Pilex

Clifford Raabe Weiss, M.D.

• Medical Director, The Johns Hopkins Center for Bioengineering, Innovation and Design (CBID)
• Associate Professor of Radiology and Radiological Science

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015953/clifford-weiss

Cross Reference One-and-a-half syndrome Pseudopapilloedema Pseudopapilloedema is the name given to elevation of the optic disc that is not due to oedema mens health look book discount pilex 60caps with mastercard. In distinction to oedematous disc swelling man health cure effective pilex 60caps, the nerve bre layer is not hazy and the underlying vessels are not obscured; however prostate awareness month order pilex toronto, spontaneous retinal venous pulsation is usually absent androgen hormone kalin buy pilex 60caps without prescription, and haemorrhages may be seen mens health flat stomach purchase pilex visa, so these are not reliable distinguishing features mens health nutrition pilex 60caps on-line. The term pseudoptosis has also been used in the context of hypotropia; when the non-hypotropic eye xates, the upper lid follows the hypotropic eye and appears ptotic, disappearing when xation is with the hypotropic eye. Cross Reference Ptosis Pseudoradicular Syndrome Thalamic lesions may sometimes cause contralateral sensory symptoms in an apparent radicular. If associated with perioral sensory symptoms this may be known as the cheiro-oral syndrome. Restricted acral sensory syndrome following minor stroke: further observations with special reference to differential severity of symptoms among individual digits. This may be due to mechanical causes such as aponeurosis dehiscence, or neurological disease, in which case it may be congenital or acquired, partial or complete, unilateral or bilateral, xed or variable, isolated or accompanied by other signs. It is frequently related to previous occupation or hobbies but is seldom pleasurable. The contralat eral (consensual) response results from bres crossing the midline in the optic chiasm and in the posterior commissure at the level of the rostral brainstem. In comatose patients, xed dilated pupils may be observed with central diencephalic herniation, whereas midbrain lesions produce xed midposition pupils. This disparity arises because pupillomo tor bres run on the outside of the oculomotor nerve and are relatively spared by ischaemia but are vulnerable to external compression. Patients can copy and write spontaneously, follow written commands, but cannot write to dictation. There may be associated amusia, depending on the precise location of cerebral damage. Pure word deafness is most commonly associated with bilateral lesions of the temporal cortex or subcortical lesions whose anatomical effect is to dam age the primary auditory cortex or isolate it. Cerebellar hypoplasia and quadrupedal locomotion in humans as a recessive trait mapping to chromosome 17p. No specic investigations are required, but a drug history, including over the counter medi cation, is crucial. There may be concurrent myelopathy, typically of extrinsic or extramedullary type. Recognized causes include connective tissue disease, especially systemic sclerosis: cervical rib or tho racic outlet syndromes; vibration white nger; hypothyroidism; and uraemia. Recruitment Recruitment, or loudness recruitment, is the phenomenon of abnormally rapid growth of loudness with increase in sound intensity, which is encountered in patients with sensorineural (especially cochlear sensory) hearing loss. Cross Reference Reexes Recurrent Utterances the recurrent utterances of global aphasia, sometimes known as verbal stereo typies, stereotyped aphasia, or monophasia, are reiterated words or syllables produced by patients with profound non-uent aphasia. This may also occur with temporomandibular joint dysfunction and thalamic lesions. Reduplicative Paramnesia Reduplicative paramnesia is a delusion in which patients believe familiar places, objects, individuals, or events to be duplicated. The syndrome is probably het erogeneous and bears some resemblance to the Capgras delusion as described by psychiatrists. Reduplicative paramnesia is more commonly seen with right (non dominant) hemisphere damage; frontal, temporal, and limbic system damage has been implicated. The latter are of particular use in clinical work because of their localizing value (see Table). Reex responses may vary according to the degree of patient relaxation or anxiety (precontraction). Moreover, there is interobserver variation in the assess ment of tendon reexes (as with all clinical signs): a biasing effect of prior knowledge upon reex assessment has been recorded. Reliability of the clinical and electromyographic examina tion of tendon reexes. Quickly moving the light to the diseased side may produce pupillary dilata tion (Marcus Gunn pupil). Although visual acuity may also be impaired in the affected eye, and the disc appears abnormal on fundoscopy, this is not necessarily the case. Isolated rel ative afferent pupillary defect secondary to contralateral midbrain compression. It is sometimes difcult to see and may be more obvious in the recumbent position because of higher pressure within the retinal veins in that position. This process may be asymptomatic in its early stages, but may later be a cause of nyctalopia (night blindness), and produce a midperipheral ring scotoma on visual eld testing. Looking