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Examination of the Cardiovascular System
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The child should be undressed appropriately to the waist. In the older child, the examination easily performed with the patient sitting over the edge of the bed or even on a chair. Preferably, examine the younger child on the parent's lap. Removing a toddler from his parents is less likely to yield good clinical signs and more likely to yield a screaming child. For examination of femoral pulses, the child should be in the supine position.
Warm your hands by rubbing them against each other.
You should use the middle three fingers of your dominant hand to palpate the pulses against the underlying bone. The finger tips are used for palpation as they have maximum sensitivity.
While palpating, the artery is stabilized by the proximal and distal fingers and the thrust of the pulse is felt by the middle finger. Partial occlusion of the artery by the distal finger improves the thrust of the pulse wave on the middle finger.
Palpate all the pulses listed below first on the right and then on the left side. Always compare the respective pulses on both sides except the carotids. In case of carotids, palpitating both sides can induce cerebral ischemia and can cause the patient to faint.
Carotid (don't palpate both sides simultaneously) - Palpated at the level of thyroid cartilage along the medial border of the sternomastoid muscle either with finger tips or thumb (left thumb for the right side and vice versa)
Brachial - Palpated with the elbow flexed along the medial aspect of the lower end of the arm
Radial - felt at the lower end of the radius on the anterior aspect of the wrist, medial to the styloid process with the patient's forearm slightly pronated and wrist semiflexed
Femoral (DO NOT FORGET FEMORALS) - felt in the middle of the groin with the leg slightly flexed and abducted and foot externally rotated.
Dorsalis pedis - can be felt on the dorsum of the foot lateral to the extensor hallucis tendon in the middle third of the foot
Posterior tibial - felt posterior to the medial malleolus and anterior to the Achilles tendon.
For assessing the pulse rate, use brachial pulse in an infant or toddler and radial pulse in older children
While counting the pulse rate, count for 15 seconds and multiply by 4. But tell the examiner that ideally, you would like to count for one minute. However, if the pulse is irregular, then count for one full minute and also count the heart rate by auscultation.
Rhythm - while looking for the rhythm, one looks for the gap between the pulse waves and comment on their regularity.
This is a highly subjective sign. It describes the thrust (expansion) of the pulse wave and reflects the pulse pressure.
If high volume, always check for collapsing nature. (Hold the right forearm of the patient by your hand in such a way as the radial artery is under the head of the metacarpals of our hand. Lift the patient's entire upper limb vertically by 90ï'°and feel for the sudden and exaggerated rise and fall of the pulsations of radial artery.)
Character - This describes the form of the wave and various types are decided by the rise, peak and waning of the wave. It is best appreciated in carotids.
Radio femoral delay (femoral pulse appears following a time delay after radial - suggests coarctation of aorta)
Make sure you don't leave the child exposed.
Thank the child/ parent for co operation if no further examination is planned
Characteristics of pulse should be described as follows
Radio-femoral delay
Comment on rate as normal, tachycardia or bradycardia based on age specific heart. In general, for children over 3 years of age pulse rate >100 beats per minute is tachycardia and pulse rate < 50 beats per minute is bradycardia
Tachycardia has poor specificity and always make sure child is not anxious/ febrile before attributing significance
Bradycardia in a child is usually point to underlying pathology once exercise (athletes), drug intake (Digoxin, beta blockers) is ruled out.
Reported as regular, Regularly irregular and Irregularly irregular
Regular - there is a normal variation of heart rate on breathing - sinus arrhythmia. It is present in most children.
Regularly Irregular: abnormal beats occur at regular intervals - pulsus bigeminus, coupled extrasystoles (digoxin toxicity), Wenckebach Phenomenon
Irregularly Irregular - no specific gaps between the waves - Extrasystoles are common in normal children and disappear with exercise. Atrial fibrillation is another common condition which causes an irregularly irregular pulse. Comment on the pulse deficit i.e. the difference between heart rate and pulse rate
High volume - anemia, carbon dioxide retention or thyrotoxicosis
Low volume pulse is seen in low cardiac output states.
