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Describe nondrug therapies that may help this patient continue than her stated age buy etodolac amex arthritis gout knee symptoms, with an anxious demeanor order etodolac 400mg free shipping arthritis of fingers exercises. What economic purchase 300mg etodolac free shipping rheumatoid arthritis shoulder, psychosocial discount generic etodolac canada arthritis diet chart in hindi, racial, and ethical issues need to Skin be considered in this patient’s treatment? What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome í Assessment and to detect or prevent adverse effects? What information should be provided to the patient about the medication you recommended to enhance compliance, ensure successful outcome, and minimize adverse effects? What information in the patient’s history can be identified as Chantix should be used to help smokers quit when compared disease or symptoms directly related to the patient’s smoking with other products used for smoking cessation. Identify the stage of change that the patient is currently in at this currently enrolling smokers to help them quit smoking. Com- time of her life, and describe your intervention plan using one of pare and contrast the three studies. Contemplation Smoking is a problem State that there is good evi- and might consider dence that cigarette smoke quitting. Preparation Cigarette smoking is Discuss options for treatment–— problematic and now both pharmacotherapeutic ready to think about and nonpharmacotherapeutic. Action Motivated to quit, insti- Encourage quit attempt, offer to tuting a plan with an be a resource during the quit identified quit date attempt and praise former and developing a plan smokers’ abstinent status. This is the first admission for Anita Gonzalez, a 32-year-old woman Develop a 10-item list stating how second-hand smoke acts as a who was brought to the state hospital by the police. Write a two-page paper delineating how you apparently has been delusional and believes people sneak into her could use this information to encourage smokers to quit smoking. She states that she is having achieved through a dynamic process involving pharmacotherapy difficulty getting her property back. Apparently, the precipitating event causing her hospitalization was that she created a disturbance at a local fast-food restaurant, claiming that she owned it. Interventions to facilitate down to eat it, and for some reason somebody called the police and smoking cessation. The Health Conse- quences of Involuntary Exposure to Tobacco Smoke: A Report of the was raped by a relative of a sister and broke her hip in the process. Department of Health and She states that her feet were cut off because she would not do what Human Services, Centers for Disease Control and Prevention, Coordinat- her impostors wanted her to do, and her feet were subsequently sent ing Center for Health Promotion, National Center for Chronic Disease back to her from Central America and were reattached. Systematic review: smoking cessation from her body, and children were produced from them and then intervention strategies for adults and adults in special populations. Treating Tobacco Use and had transmitters in her backbone and that it took 3 years to have Dependence: 2008 Update. The patient also states that on one occasion a physician was removing the snakes from her abdominal cavity, and the snakes killed the doctor and a nurse. After completing this case study, the reader should be able to: í Family Psychiatric History • Identify the target symptoms of schizophrenia. The patient claims that her alleged family is not really her family and • Manage an acutely psychotic patient with appropriate pharma- that she is not sure who is her family. Her speech is clear, constant, pressured, with many gran- Color yellow; appearance slightly cloudy; glucose (–); bili (–); diose delusions and illogical thoughts. Her affect is leukocyte esterase (–) mood-congruent, her mood is euphoric, and there is a marked degree of grandiosity. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome Ext and to detect or prevent adverse effects? Perform a literature search regarding weight gain with each of the 73 atypical antipsychotics currently marketed. A benzodiazepine (lorazepam) can be scheduled routinely during • Develop a pharmacotherapy plan for a patient with depression. The addition of lorazepam may also allow lower dosages to be used initially and during the • Discuss pharmacoeconomic considerations that must be taken maintenance phase of treatment. J Geneva Flowers is a 41-year-old woman who is referred by her family Clin Psychiatry 1998;59(Suppl 3):21–25. Expert consensus panel for optimizing pharmacologic treatment of sion, impaired concentration, and fatigue. She left her second husband after approximately 2 years olanzapine versus