Screw business
Prepacking and importing
Sunday, November 4, 2007
Use the services of an expert
When washing your car (motorvehicle) you could do it yourself, or use an expert. Doing it yourself would use your time, your equipment, your resources and your expertise. You would have to learn the task and apply your knowledge, wits, talents and skills to the task.
If you use an expert, you get a measured result, a measured cost, and a benchmarked outcome.
This may save you time and money.
Its better to spend more on planning that more on failure during or after implementation. Use a credible specialist.
Any comments? Please share your experiences
If you use an expert, you get a measured result, a measured cost, and a benchmarked outcome.
This may save you time and money.
Its better to spend more on planning that more on failure during or after implementation. Use a credible specialist.
Any comments? Please share your experiences
Wednesday, October 31, 2007
Retailing
Most retailing involves buying merchandise or a service from a manufacturer, wholesaler, agent, importer or other retailer and selling it to consumers for their personal use. The price charged for the goods or services covers the retailer's expenses and includes a profit.
Most are store retailers, though there are other types of enterprises--such as e-commerce, mail order, automatic-merchandising (vending) machines, direct retailing (door-to-door and home party sales), and service providers.
Types of Retailers
Store retailing. Store retailers operate fixed point-of-sale locations designed to attract a high volume of walk-in customers. In general, stores have extensive merchandise displays and use mass-media advertising to attract customers. They typically sell merchandise to the general public for personal or household consumption, but some also serve business and institutional clients. These include establishments such as office supply stores, computer and software stores, building materials dealers, and plumbing and electrical supply stores. Here is an example http://www.homehypercity.co.za/
Specialty retailing. While power retailers like Wal-Mart or Target tend to sell "needs," specialty retailers tend to sell "wants." They focus more on neighborhood convenience, the richness of the shopping experience, and inventory that meets the needs of their target customer on a personalized basis. Small stores show surprising strength and resilience in the face of competition from large-scale retailers and e-commerce outlets. They offer the consumer a warmer atmosphere, and perhaps a broader and deeper selection of merchandise. Many stores can be owned and operated by one person with minimal assistance. Compared to manufacturing operations, specialty retail outfits are relatively easy to start both financially and operationally. However, a number of failures are due to undercapitalization, poor location and insufficient market analysis.
Nonstore retailing. These businesses are primarily engaged in the retail sale of products through television, electronic shopping, paper and electronic catalogs, door-to-door solicitation, in-home demonstration, portable stalls, vending machines, and mail order.
With the exception of vending, these businesses do not ordinarily maintain stock for sale on the premises.
There are many advantages to this type of retailing--one being that buying, maintenance and protection of a large inventory is not necessary as you contract with others to handle these matters.
Mail order. From glossy wish books to basic brochures, catalogs are popular with those who live far from shopping areas, the elderly, those seeking the unusual or obscure, and those who simply hate to shop.
With direct mail, sales materials can be sent to thousands of potential customers at one time to either make a sale or generate a sales lead. Mail order enterprises include general merchandise businesses, companies that sell specialty goods of all kinds, novelty firms, various types of clubs (CDs, DVDs, books) and so on. In most cases, catalogs are sent to consumers in defined niches on a regular basis. You can work out of your home, a warehouse or a brick-and-mortar store. An up-to-date mailing list is the key to direct-mail profits with back-end fulfillment and relational database support.
The internet. The internet has changed the retail landscape, connecting companies, markets and individual consumers. http://www.homehypercity.co.za/ is an example.
Vending machines. Automatic merchandising--or vending machine retailing--has been a proven business concept for more than a century. Vending Times, the industry's trade magazine, reports that snacks and soda sales. As with any other sales venture, having the right product in the right place at the right time is key. This business is highly appealing because of the low startup cost, low working capital and low overhead. This is a cash business, with you collecting the money when you replenish supplies.
Most are store retailers, though there are other types of enterprises--such as e-commerce, mail order, automatic-merchandising (vending) machines, direct retailing (door-to-door and home party sales), and service providers.
Types of Retailers
Store retailing. Store retailers operate fixed point-of-sale locations designed to attract a high volume of walk-in customers. In general, stores have extensive merchandise displays and use mass-media advertising to attract customers. They typically sell merchandise to the general public for personal or household consumption, but some also serve business and institutional clients. These include establishments such as office supply stores, computer and software stores, building materials dealers, and plumbing and electrical supply stores. Here is an example http://www.homehypercity.co.za/
Specialty retailing. While power retailers like Wal-Mart or Target tend to sell "needs," specialty retailers tend to sell "wants." They focus more on neighborhood convenience, the richness of the shopping experience, and inventory that meets the needs of their target customer on a personalized basis. Small stores show surprising strength and resilience in the face of competition from large-scale retailers and e-commerce outlets. They offer the consumer a warmer atmosphere, and perhaps a broader and deeper selection of merchandise. Many stores can be owned and operated by one person with minimal assistance. Compared to manufacturing operations, specialty retail outfits are relatively easy to start both financially and operationally. However, a number of failures are due to undercapitalization, poor location and insufficient market analysis.
Nonstore retailing. These businesses are primarily engaged in the retail sale of products through television, electronic shopping, paper and electronic catalogs, door-to-door solicitation, in-home demonstration, portable stalls, vending machines, and mail order.
With the exception of vending, these businesses do not ordinarily maintain stock for sale on the premises.
There are many advantages to this type of retailing--one being that buying, maintenance and protection of a large inventory is not necessary as you contract with others to handle these matters.
Mail order. From glossy wish books to basic brochures, catalogs are popular with those who live far from shopping areas, the elderly, those seeking the unusual or obscure, and those who simply hate to shop.
With direct mail, sales materials can be sent to thousands of potential customers at one time to either make a sale or generate a sales lead. Mail order enterprises include general merchandise businesses, companies that sell specialty goods of all kinds, novelty firms, various types of clubs (CDs, DVDs, books) and so on. In most cases, catalogs are sent to consumers in defined niches on a regular basis. You can work out of your home, a warehouse or a brick-and-mortar store. An up-to-date mailing list is the key to direct-mail profits with back-end fulfillment and relational database support.
The internet. The internet has changed the retail landscape, connecting companies, markets and individual consumers. http://www.homehypercity.co.za/ is an example.
Vending machines. Automatic merchandising--or vending machine retailing--has been a proven business concept for more than a century. Vending Times, the industry's trade magazine, reports that snacks and soda sales. As with any other sales venture, having the right product in the right place at the right time is key. This business is highly appealing because of the low startup cost, low working capital and low overhead. This is a cash business, with you collecting the money when you replenish supplies.
Monday, October 29, 2007
Business Plans?
This could be tricky!
I have requests to advise on how to submit a business plan.
Any suggestions, Please Help!!!
I have requests to advise on how to submit a business plan.