Slow rising and plateau (pulsus parvus et tardus) - severe aortic stenosis
Collapsing pulse e.g. aortic incompetence
Pulsus Paradoxus- pulse is weaker or disappears on inspiration e.g. Constrictive pericarditis, tamponade, status asthmaticus
Jerky pulse - normal volume, rapidly rising and ill sustained.-suggestive of hypertrophic obstructive cardiomyopathy
Pulsus bisferiens - two peaks felt during systole, seen in the presence of moderate artic stenosis and severe aortic regurgitation
Pulsus alternans - Pulse wave with alternate small and large waves - seen in severe left ventricular failure and arrhythmias
Unequal or absent pulses may be suggestive of previous surgery e.g. Blalock-Taussig shunt, repaired coarctation, cervical rib or absent radial pulse
- Hand washing or using alcohol rub
- Asks the name and age of the child, if already not told by the examiner
- Explains the purpose of his/ her visit and what he/ she is going to do
- Positions the patient appropriately
- Uses the middle three fingers of the dominant hand to palpate the pulses
- Palpates all the pulses first on one side and then on the other side
- Compares pulses bilaterally
- Does not palpate the carotids simultaneously
- Counts the pulse rate at least for 15 seconds
- If pulse is irregular, then counts for one full minute and also counts heart rate
- Looks for Radio femoral delay
- While describing the pulse, comments on rate, rhythm, character, volume, symmetry and radio-femoral delay
- Makes sure that the child is not left exposed
- Thanks the child / parent for co operation
Task: MANUAL Measurement of blood pressure
Mercury sphygmomanometer should be used as aneroid sphygmomanometer loses accuracy on repeated usage.
Choose the appropriate size cuff - the cuff bladder should cover at least 2/3 of the length of the arm and 3/4 of the circumference . Cuff size should always be documented.
Make sure that the child is calm and not crying or agitated
Child can be either seated or in the supine position
Any clothing over the arm should be removed
The convention is to measure BP in the right arm in a calm but awake subject. If conditions differ from this they should be documented with the reading.
The elbow should be supported and flexed and should be at the level of the heart.
The cuff is wrapped around the upper arm with the bladder centered over the middle of the arm.
Approximate estimation of the systolic blood pressure is done initially by inflating the cuff fully and then deflating slowly and smoothly while palpating the radial pulse. Systolic blood pressure is noted at the point when the radial pulse returns.
Following this, the blood pressure is recorded by auscultatory method which is the more accurate measure. The diaphragm of the stethoscope is placed over the brachial artery along the medial aspect of the lower end of the arm below the edge of the cuff. The cuff should be inflated to 30 mm above the palpatory systolic blood pressure and then deflated slowly and smoothly at the rate of 2-3 mmHg per second. Systolic blood pressure is recorded at the point when clear, repetitive tapping sounds are just heard. Diastolic blood pressure is recorded when the sounds disappear.
In some children, instead of disappearing, the sounds muffle first before disappearing. In this case, the value at which the sounds muffle should be recorded as the diastolic pressure if the difference between the point of muffling and disappearance of the sounds is greater than 10 mmHg.
Make sure you do not leave the child exposed.
Thank the child/ parent for co operation if no further examination is planned
While interpreting the readings, the state of the child should be taken into account. Values should be compared to normal values with reference to the age/height and sex of child.
In infants, instead of radial, brachial pulse should be palpated. Sometimes, auscultation can be difficult in infants in which case systolic pressure by palpation should be documented.
If measuring a lower limb pressure, the same cuff can be applied to the lower leg and a foot pulse palpated.
It is advisable to measure the blood pressure in both upper and lower limbs. When coarctation is suspected, it is imperative that blood pressure is recorded in both arms and one leg. The same should be done is cases of hypertension and in those who have had shunt surgeries as in Blalock Shunt.
While recording blood pressure in the lower limb, a larger appropriate size cuff should be used and auscultation is done over the popliteal artery.
The sounds which are heard while auscultating are called as Korotkoff's sounds and has five phases. Phase 1 is the first heard clear, tapping sound, phase 2 is intermittent murmur like sound, phase 3 is the loud tapping sound, phase 4 is the muffling of sounds and phase 5 is disappearance of the sounds.
Occasionally, the sound might disappear after the Korotkoff sound phase 1 before reappearing later. This 'auscultatory gap' can lead to either underestimation of the systolic blood pressure (if prior estimation of blood pressure by palpation is not done) or overestimation of diastolic blood pressure is the auscultation is not continued till the end.
In atrial fibrillation, phase 4 of Korotkoff sound should be used for recoding diastolic blood pressure.
