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Noncardiac Causes Hyperkinetic circulation: Anemia Fever Endocrinological overactivity: � Thyrotoxicosis � Pheochromocytoma anxiety relief order venlor us. Drugs: Caffeine Alcohol (holiday coronary heart syndrome) Nicotine Cocaine Sympathomimetics Digitalis Tricyclic antidepressants 298 Clinical Methods and Interpretation in Medicine Vasodilators: � Nitrates � Calcium channel blockers anxiety 6 months pregnant discount generic venlor uk. Different Types of Arrhythmias Producing Palpitation Extrasystoles: Atrial Ventricular. Paroxysmal supraventricular tachycardia Paroxysmal atrial fibrillation Sinus tachycardia due to fever, thyrotoxicosis Arrhythmias due to tea, espresso or alcohol intake. The following enquiries to be done to diagnose the sufferers: How lengthy this problem persists During physical activity-catecholamine induced arrhythmias Clusters of palpitations in 24 hours period: � Ectopic beats at the bed time-when affected person tries to fall asleep and distracting from all stimuli � Tachyarrhythmia occurring in the course of the evening, interrupting sleep-suggestive of episodes of vagally mediated atrial fibrillation. Palpitation happens with assumption of upright posture: Tachycardia secondary to postural orthostatic tachycardia syndrome: � Occurs in dysautonomic circumstances � Occurs in young female. Heart price will increase abruptly and ends abruptly-pathologic tachycardia Heart fee will increase gradually and decreases gradually- sinus tachycardia Overlap occurs-where paroxysmal supraventricular tachycardia begins abruptly but partially overlapped by sinus tachycardia-due to arrhythmia related catecholamine discharge. Whether the signs occur at interval of hours to days or months to years Whether the affected person conscious of the palpitation: few advanced arrhythmias-patient could additionally be completely unaware In In long standing atrial fibrillation-patient could really feel discomfort and palpitation happens only during exertion or excitement Patient could also be completely unaware of symptoms, when lies down on the left aspect and go to sleep in built particular person is aware of own coronary heart block Th Awareness of skipped beat-when palpitation lasts for example Premature beat-may be described as floating sensation in the chest Pounding sensation-due to paroxysmal tachycardia Sensation of cease beating-may be as a result of compensatory pause following ectopic beat Regular fast palpitation-due to sinus tachycardia, supraventricular tachycardia or paroxysmal tachycardia Irregular fast palpitation-due to atrial flutter, atrial fibrillation, atrial tachycardia with varying block. Cardiac History Presence of ischemic coronary heart illness or prior history of myocardial infarction-may be related to ventricular or supraventricular beats Presence of suspected or recognized case of congestive cardiac failure on the basis of hypertension Presence of historical past of proper or left ventricular dysfunction with atrial fibrillation-produce atrial arrhythmia Presence of mitral valve disease-may current with atrial arrhythmia In absence of natural coronary heart disease-isolated atrial or ventricular beat producing palpitation. History of Arrhythmia Past history of radiofrequency ablation-suggest the recurrence of arrhythmia History of paroxysmal atrial fibrillation in patient with left ventricular dysfunction and prior symptomatic untimely ventricular complexes History of implantation cardiac pacemaker or implantable cardioverter defibrillator-it may produce paroxysmal Cardiovascular System 301 ventricular complexes with 1:1 retrograde conduction. This known as pacemaker syndrome History of implantation of twin chamber pacemaker or defibrillator, might produce pacemaker mediated countless loop tachycardia History of use of pacemaker device with internal sensor, it might produce overdrive ventricular pacing so during the period of inactivity, it might produce inappropriately fast heart beating. Family History Family history of sudden demise offers rise to suspicion of familial inherited arrhythmogenic disorder. History Related to Endocrine Disorders History of hyperthyroidism (iatrogenic or endogenous) may produce sinus tachycardia, paroxysmal atrial fibrillation History suggestive of pheochromocytoma-headache, diaphoresis, pallor. Patient with palpitation refers to emergency division Palpitation with: New onset syncope New onset or worsening of chest pain or dyspnea. Syncope Definition: Sudden transient lack of consciousness and postural tone with subsequent spontaneous recovery. Presyncope: Feeling of consciousness of impending faint-it might or may not progress to overt syncope-depending on whether or not the cause has been eradicated or not. Causes of Syncope Neurally Mediated Syncope Vasovagal, neurocardiogenic syncope: Precipitating factors: � Prolonged standing � Hypovolemia because of dehydration � Fear � Severe ache � Sight of blood Cardiovascular System 303 � Strong emotion � Instrumentation � No cause. Prodromal symptoms: this phase usually lasts for 30 to 60 seconds followed by syncope.