Any suggestions, Please Help!!!
WILLS AND TRUSTS
Complex Wills
Appointing guardians
You can stipulate in your will that your children's inheritance be administered in trust until he or she reaches 21 years (or any later age that you may choose). Trustees manage assets in the best interests of minors. Guardians on the other hand look after minor children. Guardians are only called for if both biological parents are deceased.
Maintenance
If you should divorce your spouse, you may be obligated to pay maintenance. These obligations may be placed on your estate as well. Some of the issues that may come to the fore:
If a spouse is left needing maintenance, he or she could lodge a claim against your estate. Factors that may influence such a claim are inter alia the duration of your marriage, the age of the living spouse, his or her ability to find work, the degree to which he or she has assets to put towards own care, the extent of your estate and the degree to which your spouse contributed to that estate.
In terms of our laws, you have an obligation as a parent to look after your children – until they are self-sufficient and not necessarily until they're 21. The fact that your child may have been born out of wedlock will not stand in the way of a maintenance claim against your estate.
A testamentary trust is by far the best mechanism to comply with all maintenance demands. By placing a capital amount in a trust that can generate sufficient income, the maintenance claim will be served and the capital also protected for your eventual heirs.
Disabled dependants
Disabled dependants require greater care, for which you should make provision in your will. A trust is an ideal vehicle for this. Objective trustees that will administer the disabled person's inheritance in trust will be able to fulfil in this need.
Estate duty payable
Where the possibility exists that estate duty may be payable at your death, it is important to do a proper estate planning. Firstly make sure that you lessen the tax through proper planning of your estate. Ensure that there is sufficient cash to pay this tax; otherwise it may lead to the forced sale of estate assets.
Living together
In cases where you live together with another person, both parties frequently contribute to the household (as with a marriage) and collection of assets without registering any assets on both parties' names or fully accounting for assets. The identification of assets therefore is very important.
To avoid friction and fighting amongst heirs, it is advisable and practical that you and your friend decide together how your assets will be inherited. This doesn't necessarily mean that you have to have a joint will.
Offshore assets
If you should have offshore assets when you die, you'll also have a foreign estate that will have to be administered. Each country has its own legislation dealing with inheritance and the signing of wills. Your South African will won't necessarily meet with the legal requirements of the country where your assets are. That might mean that your foreign assets won't be inheritable in terms of your only will.
It is important therefore that you should have more than one will: for your South African assets and for your foreign assets, which complies with the laws of the country where your assets reside.
Common-law marriages
Die matrimonial law in terms of which the couple is married has a major influence on the inheritance of their assets. In traditional marriages and those conducted according to own customs, the inheritance of assets is usually influenced by very complex rules. Some of these rules could be bypassed by drafting a valid will.
Second and third marriages
Second and third marriages require careful planning of your will. The relationship between the stepchild and parent is a potential source of conflict. The second spouse and the children from the first marriage should ideally inherit separate assets.
Organ donation
If you want to donate organs, it should not be stipulated in your will. Your will only comes into effect after your death. Organ donation is only of value if you are declared brain dead while your body is still functioning. Your next of kin will therefore have to give permission for an organ donation. Make sure you pass on your wishes to them.
Funeral arrangements/cremation
It is not advisable to describe your wishes for your funeral arrangements or cremation in your will. The content of your will is frequently only read after the funeral, which makes it too late to see to your wishes. Rather convey such wishes to your next of kin before your death.
Provisions clauses
Provisions clauses linked to an inheritance that had not been properly thought through could leave an heir severely hamstrung even though it was not the intention.
Appointing guardians
You can stipulate in your will that your children's inheritance be administered in trust until he or she reaches 21 years (or any later age that you may choose). Trustees manage assets in the best interests of minors. Guardians on the other hand look after minor children. Guardians are only called for if both biological parents are deceased.
Maintenance
If you should divorce your spouse, you may be obligated to pay maintenance. These obligations may be placed on your estate as well. Some of the issues that may come to the fore:
If a spouse is left needing maintenance, he or she could lodge a claim against your estate. Factors that may influence such a claim are inter alia the duration of your marriage, the age of the living spouse, his or her ability to find work, the degree to which he or she has assets to put towards own care, the extent of your estate and the degree to which your spouse contributed to that estate.
In terms of our laws, you have an obligation as a parent to look after your children – until they are self-sufficient and not necessarily until they're 21. The fact that your child may have been born out of wedlock will not stand in the way of a maintenance claim against your estate.
A testamentary trust is by far the best mechanism to comply with all maintenance demands. By placing a capital amount in a trust that can generate sufficient income, the maintenance claim will be served and the capital also protected for your eventual heirs.
Disabled dependants
Disabled dependants require greater care, for which you should make provision in your will. A trust is an ideal vehicle for this. Objective trustees that will administer the disabled person's inheritance in trust will be able to fulfil in this need.
Estate duty payable
Where the possibility exists that estate duty may be payable at your death, it is important to do a proper estate planning. Firstly make sure that you lessen the tax through proper planning of your estate. Ensure that there is sufficient cash to pay this tax; otherwise it may lead to the forced sale of estate assets.
Living together
In cases where you live together with another person, both parties frequently contribute to the household (as with a marriage) and collection of assets without registering any assets on both parties' names or fully accounting for assets. The identification of assets therefore is very important.
To avoid friction and fighting amongst heirs, it is advisable and practical that you and your friend decide together how your assets will be inherited. This doesn't necessarily mean that you have to have a joint will.
Offshore assets
If you should have offshore assets when you die, you'll also have a foreign estate that will have to be administered. Each country has its own legislation dealing with inheritance and the signing of wills. Your South African will won't necessarily meet with the legal requirements of the country where your assets are. That might mean that your foreign assets won't be inheritable in terms of your only will.
It is important therefore that you should have more than one will: for your South African assets and for your foreign assets, which complies with the laws of the country where your assets reside.
Common-law marriages
Die matrimonial law in terms of which the couple is married has a major influence on the inheritance of their assets. In traditional marriages and those conducted according to own customs, the inheritance of assets is usually influenced by very complex rules. Some of these rules could be bypassed by drafting a valid will.
Second and third marriages
Second and third marriages require careful planning of your will. The relationship between the stepchild and parent is a potential source of conflict. The second spouse and the children from the first marriage should ideally inherit separate assets.
Organ donation
If you want to donate organs, it should not be stipulated in your will. Your will only comes into effect after your death. Organ donation is only of value if you are declared brain dead while your body is still functioning. Your next of kin will therefore have to give permission for an organ donation. Make sure you pass on your wishes to them.
Funeral arrangements/cremation
It is not advisable to describe your wishes for your funeral arrangements or cremation in your will. The content of your will is frequently only read after the funeral, which makes it too late to see to your wishes. Rather convey such wishes to your next of kin before your death.
