening is obliquely placed forward and upward. Because of the obliquity of the opening, the apices of the lung and pleurae project upward into the neck.

It communicates with the abdomen through the large opening, which is posteriorly bounded with the 12th thoracic vertebra, laterally by curving costal margins, and anteriorly by the xiphisternal joint.

Sternal angle

It is also known as the angle of Louis. Sternal angle is formed by the articulation between the manubrium and the body of the sternum. It lies at a level to the 2nd costal cartilage and anterior to the midsection between 3rd and 4th vertebra of the thoracic vertebral column. It is recognized by the presence of transverse ridge on the anterior surface of the sternum,        

         

   

What are the Obstructing and Improving Factors of Verbal Conversation

In this context, we are focusing on the conversation between a physician and his patient, and different factors which lead this conversation to effective or drags it down. As we know that every conversation has its own techniques, which makes it effective. These techniques vary from field to field, for instance in a business field, the conversation has its own techniques and in an agricultural field, a conversation has its own. Similar to these, in medicine, a conversation has its own specific techniques which help physicians to communicate with patients properly.

• Obstructing Factors

The obstructing factors which make verbal conversations between a physician and his patient least effective are as follow:

1. Lack of exclusivity.
2. Preoccupied or anxious doctor
3. Awkward and uncomfortable seating
4. Lack of attention toward non-verbal cues
5. Offensive remarks or judgment
6.  Frequent interruptions
7. Selective listening
8. Dozing off during conversation

• Improving Factors

Following are some of the main and simple factors which make conversation effective.

1. Use of minimal prompts
2. Sit squarely to the patient
3. Lean slightly towards the patient
4. Reasonable eye contact maintained
5. Listen to the content message
6. Listen to the feelings 
7. Respond to the feeling
8. Try to build sympathetic relationship with patient
9. Note all paralinguistic and non-verbal cues during conversation 

How Verbal Techniques makes Conversation Effective

Overview

A verbal communication between a physician and his patient should be effective to solve a particular case with minimum effort and defects. Which is possible only by the practical application of some the verbal techniques during a conversation, these verbal techniques are as follow:

• Questions

Asking questions is the best way to find out the origin of a particular case. Questions are of three types.

1. Closed questions ( elicit, No/Yes)
2. Open questions ( which encourages patient to talk )
3. Leading questions ( containing why? ) Avoid using, during conversation.

• Funneling

The objective of this principle is to make conversation pure and effective. Asking questions always leads conversations from general to specific. Funneling provides a specific way to the physician.

• Paraphrasing

Explaining the whole conversation between patient and physician in simple words to let him know about his current medical condition. Which contains the repetition of last few words of the patient and summarizing what he has communicated so far and asked for validation. 

• Selective reflection

The purpose of this principle is to ensure a patient that his feelings have been well understood. To bring out the feelings attached to various symptoms and problems that a patient has stated.

• Empathy Building

Use of statements to build a sympathetic relationship with a patient, which encourages him to talk friendly with a physician. It also increases the trust of the patient on a physician.

• Checking for Understanding

Summarize patients statements time to time and ask the patient to comment to ensure if he or she has understood the problem and its associated feelings correctly.

Qualities of Good Physician

• A good physician always gives priority to the beneficence of his patient and justice.
• He should be honest, cooperative and polite.
• Capable of understanding the psychology of his patients.
• Not should be preoccupied and anxious.