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Count bricks Plurals 42 mo: fetch several items Name friend Pedal cheap 800mg viagra vigour visa erectile dysfunction papaverine injection; Up stairs adult Share order viagra vigour 800 mg free shipping erectile dysfunction statistics 2014, turns Hop 3 steps/ Jump off 2 5 brick gate Intelligible to strangers Prepositions: between Gives age Undress indep discount viagra vigour generic erectile dysfunction 19 years old. Instead cheap tadora 20mg online, does he do age appropriate work cheap levitra extra dosage online american express, need extra tuition order 160mg kamagra super fast delivery, etc Cognitive Development Overall process: Autonomy: dependent on parents peers independent Abstract thinking (what if? Usually (80%) non-disjunction at first meiotic division 5% have different karyotypes: Mosaic Down: 3 % Robertsonian translocation t14:21: 4. Chromosomal anomalies represent 15% of congenital anomalies Risk: Maternal age at birth Down in live births 25 - 29 1:1100 30 1: 900 35 1:350 37 1:200 40 1:100 43 1:50 45 and over 1:25 Neonatal Screening: Only 30% of children with Down are born to women over 35. Boys = 3 * girls 75% show some degree of general intellectual impairment Aspergers Syndrome: Symptoms overlap with autism Social interaction and behavioural problems similar to autism but not associated with significant language or intellectual delay Effect of Chronic Disease on Development See also Chronic illness and disability in Adolescents, page 669 10 15 % of children have some chronic health condition. See Attachment Disorder, page 573 For the toddler: Watch for vulnerable child syndrome: continued parental concern after child has recovered adverse affects on child. More complicated when some ongoing vigilance is required Support appropriate attitudes and plans Mobilise family support Remain optimistic If in hospital, use separations to reinforce that parents will return. Devastation of silence Denial can also be a coping mechanism Develop an acceptance of a new identity through the crisis: Seeing how the child is different Finding positives in this new identity and helping the family value these Achieve a sense of movement through the crisis. Mark positives and achievements of the family Encouraging compliance: For the highly compliant: teaching, directions For the non-compliant (those who respond yes but. Male = female + 13 cm or average their centiles) Family history: eg constitutional delay Systems Psychosocial Development Examination: Growth parameters Dysmorphic features ? Child more vulnerable to pain and stress-induced exacerbations Occurs at least monthly for a three-month period. May slow due to maternal drugs (eg pethidine) Tone: 2 for active movement, 1 for limb flexion Response to stimuli: On suction, 2 for coughs well, 1 depressed Apnoea: Primary Apnoea: pulse < 60 and cyanosis. Takes ~ 48 hours for ductus to close Other observations: Micturition: usually soon after birth, infrequent for first 24 hours Bowel: 99. Cystic Fibrosis, Hirshprungs Jaundice: 40% develop it, but transient, resolves by day 5 Vomiting: a little is common. Same range as adults when dressed appropriately st Weight: 1 3 5 days may loose 5 10% of birth weight. See Genetic Testing, page 465 Outcome after Preterm Birth At 27 weeks, 90% survive to discharge Definitions: Prematurity: < 37 = weeks Preterm, < 33 = weeks Very preterm Birth weight (? Associated with maternal infection Paediatrics 589 Frontal, usually watershed lesion Cysts long term spastic diplegia (legs worse than arm) Retinopathy of Prematurity: Abnormal vascularisation of retina following exposure to high O2 concentrations. Parents may need reassurance Non-organic failure to thrive: Inadequate parenting/poor nutrition the most common cause (will feed and gain weight well while in hospital). Harder for older women and professional who worked up to delivery to cope with ( sense of isolation post delivery) Colic: definitions vary from crying lots to well thriving baby who develops muscle spasms, flushing face, pulls up legs, screams.