Provisions clauses
Provisions clauses linked to an inheritance that had not been properly thought through could leave an heir severely hamstrung even though it was not the intention.
Sunday, October 28, 2007
OBESITY
The differential diagnosis of obesity, like that of weight loss, is best developed using physiology because most cases of obesity are caused by an absolute increased intake of calories or a relative increased intake of calories over output of energy. Fluid retention may also be associated with weight gain.
OBESITY
Increased intake of calories. This type of obesity is due to an increased appetite.
Caused by: idiopathic obesity, psychogenic obesity, hypothalamic obesity (due to pituitary tumors and other lesions affecting the hypothalamus), islet cell adenomas and carcinomas (causing hypoglycemia and, consequently, a big appetite), early stages of diabetes mellitus when functional hypoglycemia is common, Cushing syndrome and exogenous corticosteroids (which increase appetite), and alcoholism, which stimulates the appetite but which also adds calories in the alcohol (up to 250 cal per cocktail).
Decreased output of energy.
Causes: Hypothyroidism and possibly hypogonadism (such as Klinefelter syndrome), where the motivation to work or exercise may be impaired. Mild pituitary insufficiency (as in Sheehan or Fröhlich syndrome) may also cause obesity by this mechanism. This type of obesity may be occupational (e.g., white collar workers) or environmental (i.e., watching television all day).
“Obesity” due to fluid retention. This increase is in reality an increase in weight from fluid retention. Inappropriate ADH syndromes such as those that occur in carcinoma of the lung, hypothalamic lesions, and drugs are the most important obscure causes. CHF, nephrosis, cirrhosis, beriberi, and myxedema rank as significant among the obvious causes.
Miscellaneous causes. Heredity is a cause of obesity, but the physiologic mechanism is uncertain.
Patients who fail to lose weight on a strict diet may require hospitalization with observation. If they still fail to lose weight, a complete endocrine workup would seem to be indicated.
thyroid function studies may be worthwhile.
48-hour fast with glucose monitoring (insulinoma)
Plasma insulin (insulinoma)
C-peptide (insulinoma)
Serum cortisol (Cushing syndrome)
Dexamethasone suppression test (Cushing syndrome)
Pelvic sonogram (polycystic ovary)
Chromosomal analysis (Klinefelter syndrome)
Psychiatry consult
OBESITY
Increased intake of calories. This type of obesity is due to an increased appetite.
Caused by: idiopathic obesity, psychogenic obesity, hypothalamic obesity (due to pituitary tumors and other lesions affecting the hypothalamus), islet cell adenomas and carcinomas (causing hypoglycemia and, consequently, a big appetite), early stages of diabetes mellitus when functional hypoglycemia is common, Cushing syndrome and exogenous corticosteroids (which increase appetite), and alcoholism, which stimulates the appetite but which also adds calories in the alcohol (up to 250 cal per cocktail).
Decreased output of energy.
Causes: Hypothyroidism and possibly hypogonadism (such as Klinefelter syndrome), where the motivation to work or exercise may be impaired. Mild pituitary insufficiency (as in Sheehan or Fröhlich syndrome) may also cause obesity by this mechanism. This type of obesity may be occupational (e.g., white collar workers) or environmental (i.e., watching television all day).
“Obesity” due to fluid retention. This increase is in reality an increase in weight from fluid retention. Inappropriate ADH syndromes such as those that occur in carcinoma of the lung, hypothalamic lesions, and drugs are the most important obscure causes. CHF, nephrosis, cirrhosis, beriberi, and myxedema rank as significant among the obvious causes.
Miscellaneous causes. Heredity is a cause of obesity, but the physiologic mechanism is uncertain.
Patients who fail to lose weight on a strict diet may require hospitalization with observation. If they still fail to lose weight, a complete endocrine workup would seem to be indicated.
thyroid function studies may be worthwhile.
48-hour fast with glucose monitoring (insulinoma)
Plasma insulin (insulinoma)
C-peptide (insulinoma)
Serum cortisol (Cushing syndrome)
Dexamethasone suppression test (Cushing syndrome)
Pelvic sonogram (polycystic ovary)
Chromosomal analysis (Klinefelter syndrome)
Psychiatry consult
Causes of Baldness
The following medical conditions are some of the possible causes of Baldness. There are likely to be other possible causes, so ask your doctor about your symptoms.
Baldness
Male pattern baldness;
Female pattern baldness
Hereditary baldness
Normal aging
Nervous hair pulling - usually in children
Excessive shampoo or hair-drying
Childbirth - hair gets stronger during pregnancy and falls out after birth.
Poor diet
High fever
Chronic fever
Alopecia
Hormonal disorders
Thyroid disorder
Hypothyroidism
Hyperthyroidism
Pituitary disorder
Autoimmune disease
SLE
Alopecia areata
Alopecia totalis
Scalp disorder
Scalp fungal infection
Tinea capitis
Radiation therapy
Chemotherapy
Certain medications
Baldness
Male pattern baldness;
Female pattern baldness
Hereditary baldness
Normal aging
Nervous hair pulling - usually in children
Excessive shampoo or hair-drying
Childbirth - hair gets stronger during pregnancy and falls out after birth.
Poor diet
High fever
Chronic fever
Alopecia
Hormonal disorders
Thyroid disorder
Hypothyroidism
Hyperthyroidism
Pituitary disorder
Autoimmune disease
SLE
Alopecia areata
Alopecia totalis
Scalp disorder
Scalp fungal infection
Tinea capitis
Radiation therapy
Chemotherapy
Certain medications
Headache
Differential Overview
Migraine, Tension, Acute sinusitis, Acute glaucoma, Postconcussive, Cluster, Meningitis, Drugs, Hypoglycemia, Benign exertional headache, Temporomandibular joint inflammation, Subdural hematoma, Subarachnoid hemorrhage, Acute epidural hematoma, Lumbar puncture, Brain tumor, Headache in HIV, Pseudotumor cerebri, Hypertensive encephalopathy, Carbon monoxide intoxication, Giant cell arteritis, Psychogenic, Brain abscess, Encephalitis, Arteriovenous malformations, Cavernous sinus thrombosis, Pituitary apoplexy, Carotid artery dissection
Diagnostic Approach
Red flags to serious causes include: Sudden onset of “the worst headache of my life,” especially in a non—headache-prone person;
headache different from previous headaches;
headache precipitated by position change, cough, or exertion;
a history of trauma or fever;
abnormal mental status or other neurological findings;
a headache that disturbs sleep or is present immediately on awakening;
immune deficiency such as HIV.
The time course helps in diagnosing headache.
A “thunderclap” headache of a ruptured aneurysm peaks instantly.
Cluster headache peaks over 3 to 5 minutes, remains at maximum for 45 minutes, and then gradually recedes.