clozapine in treatment-resistant schizophrenia: a dou- because of problems involving his children that caused increasing ble-blind crossover study. She began dose quetiapine in treatment refractory schizophrenia: preliminary results from an open-label trial. Atypical antipsychotics and weight gain: a was visiting her son at her house, but she was amnestic for the systematic review. Her present husband, her third, has been supportive of her, but she feels guilty about her failed previous marriages and her sons, worries about her debt, and has become more despondent. Because of vague references the physician believed could possibly Effectiveness of antipsychotic drugs in patients with chronic schizo- indicate suicidal ideas, she has been referred for psychiatric phrenia. Despite not having much of an Normal skin, hair, and nails appetite, reports eating more since taking mirtazapine. Drinks three to four cups of caffeinated coffee per day; usually drinks iced Genit/Rect tea with evening meal; drinks colas as leisure beverage. Used Deferred marijuana a few times after high school, denies any use in more than 10 years; denies use of other illicit substances. Her husband is good to her, but she feels everyone else General appearance—pt c/o feeling tired much of the time she loves has left her. She feels no c/o nasal congestion; Hx of dental repair for caries worthless and blames herself for her problems. She admits she sometimes wishes she could just go to months; no syncope, vertigo, weakness or paralysis, numbness or sleep and not wake up. Discuss pharmacoeconomic considerations in antidepressant Refer for support group, psychotherapy; begin antidepressant med- therapy, including choice of agents for inclusion in the formulary ication of a hospital or health maintenance organization. Economic evaluation of antide- pressive agents: a systematic critique of experimental and observa- tional studies. What drug regimen (drug, dosage, schedule, and duration) is antidepressant drug treatment in depressive disorders: a systematic best for this patient? What alternatives would be appropriate if the patient fails to and T(3) augmentation following two failed medication treatments for respond to initial therapy? If I sleep, America will fall, and it will all be on my of bipolar disorder when given patient interview information. The towers in New York City have already fallen because • Recommend appropriate pharmacotherapy for patients with I didn’t get there in time. He also • Identify the pharmacotherapeutic options for treating the sub- seems to believe that he has been given a mission from God as types of bipolar disorder. Several times during the interview, he began crying and wailing loudly, begging to be saved and shouting, “I’m sorry. When told that he might need to stay at the hospital í Chief Complaint so we could help him with his problems, he screamed, “You can’t help me! They have drunk from the fruit “There are hundreds of vampires in this city, and I have the of the vine.


  • Renal tubular acidosis, distal, type 3
  • Melanoma, familial
  • Leao Ribeiro Da Silva syndrome
  • Ventricular fibrillation, idiopathic
  • Anencephaly
  • Campylobacteriosis
  • Congenital heart disorder
  • Chromosome 15, trisomy mosaicism

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Elderly patients may be particularly sensitive to the side-effects of tricyclic antidepressants and reduced doses are recommended generic 400mg etodolac with amex arthritis foot. Bradykinesia which is general slowness of movement buy etodolac without prescription arthritis in the knee natural remedies, is the main symptom for parkinsonism buy etodolac 300mg mastercard rheumatoid arthritis diet soda, which buy etodolac no prescription arthritis inflammation fingers, during the initial phases of the disease, may occur as the only symptom or in combination with tremor at rest that disappears with activity and muscular rigidity. As the disease progresses, patients develop reduced blink frequency, monotonous and impaired speech, greasy skin leading to sebor- rhoea, urinary incontinence and constipation. Test 2: Answers 111 A72 B Amitriptyline, being a tricyclic antidepressant, may cause movement disorders and dyskinesias. Atopic eczema occurs mostly in children and it is characterised by pruritus, itchy papules, inflamed and lichenified skin especially on flexures such as elbows and knees. It is associ- ated with a family history of asthma and hayfever and it may be exacerbated by allergens. The area may become infected because of pruritus, leading to a flare-up of the condition and a bacterial infection. Atopic eczema is a chronic condition that may be exacerbated by exposure to allergens such as clothing fibres, by changes in environment such as exposure to sun, hot temperatures or cold temperatures. Ringworm infection is a fungal infection