at protein misfolding neurodegenerative disease through retinitis pigmentosa. Cross References Maculopathy; Retinitis pigmentosa; Scotoma Retrocollis Retrocollis is an extended posture of the neck. Retrocollis may also be a feature of cervical dystonia (torticollis) and of kernicterus. This phenomenon does not have partic ular localizing value, since it may occur with both occipital and anterior visual pathway lesions. Cross References Acalculia; Agraphia; Autotopagnosia; Finger agnosia; Gerstmann syndrome Rigidity Rigidity is an increased resistance to the passive movement of a joint which is constant throughout the range of joint displacement and not related to the speed of joint movement; resistance is present in both agonist and antagonist mus cles. Rigidity is a feature of parkinsonism and may coexist with any of the other clinical features of extrapyramidal system disease, but particularly akinesia (akinetic-rigid syndrome); both are associated with loss of dopamine projections from the substantia nigra to the putamen. The pathophysiology of rigidity is thought to relate to overactivity of tonic stretch reexes in the spinal cord due to excessive supraspinal drive to spinal cord -313 R Rindblindheit -motor neurones following loss of descending inhibition as a result of basal gan glia dysfunction. In other words, there is a change in the sensitivity of the spinal interneurones which control -motor neurones due to defective supraspinal con trol. Hence rigidity is a positive or release symptom, reecting the operation of intact suprasegmental centres. In support of this, pyramidotomy has in the past been shown to produce some relief of rigidity. Risus sardonicus may also occur in the context of dystonia, more usually symptomatic (secondary) than idiopathic (primary) dystonia. Before asking the patient to close his or her eyes, it is advisable to position ones arms in such a way as to be able to catch the patient should they begin to fall. A modest increase in sway on closing the eyes may be seen in normal subjects and patients with cerebellar ataxia, frontal lobe ataxia, and vestibular disorders (towards the side of the involved ear); on occasion these too may produce an increase in sway sufcient to cause falls. Development of numbness, pain, and paraesthesia, along with pallor of the hand, supports the diagnosis of thoracic outlet syndrome. A number of parameters may be observed, including latency of saccade onset, saccadic amplitude, and saccadic velocity. Of these, saccadic velocity is the most important in terms of localization value, since it depends on burst neurones in the brainstem (para median pontine reticular formation for horizontal saccades, rostral interstitial nucleus of the medial longitudinal fasciculus for vertical saccades). In progressive supranuclear palsy slowing of vertical saccades is an early sign (suggesting brainstem involvement; horizontal saccades may be affected later), whereas vertical saccades are affected late (if at all) in cor ticobasal degeneration, in which condition increased saccade latency is the more typical nding, perhaps reective of cortical involvement. Several types of saccadic intrusion are described, including ocular utter, opsoclonus, and square wave jerks. This is a late, unusual, but diagnostic feature of a spinal cord lesion, usually an intrinsic (intramedullary) lesion but sometimes an extramedullary compression. Sacral sparing is explained by the lamination of bres within the spinotha lamic tract: ventrolateral bres (of sacral origin), the most external bres, are involved later than the dorsomedial bres (of cervical and thoracic ori gin) by an expanding central intramedullary lesion. Although sacral sparing is rare, sacral sensation should always be checked in any patient with a spastic paraparesis. The outstanding ability may be feats of memory (recalling names), calculation (especially calendar calculation), music, or artis tic skills, often in the context of autism or pervasive developmental disorder. Scanning speech correlates with midbrain lesions, often after recovery from prolonged coma. The examiner then places the tuning fork over his/her own mastoid, hence comparing bone conduc tion with that of the patient. If still audible to the examiner (presumed to have normal hearing), a sensorineural hearing loss is suspected, whereas in conductive hearing loss the test is normal. Mapping of the defect may be performed manually, by confrontation testing, or using an automated system. Infarction of the occipital pole will produce a central visual loss, as will optic nerve inammation. Scotomata may be absolute (no perception of form or light) or relative (preservation of form, loss of colour). A scotoma may be physiological, as in the blind spot or angioscotoma, or pathological, reecting disease anywhere along the visual pathway from retina and choroid to visual cortex. It has been claimed as a reliable test of poste rior column function of the spinal cord. Partial: simple (no impairment of consciousness), for example, jerk ing of one arm, which may spread sequentially to other body parts (Jacksonian march); or complex, in which there is impairment or loss of consciousness: may be associated with specic aura (olfactory, deja vu, jamais vu) and/or automatisms (motor. Otherwise, as for idiopathic generalized epilepsies, various antiepileptic medica tions are available.