Migraine builds over hours, lasts hours to days, and is improved with sleep.
In evaluating patients with recurrent migraine, it is critical to ascertain whether the present headache differs from prior migraines and whether fever is present or spontaneous retinal venous pulsations are abnormally absent. These should prompt a search for alternative causes.
If fever is present with headache, rule out meningitis.
Raised intracranial pressure should be suspected with blurred vision upon bending the head forward, headache upon awakening that improves with sitting up, double vision, loss of coordination and balance, or daily progressive headache with nausea.
Pain originating above the tentorium is referred to the frontal, temporal, or parietal region. Pain from the posterior fossa and below is referred to the occiput. Pain from the posterior sagittal and transverse sinuses may be referred to the eye or forehead.
Lumbar puncture, subdural hematoma, or benign intracranial hypertension can cause orthostatic headache.
Occipital headache radiating to the vertex and forehead is usually a result of cervical spondylosis but can also be caused by basal subarachnoid hemorrhage, posterior fossa tumor, or meningitis.
Clinical Findings
Migraine:
A prodrome virtually always indicates migraine and is the sine qua non of migraine with aura (classic migraine).
Neurological phenomena include visual scotoma (an expanding jagged bright border with a dark center, like a wildfire), or mood changes (usually depression or irritability). More unusually, a prodrome may consist of aphasia or hemiplegia. A unilateral headache follows, usually with vegetative symptoms of nausea, anorexia, or sensitivity to light and sound. The fundi may show arterial or venous dilation. Common migraine has no neurological prodrome although patients can often sense it coming on. Migraine can be recognized by vegetative symptoms, activators (e.g., red wine, stress, sleep or food deprivation, or strong odors) or deactivators (e.g., sleep, pregnancy, exhilaration, or sumatriptan). These headaches have their onset in adolescence or young adult age; new onset in older patients can occur but should prompt a search for structural causes.
Tension: These are experienced as pressure, a vice, or bandlike sensation around the head (vertex, frontal, or temporal). Dull and steady, they worsen as the day progresses. They may last days, weeks, or months, but tension headaches are not relentlessly progressive. Anxiety, depression, and emotional conflicts are frequent precipitants.
Acute sinusitis: The epicenter may be frontal (frontal sinuses), over cheeks (maxillary sinuses), between the eyes (ethmoid sinuses), or in the frontotemporal and occipital region (sphenoid sinus). Headache is a continuous pressure sensation that is worsened by bending forward. Fever, nasal obstruction, and purulent nasal drainage are usually present.
Acute glaucoma: Orbital headache begins with aching around the rim and spreads through the trigeminal ophthalmic division. A tender hard globe, red eye with limbic flush, dull cornea, and impaired transmission of tangential light through the anterior chamber may be present.
Postconcussive: Contusion produces scalp tenderness at the impact site or tension-type headache. Especially after the patient’s vehicle has been rear-ended in an accident, there is headache, dizziness, vertigo, memory impairment, reduced concentration, and anxiety.
Cluster: Cluster occurs in middle-aged men as nocturnal episodes of high intensity, steady, boring, burning, unilateral orbital pain accompanied by ipsilateral red and tearing eye, nasal congestion, facial flushing, and diaphoresis. There also may be ipsilateral ptosis and miosis (20% to 40%). The headache begins a few hours after going to bed and lasts 1 to 2 hours. It recurs nightly for weeks to months and then disappears for years.
Meningitis: Fever is the key sign. The headache is severe, generalized, and constant, most intense at the base of the skull, and aggravated by forward flexion of the neck. The neck and back will be reflexively stiff to flexion (Kernig and Brudzinski sign). Nausea, photophobia, and altered mental status ranging from delirium to coma often accompany the headache. Clues regarding the cause include the following: petechial rash (meningococcus, enterovirus, S. aureus, leptospira); parotitis (coxsackie, LCM, EBV); vesicles (HSV); HIV (Listeria, pneumococcus); diabetes (pneumococcus, gram-negative, S. aureus, cryptococcus, mucormycosis); freshwater swimming (ameba); steroids (cryptococcus, mycobacteria); summer or fall onset (enterovirus, Borrelia, Leptospira). Acute otitis, sinusitis or pneumonia, basilar skull fracture, or splenectomy suggest pneumococcal meningitis. Meningococcal meningitis is suggested by fulminant onset with vascular collapse and angular purpura with a gunmetal gray color. Tuberculous meningitis is suggested by a gradual onset and multiple cranial nerve abnormalities.
Drugs: Sulfamethoxazole, ibuprofen, sulindac, ketorolac, isoniazid, azathioprine, and penicillin may cause aseptic meningitis, especially in patients with systemic lupus or mixed connective tissue disease. Concurrent facial swelling, urticaria, and conjunctivitis are helpful clues. Nitrates, ergots, amphetamines, phenothiazines, alcohol, and withdrawal from caffeine may also cause headache.
Hypoglycemia: Suspect this in a diabetic exhibiting diffuse sweating, throbbing frontal or generalized headache, weakness, confusion, and irritability.
Benign exertional headache: It occurs more commonly in patients who have migraines. Coital headache occurs abruptly with orgasm and subsides within minutes. It is usually benign, but if it lasts for hours or is accompanied by vomiting, subarachnoid hemorrhage should be considered.
Temporomandibular joint inflammation: Chewing aggravates the symptoms, and involuntary nocturnal bruxism and jaw clenching are common. Tenderness and a click over the TMJ are sensitive but not specific findings.
Subdural hematoma: Head trauma with concussion is followed by a lucid interval, then the development of mental status changes and/or focal neurological deficits such as hemiparesis, dilated pupil, and papilledema. Subdural hematoma presents with mild persistent headache, drowsiness, and confusion, and progresses to loss of consciousness.
Subarachnoid hemorrhage: Hemorrhage is sudden in onset and very severe. Headache, photophobia, nausea, meningismus, and loss of consciousness develop rapidly. A major hemorrhage has often been preceded by a similar, less severe, self-limited “herald bleed.”
Acute epidural hematoma: This is usually caused by a temporal skull fracture. A progressive decrease in the level of consciousness is the rule, although a brief lucid interval may follow recovery from a concussion before blood has accumulated.
Lumbar puncture: An intense occipitofrontal headache develops when the patient is upright and is relieved when supine. The onset may be as many as 12 days after the procedure. The original CNS indications for the lumbar puncture may make this difficult to recognize.
Brain tumor: The “classic” tumor headache that is worse in morning, accompanied by nausea and vomiting, occurs in less than 20%. It is relieved by lying down and worsened by straining at defecating, by coughing, or by bending over. Characteristically, it remains in the same location but is progressive, increasing in duration and severity over months. Being awakened at night with the headache is common but not diagnostic. Usually there are subtle neurological changes by the time the headache develops. Fundoscopy often shows increased intracranial pressure, manifest as absence of spontaneous venous pulsations to overt papilledema. Cerebral vomiting, without food, may occur. An occipital lobe tumor may be mistaken for migraine because of the production of scotoma.
