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Vice Chair, Oakland University William Beaumont School of Medicine

Because most terms are derived rom Latin and Greek cholesterol ratio levels uk order 60 caps lasuna visa, medical language may seem dicult at rst; however cholesterol test levels uk discount lasuna 60caps fast delivery, as you learn the origin o terms cholesterol levels ati buy generic lasuna canada, the words make sense cholesterol levels normal range chart australia discount 60 caps lasuna overnight delivery. Consequently, the esophagogastric junction is the site where the esophagus connects with the stomach, gastric acid is the digestive juice secreted by the stomach, and a digastric muscle is a muscle divided into two bellies. For example, some muscles have descriptive names to indicate their main characteristics. The deltoid muscle, which covers the point o the shoulder, is triangular, like the symbol or delta, the ourth letter o the Greek alphabet. Some muscles are named according to their shape-the piriormis muscle, or example, is pear shaped (L. In some cases, actions are used to describe muscles- or example, the levator scapulae elevates the scapula (L. Anatomical terminology applies logical reasons or the names o muscles and other parts o the body, and i you learn their meanings and think about them as you read and dissect, it will be easier to remember their names. Abbreviations o terms are used or brevity in medical histories and in this and other books, such as in tables o muscles, arteries, and nerves. Clinical abbreviations are used in discussions and descriptions o signs and symptoms. More extensive lists o common medical abbreviations may be ound in the appendices o comprehensive medical dictionaries. By using this position and appropriate terminology, you can relate any part o the body precisely to any other part. It should also be kept in mind, however, that gravity causes a downward shit o internal organs (viscera) when the upright position is assumed. Since people are typically examined in the supine position, it is oten necessary to describe the position o the aected organs when supine, making specic note o this exception to the anatomical position. Sagittal planes are vertical planes passing through the body parallel to the median plane. However, a plane parallel and near to the median plane may be reerred to as a paramedian plane. Frontal (coronal) planes are vertical planes passing through the body at right angles to the median plane, dividing the body into anterior (ront) and posterior (back) parts. Transverse planes are horizontal planes passing through the body at right angles to the median and rontal planes, dividing the body into superior (upper) and inerior (lower) parts. Radiologists reer to transverse planes as transaxial, which is commonly shortened to axial planes. Since the number o sagittal, rontal, and transverse planes is unlimited, a reerence point (usually a visible or palpable landmark or vertebral level) is necessary to identiy the location or level o the plane, such as a "transverse plane through the umbilicus". Sections o the head, neck, and trunk in precise rontal and transverse planes are symmetrical, passing through both the right and let members o paired structures, allowing some comparison. Anatomical Position All anatomical descriptions are expressed in relation to one consistent position, ensuring that descriptions are not ambiguous. One must visualize this position in the mind when describing patients (or cadavers), whether they are lying on their sides, supine (recumbent, lying on the back, ace upward), or prone (lying on the abdomen, ace downward). The anatomical position reers to the body position as i the person were standing upright with the: Head, gaze (eyes), and toes directed anteriorly (orward). The main planes o the body are illustrated: median and sagittal (A), rontal or coronal (B, C), and transverse (axial) (C). Transverse sections, or cross sections, are slices o the body or its parts that are cut at right angles to the longitudinal axis o the body or o any o its parts. Because the long axis o the oot runs horizontally, a transverse section o the oot lies in the rontal plane. Oblique sections are slices o the body or any o its parts that are not cut along the previously listed anatomical planes. In practice, many radiographic images and anatomical sections do not lie precisely in sagittal, rontal, or transverse planes; oten, they are slightly oblique. Terms o Relationship and Comparison Various adjectives, arranged as pairs o opposites, describe the relationship o parts o the body or compare the position o two structures relative to each other. Anatomicomedical Terminology 7 * Superficial Nearer to surface the muscles of the arm are superficial to its bone (humerus). Dorsal Anterior hand (palm) Posterior hand (dorsum) Dorsal surface Dorsum Palmar surface Palm 1 * Intermediate Between a superficial and a deep structure the biceps muscle is intermediate between the skin and the humerus. Dorsal Inferior foot surface (sole) * Deep Farther from surface the humerus is deep to the arm muscles. Median plane Superior foot surface (dorsum) Dorsal Plantar surface surface Dorsum Coronal plane Medial Nearer to median plane the 5th digit (little finger) is on the medial side of the hand. Lateral Farther from median plane the 1st digit (thumb) is on the lateral side of the hand. Key Terms applied to the entire body Terms specific for hands and feet Terms independent of anatomical position Inferior (caudal) Nearer to feet the stomach is inferior to the heart. Cranial relates to the cranium and is a useul directional term, meaning toward the head or cranium. Rostral is oten used instead o anterior when describing parts o the brain; it means toward the rostrum (L. Medial is used to indicate that a structure is nearer to the median plane o the body. For example, the 5th digit o the hand (little nger) is medial to the other digits. Conversely, lateral stipulates that a structure is arther away rom the median plane. Dorsum usually reers to the superior aspect o any part that protrudes anteriorly rom the body, such as the dorsum o the tongue, nose, penis, or oot.