Diseases

• Chiari type 1 malformation
• Stalker chitayat syndrome
• Fistulous vegetative verrucous hydradenoma
• Bulbospinal amyotrophy, X-linked
• Dentinogenesis imperfecta
• Adrenal cancer
• Follicular ichthyosis
• Blepharospasm

Importantly prostate oncology kansas cheap pilex, the instruments discussed in the following section are to be used only with children who have a developmental age of at least 12 months prostate operations for enlarged prostate generic pilex 60 caps without a prescription. Through a series of play based tasks man health problems safe pilex 60 caps, the semi-structured instrument enables trained professionals to assess communication thyroid hormone androgen receptor cheap pilex 60 caps with mastercard, social interaction man health issues buy pilex paypal, play and restricted and repetitive behaviors (Lord et al man health daily cheap pilex online visa. The Toddler Module does not produce a score; only ranges of concern (little-or-no, mild-to-moderate, moderate-to-severe) result from administering the assessment (Luyster et al. The instrument aids in distinguishing autism spectrum conditions from other child psychiatric conditions by identifying the presence and extent of autistic social impairment. It is administered with children as young as 30 months through adulthood and takes 15 to 20 minutes to administer. Each version contains a total of 65 items which sum to a total score and also include fve subscales: social awareness; social cognition; social communication; social motivation; and restricted interests and repetitive behavior. Items are posed in three ways, including a 4-point Likert scale, parent interview, and open-ended questions. It is designed to be completed by parents, teachers, or professionals who are assessing individuals 3 to 22 years of age. In terms of specifcity, a study by Sikora, Hall, Hartley, Gerrard-Morris, & Cagle (2008) reported a specifcity of. In such situations, further use of norm-referenced standardized measures that assess various aspects of development may provide additional diagnostic information. If standardized instruments are not used to assess developmental level or cognitive ability and adaptive behavior prior to or during the initial diagnostic evaluation, the diagnostician should refer to a qualifed professional who can complete cognitive and adaptive testing as part of the assessment for intervention planning or to contribute to intervention planning. Examples of assessments for developmental domains, adaptive functioning, communication and language development, social interaction, and behavior appear in Appendix D. Accurately identifying co-occurring conditions assists in determining which interventions or treatments are appropriate for the child. Adaptations of traditional evaluation methods may be needed for individuals who lack verbal communication skills or use other alternative forms of communication. A more recent study indicates that boys with regressive autism have typical head circumference at birth but an enlarged head by four to six months of age (Nordahl et al. These soft signs may be exhibited by signs such as toe walking early in life, diffculty with rapidly alternating movements, or general clumsiness. Examples of tests that might be performed include: visual acuity test; stereoacuity test; autorefraction; Hirschberg light refex test; and cover-uncover test. Creedon (2006) suggests additional tests that specialists can perform for individuals with autism who need vision screening, including tests that do not require verbal communication on the part of the person having the test, in such cases, a referral to the appropriate physician should be made. Associated Medical Conditions Part of the comprehensive medical exam should include an assessment as to whether the child has any associated medical conditions. Where needed, the clinician should refer to a specialist for further testing for a more in depth assessment of the cause of symptoms and behaviors. Seizures are caused by abnormal cerebral electrical activity that varies in type and duration. Although they may occur at any age, seizures typically present in a bimodal fashion, either before 5 years of age or after age 10 (Bolton et al. Further, seizures may be associated with signifcant language and cognitive impairments. Epilespy is a specifc seizure disorder that is a brain disorder characterized by a history of at least one seizure and the potential for recurrence of seizures (Fisher et al. Landau-Kleffner Syndrome is a considered to be a very rare disorder, although