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Chronic renal failure may progress to end-stage renal disease and re- Acute Chronic quire renal replacement therapy buy generic viagra vigour 800 mg on line male erectile dysfunction pills. See also Renal Tubu- depletion buy discount viagra vigour 800mg erectile dysfunction can cause pregnancy, polyuria and immunodeciency secondary lar Acidosis (see below) buy viagra vigour cheap erectile dysfunction treatment in allopathy. Water and r Phosphate transport defects: There are several types buy apcalis sx cheap online, anions such as aminoacids follow sodium purchase levitra soft uk. Osmotic di- usually X-linked purchase cheap fildena on line, although occasional sporadic inher- uretics and carbonic anhydrase inhibitors act at this site. Treatment is with oral phosphate supple- condition characterised by glycosuria with normal ments with vitamin D or 1,25 dihydroxyvitamin D blood glucose. Thick ascending loop of Henle: Sodium is pumped Glycosuria is a normal response during pregnancy. The most important single defect is cystinuria, an concentration gradient within the medulla of the kid- autosomal recessive condition which predisposes to ney, which draws water out of the collecting duct and urinary stone formation (see page 270). Loop diuretics such as with high uid intake and alkali ingestion, because the furosemide act from within the lumen of the ascending cystine is more soluble in alkaline conditions. Even when bicarbonate levels fall to as low This results in a similar syndrome of sodium loss, de- as 10 mmol/L or below, the urine remains relatively hydration and hypercalciuria as Bartter type I; how- alkaline (pH 5. If untreated, persistent metabolic ever, hypokalaemia only occurs after treatment with acidosis leads to increased mobilisation of calcium sodium supplements. Once 3 collecting duct resulting in a hypokalaemic metabolic plasma bicarbonate levels fall to about 1216 mmol/L, alkalosis. This The main problems occur due to the loss of other is under the inuence of aldosterone which increases substances such as amino acids and phosphate. Spironolactone 2istreated with bicarbonate, thiazide diuretic and and amiloride affect this exchange and hence increase potassium bicarbonate or potassium-sparing diuret- urinary water and sodium loss. Fanconi syndrome is treated with large doses of diuretics, these cause potassium reabsorption and are vitamin D. This results in excessive water loss deciency causes hyperkalaemia, which is associated in the urine. Hyper- Renal tubular acidosis kalaemia may be life-threatening and the underlying Denition disorder often shortens life expectancy. Under physiologi- Disorders of uric acid metabolism may cause renal dis- cal conditions, the kidneys help to maintain acidbase easeduetoachronicnephropathy,anacutenephropathy balance, together with the lungs (which remove carbon or through the formation of uric acid stones. Renal failure leads to raised uric acid levels Adult polycystic kidney disease is an autosomal dom- and in some cases there may have been another cause inant inherited condition characterised by gradual re- for their renal failure. It is thought that urate crys- placement of renal and occasionally other tissue by cysts. There is a distinct autosomal dominant disorder of uric acid metabolism which is associated with early Age onset renal failure and hypertension. Allopurinol may improve renal function, but M=F rarely completely prevents deterioration. This gene is closely cipitateinthecollectingducts,renalpelvisandureters, related to the tuberous sclerosis gene in which renal cysts causing obstruction.

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The mobility of the valve is denoted by the presence Symptoms ofanopeningsnapandaloudmitralrstsound(and buy genuine viagra vigour on-line icd-9-cm code for erectile dysfunction. Dyspnoea occurs at night and on exertion and is absence of valve calcication on the chest X-ray) buy viagra vigour mastercard impotence natural remedy. Haemoptysis is caused by pulmonary hypertension cheap viagra vigour 800mg on line impotence questionnaire, pertensionisindicatedbyadominantawaveinthe pulmonary oedema or pulmonary embolism purchase discount cytotec line. Fatigue and cold extremities are caused by a low loud pulmonary second sound discount 20 mg levitra soft fast delivery, right ventricular cardiac output cheap 25 mg viagra otc. This is a dusky purple ush of the other valve lesions must be noted and assessed, cheeks with dilated capillaries (malar ush). It may be irregular of myocardial disease, which is always present to because of atrial brillation. Right ventricular hyper- a left parasternal heave of right ventricular hyper- trophy may be present. Haemo- The mitral rst sound is loud because the mitral valve siderosis in the lung elds is rare. It The length of the murmur is proportional to the alsodemonstratesvalvethickeningandcalcication degree of stenosis. The murmur can be difcult to hear in mild cases,but it can be madeeasier to hear by Complications exercise tachycardia and with the patient lying on the left side. Anticoagulation is indicated when atrial brillation developsorthereisleftatrialenlargement. Atrial brillation is less common than omy) is indicated in patients who are symptomatic or in mitral stenosis. Chest X-ray: the left atrium and ventricle are en- indicated if the valve morphology is not suitable for larged, the former sometimes being enormous. Echocardiography helps to distinguish between the anticoagulation or concomitant moderate to severe various causes and to assess left ventricular regurgitation. Assessment of the dominance of the lesions in com- Mitral regurgitation bined mitral stenosis/mitral regurgitation: mitral stenosis is more likely to be the dominant lesion if Aetiology the pulse volume is small (in the absence of failure). Indications nary congestion and this is followed by right heart for anticoagulation are atrial brillation, systemic failure. A left parasternal heave may be present and is Tricuspidregurgitationmaybecausedbydilatationof causedbysystolicexpansionoftheleftatriumrather thetricuspidvalveringinrightventricularfailurefrom than by right ventricular hypertrophy. Auscultation: there is an apical pansystolic murmur associatedwithdisease ofmitraland/oraorticvalves), radiating to the left axilla. Mitral valve prolapse produces a late systolic click open tricuspid valve) andmurmur. It occurs in two clinical murmur, loudest in inspiration, heard at the lower situations. Cardiovascular disease 101 Pulmonary stenosis previous infection and there is little or no risk to the fetus.