The our parts o the medial (deltoid) ligament o the ankle are demonstrated in this dissection cholesterol levels zocor order lasuna 60caps line. Inversion is augmented by fexion o the toes (especially the great and 2nd toes) high cholesterol medication side effects purchase genuine lasuna, and eversion by their extension (especially o the lateral toes) cholesterol test ppt buy cheap lasuna. All bones o the oot proximal to the metatarsophalangeal joints are united by dorsal and plantar ligaments cholesterol ratio hdl purchase lasuna with amex. The bones o the metatarsophalangeal and interphalangeal joints are united by lateral and medial collateral ligaments. The subtalar joint occurs where the talus rests on and articulates with the calcaneus. The anatomical subtalar joint is a single synovial joint between the slightly concave posterior calcaneal articular surace o the talus and the convex posterior articular acet o the calcaneus. The joint capsule is weak but is supported by medial, lateral, posterior, and interosseous talocalcaneal ligaments. The interosseous talocalcaneal ligament lies within the tarsal sinus, which separates the subtalar and talocalcaneonavicular joints, and is especially strong. Orthopedic surgeons use the term subtalar joint or the compound unctional joint consisting o the anatomical subtalar joint plus the talocalcaneal part o the talocalcaneonavicular joint. The two separate elements o the clinical subtalar joint straddle the talocalcaneal interosseous ligament. Structurally, the anatomical denition is logical because the anatomical subtalar joint is a discrete joint, having its own joint capsule and articular cavity. The subtalar joint (by either denition) is where the majority o inversion and eversion occurs, around an axis that is oblique. The transverse tarsal joint is a compound joint ormed by two separate joints aligned transversely: the talonavicular part o the talocalcaneonavicular joint and the calcaneocuboid joint. Transection across the transverse tarsal joint is a standard method or surgical amputation o the oot. Joint Capsule Fibrous layer o joint capsule is attached to margins o articular suraces Ligaments Medial, lateral, and posterior talocalcaneal ligaments support capsule; interosseous talocalcaneal ligament binds bones together. Movements Inversion and eversion o oot Blood Supply Posterior tibial and fbular arteries Nerve Supply Talocalcaneonavicular Synovial joint; talonavicular part is ball and socket type Plane synovial joint Joint capsule incompletely encloses joint. Dorsal calcaneocuboid ligament, plantar calcaneocuboid, and long plantar ligaments support joint capsule. Dorsal and plantar cuneonavicular ligaments Gliding and rotatory movements possible Calcaneocuboid Fibrous capsule encloses joint. Inversion and eversion o oot; circumduction Anterior tibial artery via lateral tarsal artery, a branch o dorsalis pedis artery (dorsal artery o oot) Plantar aspect: medial or lateral plantar nerve Dorsal aspect: deep fbular nerve Cuneonavicular joint Anterior navicular articulates with posterior suraces o cuneiorms. Dorsal, plantar, and interosseous intermetatarsal ligaments bind lateral our metatarsal bones together. Gliding or sliding Deep fbular; medial and lateral plantar nerves; sural nerve 7 Intermetatarsal Little individual movement occurs. Metatarsophalangeal Condyloid synovial joint Heads o metatarsal bones articulate with bases o proximal phalanges. Collateral ligaments support capsule on each side; plantar ligament supports plantar part o capsule. A) Flexor hallucis longus Flexor digitorum longus Flexor digitorum brevis Quadratus plantae Extensor hallucis longus Extensor digitorum longus Extensor digitorum brevis Extension (fg. B) a Muscles in boldace are chiey responsible or the movement; the other muscles assist them. Sequential stages o a deep dissection o the sole o the right oot showing the attachments o the ligaments and the tendons o the long evertor and invertor muscles. The spring ligament supports the head o the talus and plays important roles in the transer o weight rom the talus and in maintaining the longitudinal arch o the oot, o which it is the keystone (superiormost element). Some o its bers extend to the bases o the metatarsals, thereby orming a tunnel or the tendon o the bularis longus. The long plantar ligament is important in maintaining the longitudinal arch o the oot. It extends rom the anterior aspect o the inerior surace o the calcaneus to the inerior surace o the cuboid. Body weight is divided approximately equally between the hindoot (calcaneus) and the oreoot (heads o the metatarsals). The oreoot has fve points o contact with the ground: a large medial one that includes the two sesamoid