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A bovine cough may be heard in patients with tumours of the upper lobes of the lung (Pancoast tumour) due to arrhythmia chapter 1 cheap cardizem 120 mg recurrent laryngeal nerve palsy pulse pressure equation buy cardizem 60 mg line. Bovine cough may also result from any cause of bulbar weakness heart attack vs angina generic cardizem 120mg with amex, such as motor neurone disease, Guillain­Barrй syndrome, and bulbar myopathies. Cross References Bulbar palsy; Diplophonia; Signe de rideau Bradykinesia Bradykinesia is a slowness in the initiation and performance of voluntary movements in the absence of weakness and is one of the typical signs of parkinsonian syndromes, in which situation it is often accompanied by difficulty in the initiation of movement (akinesia, hypokinesia) and reduced amplitude of movement (hypometria) which may increase with rapid repetitive movements (fatigue). It may be overcome by reflexive movements or in moments of intense emotion (kinesis paradoxica). Bradykinesia in parkinsonian syndromes reflects dopamine depletion in the basal ganglia. It may be improved by levodopa and dopaminergic agonists, less so by anticholinergic agents. Cross References Abulia; Akinesia; Fatigue; Hypokinesia; Hypometria; Kinesis paradoxica; Parkinsonism; Psychomotor retardation Bradylalia Bradylalia is slowness of speech, typically seen in the frontal­subcortical types of cognitive impairment, with or without extrapyramidal features, or in depression. Cross References Palilalia; Tachylalia Bradyphrenia Bradyphrenia is a slowness of thought, typically seen in the frontal­subcortical types of cognitive impairment. Silent reading may also be impaired (deep dyslexia) as reflected by poor text comprehension; Writing: similarly affected. There is a mild and transient aphasia or anomia which may share some of the characteristics of aphemia/phonetic disintegration. More commonly there is infarction in the perisylvian region affecting the insula and operculum (Brodmann areas 44 and 45), which may include underlying white matter and the basal ganglia (territory of the superior branch of the middle cerebral artery). Passive flexion of the neck to bring the head onto the chest is accompanied by flexion of the thighs and legs. Cross References Blepharospasm; Dystonia Bruit Bruits arise from turbulent blood flow causing arterial wall vibrations which are audible at the body surface with the unassisted ear or with a stethoscope (diaphragm rather than bell, better for detecting higher frequency sounds). They are associated with stenotic vessels or with fistulae where there is arteriovenous shunting of blood. Examination for carotid bruits in asymptomatic individuals is probably best avoided, other than in the clinical trial - 67 - B Brushfield Spots setting, since the optimal management of asymptomatic carotid artery stenosis has yet to be fully defined. Dysfunction of efferent and/or afferent thalamic and striatopallidal tracts has been suggested as the neural substrate. If necessary, a rubber gum shield or bite may be worn in the mouth to protect the teeth. This may be differentiated clinically from bulbar weakness of upper motor neurone origin (pseudobulbar palsy). Recognized causes include Brainstem disorders affecting cranial nerve motor nuclei (intrinsic): Motor neurone disease (which may also cause a pseudobulbar palsy); Poliomyelitis; Glioma; Syringobulbia. A myogenic bulbar palsy may be seen in oculopharyngeal muscular dystrophy, inclusion body myositis, and polymyositis. Cross References Cauda equina syndrome; Reflexes Buphthalmos Buphthalmos, literally ox-eye, consists of a large and bulging eye caused by raised intraocular pressure due to congenital or secondary glaucoma. Cross Reference Diamond on quadriceps sign Calf Hypertrophy Calf enlargement has many causes; it may reflect true hypertrophy (enlargement of muscle fibres) or, more commonly, pseudohypertrophy, due to infiltration with tissue elements other than muscle. Hypertrophy may be due to neuromuscular disorders producing chronic partial denervation. Calf pseudohypertrophy may be due to: Dystrophinopathies (Duchenne muscular dystrophy, Becker dystrophy), due to excess connective tissue; Infection/inflammation: myositis; Infiltration: amyloidosis, tumour, cysticercosis. Head flexion to 30 above the horizontal allows maximum stimulation of the horizontal semicircular canals, whereas 60 below horizontal maximally stimulates the lateral semicircular canals. Induced nystagmus is then timed both with and without visual fixation (in the dark, Frenzel glasses). Normally, the eyes show conjugate deviation towards the ear irrigated with cold water, with corrective nystagmus in the opposite direction; with warm water the opposite pattern is seen. A reduced duration of induced nystagmus is seen with canal paresis; enhancement of the nystagmus with removal of visual fixation suggests this is peripheral in origin (labyrinthine, vestibulocochlear nerve), whereas no enhancement suggests a central lesion. As coma deepens even the caloric reflexes are lost as brainstem involvement progresses. A distinction is sometimes drawn between camptodactyly and streblodactyly: in the latter, several fingers are affected by flexion contractures (streblo = twisted, crooked), but it is not clear whether the two conditions overlap or are separate. The term streblomicrodactyly has sometimes been used to designate isolated crooked little fingers.