Pulsus paradoxus is best appreciated while recording blood pressure by auscultation and is identified by recording the value at which the tapping sounds are heard only during expiration and the value at which the sounds are heard both during inspiration and expiration. When the difference between the two values is greater than 10 mmHg, pulsus paradoxus is said to be present.
Pulse pressure is the difference between systolic blood pressure and diastolic blood pressure. A weak pulse is associated with narrow pulse pressure and is seen in cardiac failure, shock, aortic stenosis and constrictive pericarditis. Pulse pressure is wide in aortic regurgitation, hyperthyroidism, anemia and febrile states.
Washes hands or uses alcohol rub
Explains the purpose of his/ her visit and what he/ she is going to do
Positions the patient appropriately
Chooses mercury sphygmomanometer
Chooses the appropriate size cuff
Removes any clothing over the arm
Supports the elbow and keeps it at the level of the heart.
Wraps the cuff around upper arm with the bladder centered over the middle of arm
Estimates systolic blood pressure by palpatory method
Uses brachial pulse in infants for palpatory method
Estimates systolic blood pressure by auscultatory method
Uses diaphragm of the stethoscope for auscultation
Makes sure that the child is not left exposed
Thanks the child / parent for co operation
Records blood pressure as estimated by palpatory and auscultatory method including the site and the position of the child
Interprets the blood pressure
Task: Evaluation of jugular venous pulse
The room should be adequately lit for the assessment of jugular venous pulse
The patient should be in semi-reclining position with the trunk at 45ï'° to the bed.
The head and the back should be well supported with a pillow under the head.
The head should be positioned in the midline
Stand on the right side of the patient and assess the jugular venous pulse.
The torch should be shined from the left in an oblique direction and the jugular pulsation is observed
Jugular venous pulse is located just lateral to the clavicular head of the sternomastoid muscle.
Pulsations of the jugular veins should be differentiated from the carotid pulsations as discussed below.
The jugular venous pressure is assessed by measuring the vertical distance between the top of the jugular venous pulsations and the sternal angle (angle of Louis). In cases where the top of the jugular pulsations is not visible at 45ï'°, increasing the reclining angle up to 90ï'° can make the top of the pulsations obvious. The assessment is done when the child is breathing quietly
Look for hepato-jugular reflex. This performed by exerting firm and sustained pressure on the right upper quadrant of the abdomen and looking for an elevation in the jugular venous pressure by 2-3 cm.
Make sure you do not leave the child exposed.
Thank the child/ parent for co operation if no further examination is planned
Assessment of jugular venous pressure is rarely important in the younger child. It is also difficult to obtain an accurate reading because of the short neck in children
It can be generally measured easily if the child is greater than 10 years
Jugular Venous Pulsation
Carotid Pulsation
Pulse lateral to sternomastoid
Pulse medial to sternomastoid
Better seen
Better felt
Multiple waves seen
Single wave
Abdominal pressure makes the pulsations prominent
Abdominal pressure has no effect
Valsalva maneuver makes the pulsations prominent
Valsalva maneuver has no effect
Can be obliterated with pressure
Cannot be obliterated with pressure
The right jugular vein is in a straight line with the right atrium and is more likely to show the pressure effects than the left jugular vein which has more tortuous course and is more likely to kinked. This can lead to false elevation of the jugular pressure.
In patients with highly elevated JVP, the pulsation may be seen only below the angle of jaw. In such cases, increasing the reclining angle to 60ï'° or more makes the pulsations more obvious.
Turning the head slightly towards the contralateral side can make the pulsations prominent, if the pulsations are not obvious.
JVP consists of a, c and v waves and x and y descent. 'a' wave is due to right atrial contraction, 'c' wave is due to bulging of the tricuspid valve and 'v' wave is due to atrial filing. 'x' descent is due to atrial relaxation and 'y' descent results from ventricular filling and tricuspid valve opening.
The sternal angle (angle of Louis) is taken as the reference point as it roughly corresponds to the middle of the right atrium.
JVP is elevated in congestive cardiac failure, fluid overload, constrictive pericarditis, pericardial tamponade, tricuspid stenosis and tricuspid regurgitation.
Non-pulsatile elevation of JVP is seen in superior vena cava obstruction.
'a' wave are absent in atrial fibrillation.
Large 'a' waves: are caused either by hypertrophied right atrium in response to decreased right ventricular compliance as in pulmonary hypertension and pulmonary stenosis or contraction of atrium against resistance as in tricuspid stenosis.