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Thalamic Representation of Vestibular Function Posterior nuclear group of thalamus anxiety vs panic attack purchase venlor 75 mg amex. Vertigo: this can be described as sensation of motion,-MACROS-, which can be subjective (he/she is spinning) or objective (surrounding environment is moving) anxiety symptoms one side generic venlor 75 mg fast delivery. Vertigo may be related with-nausea with or with out vomiting (related to lesion of peripheral vestibular apparatus) pallor,-MACROS-, presence or absence of sweating. Paroxysmal or continuous-pulsatile or nonpulsatile tinnitus associated without vertigo-mainly because of peripheral lesions. Unilateral,-MACROS-, pulsatile,-MACROS-, fluctuating tinnitus or tinnitus related to vertigo-It may be because of central or peripheral serious lesions. Pulsatile tinnitus as a end result of all above causes except idiopathic intracranial hypertension may be decreased by rotating head to ipsilateral facet. Gaze-evoked Tinnitus this kind of tinnitus associated with saccades,-MACROS-, vestibulo-ocular eye actions could occur because of aberrant connection between vestibular and cochlear nerve,-MACROS-, because of sprouting after part of vestibulocochlear nerve following operation of cerebellopontine angle tumor. Other Vestibular Causes of Tinnitus Labyrinthitis Perilymphatic fistulas Patulous eustachian tube Middle ear myoclonus Tensor tympani muscle spasm. If vertigo is associated with different cranial nerve or brainstem dysfunction-central pathway lesion. To search for etiology of vertigo-following examinations must be accomplished: Complete otologic evaluation Complete audiological evaluation Blood strain examination in: Both arms Standing and lying down place Neurology 1049 Carotid bruit Cardiac murmur and if present,-MACROS-, its radiation Detailed cranial nerve examination Evaluation of vestibular management of stability: Romberg test. Balance throughout motion test: the patient is requested to step forward 3 steps and backward three steps with eye closed. Provocative take a look at for positional nystagmus: By: Postural change Head turning Sudden turn whereas walking Valsalva maneuver Caloric testing. The following lesions are liable for totally different type of hearing loss: Unilateral lesion-it might produce refined listening to loss. Bilateral lesion in auditory cortical region-It produces: Auditory agnosia Selective auditory agnosia Pure word deafness Milder disturbance in temporal evaluation of sounds Amusia. During and after recovery-minor audiometric speech issue with varying diploma of impairment of interpretating the verbal and nonverbal sounds. Type of Lesion Irritative lesion in temporal cortex produces-auditory hallucination-may be easy. Focal seizure involving temporal lobe may present initially with auditory aura or vertiginous aura. The following lesions are: Bilateral brainstem lesion due to infarction or hemorrhage- produce bilateral hearing loss. Small hemorrhage lesion in medial geniculate physique produces- hyperacusis,-MACROS-, palinacousis (perseveration of sounds). Tumor in midbrain and pineal body-sudden and full bilateral deafness-because here auditory pathways are carefully packed collectively. Neurology 1051 Lesions in low midbrain and rostral pontine tegmentum-auditory hallucinations related to listening to loss and clear sensorium. Peripheral Nerve Lesions Peripheral cochlear nerve lesion produces: Unilateral deafness Ipsilateral tinnitus (for high frequency sound).