  • Hypospadias -- urethra opening is on the underside of the penis, rather than at the tip
  • The doctor may also order periodic computed tomography (CT) scans of your chest, abdomen, and pelvic area.
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  • Severe illness in the mother, including heart disease, preeclampsia or eclampsia
  • The eyes, causing cataracts and other problems (such as a dislocation of the lenses)
  • Lightheadedness
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Consolidated stormwater treatment areas and surface conveyances define more traditional park recreation and play areas arterial order cardizem 60mg visa. Over 1 blood pressure too low symptoms buy cardizem mastercard,200 rental blood pressure chart android app cheap cardizem 120mg on-line, affordable, and market-rate single- and multi-family housing units have been provided in the 100-acre project area. The neighborhood is organized around two neighborhood parks and a parkway that serve dual functions as neighborhood recreation space and as surface stormwater conveyance and a consolidated treatment system (see Figure 5-57). Water quality treatment is being provided for a combined area of over 660 acres that includes the 100-acre project area and over 500 acres of adjacent neighborhoods. The sediment trap in the center left of the photo was designed for ease of maintenance access by city crews with standard city maintenance equipment. Vegetated swales, porous concrete sidewalks, and frontyard rain gardens convey and treat stormwater on-site. Water is circulated through a series of biofiltration areas and used for toilets and other mechanical systems in the building complex. Menomonee Valley Redevelopment, Wisconsin the 140-acre redevelopment of abandoned railyards illustrates how a Brownfield site within an existing floodplain can be redeveloped using both on-site and consolidated treatment. As shown in Figure 5-60, consolidated treatment is incorporated into park areas which provide recreation for adjacent neighborhoods and serve as a centerpiece for a developing light industrial area that provides jobs to surrounding neighborhoods. Treatment on individual privately owned parcels is limited to the removal of larger sediments and debris only, making more land available for development. The volume of water that, by regulation, must be captured and treated on individual sites is conveyed through a conventional subsurface system for treatment in park areas. The image on the left illustrates the fair weather condition, the center image the water quality capture volume, and the image on the right the 100-year storm event. In general, the watershedor receiving water-based criteria are more specific and detailed than would be found in a regional or statewide stormwater manual. Like the identification of stressors or pollutants of concerns, this step is rarely taken under current paradigms of stormwater management. Communities may choose to establish some kind of stormwater trading or mitigation system in the event that full compliance is not possible due to physical constraints or because it is more cost effective or equitable to achieve pollutant reduction elsewhere in the local watershed. This kind of trading can provide for greater cost equity between low-cost Greenfield sites and higher-cost ultra-urban sites. Ensuring the Safe and Effective Performance of the Drainage Network, Streams, and Floodplains the urban water system is not solely designed to manage the quality of runoff. It also must be capable of safely handling flooding from extreme storms to protect life and property. Consequently, communities need to ensure that their stormwater infrastructure can prevent increased flooding caused by development (and possibly exacerbated future climate change). This usually requires a watershed approach to stormwater management to ensure that quality and quantity control are integrated together, with an emphasis on the connection and effective use of conveyance channels, streams, riparian buffers, and floodplains. In these situations, communities need to devise a workable model that will be used to operate, inspect, and maintain the stormwater infrastructure across their local watershed. They can elect to assign the responsibility to the public sector, the private sector. Summary Taking all of the elements above into consideration, the emerging goal of stormwater management is to mimic, as much as possible, the hydrological and water quality processes of natural systems as rain travels from the roof to the stream through combined application of a series of practices throughout the entire development site and extending to the stream corridor. By contrast, Tables 5-9 and 5-10 outline how the general "roof-to-stream" stormwater approach is adapted for intense industrial operations and urban redevelopment sites, respectively. The tables are meant to be illustrative of certain situations; other scenarios, such as commercial development, would likely require additional tables. This "roof-to-stream" approach works best for low- to medium-density residential development. First, stormwater management financed through general tax receipts does not link or attempt to link financial obligation with services received. The absence of such links can reduce the ability of a municipality to adequately plan and meet basic stormwater management obligations. Second, when funded through general tax revenues, stormwater programs must compete with other municipal programs and funding obligations. Finally, in programs funded by general tax revenue, responsibilities for stormwater management tend to be distributed into the work responsibilities of existing and multiple departments. One recent survey conducted in the Charles River watershed in Massachusetts found that three-quarters of local stormwater management programs did not have staff dedicated exclusively for stormwater management (Charles River Watershed Association, 2007). Increasingly, many municipalities are establishing stormwater utilities to manage stormwater (Kaspersen, 2000).

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