bones associated with the head o the 1st metatarsal and the heads o the lateral our metatarsals. The 1st metatarsal supports the major share o the load, with the lateral oreoot providing balance. I the eet were more rigid structures, each impact with the ground would generate extremely large orces o short duration (shocks) that would be propagated through the skeletal system. Because the oot is composed o numerous bones connected by ligaments, it has considerable lexibility that allows it to deorm with each ground contact, thereby absorbing much o the shock. Furthermore, the tarsal and metatarsal bones are arranged in longitudinal and transverse arches passively supported and actively restrained by lexible tendons that add to the weight-bearing capabilities and resiliency o the oot. Thus, much smaller orces o longer duration are transmitted through the skeletal system. The arches distribute weight over the pedal platorm (oot), acting not only as shock absorbers but also as springboards or propelling it during walking, running, and jumping.

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The greater sciatic oramen is the passageway or structures entering or leaving the pelvis cholesterol ratio levels uk lasuna 60caps without a prescription. The sacrotuberous and sacrospinous ligaments convert the greater and lesser sciatic notches into oramina cholesterol test lab cheap lasuna 60 caps otc. Lateral surace o greater trochanter o emur Anterior surace o greater trochanter o emur Innervationa Inerior gluteal nerve (L5 how much cholesterol in eggs order lasuna 60caps on line, S1 cholesterol effects buy discount lasuna 60 caps on line, S2) Main Action Extends thigh (especially rom exed position) and assists in its lateral rotation; steadies thigh and assists in rising rom sitting position Gluteus medius. The gluteus maximus covers all o the other gluteal muscles, except or the anterosuperior third o the gluteus medius. The ischial tuberosity can be elt on deep palpation through the inerior part o the muscle, just superior to the medial part o the gluteal old. You do not sit on your gluteus maximus; you sit on the atty brous tissue and the ischial bursa that lie between the ischial tuberosity and skin. The bers o the superior and larger part o the gluteus maximus and supercial bers o its inerior part insert into the iliotibial tract and indirectly, via the lateral intermuscular septum, into the linea aspera o the emur. Some deep bers o the inerior part o the muscle (roughly the deep anterior and inerior quarter) attach to the gluteal tuberosity o the emur. The inerior gluteal nerve and vessels enter the deep surace o the gluteus maximus at its center. In the superior part o its course, the sciatic nerve passes deep to the gluteus maximus. The main actions o the gluteus maximus are extension and lateral rotation o the thigh. When the distal attachment o the gluteus maximus is xed, the muscle extends the trunk on the lower limb. Although it is the strongest extensor o the hip, it acts mostly when orce is necessary (rapid movement or movement against resistance). Shown are superfcial (A) and deep (B) views o the lateral musculofbrous complex ormed by the tensor asciae latae and gluteus maximus muscles and their shared aponeurotic tendon, the iliotibial tract. The iliotibial tract is continuous posteriorly and deeply with the dense lateral intermuscular septum. Gluteal and Posterior Thigh Regions 725 position, walking uphill and upstairs, and running. It is used only briefy during casual walking and usually not at all when standing motionless. The gluteus maximus contracts only briefy during the earliest part o the stance phase (rom heel strike to when the oot is fat on the ground, to resist urther fexion as weight is assumed by the partially fexed limb). I you climb stairs and put your hands on your buttocks, you will eel the gluteus maximus contract strongly. Because the iliotibial tract crosses the knee and attaches to the anterolateral tubercle o the tibia (Gerdy). Because the iliotibial tract attaches to the emur via the lateral intermuscular septum, it does not have the reedom necessary to produce motion at the knee. Testing the gluteus maximus is perormed when the person is prone with the lower limb straight. The person tightens the buttocks and extends the hip joint as the examiner observes and palpates the gluteus maximus. Bursae are membranous sacs lined by a synovial membrane containing a capillary layer o slippery fuid resembling egg white. Three bursae (trochanteric, gluteoemoral, and ischial) usually separate the gluteus maximus rom underlying bony prominences. Gluteus medius (cut) Gluteus minimus Piriformis Tensor fasciae latae Trochanteric bursa Iliotibial tract (and cut edge) Gluteofemoral bursa Femur Gluteus maximus (cut) ree movement. The trochanteric bursa separates superior bers o the gluteus maximus rom the greater trochanter. This bursa is commonly the largest o the bursae ormed in relation to bony prominences and is present at birth. The ischial bursa separates the inerior part o the gluteus maximus rom the ischial tuberosity; it is oten absent. The gluteoemoral bursa separates the iliotibial tract rom the superior part o the proximal attachment o the vastus lateralis. The gluteus minimus and most o the gluteus medius lie deep to the gluteus maximus on the external surace o the ilium. The gluteus medius and minimus abduct or stabilize the thigh and rotate it medially. Testing the gluteus medius and minimus is perormed while the person is sidelying with the test limb uppermost and the lowermost limb fexed at the hip and knee or stability. The person abducts the thigh without fexion or rotation against straight downward resistance. The gluteus medius can be palpated inerior to the iliac crest, posterior to the tensor asciae latae, which is also contracting during abduction o the thigh. The tensor asciae latae and the supercial and anterior part o the gluteus maximus share a common distal attachment to the anterolateral tubercle o the tibia via the iliotibial tract, which acts as a long aponeurosis or the muscles. However, unlike the gluteus maximus, the tensor asciae latae is served by the superior gluteal neurovascular bundle.

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Four successive layers o brous tissue that bowstring the longitudinal arch (supercial to deep): 1 cholesterol definition anatomy discount lasuna 60 caps. Dynamic supports involved in maintaining the arches o the oot include: Active (refexive) bracing action o intrinsic muscles o oot (longitudinal arch) cholesterol niacin order generic lasuna from india. Active and tonic contraction o muscles with long tendons extending into oot: Flexors hallucis and digitorum longus or the longitudinal arch cholesterol medication new guidelines discount lasuna 60caps without prescription. Surace Anatomy o Joints o Knee cholesterol medication side effects erectile dysfunction buy cheap lasuna on line, Ankle, and Foot the knee region is between the thigh and the leg. Superolateral to the knee is the iliotibial tract, which can be ollowed ineriorly to the anterolateral (Gerdy) tubercle o the tibia. The patella, easily palpated and moveable rom side to side during extension, lies anterior to the emoral condyles (palpable to each side o the middle o the patella). Extending rom the apex o the patella, the patellar ligament is easily visible, especially in thin people, as a thick band attached to the prominent tibial tuberosity. The plane o the knee joint, between emoral condyles and tibial plateau, may be palpated on each side o the junction o patellar apex and ligament when the knee is extended. Laterally, the head o the bula is readily located by ollowing the tendon o the biceps emoris ineriorly. The bular collateral ligament may be palpated as a cord-like structure superior to the bular head and anterior to biceps tendon, when the knee is ully fexed. The prominences o the lateral and medial malleoli provide an approximation o the axis o the ankle joint. When the ankle is plantarfexed, the anterior border o the distal end o the tibia is palpable proximal to the malleoli, providing an indication o the joint plane o the ankle joint. The sustentaculum tali, approximately 2 cm distal to the tip o the medial malleolus, is best elt by palpating it rom below where it is somewhat obscured by the tendon o the fexor digitorum longus, which crosses it. On the lateral side, when the oot is inverted, the lateral margin o the anterior surface of the calcaneus is uncovered and palpable. The calcaneal tendon at the posterior aspect o the ankle is easily palpated and traced to its attachment to the calcaneal tuberosity. The transverse tarsal joint is indicated by a line rom the posterior aspect o the tuberosity o the navicular to a point halway between the lateral malleolus and the tuberosity o the 5th metatarsal. The metatarsophalangeal joint of the great toe lies distal to the knuckle ormed by the head o the 1st metatarsal. Gout, a metabolic disorder, commonly causes edema and tenderness o this joint, as does osteoarthritis (degenerative joint disease). The weight-bearing iliac portion o the acetabular rim overlies the emoral head, which is important or transer o weight to the emur in the erect (standing/walking) position. Consequently, o the positions commonly assumed by humans, the hip joint is mechanically most stable when a person is bearing weight, as when liting a heavy