Headache in HIV: Acute HIV causes aseptic meningitis accompanied by sore throat, diffuse maculopapular rash, and generalized lymphadenopathy. Cryptococcosis causes headache, fever, and nausea. Toxoplasmosis usually presents with encephalopathy or seizures. CNS lymphoma has headache or seizures. HIV encephalitis presents with seizures, memory loss, or decreased attention span.
Pseudotumor cerebri: It presents like tumor in an obese young woman, with chronic retro-orbital headache increased by eye movement. Transient blurred vision, diplopia, and vague symptoms of dizziness or facial numbness are experienced. Papilledema will often be present on examination.
Hypertensive encephalopathy: An occipital headache usually occurs with accelerated hypertension (BP .230/130), but may be seen with diastolic pressures as low as 110. The headache is worse in the morning. Hypertensive encephalopathy presents with headache, nausea, vomiting, visual disturbances, confusion, seizures, or coma. Focal neurological deficits, retinal hemorrhages, and papilledema are clues. Suspect pheochromocytoma if the headache and hypertension are paroxysmal and associated with sweating, palpitations, and weight loss.
Carbon monoxide intoxication: A prominent pounding headache develops with exposure to engine exhaust or a kerosene heater in a closed space.
Giant cell arteritis: Temporal arteritis should be considered in an elderly patient with a unilateral, dull, aching, continuous headache. It will be most intense over the temporal artery, which may be exquisitely tender and ropy or nodular. Systemic symptoms of fever and anorexia, jaw claudication (weakness, fatigue, or pain precipitated by chewing), or scalp tenderness (painful to comb the hair) often accompany the headache.
Psychogenic: Headaches are described in flamboyant terms but have no clear pattern. Terms such as lightning-like or explosive are used, but the patient experiences no visible discomfort.
Brain abscess: Parenteral drug use, lung abscess, immunodeficiency, and a parameningeal focus are clues. Fever and focal neurologic signs should be sought, but these are not universally present.
Encephalitis: Encephalitis begins acutely or subacutely with headache, fever, and signs of parenchymal involvement, such as coma, seizures, change in mental status, or focal neurological findings. Herpesvirus presents with frontal or temporal lobe neurological findings, or focal seizures, in 85%.
Arteriovenous malformations: Unilateral (always on the same side) throbbing chronic headache without aura occurs. A bruit may be heard with the stethoscope over the eye or temporal region.
Cavernous sinus thrombosis: It begins with retro-orbital headache, which is worse on sitting. Chemosis, proptosis, and painful ophthalmoplegia (deficits of cranial nerves III, IV, V) are found. Seizures or unilateral numbness or weakness may be seen. Predisposing causes include acute sinusitis, otitis, or coagulopathy.
Pituitary apoplexy: Severe bifrontal headache, drowsiness, diplopia, and visual loss (especially bitemporal hemianopia) are found.
Carotid artery dissection: Dissection occurs with neck trauma. Ipsilateral frontal, orbital, or temporal pain with Horner syndrome and focal neurological signs are clues. A carotid bruit is often found.
Migraine, Tension, Acute sinusitis, Acute glaucoma, Postconcussive, Cluster, Meningitis, Drugs, Hypoglycemia, Benign exertional headache, Temporomandibular joint inflammation, Subdural hematoma, Subarachnoid hemorrhage, Acute epidural hematoma, Lumbar puncture, Brain tumor, Headache in HIV, Pseudotumor cerebri, Hypertensive encephalopathy, Carbon monoxide intoxication, Giant cell arteritis, Psychogenic, Brain abscess, Encephalitis, Arteriovenous malformations, Cavernous sinus thrombosis, Pituitary apoplexy, Carotid artery dissection
Diagnostic Approach
Red flags to serious causes include: Sudden onset of “the worst headache of my life,” especially in a non—headache-prone person;
headache different from previous headaches;
headache precipitated by position change, cough, or exertion;
a history of trauma or fever;
abnormal mental status or other neurological findings;
a headache that disturbs sleep or is present immediately on awakening;
immune deficiency such as HIV.
The time course helps in diagnosing headache.
A “thunderclap” headache of a ruptured aneurysm peaks instantly.
Cluster headache peaks over 3 to 5 minutes, remains at maximum for 45 minutes, and then gradually recedes.
Migraine builds over hours, lasts hours to days, and is improved with sleep.
In evaluating patients with recurrent migraine, it is critical to ascertain whether the present headache differs from prior migraines and whether fever is present or spontaneous retinal venous pulsations are abnormally absent. These should prompt a search for alternative causes.
If fever is present with headache, rule out meningitis.
Raised intracranial pressure should be suspected with blurred vision upon bending the head forward, headache upon awakening that improves with sitting up, double vision, loss of coordination and balance, or daily progressive headache with nausea.
Pain originating above the tentorium is referred to the frontal, temporal, or parietal region. Pain from the posterior fossa and below is referred to the occiput. Pain from the posterior sagittal and transverse sinuses may be referred to the eye or forehead.
Lumbar puncture, subdural hematoma, or benign intracranial hypertension can cause orthostatic headache.
Occipital headache radiating to the vertex and forehead is usually a result of cervical spondylosis but can also be caused by basal subarachnoid hemorrhage, posterior fossa tumor, or meningitis.
Clinical Findings
Migraine:
A prodrome virtually always indicates migraine and is the sine qua non of migraine with aura (classic migraine).
Neurological phenomena include visual scotoma (an expanding jagged bright border with a dark center, like a wildfire), or mood changes (usually depression or irritability). More unusually, a prodrome may consist of aphasia or hemiplegia. A unilateral headache follows, usually with vegetative symptoms of nausea, anorexia, or sensitivity to light and sound. The fundi may show arterial or venous dilation. Common migraine has no neurological prodrome although patients can often sense it coming on. Migraine can be recognized by vegetative symptoms, activators (e.g., red wine, stress, sleep or food deprivation, or strong odors) or deactivators (e.g., sleep, pregnancy, exhilaration, or sumatriptan). These headaches have their onset in adolescence or young adult age; new onset in older patients can occur but should prompt a search for structural causes.
Tension: These are experienced as pressure, a vice, or bandlike sensation around the head (vertex, frontal, or temporal). Dull and steady, they worsen as the day progresses. They may last days, weeks, or months, but tension headaches are not relentlessly progressive. Anxiety, depression, and emotional conflicts are frequent precipitants.