an exact prevalence is unknown (Simpson, 2013; Stefanatos, Kinsbourne & Wasserstein, 2002). Pica is the persistent mouthing of fngers or objects, which requires monitoring of blood lead levels, particularly in young children. Approximately 10% to 32% of typically developing children between one to six years of age experience some form of pica. Laboratory Tests A synthesis of the information gathered from the child and family during the medical exam will inform which laboratory tests, if any, should be conducted. In some cases, it may be possible to determine if there is a known etiology to the presenting symptoms or if multiple conditions are evident. The technology to identify small abnormalities in the genome is rapidly changing and evolving and the expected yield from diagnostic studies is anticipated to increase over time. Following is an overview of current recommended laboratory, neuroimaging and other diagnostic tests. Balanced rearrangements may not be detected by this methodology (<1% of the time). Information on differential disorders, co-occurring conditions, environmental factors, and etiological factors follow and these are listed on Table 8. Intellectual disability (formerly referred to as mental retardation) is characterized by defcits in intellectual (cognitive) functioning as well as defcits in adaptive functioning, including conceptual, practical and social skills that are manifested during the developmental period. Because it is a new disorder, estimates of the prevalence cannot be made at this time. Stereotypic Movement Disorder is characterized by repetitive movements with onset in the developmental period that appear to lack a purpose. An estimated 7% of children have Stereotypic Movement Disorder (Zinner & Mink, 2010). Data on the prevalence of anxiety disorders for adolescent-aged children is estimated to be about 13% (Costello et al. Depressive disorders in children (ages 6 to 12 years) may be characterized by irritability, anxiety, sleeping and behavior problems, whereas adolescents (ages 13 to 18 years) may express feelings of hopelessness and guilt (Birmaher et al. The prevalence of depression in children (ages 6 to 12 years) is estimated to be 2% and in adolescents (ages 13 to 18 years) between 4 to 8% (Birmaher et al. The lifetime prevalence of personality disorders is estimated to be 9% (Lenzenweger, Lane, Loranger, & Kessler, 2007). Onset of Selective Mutism typically occurs before age fve but may not be recognized until the child begins school. Selective Mutism is often accompanied by excessive shyness and fear of social embarrassment, which may present as atypical or withdrawn social interaction. Another distinguishing factor is that children with Selective Mutism do not have restricted or repetitive behaviors. The prevalence of Selective Mutism is thought to be between 1 and 2% (Viana, Beidel, & Rabian, 2009). Communication defcits, hand-fapping, motor hyperactivity, sudden bursts of laughter, seizures, facial dysmorphology, and intellectual disability are core features of Angelman syndrome (Cohen et al. Children with Angelman syndrome enjoy being around other people and demonstrate a desire to communicate with others and display this in a variety of ways including the use of non-verbal gestures. Individuals with Cornelia deLange are typically of small stature, have limb abnormalities, and have facial dsymorphology. They may be hypersensitive, impulsive, exhibit self-injurious, aggressive and compulsive behavior, have expressive communication and cognitive defcits (Oliver, Arron, Sloneem, & Hall, 2008). The prevalence of Cornelia deLange syndrome is approximately 1 in 10,000 to1/100,000 (Simpson, 2013). Down syndrome, also known as trisomy 21, is a genetic disorder characterized by intellectual disability, language delays, characteristic facial features and weak muscle tone, with increased risk for a variety of medical conditions (Roizen, 2013). Chromosomal analysis can reveal whether a child has Down syndrome, which is caused by the presence of all or part of a third copy of chromosome 21. Fragile X is an inherited disorder and the most commonly known inherited cause of intellectual disability characterized by poor eye contact, hand fapping and biting, attention defcits, anxiety, social avoidance, and language delays (Abrams et al. Some of the features characteristic of Prader-Willi syndrome include speech delays, intellectual disability, repetitive and obsessive behaviors and self injurious behaviors in addition to an insatiable appetite and obesity beginning in childhood