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Another speculation is that the basal tone of arterioles is the results of a tonic manufacturing of local vasoconstrictor substances by the endo thelial cells that line their inside surface anxiety symptoms back pain buy cheap venlor on line. In any case anxiety while sleeping buy generic venlor 75mg on line, this basal tone establishes a baseline of partial arteriolar constriction from which the external influences on arterioles exert their dilating or constricting effects. These influences may be separated into three classes: local influences, neural inf luences, and hormonal influences. Conversely, inter stitial oxygen ranges rise each time extra oxygen is being delivered to a tissue from the blood. Many substances along with oxygen are present within tissues and can affect the tone of the vascular clean muscle. When the metabolic fee of skel etal muscle is increased by exercise, tissue levels of oxygen decrease, but these of carbon dioxide, H+, and K+ enhance. In addition, with increased metabolic exercise or oxygen deprivation, cells in lots of tissues could release adenosine, which is a particularly potent vasodilator agent. It appears doubtless that arteriolar tone depends on the combined action of many factors. Vasodilator elements enter the interstitial house from the tissue cells at a rate proportional to tissue metabolism. These vasodilator fac tors are faraway from the tissue at a price proportional to blood circulate. Whenever tissue metabolism is continuing at a rate for which the blood circulate is inade quate, the interstitial vasodilator issue concentrations automatically construct up and trigger the arterioles to dilate. The course of continues until blood move has risen sufficiently to appropriately match the tissue metabolic rate and forestall further accumulation of vasodilator 3 An necessary exception to this rule happens within the pulmonary circulation and is mentioned later in this chapter. Local metabolic mechanisms represent by for crucial meam of native flow management. By these mechanisms, particular person organs are capable of regulate their own flow in accordance with their specific metabolic wants. As indicated below, a quantity of other kinds of native influences on blood vessels have been recognized. However, many of these symbolize fine-tuning mechanisms and heaps of are necessary solely in sure, usually pathological, situations. A giant variety of studies have proven that blood vessels respond very in one other way to certain vascular influences when their endothelial lining is lacking. Acetylcholine, for instance, causes vasodilation of intact vessels however causes vasoconstriction of vessels stripped of their endothelial lining. This and comparable results led to the conclusion that endothelial cells can actively participate in the control of arterio lar diameter by producing local chemicals that affect the tone of the encircling smooth muscle cells. In the case of the vasodilator effect of infusing acetylcholine via intact vessels, the vasodilator affect produced by endothelial cells has been recognized as nitric oxide.

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Growth and improvement of the vascular system parallels progress and develop ment of the body with a lot of the native and reflex regulatory mechanisms opera tional shortly after start anxiety symptoms heart palpitations buy venlor 75 mg mastercard. Connective this sue becomes much less elastic anxiety symptoms confusion buy venlor 75 mg cheap, capillary density decreases in many tissues, mitotic activ ity of dividing cells turns into slower, and glued postmitotic cells (such as nerve and muscle fibers) are misplaced. The enhance in arterial strain might impose a larger afterload on the heart, which may be partially liable for the age-dependent decreases in cardiac index. Arterial baroreceptor-induced responses to modifications in blood pressure are blunted with age. In addition, the entire quantity of norepinephrine contained within the sympathetic nerve endings of the myocardium decreases with age, and the myocardial respon siveness to catecholamines declines. These adjustments may partially account for the apparent age dependent sluggishness within the responses to postural changes and restoration from exercise. It is necessary (although usually difficult) to separate true age-dependent alterations from changes due to progressive inactivity or from disease-induced adjustments in physiological perform. These "illnesses" lack the universality neces sary to be categorized as true getting older processes however usually happen with rising incidence within the older inhabitants. Pharmacological interventions and discount of danger components (smoking, weight problems, inactivity, and high-fat or high-sodium diets) by modification of lifestyle can alter the incidence, depth, and progression of those cardiovascular illnesses. It can additionally be attainable that a few of the beforehand men tioned interventions could prevent early expression of a variety of the regular getting older processes and delay the lifespan of a given particular person. No sensible interven tion, however, is currently obtainable that can enhance the utmost potential lifespan of people. Compared with age-matched men, premenopausal women have a lower left ventricular mass to body mass ratio, which may reflect a decrease cardiac afterload in girls. This might result from their decrease arte rial blood pressure, higher aortic compliance, and improved capability to induce vasodilatory mechanisms (such as endothelial-dependent flow-mediated vasodila tion). In truth, older girls with ischemic coronary heart disease usually have a worse prognosis than men. In all conditions, regulation of arte rial stress by changes in cardiac output and vascular resistance assures that blood move to crucial organs is properly regulated and matched to the metabolic wants of the individual cells. One of the matters missing from this textual content has to do with maintenance and repair of the cardiovascular elements. Major advances in our information of the method to look after our cardio vascular system have contributed greatly to the advance in our longevity and high quality of life in the later years. However, we people seem to have an approximate 100-year maximum restrict on our lifespan. Planned obsolescence seems to be a major a half of most life forms, and private longevity is partially controlled by genetics. An age-dependent progressive lack of ability to rebuild and repair our cardiovascular system seems to be a major contributor to total deterioration of all bodily features. Cyclical modifications in intrathoracic pressure due to respiratory activity have signifi cant effects on the cardiovascular system, partly by influencing venous return and cardiac filling and inflicting a normal nsinus arrhythmia". Gravity has a significant effect on the cardiovascular system, and various reflex compensatory mechanisms are required to overcome peripheral venous pooling and decreased cardiac filling that accompanies altering from a recumbent to an the upright place.