and when it occurs on non-hairy areas (tinea corporis) it is characterised by discoid, erythematous scaly plaques. Topical antihistamines such as mepyramine should be avoided in eczema as they may cause hypersensitivity reactions and exacerbate the condition. They should be advised on the regular use of emollients, to avoid soaps and bubble baths and to use emollient bath oils instead. They should be informed that the condition may be exacerbated by allergens such as wool, excipients in cosmetic cream preparations, and by sun exposure. It occurs as a result of a stressful situation, such as activities that cause the individual stress and anxiety (psycho- logical and environmental factors). Management of the condition includes analgesics, helping the patient to identify activities that precipitate an attack, physical therapy such as heat application to the head and neck area, and relaxation techniques. Test 2: Answers 113 A76 D Tension headaches tend to occur repeatedly in patients who are prone to develop this syndrome. The vasoconstriction is followed with vasodilation and inflammation leading to pain associated with a migraine attack. A77 A Patients with tension headache complain of mild, dull ache that is steady and usually bilateral and non-throbbing. These could include prolonged posture posing strain on head and neck muscles and activities that induce stress. Specific food consumption has not been established to have a direct effect on the occurrence of tension headache. It has been documented that dietary factors such as consumption of cheese and wine may induce migraine attacks. Aspirin should be avoided during breast- feeding because there is a risk of Reye’s syndrome in the infant. Reye’s syndrome is a condition characterised by acute encephalopathy and fatty degeneration of the liver that is associated with the use of aspirin in children. Regular use of aspirin by breast-feeding mothers may impair platelet function in the infant resulting in hypoprothrombinaemia. Test 3 Questions Questions 1–6 Directions: Each group of questions below consists of five lettered headings followed by a list of numbered questions. Then choose: A ❏ if 1, 2 and 3 are correct B ❏ if 1 and 2 only are correct C ❏ if 2 and 3 only are correct D ❏ if 1 only is correct E ❏ if 3 only is correct Directions summarised A 1, 2, 3 1, 2 only 2, 3 only 1 only 3 only Q7 Transdermal fentanyl: 1 ❏ is used for pain relief 2 ❏ contains a pure agonist for μ-opioid receptors 3 ❏ provides long-lasting analgesic effect Questions 7–26 117 Q8 Unexpected fluctuations in dose response in patients receiving warfarin may be attributed to: 1 ❏ changes in vitamin K intake 2 ❏ major changes in intake of salads and vegetables 3 ❏ major changes in alcohol consumption Q9 Clozapine has an affinity for: 1 ❏ dopamine receptors 2 ❏ serotonin receptors 3 ❏ muscarinic receptors Q10 Ciclosporin: 1 ❏ has an inhibitory effect on T-lymphocytes 2 ❏ may cause a dose-dependent increase in serum creatinine during the first few weeks of treatment 3 ❏ causes hyperlipidaemia Q11 When candesartan is started in the older person, recommended moni- toring includes: 1 ❏ plasma potassium 2 ❏ bilirubin 3 ❏ blood glucose Q12 Prostate cancer: 1 ❏ testosterone replacement therapy is the mainstay of treatment 2 ❏ growth is androgen-dependent 3 ❏ may be diagnosed by prostate-specific antigen screening 118 Test 3: Questions Q13 Ondansetron: 1 ❏ may be administered with dexamethasone 2 ❏ is the drug of first choice in managing delayed chemotherapy-induced nausea and vomiting 3 ❏ is used prophylactically for motion sickness Q14 Dose reduction and delays in administration of planned cytotoxic chemotherapy are caused by: 1 ❏ alopecia 2 ❏ extravasation 3 ❏ leucopenia Q15 Spirometry measures: 1 ❏ forced expiratory volume 2 ❏ forced vital capacity 3 ❏ total lung capacity Q16 Methicillin-resistant Staphylococcus aureus: 1 ❏ is a cause of nosocomial infections 2 ❏ spreading of infection may be reduced by alcohol hand rubs 3 ❏ presents an economic issue to institutions Q17 Alanine aminotransferase: 1 ❏ is found predominantly in the liver 2 ❏ levels are significantly decreased in viral hepatitis 3 ❏ is never released into the bloodstream Q18 Aldosterone: 1 ❏ production is regulated primarily by the liver 2 ❏ levels are decreased by low-sodium diets 3 ❏ is produced by the adrenal cortex Questions 7–26 119 Q19 Proteinuria: 1 ❏ is an indicator of renal disease 2 ❏ may be an indicator of pre-eclampsia 3 ❏ 24-h urine specimen collection could be recommended if proteinuria is significant Q20 Patients with type I diabetes should be advised: 1 ❏ to self-monitor blood glucose 2 ❏ to have access to a source of fast sugars 3 ❏ to avoid participating in sport Q21 When aspirin is compared with warfarin, it: 1 ❏ decreases platelet aggregation 2 ❏ has higher rates of major haemorrhage 3 ❏ requires