object, or example. Decreases in the degree to which the ilium overlies the emoral head (detectable radiographically as the angle o Wiberg;. Consequently, the articular suraces o the head and acetabulum are not ully congruent in the erect (bipedal) posture. The anterior part o the emoral head is "exposed" and articulates mostly with the joint capsule. Nonetheless, rarely is >40% o the available articular surace o the emoral head in contact with the surace o the acetabulum in any position. Angle of acetabulum in horizontal plane Acetabular labrum Fractures o Femoral Neck Fractures o the neck o the emur (unortunately reerred to as "ractured hips," implying that the hip bone is broken) are uncommon in most contact sports because the participants are usually young and the emoral neck is strong in people <40 years o age. When they do occur in this age group, these ractures usually result rom high-energy impacts. For example, i the oot is rmly braced against the car foor with the knee locked, or i the knee is braced against the dashboard during a head-on collision, the orce o the impact may be transmitted superiorly and produce a emoral neck racture. Femoral neck ractures are especially common in individuals >60 years, especially in women, because their emoral necks are more oten weak and brittle, as a result o osteoporosis. Fractures o the emoral neck are oten intracapsular, and realignment o the neck ragments requires internal skeletal xation. Most o the blood to the head and neck o the emur is supplied by the medial circumfex emoral artery. The retinacular arteries arising rom this artery are oten torn when the emoral neck is ractured or the hip joint is dislocated. Joints o Lower Limb 819 As a result, incongruity o the joint suraces develops, and growth at the epiphysis is retarded. Dislocation o Hip Joint Congenital dislocation o the hip joint is common, occurring in approximately 1. Dislocation occurs when the emoral head is not properly located in the acetabulum. In addition, the aected limb appears (and unctions as i it is) shorter because the dislocated emoral head is more superior than on the normal side, resulting in a positive Trendelenburg sign (hip appears to drop on one side during walking). Approximately 25% o all cases o arthritis o the hip in adults are the direct result o residual deects rom congenital dislocation o the hip. Acquired dislocation o the hip joint is uncommon because this articulation is so strong and stable. Nevertheless, dislocation may occur during an automobile accident when the hip is fexed, adducted, and medially rotated, the usual position o the lower limb when a person is riding in a car. A head-on collision that causes the knee to strike the dashboard may dislocate the hip when the emoral head is orced out o the acetabulum.

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During their course through the anterolateral abdominal wall cholesterol test over the counter discount lasuna 60caps with amex, the thoraco-abdominal cholesterol in eggs and chicken lasuna 60caps, subcostal keeping cholesterol levels down purchase lasuna overnight, and iliohypogastric nerves communicate with each other cholesterol levels high risk purchase discount lasuna on-line. The deeper veins o the anterolateral abdominal wall accompany the arteries, bearing the same name. A deeper, medial venous anastomosis may exist or develop between the inerior epigastric vein (an external iliac vein tributary) and the superior epigastric/internal thoracic veins (subclavian vein tributaries). The superfcial and deep anastomoses may aord collateral circulation during blockage o either vena cava. The primary blood vessels (arteries and veins) o the anterolateral abdominal wall are as ollows: Superior epigastric vessels and branches o the musculophrenic vessels rom the internal thoracic vessels. The arterial supply to the anterolateral abdominal wall is demonstrated in Figure 5. The distribution o the deep abdominal blood vessels reects the arrangement o the muscles: the vessels o the anterolateral abdominal wall have an oblique, circumerential pattern (similar to the intercostal vessels;. The superior epigastric artery is the direct continuation o the internal thoracic artery. It enters the rectus sheath superiorly through its posterior layer and supplies the superior part o the rectus abdominis and anastomoses with the inerior epigastric artery approximately in the umbilical region. The inferior epigastric artery arises rom the external iliac artery just superior to the inguinal ligament. It runs superiorly in the transversalis ascia to enter the rectus sheath below the arcuate line. It enters the lower rectus abdominis and anastomoses with the superior epigastric