Acute sinusitis: The epicenter may be frontal (frontal sinuses), over cheeks (maxillary sinuses), between the eyes (ethmoid sinuses), or in the frontotemporal and occipital region (sphenoid sinus). Headache is a continuous pressure sensation that is worsened by bending forward. Fever, nasal obstruction, and purulent nasal drainage are usually present.
Acute glaucoma: Orbital headache begins with aching around the rim and spreads through the trigeminal ophthalmic division. A tender hard globe, red eye with limbic flush, dull cornea, and impaired transmission of tangential light through the anterior chamber may be present.
Postconcussive: Contusion produces scalp tenderness at the impact site or tension-type headache. Especially after the patient’s vehicle has been rear-ended in an accident, there is headache, dizziness, vertigo, memory impairment, reduced concentration, and anxiety.
Cluster: Cluster occurs in middle-aged men as nocturnal episodes of high intensity, steady, boring, burning, unilateral orbital pain accompanied by ipsilateral red and tearing eye, nasal congestion, facial flushing, and diaphoresis. There also may be ipsilateral ptosis and miosis (20% to 40%). The headache begins a few hours after going to bed and lasts 1 to 2 hours. It recurs nightly for weeks to months and then disappears for years.
Meningitis: Fever is the key sign. The headache is severe, generalized, and constant, most intense at the base of the skull, and aggravated by forward flexion of the neck. The neck and back will be reflexively stiff to flexion (Kernig and Brudzinski sign). Nausea, photophobia, and altered mental status ranging from delirium to coma often accompany the headache. Clues regarding the cause include the following: petechial rash (meningococcus, enterovirus, S. aureus, leptospira); parotitis (coxsackie, LCM, EBV); vesicles (HSV); HIV (Listeria, pneumococcus); diabetes (pneumococcus, gram-negative, S. aureus, cryptococcus, mucormycosis); freshwater swimming (ameba); steroids (cryptococcus, mycobacteria); summer or fall onset (enterovirus, Borrelia, Leptospira). Acute otitis, sinusitis or pneumonia, basilar skull fracture, or splenectomy suggest pneumococcal meningitis. Meningococcal meningitis is suggested by fulminant onset with vascular collapse and angular purpura with a gunmetal gray color. Tuberculous meningitis is suggested by a gradual onset and multiple cranial nerve abnormalities.
Drugs: Sulfamethoxazole, ibuprofen, sulindac, ketorolac, isoniazid, azathioprine, and penicillin may cause aseptic meningitis, especially in patients with systemic lupus or mixed connective tissue disease. Concurrent facial swelling, urticaria, and conjunctivitis are helpful clues. Nitrates, ergots, amphetamines, phenothiazines, alcohol, and withdrawal from caffeine may also cause headache.
Hypoglycemia: Suspect this in a diabetic exhibiting diffuse sweating, throbbing frontal or generalized headache, weakness, confusion, and irritability.
Benign exertional headache: It occurs more commonly in patients who have migraines. Coital headache occurs abruptly with orgasm and subsides within minutes. It is usually benign, but if it lasts for hours or is accompanied by vomiting, subarachnoid hemorrhage should be considered.
Temporomandibular joint inflammation: Chewing aggravates the symptoms, and involuntary nocturnal bruxism and jaw clenching are common. Tenderness and a click over the TMJ are sensitive but not specific findings.
Subdural hematoma: Head trauma with concussion is followed by a lucid interval, then the development of mental status changes and/or focal neurological deficits such as hemiparesis, dilated pupil, and papilledema. Subdural hematoma presents with mild persistent headache, drowsiness, and confusion, and progresses to loss of consciousness.
Subarachnoid hemorrhage: Hemorrhage is sudden in onset and very severe. Headache, photophobia, nausea, meningismus, and loss of consciousness develop rapidly. A major hemorrhage has often been preceded by a similar, less severe, self-limited “herald bleed.”
Acute epidural hematoma: This is usually caused by a temporal skull fracture. A progressive decrease in the level of consciousness is the rule, although a brief lucid interval may follow recovery from a concussion before blood has accumulated.
Lumbar puncture: An intense occipitofrontal headache develops when the patient is upright and is relieved when supine. The onset may be as many as 12 days after the procedure. The original CNS indications for the lumbar puncture may make this difficult to recognize.
Brain tumor: The “classic” tumor headache that is worse in morning, accompanied by nausea and vomiting, occurs in less than 20%. It is relieved by lying down and worsened by straining at defecating, by coughing, or by bending over. Characteristically, it remains in the same location but is progressive, increasing in duration and severity over months. Being awakened at night with the headache is common but not diagnostic. Usually there are subtle neurological changes by the time the headache develops. Fundoscopy often shows increased intracranial pressure, manifest as absence of spontaneous venous pulsations to overt papilledema. Cerebral vomiting, without food, may occur. An occipital lobe tumor may be mistaken for migraine because of the production of scotoma.
Headache in HIV: Acute HIV causes aseptic meningitis accompanied by sore throat, diffuse maculopapular rash, and generalized lymphadenopathy. Cryptococcosis causes headache, fever, and nausea. Toxoplasmosis usually presents with encephalopathy or seizures. CNS lymphoma has headache or seizures. HIV encephalitis presents with seizures, memory loss, or decreased attention span.
Pseudotumor cerebri: It presents like tumor in an obese young woman, with chronic retro-orbital headache increased by eye movement. Transient blurred vision, diplopia, and vague symptoms of dizziness or facial numbness are experienced. Papilledema will often be present on examination.
Hypertensive encephalopathy: An occipital headache usually occurs with accelerated hypertension (BP .230/130), but may be seen with diastolic pressures as low as 110. The headache is worse in the morning. Hypertensive encephalopathy presents with headache, nausea, vomiting, visual disturbances, confusion, seizures, or coma. Focal neurological deficits, retinal hemorrhages, and papilledema are clues. Suspect pheochromocytoma if the headache and hypertension are paroxysmal and associated with sweating, palpitations, and weight loss.
Carbon monoxide intoxication: A prominent pounding headache develops with exposure to engine exhaust or a kerosene heater in a closed space.
Giant cell arteritis: Temporal arteritis should be considered in an elderly patient with a unilateral, dull, aching, continuous headache. It will be most intense over the temporal artery, which may be exquisitely tender and ropy or nodular. Systemic symptoms of fever and anorexia, jaw claudication (weakness, fatigue, or pain precipitated by chewing), or scalp tenderness (painful to comb the hair) often accompany the headache.
Psychogenic: Headaches are described in flamboyant terms but have no clear pattern. Terms such as lightning-like or explosive are used, but the patient experiences no visible discomfort.
Brain abscess: Parenteral drug use, lung abscess, immunodeficiency, and a parameningeal focus are clues. Fever and focal neurologic signs should be sought, but these are not universally present.