when not controlled (Veltman, Craig, & Bolton, 2005). Common traits of Williams syndrome are intellectual disability, communication delay in early childhood, extroverted personality, disinhibition in social interactions, and characteristic physical features (Simpson, 2013; Kaufmann, Capone, Carter & Lieberman, 2008). A combination of medical tests can be used to determine if a person has Williams syndrome (blood pressure, blood test, echocardiogram and Doppler ultrasound, and kidney ultrasound). Characteristics of fetal alcohol spectrum disorder are delayed development, defcits in executive functioning, impaired social skills and diffculties with adaptive skills (Pei, Job, Kully-Marten & Rasmussen, 2011). Children with fetal alcohol spectrum disorder often have diffculty reading social cues, have poor social judgment and can be indiscriminate in their social approach such that their social behaviors appear atypical (Wyper & Rasmussen, 2011). Generally, it is reported that up to 30/10,000 infants are born with a pattern of physical, developmental, and functional problems indicative of fetal alcohol spectrum disorder (Chudley et al. Features indicative of untreated visual impairment in young children include abnormal movement of the eyes, eyes that look in only one direction, eyes that do not react to stimuli or habitual pressing of the eyes (Geddie et al. Those who are deaf or hard of hearing experience loss of hearing that may be mild, moderate, severe or profound and may be temporary or permanent (Buethe, Vohr, & Herer, 2013). Features of hearing loss in an infant include not awakening in reaction to loud noises and reduced, delayed or absent babbling by six months and later poor speech intelligibility (Buethe et al. Children with hearing loss may appear to be uninterested in social interactions or have limited social skills due to an inability to attend to what is being said. Mitochondrial disorders describe disorders that are caused by abnormal functioning of the mitochondria (energy producers of the cell) or mitochondrial metabolism. The diverse group of disorders often shares several features: drooping eyelid (ptosis), short stature, paralysis of external eye muscles and hypothyroidism (Simpson, 2013, p. Mitochondrial disorders are estimated to affect approximately 5/10,000 (Schaefer, McFarland, et al. Regulation disorders of sensory processing are exhibited by unusual reactions to sensory stimulation. Sensory features are commonly described as hyper-responsiveness, hypo responsiveness, and sensory seeking (Baranek, 2002; Ben-Sasson et al. The evaluation of very young children, those less than 24 months old, presents particular challenges for diagnosticians and families, as these children display symptoms that may be more subtle and more diffcult to distinguish from other developmental delays or even typical development (Zwaigenbaum et al. When giving a diagnosis to a very young child, a follow-up evaluation may be needed, as the stability of early diagnoses have shown some individuals might not meet diagnostic criteria later in life (Zwaigenbaum, et al. It will be important to track the implications of the new criteria on the diagnosis of young children. There are some school age children who perform well academically and therefore may not come to the attention of their teachers or parents. Some of these children may display social communication problems, experience social isolation, loneliness, be rejected socially by their peers, and/or have highly intense preoccupying interests. There are some older children, more specifcally, adolescents, who may come to the attention of professionals when they experience signifcant anxiety or depression related to unsuccessful attempts at social engagement. The signs and symptoms exhibited by children ages 11 and older can be found in Appendix E. There is evidence to indicate that among children up to age eight, girls are diagnosed later than boys (6. Therefore, it is critical that parents, providers and educators remain vigilant in ensuring that all children, regardless of race, ethnicity or socioeconomic status are diagnosed early and provided with the individualized services that will result in optimal outcomes. Disparities in accessing medical care are generally found when families speak a language other than English. Providers can support families by ensuring access to professional interpreter services. Currently, there are no medical tests or procedures to defnitively diagnose this complex neurodevelopmental disorder. In addition, the research over the past