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Patients may present with diarrhoea or develop it through the perioperative interval anxiety disorder definition venlor 75 mg low cost. Intravenous fluid administration When selecting and administering intravenous fluids (Table 1 anxiety 24 hours a day buy cheap venlor 75mg on line. Dextrose options are therefore of little worth as resuscitation fluids to expand intravascular volume. Dextrose 5% is an isotonic answer in distinction to more concentrated dextrose solutions (10%, 20% and 50%), that are hypertonic. These solutions are an irritant to veins If gastrointestinal loss continues for more than 2�3 days, samples of fluid and urine ought to be collected regularly and sent to the laboratory for measurement of electrolyte content material. For calculation of electrolyte replacement, blended gastric aspirate composition can be used for ease of calculation. For instance, replacement of 2 litres of nasogastric aspirate would require a further supply of 240 mEq of Na+ and 20 mEq of K+ in addition to the day by day requirement. The acetate and gluconate present in Plasma-Lyte 148 is rapidly metabolised within the body. Fluid and electrolyte steadiness � thirteen (minimizing the chance of hyperkalaemia, especially when renal failure or hyperkalaemia could additionally be present). The options include a substrate that the body can metabolise to generate bicarbonate ions as part of the metabolic pathway. These solutions decrease the danger of hyperchloraemia, which may occur following large volumes of fluids with higher sodium and chloride concentrations, such as sodium chloride zero. When administered, colloid stays largely throughout the intravascular house until the colloid particles are removed by the reticuloendothelial system. The intravascular half-life is normally between 6 and 24 hours and such solutions are therefore appropriate for fluid resuscitation. Synthetic colloids are more expensive than crystalloids and have variable side impact profiles. Recognised risks embody coagulopathy, reticuloendothelial system dysfunction, pruritus and anaphylactic reactions. Hydroxyethyl starch particularly appears to be associated with increased mortality and renal failure, and is now not beneficial. The theoretical benefit of colloids over crystalloids is that, as they remain within the intravascular space for several hours, smaller volumes are required. Maintenance fluid necessities Under normal circumstances, adult every day sodium necessities (80 mmol) could also be supplied by the administration of 500� one thousand mL of 0. The remaining water requirement to maintain up fluid balance (2000�2500 mL) is typically provided as 5% dextrose. The total fluid requirements per 24 hours differ according to affected person weight and fluid losses, however are sometimes 2000�3000 mL per 24 hours Intravenous fluid 500 mL 0.

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Every alternative must be taken to amass this ability within the elective situation within the anaesthetic room anxiety 60 mg cymbalta 90 mg prozac purchase 75mg venlor overnight delivery. Retaining a pillow under the top but leaving a space free from beneath the shoulders will often help to realize this place anxiety fatigue purchase venlor in india. Failure to position the patient appropriately is one of the most typical causes of issue in intubation. The laryngoscope is pulled upwards and forwards, consistent with the deal with, not used as a lever, to lift the tongue and jaw and reveal the epiglottis. The blade is then advanced to the base of the epiglottis and the laryngoscope pulled additional upwards and forwards once more according to the handle to reveal the vocal cords. The endotracheal tube is handed by way of the vocal cords into the trachea and advanced till its cuff is about 1 cm by way of. The laryngoscope blade is withdrawn and the cuff inflated to provide an airtight seal within the trachea. The most critical complication of endotracheal intubation is failure to recognise misplacement of the tube, particularly within the oesophagus or, to a lesser degree, in the best primary bronchus. Misplacement is best averted by direct visualisation of passage of the tube between the vocal cords, inspection of the chest wall for equal motion of both sides of the chest, and auscultation for breath sounds bilaterally within the midaxillary line. Absence of breath sounds or the presence of solely quiet ones within the epigastrium is an extra reassuring signal. Changing a tracheostomy tube It is common follow to change a tracheostomy tube each 7 days. If replacement is prone to be troublesome, a suction catheter inserted into the old tracheostomy tube can be used as an introducer for the new tube. The new tube is inserted with an analogous motion to that employed for removal, and its cuff inflated. Any signs of respiratory misery should increase suspicion of the potential for misplacement or occlusion of the tube. The tube and trachea are immediately checked for patency by passing a suction catheter through the tube. If the catheter passes simply into the respiratory tract, often signified by the affected person coughing as the catheter touches the carina, other causes for respiratory distress must be sought. When the tracheostomy is not needed, an hermetic dressing is applied over the location after eradicating the tube. For the first few days, patients ought to be encouraged to press firmly on the dressing once they want to cough, so as to keep away from air leakage by way of the tracheostomy website. Surgical airway Inability to intubate the trachea is an indication for making a surgical airway. In the emergency scenario, corresponding to in sufferers with severe facial trauma or pharyngeal oedema secondary to burns, the insertion of a large-calibre plastic cannula by way of the cricothyroid membrane (needle cricothyroidotomy) below the extent of the obstruction can be life-saving.