the same degree of monitoring Q22 Patients with gallstone disease: 1 ❏ present with visceral pain in the abdomen 2 ❏ report precipitation of the condition with fatty meals 3 ❏ are referred for a gastroscopy Q23 Sleep apnoea: 1 ❏ is associated with cessation of breathing for at least 5 minutes during sleep 2 ❏ occurs more commonly in obese patients 3 ❏ presents with snoring Q24 Potential beneficial effects of cannabis include: 1 ❏ anti-emetic 2 ❏ analgesia 3 ❏ appetite suppressant 120 Test 3: Questions Q25 Drugs that may cause hypertension include: 1 ❏ corticosteroids 2 ❏ phenothiazines 3 ❏ alpha-adrenoceptor blockers Q26 Patients receiving oral iron tablets should be advised: 1 ❏ to take the preparation with food 2 ❏ that stools may be black-coloured 3 ❏ to rinse their mouth after drug administration Questions 27–80 Directions: These questions involve cases. Unwanted effects of medications may have an impact in a particular patient because of concomitant disease states, resulting in deterioration of the condition. A1 D Wilson’s disease is a rare disorder associated with a decrease in cerulo- plasmin, which causes copper to accumulate slowly in the liver and then be released into the circulation where it is taken up by other tissues. Accumulation of copper in the brain causes tremors, muscle rigidity and speech impairment, whereas its accumulation in erythrocytes leads to haemolysis and haemolytic anaemia. A2 B Cushing’s disease is a disorder where there is an increased secretion of adrenocortical steroids. This results in accumulation of fat on the face, chest and upper back and leads to the development of oedema, hyperglycaemia, increased gluconeogenesis, muscle weakness and osteoporosis. The condition is caused by increased amounts of adrenocorticotrophic hormone, which is released from the pituitary. A3 A Phaeochromocytoma is a tumour of the chromaffin tissue of the adrenal medulla or sympathetic paraganglia. Its occurrence results in hypersecretion 143 144 Test 3: Answers of adrenaline and noradrenaline leading to the development of persistent or intermittent hypertension, headache, palpitations, sweating, hyperglycaemia, syncope, nausea and vomiting. A change in the concentration of electrolytes in blood is important information that is required for diagnosis and for patient monitoring. Hyperparathyroidism leads to increased parathyroid hormone levels, which lead to increased gastrointestinal absorption of calcium, decreased calcium urinary excretion and increased bone resorption. A6 E Hypokalaemia increases cardiac muscle sensitivity to digoxin and hence patients are more prone to digoxin toxicity. Patients who are taking digoxin and may be predisposed to hypokalaemia should have their serum potassium levels monitored and potassium supplementation may be required. Digoxin Test 3: Answers 145 toxicity is manifested by anorexia, nausea, vomiting, diarrhoea, abdominal pain, visual disturbances, headache, confusion, drowsiness, arrhythmias and heart block. Questions 7–26 A7 A Fentanyl is a phenylpiperidine derivative and it is a potent opioid analgesic, which is a pure agonist of μ-opioid receptors. A8 A Warfarin is an anticoagulant that acts by reducing the vitamin-K-dependent synthesis of coagulation factors in the liver. Any activity that changes vitamin K concentrations in the body may result in unexpected fluctuations in dose response in patients receiving warfarin. An increase in vitamin K levels through direct vitamin K intake or through an increased intake of salads and vegetables reverses the effect of warfarin. A decrease in consumption leads to a higher anticoagulant effect for the same dose of warfarin as the levels of vitamin K, which oppose its activity, are reduced. Alcohol has a variable effect on warfarin therapy and major changes in consumption may lead to changes in therapeutic outcome. It has activity as a dopamine-receptor blocker, an antiserotonergic, an anti- muscarinic, an alpha-adrenergic blocker, and an antihistamine. It inhibits the activation of calcineurin, which is required for the production of lymphokines, including interleukin-2. When treatment is started, kidney function should be monitored for the first few weeks as a dose-dependent increase in serum creatinine and urea may occur. When candesartan is started in older persons, monitoring of plasma potassium concentration is recommended as hyperkalaemia may occur occasionally. The concentration of the protein is elevated in patients with cancer or other prostate disease states. Treatment is aimed at androgen depletion and includes use of anti-androgens such as cyproterone and gonadorelin analogues such as goserelin. It is used to counteract cytotoxic chemotherapy-induced nausea and Test 3: Answers 147 vomiting, and in the postoperative nausea and vomiting that can be caused by anaesthetics and opioid analgesics.