several decades has evolved in its understanding of the core features of the disorder, how the disorder is expressed, and when the core features are frst expressed (Karmel et al. Diagnosticians may need to refer a child to appropriate programs and services for interventions that are evidence-based, and to refer families to available family and medical support services. A diagnostic evaluation may be conducted independently by a clinician or by a multidisciplinary team that could include to a developmental behavioral pediatrician, a neurologist, a psychiatrist, a psychologist, an advanced practice registered nurse, a clinical social worker, a speech-language pathologist, an occupational therapist, a physical therapist, a board certifed behavior analyst, or an educator/special educator, or any combination. Importantly, if the diagnostic evaluation is conducted by one clinician, it must be within the scope of his or her practice. Notably, the three types professionals listed are not the only clinicians who are competent to diagnose a child accurately. To remain profcient in the feld, diagnosticians must be lifelong learners who view ongoing professional development as a critical component in the provision of evidence based care to children and families in a markedly changing feld.

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Reduced stimula tion of the visual system leading to increased cortical hyperexcitability is one possible explanation (the deafferentation hypothesis) androgen insensitivity syndrome hormone levels order pilex 60 caps mastercard, although the syndrome may occasionally occur in people with normal vision mens health 6 pack diet buy pilex discount. Functional magnetic res onance imaging suggests ongoing cerebral activity in ventral extrastriate visual cortex mens health 3 month workout plan best pilex 60 caps. Complex visual hallucinations in the visually impaired: the Charles Bonnet syndrome prostate examination order pilex online from canada. There may be concurrent abnormal muscle tone prostate cancer icd-9 purchase cheapest pilex, 80 Chorea prostate oncology quizlet buy cheap pilex 60 caps on-line, Choreoathetosis C either hypotonia or rigidity. One model of basal ganglia function suggests that reduced basal ganglia output to the thalamus disinhibits thalamic relay nuclei leading to increased excitability in thalamocortical pathways which passes to descending motor pathways resulting in involuntary movements. Cross Reference Pupillary reexes Cinematic Vision Cinematic vision is a form of metamorphopsia, characterized by distortion of movement with action appearing as a series of still frames as if from a movie. Cross References Rigidity; Spasticity Claudication Claudication (literally limping, Latin claudicatio) refers to intermittent symp toms of pain secondary to ischaemia. Cross Reference Pes cavus Claw Hand Claw hand, or mainengriffe, is an abnormal posture of the hand with hyperex tension at the metacarpophalangeal joints (fth, fourth, and, to a lesser extent, third nger) and exion at the interphalangeal joints. Cross References Benediction hand; Camptodactyly Clonus Clonus is rhythmic, involuntary, repetitive, muscular contraction and relaxation. It may be induced by sudden passive stretching of a muscle or tendon, most usu ally the Achilles tendon (ankle clonus) or patella (patellar clonus). Ankle clonus is best elicited by holding the relaxed leg underneath the moderately exed knee, then quickly dorsiexing the ankle and holding it dorsiexed. Clonus reects hyperactivity of muscle stretch reexes and may result from self-re-excitation. It is a feature of upper motor neurone disorders affecting the corticospinal (pyramidal) system. Patients with disease of the corticospinal tracts may describe clonus as a rhythmic jerking of the foot, for example, when using the foot pedals of a car. Cluster Breathing Damage at the pontomedullary junction may result in a breathing pattern char acterized by a cluster of breaths following one another in an irregular sequence. Cross Reference Coma Coactivation Sign this sign is said to be characteristic of psychogenic tremors, namely, increased tremor amplitude with loading (cf. It represents a greater degree of impairment of consciousness than stupor or obtundation, all three forming part of a continuum, rather than discrete stages, ranging from alert to comatose. Assessment of the depth of coma may be made by observing changes in eye move ments and response to central noxious stimuli: roving eye movements are lost before oculocephalic