Encephalitis: Encephalitis begins acutely or subacutely with headache, fever, and signs of parenchymal involvement, such as coma, seizures, change in mental status, or focal neurological findings. Herpesvirus presents with frontal or temporal lobe neurological findings, or focal seizures, in 85%.
Arteriovenous malformations: Unilateral (always on the same side) throbbing chronic headache without aura occurs. A bruit may be heard with the stethoscope over the eye or temporal region.
Cavernous sinus thrombosis: It begins with retro-orbital headache, which is worse on sitting. Chemosis, proptosis, and painful ophthalmoplegia (deficits of cranial nerves III, IV, V) are found. Seizures or unilateral numbness or weakness may be seen. Predisposing causes include acute sinusitis, otitis, or coagulopathy.
Pituitary apoplexy: Severe bifrontal headache, drowsiness, diplopia, and visual loss (especially bitemporal hemianopia) are found.
Carotid artery dissection: Dissection occurs with neck trauma. Ipsilateral frontal, orbital, or temporal pain with Horner syndrome and focal neurological signs are clues. A carotid bruit is often found.
BLURRED VISION, BLINDNESS, AND SCOTOMATA
The causes of blurred vision and blindness can best be recalled with the use of anatomy. If the path of light is followed through the eye to the nervous system, the various components of the eye and nervous system that may be involved may be considered in terms of the common diseases that may affect them.
Conjunctiva. Chemical, allergic, and infectious conjunctivitis may cause blurred vision, but it rarely causes blindness. A pterygium may grow across the cornea and impair vision. Trachoma may cause blindness if left untreated.
Cornea. Foreign bodies, keratitis, herpes ulcers, and keratoconus may cause blurred vision and blindness. Congenital syphilis forms an extensive progressive interstitial keratitis. Trachoma may cause corneal ulcers and blurred vision.
Canal of Schlemm. At the angle of the iris and cornea, the canal of Schlemm prompts the recall of glaucoma because obstruction of this area figures so prominently in the pathophysiology.
Iris. Iritis from sarcoid, tuberculosis, histoplasmosis, and other causes is considered here. Iridocyclitis occurs when both the lens and iris are involved.
Lens. The two most common causes of blurred vision, cataracts and refractive errors, are considered here. Cataracts may result from diabetes, myotonic dystrophy, galactosemia, and many systemic diseases. They are also congenital and senile, posttraumatic, and associated with various mental deficiency states. Refractive errors include myopia, hyperopia, and astigmatism. These are usually correctable.
Vitreous humor. Hemorrhages of the vitreous and precipitation of triglycerides (lipemia retinalis) may cause blurred vision.
Retina. Chorioretinitis causes blurred vision and blindness and may result from syphilis, tuberculosis, toxoplasmosis, retinitis pigmentosa, and proliferative retinitis in diabetes mellitus. Retinal detachment may result from all the above. Retinal hemorrhages, exudates of hypertension, diabetes, lupus erythematosus, aplastic anemia, and subacute bacterial endocarditis are all possible causes of blurred vision and blindness.
Retinal artery. Occlusion of the retinal artery is a prominent cause of blurred vision or blindness in older people. Emboli, thrombi, and vasculitis secondary to temporal arteritis are all possible causes of the occlusion. Migraine and birth control pills should be considered, and migraine, in particular, should be a prominent consideration in scintillating scotomata.
Retinal vein. A retinal vein thrombosis is a possibility here. Following the course of the vein, however, one encounters the cavernous sinus, and a thrombosis here may lead to bilateral blurred vision and blindness.
Optic nerve. Papilledema, optic neuritis, and optic atrophy are the most important conditions to consider. The papilledema is usually due to an intracranial space-occupying lesion, but hypertension and benign intracranial hypertension need attention in the differential. Optic neuritis requires the consideration of multiple sclerosis, neurosyphilis, tuberculosis, diabetes mellitus, sinusitis, and lead poisoning. Optic atrophy should suggest syphilis, methyl alcohol poisoning, hereditary optic atrophy, Foster Kennedy syndrome (frontal lobe tumors), and various congenital anomalies. It may be secondary to diseases of the retina. The optic nerve may be severed by an orbital fracture.
Optic chiasma. Pituitary tumors, sphenoid ridge meningiomas, colloid cysts of the third ventricle, aneurysms, and cavernous sinus thrombosis are possible causes. Syphilitic or tuberculosis meningitis may also involve the chiasma, as may the spread of a Schmincke tumor from the nasopharynx. Basilar skull fractures infrequently involve the chiasma.
Optic tract, optic radiations, and occipital cortex. Intracranial hematomas, cerebral thrombi or emboli, transient ischemic attacks (TIAs), aneurysms, cerebral tumors, and abscesses may involve these structures. Certain forms of acute and chronic encephalitis may also involve these areas, causing blurred vision and blindness. Cortical blindness may result from an occlusion of both posterior cerebral arteries at their origin from the basilar artery.
BLURRED VISION, BLINDNESS, AND SCOTOMATA
BLURRED VISION, BLINDNESS, AND SCOTOMATA
Diagnosis
A careful eye examination with magnification and fluorescence to rule out a foreign body and ulcers is essential in the acute case of blurred vision. Ophthalmoscopic examination may reveal optic neuritis or a retinal vein thrombosis. Visual field examination by confrontation may reveal a field defect. If these test results are negative, ocular tension should be checked to rule out glaucoma. A history of migraine, the use of birth control, and alcohol intake must be investigated. If there is headache on the side of the lesion, a sedimentation rate is done, steroids should probably be started immediately, and referral to a neurologist made promptly in case temporal arteritis is possible, especially in the aged. Otherwise, referral to an ophthalmologist is necessary. The ophthalmologist will perform visual field examinations with perimetry, a slit lamp examination, and look for refractive errors. If other neurologic findings are present, a CT scan, skull x-ray film, and spinal tap may be indicated. A neurologic consultant can determine this.
Other Useful Tests
VDRL test (syphilis)
Toxicology screen (drug abuse)
Tuberculin test
Histoplasmosis skin test
Serology for histoplasmosis
Serology for toxoplasmosis
Kveim test (sarcoidosis)
MRI (brain tumor)
Visual evoked potentials (multiple sclerosis)
ANA (collagen disease)
Pituitary function studies
Four-vessel cerebral angiography
Conjunctiva. Chemical, allergic, and infectious conjunctivitis may cause blurred vision, but it rarely causes blindness. A pterygium may grow across the cornea and impair vision. Trachoma may cause blindness if left untreated.
Cornea. Foreign bodies, keratitis, herpes ulcers, and keratoconus may cause blurred vision and blindness. Congenital syphilis forms an extensive progressive interstitial keratitis. Trachoma may cause corneal ulcers and blurred vision.
Canal of Schlemm. At the angle of the iris and cornea, the canal of Schlemm prompts the recall of glaucoma because obstruction of this area figures so prominently in the pathophysiology.