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The tendon of • a depression formed by the medialmalleolus of the tibia order etodolac 400mg fast delivery rheumatoid arthritis new treatments, the tibialis posterior is medial to the tendon of the flexor the medial and posterior surfaces of the talus buy etodolac 400mg arthritis upper back, themedial digitorum longus generic 200mg etodolac mastercard arthritis diet potatoes. The pulse of the posterior tibial artery can be felt through the flexor reti­ Flexor retinaculum naculum midway between the medial malleolus and the The flexor retinaculum is a strap-like layer of connective calcaneus generic 400 mg etodolac free shipping arthritis pain formula commercial. Tendon of flexor Tibia digitorum longus Tendon of tibialis posterior Tendon of hallucis longus I /- Pulse of post-tibial artery / midway between heel Flexor retinaculum I and medial malleolus I I I A 8 Fig. Medial to these tendons, the dor­ muscles to the ankle region and prevent tendon bowing salis pedis artery (terminal branch of the anterior tibial during extension of the foot and toes (Fig. Fibular (peroneal) retinacula bind the tendons of thefbu­ • An inferior retinaculum is Y-shaped, attached by its laris longus and fbularis brevis muscles to the lateral side base to the lateral side of the upper surface of the cal­ of the foot (Fig. Anterior tibial artery Tendon of extensor At the fbular trochlea, a septum separates the compart­ hallucis longus ment for the tendon of the fbularis brevis muscle above from that for the fbularis longus below. Superior extensor Tendons of fibularis longus and retinaculum brevis muscles Inferior extensor retinaculum Extensor digitorum longus Dorsalis Fibularis terius pedis artery First dorsal interosseous muscle Inferior fibular retinaculum (at fibular trochlea on calcaneus) Superior fibular retinaculum Fig. Medial longitudinal arch Longitudinal arch The longitudinal arch of the foot is formed between the posterior end of the calcaneus and the heads of the meta­ tarsals (Fig. It is highest on the medial side, where it forms the medial part of the longitudinal arch, and lowest on the lateral side, where it forms the lateral part. Transverse arch Thetransverse arch of thefoot is highest in a coronal plane that cuts through the head of the talus and disappears near the heads of the metatarsals, where these bones are held together by the deep transverse metatarsal ligaments {Fig. Tibialis anterior and Plantar calcaneonavicular ligament posterior tendons Fibularis longus tendon Long plantar ligament A B Fig. The tendons of the flexor digitorum longus, flexor digito­ rum brevis, andflexorhallucis longus muscles enter fbrous digital sheaths or tunnels on the plantar aspect of the Plantar aponeurosis digits (Fig. These fbrous sheaths begin anterior The plantar aponeurosis is a thickening of deep fascia in to the metatarsophalangeal joints and extend to the thesoleof thefoot (Fig. They are formed by fbrous arches and medial process of the calcaneal tuberosity and extends cruciate (cross-shaped) ligaments attached posteriorly to forward as a thick band of longitudinally arranged connec­ the margins of the phalanges and to the plantar ligaments tive tissue fbers. The fbers diverge as they pass anteriorly associated with the metatarsophalangeal and interphalan­ and form digital bands, which enter the toes and connect geal joints. These fbrous tunnels hold the tendons to the bony Distal to the metatarsophalangeal joints, the digital plane and prevent tendon bowing when the toes are flexed. The plantar aponeurosis supports the longitudinal arch of the foot and protects deeper structures in the sole. Fibrous digital sheaths Flexor digitorum brevis tendon Flexor digitorum longus tendon Tibialis anterior Anterior arm of inferior extensor retinaculum Fibularis Tibialis posterior longus Flexor digitorum longus Medial process of Flexor hallucis longus calcaneal tuberosity Fig. Extensor hoods The tendons of the extensor digitorum longus, extensor Intrinsic muscles digitorum brevis, and extensor hallucis longus pass into Intrinsic muscles of thefoot originate andinsert in thefoot: the dorsal aspect of the digits and expand over the proximal phalanges to form complex dorsal digital expansions • the extensor digitorum brevis and extensor hallucis ("extensor hoods") (Fig. The corners of the and lumbricals-are on the plantar side of the foot in hoods attach mainly to the deep transverse metatarsal the sole where they are organized into four layers. Many of the intrinsic muscles of the foot insert into the Intrinsic muscles mainly modify the actions of the long free margin of the hood on each side. The function of these movements in the foot is sei also may receive part of their innervation from the deep uncertain, but they may prevent overextension of the fbular nerve. The extensor digitorum brevis extends the middle three toes through attachments to the long extensor tendons and extensor hoods. The muscle extends the metatarsophalangeal joint of the great digitorum toe and is innervated by the deep fbular nerve. From superfcial to deep, or plantar to dorsal, these layers