responses; caloric responses are last to go. A number of neurobehavioural states may be mistaken for coma, including abulia, akinetic mutism, catatonia, and the locked-in syndrome. This has been interpreted as a motor grasp response to contralateral hand movements and a variant of anarchic or alien hand. Reading comprehension is good or normal and is better than reading aloud which is impaired by paraphasic errors. This phenomenon sug gests that an acoustic image of the target word is preserved in this condition. A similar phenomenon may be observed in patients with optic aphasia attempting to name a visual stimulus. A similar behaviour is seen in so-called speech apraxia, in which patients repeatedly approximate to the desired output before reaching it. The term may also be used to refer to a parapraxis in which patients attempt to perform a movement several times before achieving the correct movement. Schnider has developed a fourfold schema of intrusions, momentary confabulations, fantastic confabulations, and behaviourally sponta neous confabulations, of which the latter are clinically the most challenging. This may be due to a variety of factors, including prolonged muscle spasticity with or without muscle brosis. This often occurs in the context of limb immobilization or inactivity, for example, in a exed posture. The former is a complex vocal tic most characteristically seen in Tourette syndrome although it actually occurs in less than half of affected individuals. The pathophysiology of coprolalia is unknown but may be related to frontal (cingulate and orbitofrontal) dysfunction, for which there is some evidence in Tourette syndrome. Cross Reference Tic Copropraxia Copropraxia is a complex motor tic comprising obscene gesturing, sometimes seen in Tourette syndrome. Corneal Reex the corneal reex consists of a bilateral blink response elicited by touching the cornea lightly, for example, with a piece of cotton wool. As well as observing whether the patient blinks, the examiner should also ask whether the stimulus was felt: a difference in corneal sensitivity may be the earliest abnormality in this reex. Trigeminal nerve lesions cause both ipsilateral and contralateral corneal reex loss. Cerebral hemisphere (but not thalamic) lesions causing hemiparesis and hemisensory loss may also be associated with a decreased corneal reex. Although this may occur in the context of psychiatric disease, especially depression and schizophrenia, it may also occur in association with organic brain abnormalities, specically lesions of the non-dominant temporoparietal cortex, or migraine. Cross References Capgras syndrome; Delusion; Disconnection syndromes Coup de Poignard Coup de poignard, or dagger thrust, refers to a sudden precordial pain, as may occur in myocardial infarction or aortic dissection, also described with spinal subarachnoid haemorrhage. Coup de Sabre Coup de sabre is a localized form of scleroderma manifest as a linear, atrophic lesion on the forehead which may be mistaken for a scar. This lesion may be associated with hemifacial atrophy and epilepsy, and neuroimaging may -95 C Cover Tests show hemiatrophy and intracranial calcication. The cover test demonstrates tropias: the uncovered eye is forced to adopt xation; any movement therefore represents a manifest strabismus (heterotropia). The alternate cover or cross-cover test, in which the hand or occluder moves back and forth between the eyes, repeatedly breaking and re-establishing xa tion, is more dissociating, preventing binocular viewing, and therefore helpful in demonstrating whether or not there is strabismus. It should be performed in the nine cardinal positions of gaze to determine the direction that elicits maxi mal deviation. Cramps are not uncommon in normal individuals but in a minority of cases they are associated with an underlying neurological or metabolic disorder. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the Therapeutics and Technology Subcommittee of the American Academy of Neurology. Cross References Fasciculation; Myokymia; Neuromyotonia; Spasm; Stiffness Cremasteric Reex the cremasteric reex is a supercial or cutaneous reex consisting of con traction of the cremaster muscle causing elevation of the testicle, following stimulation of the skin of the upper inner aspect of the thigh from above downwards. It may also be absent in elderly men or with local pathology such as hydrocele, varicocele, orchitis, or epididymitis. Cross Reference Reexes -97 C Crossed Aphasia Crossed Aphasia Aphasia from a right-sided lesion in a right-handed