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Pelvic ligaments these are well developed in the pelvis due to the stresses to which the pelvic bones are subjected anxiety disorder definition buy genuine venlor. Apart from the ligaments specifically related to the joints talked about anxiety jury duty discount venlor 75mg on-line, there are two others of importance: the sacrospinous and sacrotuberous. These run from the sacrum to the ischial backbone and ischial tuberosity respectively. Together with the coccyx and lowest part of the sacrum, they kind the posterior aspect of the pelvic outlet. The pelvic gentle tissues the bony pelvis is clothed by a quantity of muscular tissues, the chief of which form the ground of the pelvis and the perineum. Levator ani the levator ani muscular tissues run on all sides from the back of the symphysis pubis and across the lateral pelvic wall on the fascia over the obturator internus muscle to the ischial spine and facet of the coccyx, together with the particular muscular bundle, the puborectalis. The puborectalis decussates or joins with its opposite number around the vagina and decrease rectum. The urethra, vagina and rectum all cross via this muscular diaphragm, which is accomplished by fascial condensations on its upper and lower surfaces. The muscles of the two sides slope downwards and forwards within the type of a gutter, which assists rotation of the fetal head to occipitoanterior as it strikes towards the pelvic ground. The puborectalis is necessary in helping to maintain closure of the outlet by drawing the different buildings passing through it anteriorly towards the shelf of the symphysis pubis. Oestrogen has a growthstimulating impact on the blood vessels, stromal and epithelial cells of the uterine endometrium, producing a proliferative endometrium. There is also a stimulatory impact of oestrogen on the myometrial muscle cells, as nicely as on the duct tissues of the breast. The ovum passes into the fimbrial finish of the uterine tube to await the potential arrival of ascending spermatozoa. Urogenital diaphragm the urogenital diaphragm is a triangular-shaped muscular diaphragm via which pass the urethra and vagina. On its deep aspect are two sets of muscle tissue: the constrictors of the urethra and vagina, and the deep transverse perinei. Between the vagina and rectum, the superficial and deep perineal muscle tissue, including the anal sphincter, decussate and join to form the strong perineal body. Behind the anal canal, the sphincter muscles decussate to type the anococcygeal raphe. Like oestrogen, progesterone has results on the uterus, breasts and hypothalamic­pituitary system. The menstrual cycle is a cycle of the hypothalamic­pituitary­ovarian axis, as properly as a cycle of the targets of the ovarian hormones: the endometrium of the uterus. Therefore, the menstrual cycle consists of both an ovarian cycle (which includes the follicular phase, ovulation and the luteal phase) and an endometrial cycle (which includes the menstrual, proliferative and secretory phases).