are the frst, second, third, and fourth layers. From medial to lateral, these muscles are the abductor hallucis, fexor digitorum brevis, and abductor digiti minimi. Abductor hallucis The abductor hallucis muscle forms the medial margin of the foot and contributes to a soft tissue bulge on the medial side of the sole (Fig. It originates fom the medial process of the calcaneal tuberosity and adjacent margins of the flexor retinaculum and plantar aponeuro­ sis. It forms a tendon that inserts on the medial side of the base of the proximal phalanx of the great toe and on the medial sesamoid bone associated with the tendon of the flexor hallucis brevis muscle. The abductor hallucis abducts and flexes the great toe at the metatarsophalangeal joint and is innervated by the medialplantar branch of the tibial nerve. Flexor digitorum brevis The flexor digitorum brevis muscle lies immediately superior to the plantar aponeurosis and inferior to the tendons of the flexor digitorum longus in the sole of the foot (Fig. The flat spindle-shaped muscle belly origi­ nates as a tendon from the medial process of the calcaneal tuberosity and from the adjacent plantar aponeurosis. The muscle fbers of the flexor digitorum brevis con­ between calcaneus and verge anteriorly to form four tendons, which each enter metatarsal V one of the lateral four toes. Abductor digiti minimi The abductor digiti minimi muscle isonthe lateral side of the foot and contributes to the large lateral plantar emi­ nence on the sole (Fig. It has a broad base of origin, mainly from the lateral and medial processes of the calca­ neal tuberosity and from a fbrous band of connective tissue, which connects the calcaneus with the base of metatarsal V The abductor digiti minimi forms a tendon, which travels in a shallow groove on the plantar surface of the Lumbrical muscles base of metatarsal V and continues forward to attach to the lateral side of the base of the proximal phalanx of the little toe. Flexor hallucis The abductor digiti minimi abducts the little toe at the longus metatarsophalangeal joint and is innervated by the lateral plantar branch of the tibial nerve. Quadratus plantae The quadratus plantae muscle is a flat quadrangular muscle with two heads of origin (Fig. The quadratus plantae muscle inserts into the lateral side of the tendon of the flexor digitorum longus in the proximal half of the sole of the foot near where the tendon divides. The quadratus plantae assists the flexor digitorum longus tendon in flexing the toes and may also adjust the "line of pull" of this tendon as it enters the sole of the foot from the medial side. Lumbricals The lumbrical muscles are four worm-like muscles that originate from the tendons of the flexor digitorum longus and pass dorsally to insert into the free medial margins of the extensor hoods of the four lateral toes (Fig. The frst lumbrical originates from the medial side ofthe tendon of the flexor digitorum longus that is associated with the second toe. The lumbrical muscles act through the extensor hoods to resist excessive extension of the metatarsophalangeal joints and flexion of the interphalangeal joints when the Tendon of posterior muscle heel leaves the ground during walking. The frst lumbrical is innervated by the medial plantar nerve, while the other three are innervated by the lateral plantar nerve. The tendon of insertion of the adductor hallucis The medial and lateral heads unite and give rise to a attaches to the lateral sesamoid bone associated with the muscle belly, which itself is separated into medial and tendon of the flexor hallucis brevis muscle in addition to lateral parts adjacent to the plantar surface of metatarsal attaching to the proximal phalanx. Each part of the muscle gives rise to a tendon that inserts The adductor hallucis adducts the great toe at the meta­ on either the lateral or medial side of the base of the proxi­ tarsophalangeal joint and is innervated by the lateral mal phalanx of the great toe. A sesamoid bone occurs in each tendon of the flexor hallucis brevis as it crosses the plantar surface of the head Flexor digiti minimi brevis of metatarsal I. The tendon of the flexor hallucis longus The flexor digiti minimi brevis muscle originates from passes between the sesamoid bones. It geal joint of the great toe and is innervated by the medial inserts on the lateral side of the base of the proximal plantar nerve. The flexor digiti minimi brevis flexes the little toe at the Adductor hallucis metatarsophalangeal joint and is innervated by the lateral The adductor hallucis muscle originates by two muscu­ plantar nerve. Deep transverse metatarsal ligaments Dorsal interossei The four dorsal interossei arethe most superior muscles in the sole of the foot and abduct the second to fourth toes relative to the long axis through the second toe (Fig. The tendons of the dorsal interossei insert into the free margin of the extensor hoods and base of the proximal phalanges of the toes. The second toe can be abducted to either side of its long axis, so it has two dorsal interossei associated with it, one on each side.

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