artery. Lymphatic drainage o the anterolateral abdominal wall ollows the ollowing patterns. Superfcial lymphatic vessels inerior to the transumbilical plane drain to the superfcial inguinal lymph nodes. For an overview o superfcial and deep lymphatic drainage, see Chapter 1, Overview and Basic Concepts. The skin and subcutaneous tissue o the abdominal wall are served by an intricate subcutaneous venous plexus, draining superiorly to the internal thoracic vein medially and the lateral thoracic vein laterally and ineriorly to the superfcial and inerior epigastric veins, tributaries o the emoral and external iliac veins, respectively. Cutaneous veins surrounding the umbilicus anastomose with para-umbilical veins, small tributaries o the hepatic portal vein that parallel the obliterated umbilical vein (round ligament o the liver). When closing abdominal skin incisions inerior to the umbilicus, surgeons include the membranous layer o subcutaneous tissue when suturing because o its strength. Between this layer and the deep ascia covering the rectus abdominis and external oblique muscles is a potential space where fuid may accumulate. Although there are no barriers (other than gravity) to prevent fuid rom spreading superiorly rom this space, it cannot spread ineriorly into the thigh because the deep membranous layer o subcutaneous tissue uses with the deep ascia o the thigh (ascia lata) along a line approximately 5. It provides a plane that can be opened, enabling the surgeon to approach structures on or in the anterior aspect o the posterior abdominal wall, such as the kidneys or bodies o lumbar vertebrae, without entering the membranous peritoneal sac containing the abdominal viscera. An anterolateral part o this potential space between the transversalis ascia and the parietal peritoneum (space o Bogros) is used or placing prostheses. Excess at accumulation due to overnourishment most commonly involves the subcutaneous atty layer; however, there may also be excessive depositions o extraperitoneal at in some types o obesity. Tumors and organomegaly (organ enlargement such as splenomegaly- enlargement o the spleen) also produce abdominal enlargement. When the anterior abdominal muscles are underdeveloped or become atrophic, as a result o old age or insucient exercise, they provide insucient tonus to resist the increased weight o a protuberant abdomen on the anterior pelvis. The pelvis tilts anteriorly at the hip joints when standing (the pubis descends and the sacrum ascends) producing excessive lordosis o the lumbar region. Abdominal Hernias the anterolateral abdominal wall may be the site o abdominal hernias. Most hernias occur in the inguinal, umbilical, and epigastric regions (see the Clinical Box "Inguinal Hernias," p. Umbilical hernias are common in neonates because the anterior abdominal wall is relatively weak in the umbilical ring, which had ailed to close normally, causing a protrusion at the umbilicus, especially in low-birth-weight inants. Umbilical hernias are usually small and result rom increased intra-abdominal pressure in the presence o weakness and incomplete closure o the anterior abdominal wall ater ligation o the umbilical cord at birth. The lines along which the bers o the abdominal aponeuroses interlace are also potential sites o herniation. Occasionally, gaps exist where these ber exchanges occur-or example, in the midline or in the transition rom aponeurosis to rectus sheath. These gaps may be congenital, the result o the stresses o obesity and aging, or the consequence o surgical. An epigastric hernia, a hernia in the epigastric region through the linea alba, occurs in the midline between the xiphoid process and the umbilicus. These types o hernia tend to occur in people older than 40 years and are usually associated with obesity. The hernial sac, composed o peritoneum, is oten covered with only skin and atty subcutaneous tissue, but may occur deep to the muscle. In addition, their anterolateral abdominal cavities are enlarging and their abdominal muscles are gaining strength. Abdominal muscles protect and support the viscera most eectively when they are well toned; thus, the wellconditioned adult o normal weight has a fat or scaphoid (lit. The six common causes o abdominal protrusion begin with the letter F: ood, fuid, at, eces, fatus, and etus. Intense guarding, board-like refexive muscular rigidity that cannot be willully suppressed, occurs during palpation when an organ (such as the appendix) is infamed and in itsel constitutes a clinically signicant sign o acute abdomen. The involuntary muscular spasms attempt to protect the viscera rom pressure, which is painul when an abdominal inection is present.

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