patient, crossed aphasia, is rare, presumably a reection of crossed or mixed cerebral dominance. Cross Reference Aphasia Crossed Apraxia A name given to apraxia in right-handed patients with right-sided lesions; apraxia is more commonly associated with left-sided brain injury. Cross Reference Lid retraction Dazzle Dazzle is a painless intolerance of the eyes to bright light (cf. It may be peripheral in origin (retinal disease; opacities within cornea, lens, vitreous); or central (lesions anywhere from optic nerve to occipitotemporal region). Cross Reference Photophobia Decerebrate Rigidity Decerebrate rigidity is a posture observed in comatose patients in which there is extension and pronation of the upper extremities, extension of the legs, and plantar exion of the feet (= extensor posturing), which is taken to be an exagger ation of the normal standing position. Painful stimuli may induce opisthotonos, hyperextension, and hyperpronation of the upper limbs. A similar picture was rst observed by Sherrington (1898) following section of the brain stem of cats at the collicular level, below the red nuclei, such that the vestibular nuclei were intact. Cross References Coma; Decerebrate rigidity Deja Entendu A sensation of familiarity akin to deja vu but referring to auditory rather than visual experiences. Recurrent hallucinations or vivid dream-like imagery may also enter the differential diagnosis. Epileptic deja vu may last longer and be more frequent and may be associated with other features such as depersonalization and derealization, strong emotion such as fear, epigastric aura, or olfactory hallucinations. Cross References Aura; Hallucination; Jamais vu Delirium Delirium, also sometimes known as acute confusional state, acute organic reaction, acute brain syndrome, or toxic-metabolic encephalopathy, is a neurobe havioural syndrome of which the cardinal feature is a decit of attention, the ability to focus on specic stimuli. The course of delirium is usually brief (seldom more than a few days, often only hours). On recovery the patient may have no recollection of events, although islands of recall may be preserved, corresponding with lucid intervals (a useful, if retrospective, diagnostic feature). However, it should be noted that in the elderly delirium is often superimposed on dementia, which is a predisposing factor for the development of delirium, perhaps reecting impaired cerebral reserve. Risk factors for the development of delirium may be categorized as either predisposing or precipitating. Cross References Delirium; Dementia; Hallucination; Illusion; Intermetamorphosis; Misidentication syndromes; Reduplicative paramnesia Dementia Dementia is a syndrome characterized by loss of intellectual (cognitive) func tions sufcient to interfere with social and occupational functioning. Amnesia may or may not, depending on the classication system used, be a sine qua non for the diagnosis of dementia. Attentional mechanisms are largely preserved, cer tainly in comparison with delirium, a condition which precludes meaningful neuropsychological assessment because of profound attentional decits. Although more common in the elderly, dementia can also occur in the pre senium and in children who may lose cognitive skills as a result of hereditary metabolic disorders. A distinction is drawn by some authors between cortical and subcortical dementia: in the former the pathology is predominantly cortical and neuropsychological ndings are characterized by amnesia, agnosia, apraxia, and aphasia. Behavioural abnormalities are common in demen tias due to degenerative brain disease and may require treatment in their own right. Because of the possibility of progression, reversible causes are regularly sought though very rare. Cross Reference Calf head sign Diaphoresis Diaphoresis is sweating, either physiological as in sympathetic activation. Diaphoresis may be seen in syncope, delirium tremens, or may be induced by certain drugs. Anticholinergics decrease diaphoresis but increase core temperature, resulting in a warm dry patient. The spatial and temporal characteristics of the diplopia may help to ascertain its cause. Conversely, diplopia resulting from the breakdown of a latent tendency for the visual axes to deviate (latent strabismus, squint) results in diplopia in all directions of gaze. Examination of the eye movements should include asking the patient to look at a target, such as a pen, in the various directions of gaze (versions) to ascertain where diplopia is maximum.

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