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Gustation Relevant chapter in Pathophysiology for Nurses at a Glance Chapter forty eight Chapter forty five Chapter 47 Chapter 46 Chapters forty nine anxiety burning sensation venlor 75mg cheap, 50 anxiety symptoms pain order venlor line, 51 and fifty two Chapters 50 and fifty two Chapters 34 and forty nine Chapters fifty three, 54, 55, fifty six and fifty seven Chapters fifty three, 54 and fifty five Chapters 53, 54 and fifty five Chapters 53, 54, fifty five, 56 and fifty seven Chapters 58, 59, 60 and 61 Chapters fifty eight, 59, 60 and 61 Chapters 58, 59 and 61 Chapters fifty eight, fifty nine and 61 Chapters sixty seven, sixty eight, sixty nine and 70 Chapters 62 and sixty three Chapters sixty four and 66 Chapters 64 and 65 137 Appendix 2: Normal physiological values Full blood count Haemoglobin (males) thirteen. Resection, excision vomiting condition blood situation Of or pertaining to the mind. Antigens: A substance that when introduced into the body stimulates antibody production. Hypoxia: Term used when a cell or tissue is deprived of oxygen IgA: Antibodies are present in areas of the body such the nostril, respiratory passages, digestive tract, ears, eyes and vagina IgD: Antibodies present in small amounts within the tissues that line the chest IgE: Antibodies found in the lungs, pores and skin, and mucous membranes IgG: Antibodies found in all physique fluids IgM: the biggest antibody Immunocompetent: Having a normal immune response Incus: the center of three auditory ossicles throughout the middle-ear chamber (anvil) Inferior: Below Inferolateral: Located beneath and in the course of the facet Insulin: A peptide hormone, produced by beta cells of the pancreas, it regulates carbohydrate and fats metabolism within the physique Ischaemia: Inadequate blood supply to an organ or part of the physique, especially the center muscle tissue Isthmus: A narrow organ, passage, or piece of tissue connecting two bigger parts. Juxtaglomerular cells: A microscopic structure within the kidney, which regulates the operate of every nephron Keratin: An insoluble protein present within the dermis and in epidermal derivatives, corresponding to hair and nails Labyrinth: An intricate structure consisting of interconnecting passages, for example, the bony and membranous labyrinths of the inner ear 148 Lactation: the manufacturing and secretion of milk by the mammary glands Lacuna: A small, hole chamber housing an osteocyte in mature bone tissue or a chondrocyte in cartilage tissue Lamella: Concentric ring of matrix surrounding the central canal in an osteon of mature bone tissue Lateral: To the side Lesion: A wounded or broken area Libido: Sexual need Ligament: A brief band of robust, flexible fibrous connective tissue connecting two bones or cartilages, or holding together a joint Limbic system: Limbic system constructions are concerned in a lot of our feelings and motivations, significantly those that are related to survival Lipogenesis: the method by which simple sugars such as glucose are transformed to fatty acids Locomotion: Movement Lymphocytes: White blood cells Lysosyme: Cellular organelles that contain acid hydrolase enzymes that break down waste materials and mobile particles Macrophages: White blood cells within tissues, produced by the division of monocytes Mast cell: A sort of connective tissue cell producing and secreting histamine and heparin and promoting local inflammation. So called because they originate from the thymus gland Trabeculae: A supporting framework of fibres crossing the substance of a structure, as within the lamellae of spongy bone Tympanic membrane: the membranous eardrum positioned between the external and center ear Unmyelinated: Not covered by myelin sheath Ureter: Membranous tube that drains urine from the kidneys to the bladder Urethra: Muscular tube that drains urine from the bladder Vasodilate: Dilation of blood vessels Vasoconstrict: Constriction of the blood vessels Visceral: Pertaining to internal organs of the body Vomer: One of the unpaired facial bones of the cranium White matter: Myelinated nerve fibres Zygote: A fertilised egg cell fashioned by the union of a sperm cell and an ovum 149 Further studying Gilroy, A. Labia majora the hair-covered, fibrofatty folds that stretch from the mons above to the perineum beneath are the labia majora. They have each sweat and sebaceous glands, and are homologous with the scrotum in the male. Labia minora the labia minora are enclosed by the labia majora and are smaller and extra delicate than the labia majora. They are pink in color and devoid of hair, however include sebaceous glands and a few sweat glands. Superiorly, they enclose the clitoris; inferiorly, they merge to kind the fourchette, or posterior ring, of the vaginal introitus. It is usually coated by the folds of the labia minora, which have to be separated to expose it. It is composed of a vascular plexus (erectile tissue) organized in a central corpus with two crura which are hooked up to the inferior rami of the pubis. The folds of the labia minora sweep upwards to enclose the clitoris, forming the prepuce above and the frenulum under. Before puberty, the orifice is closed by the hymenal membrane, which can have one or more small orifices in it. This woman has giant skinny labia, a comparatively large clitoris and a patulous vagina. Note the sebaceous glands on the perineum, small thick labia minora and hence straightforward identification of the urinary meatus. The glands are pea-sized and are responsible for lubricating the introitus throughout sexual activity. Badly positioned episiotomy incisions will either sever the ducts or involve them within the subsequent repair or fibrous scarring. If overdistension of the vagina happens throughout childbirth, the fascial supports (vesicovaginal and rectovaginal septa) separating the vagina from the bladder and rectum tear, normally in the midline, permitting prolapse to occur (cystocele, urethrocele, rectocele). Its moisture is provided mainly by the secretion of the cervical mucous glands and, at the time of coitus, by vaginal transudation.