Iris. Iritis from sarcoid, tuberculosis, histoplasmosis, and other causes is considered here. Iridocyclitis occurs when both the lens and iris are involved.
Lens. The two most common causes of blurred vision, cataracts and refractive errors, are considered here. Cataracts may result from diabetes, myotonic dystrophy, galactosemia, and many systemic diseases. They are also congenital and senile, posttraumatic, and associated with various mental deficiency states. Refractive errors include myopia, hyperopia, and astigmatism. These are usually correctable.
Vitreous humor. Hemorrhages of the vitreous and precipitation of triglycerides (lipemia retinalis) may cause blurred vision.
Retina. Chorioretinitis causes blurred vision and blindness and may result from syphilis, tuberculosis, toxoplasmosis, retinitis pigmentosa, and proliferative retinitis in diabetes mellitus. Retinal detachment may result from all the above. Retinal hemorrhages, exudates of hypertension, diabetes, lupus erythematosus, aplastic anemia, and subacute bacterial endocarditis are all possible causes of blurred vision and blindness.
Retinal artery. Occlusion of the retinal artery is a prominent cause of blurred vision or blindness in older people. Emboli, thrombi, and vasculitis secondary to temporal arteritis are all possible causes of the occlusion. Migraine and birth control pills should be considered, and migraine, in particular, should be a prominent consideration in scintillating scotomata.
Retinal vein. A retinal vein thrombosis is a possibility here. Following the course of the vein, however, one encounters the cavernous sinus, and a thrombosis here may lead to bilateral blurred vision and blindness.
Optic nerve. Papilledema, optic neuritis, and optic atrophy are the most important conditions to consider. The papilledema is usually due to an intracranial space-occupying lesion, but hypertension and benign intracranial hypertension need attention in the differential. Optic neuritis requires the consideration of multiple sclerosis, neurosyphilis, tuberculosis, diabetes mellitus, sinusitis, and lead poisoning. Optic atrophy should suggest syphilis, methyl alcohol poisoning, hereditary optic atrophy, Foster Kennedy syndrome (frontal lobe tumors), and various congenital anomalies. It may be secondary to diseases of the retina. The optic nerve may be severed by an orbital fracture.
Optic chiasma. Pituitary tumors, sphenoid ridge meningiomas, colloid cysts of the third ventricle, aneurysms, and cavernous sinus thrombosis are possible causes. Syphilitic or tuberculosis meningitis may also involve the chiasma, as may the spread of a Schmincke tumor from the nasopharynx. Basilar skull fractures infrequently involve the chiasma.
Optic tract, optic radiations, and occipital cortex. Intracranial hematomas, cerebral thrombi or emboli, transient ischemic attacks (TIAs), aneurysms, cerebral tumors, and abscesses may involve these structures. Certain forms of acute and chronic encephalitis may also involve these areas, causing blurred vision and blindness. Cortical blindness may result from an occlusion of both posterior cerebral arteries at their origin from the basilar artery.
BLURRED VISION, BLINDNESS, AND SCOTOMATA
BLURRED VISION, BLINDNESS, AND SCOTOMATA
Diagnosis
A careful eye examination with magnification and fluorescence to rule out a foreign body and ulcers is essential in the acute case of blurred vision. Ophthalmoscopic examination may reveal optic neuritis or a retinal vein thrombosis. Visual field examination by confrontation may reveal a field defect. If these test results are negative, ocular tension should be checked to rule out glaucoma. A history of migraine, the use of birth control, and alcohol intake must be investigated. If there is headache on the side of the lesion, a sedimentation rate is done, steroids should probably be started immediately, and referral to a neurologist made promptly in case temporal arteritis is possible, especially in the aged. Otherwise, referral to an ophthalmologist is necessary. The ophthalmologist will perform visual field examinations with perimetry, a slit lamp examination, and look for refractive errors. If other neurologic findings are present, a CT scan, skull x-ray film, and spinal tap may be indicated. A neurologic consultant can determine this.
Other Useful Tests
VDRL test (syphilis)
Toxicology screen (drug abuse)
Tuberculin test
Histoplasmosis skin test
Serology for histoplasmosis
Serology for toxoplasmosis
Kveim test (sarcoidosis)
MRI (brain tumor)
Visual evoked potentials (multiple sclerosis)
ANA (collagen disease)
Pituitary function studies
Four-vessel cerebral angiography
I cant shit in peace
HELP. I can't shit in peace without the cellphone ringing or the kids switching the lights off or the wife WAITInG. Aaaaaggg!!!!
I cant shit in peace
HELP. I can't shit in peace without the cellphone ringing or the kids switching the lights off or the wife WAITInG. Aaaaaggg!!!!
Samsung LCD LA46M81 from Home Hyper City is the best
I just purchased a full HD Samsung LA46M81 from www.homehypercity.co.za
Its a full High definition Samsung LCD panel. WOW what excellent service. The price was R28500 for the 46 inch. That's like USD3800.
What a bargain. I just thought I would like to thank the guys there. Please help me give them a shout out. If you had a positive experience from Home Hyper City please drop a line, I would like to hear about it.
Its a full High definition Samsung LCD panel. WOW what excellent service. The price was R28500 for the 46 inch. That's like USD3800.
What a bargain. I just thought I would like to thank the guys there. Please help me give them a shout out. If you had a positive experience from Home Hyper City please drop a line, I would like to hear about it.
Saturday, October 27, 2007
become an early riser
Being an early riser is the secret to a productive and effective day. How do I do this you may ask. As with everything practice. Mental preperation and lots of good luck.
Remember procrastination is the thief of time, love and success.
Remember procrastination is the thief of time, love and success.
IF The heat is too hot get out of the kitchen
If you can't stand the heat get out of the kitchen. What do you do in an emerging economy, high taxes and low governmental service. Increasing corruption and poor corporate governance are signs of sociatal decay, or a red light to start the search for a greener pasture.
Business partnerships
Business partnerships can be a real test in resolve, especially when the enterpreniure has to grow. What are you experience. How does one get around the painful process of setting standards? Can they be multigenerational? Any experience on partnerships that work!
persistant trophoblastic disease, choriocarcinoma, and mola pregnancies
Persistant trophoblastic disease arises after a mola pregnancy. Its a rather disturbing condition that may cause death if not treated or may be fully cured with chemotherapy. Its usually recognised by persistant rise in bHCG in a female of chilbaring age. Its a malignant condition that's curable.
Any people that have had encounters with this condition?
Any people that have had encounters with this condition?
Trusts
Have you ever wondered how to get rich? Why the rich have trusts? Why the average joe soap never gets away with any money after all is said and done? and how is it that the super rich never pay any Tax? I have. Before I share by story I would like to hear what you, yes you the CPA, the CA, the MBA, the BCom think, and you and you think.
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