Cannon 'a' waves are giant 'a' waves seen in early systole and is caused by contraction of the atrium against a closed tricuspid valve. It is usually seen in complete heart block and ectopics.
Large 'v' waves are seen in tricuspid insufficiency.
Sharp 'x' and Sharp 'y' descents are seen in constrictive pericarditis and restrictive cardiomyopathy.
Washes hands or uses alcohol rub
Explains what he/ she is going to do
Makes sure that the room is adequately lit
Positions the patient in semi-reclining position with the trunk at 45ï'° to the bed
Supports the head with pillow to ensure relaxation of the neck
Positions the head in midline
Stands on the right side of the patient and assesses the right jugular venous pulse.
Locates the jugular pulse correctly
If the jugular pulse is not obvious, then makes it obvious by turning the head slightly to the left and shines the torch from left obliquely if necessary
Measures the jugular venous pressure correctly
Looks for hepato-jugular reflex.
Makes sure that the child is not left exposed
Thanks the child / parent for co operation
Lists the differences between carotid pulse and jugular pulse
Task: general inspection of the body with reference to cardiovascular system
Introduce yourself to the child and carer and ask for permission to examine
For inspection, the room should be well lit. Ensure that the lights are turned on and the windows are open
The child should be undressed appropriately to the waist.
In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chair
Examine the younger child on the parent's lap.
General well being - Well/ Ill looking child
Interest in the surroundings - Sick child will not be interested
Size of the child - thin & small, thin & tall, well nourished and tall, well nourished and short.
Degree of breathlessness - classify as none, mild or severe
Environment (Equipment) - oxygen mask, nasal cannula, intravenous catheter, pulse oximetry, feeding tube/ gastrostomy,
Head - look at the size (microcephaly or macrocephaly) and shape (dolichocephaly)
Face - Normal or dysmorphic features, malar flush
Conjunctiva - pallor, jaundice (refer chapter on general examination)
Mouth - Using the pen torch, take a quick look in the mouth and look for the presence of age appropriate teeth, abnormal teeth and caries. Ask the child to stick their tongue "outwards and upwards towards the nose" and examine the tongue for central cyanosis.
Hands and fingers - pallor; clubbing; polydactyly and syndactyly; Osler's nodes; Janeway lesions; splinter haemorrhages. Examine both the hands quickly.
Difference in colour between limbs
Make sure that the child is not left exposed
Thank the child / parent for cooperation
Always think whether the findings combine to form a recognizable clinical syndrome.
It is preferable to inspect the child in sunlight than in artificial light.
Children with chronic cardiac conditions are usually thin and small for age.
Breathlessness is classified as mild when the child has only chest recession, and there is no contraction of sternocleidomastoid or nasal flaring and severe when all three are present
Microcephaly can be associated with some of the intrauterine infections and genetic disorders like congenital rubella syndrome and Edward's syndrome
Dolichocephaly (increased antero-posterior diameter) is seen in ex-preterms
Syndromes with dysmorphic facial features
Downs syndrome - almond shaped eyes (due to epicanthal folds); Brushfield spots (light colored spots in the iris); small, flat nose; small mouth with a protruding tongue; small, low set ears; round faces; flat occiput
Turners syndrome - prominent, posteriorly rotated auricles with looped helices and attenuated tragus; infraorbital skin creases; mildly foreshortened mandible
Williams syndrome - broad forehead; short nose with broad tip; full cheeks; wide mouth with full lips
Noonan's syndrome - downwards slanting eyes with arched eyebrows; epicanthal folds; broad forehead; nose with wide base and bulbous tip; pointed chin
Marfan's syndrome - long, thin face; deep-set eyes; down-slanting palpebral fissures; receding chin; dolichocephaly; malar hypoplasia; enophthalmos
DiGeorge syndrome - small ears; asymmetric facies; small mouth and chin
Malar flush - plum coloured malar eminences
Hutchinson (conical) incisor is seen in congenital syphilis (patent ductus arteriosus) and enamel hypoplasia in Ellis-van Creveld Syndrome (atrioventricular canal, ventricular septal defect, atrial septal defect, and patent ductus arteriosus).
Caries tooth may be a cause of infective endocarditis in congenital heart disease.
In preaxial polydactyly, the extra digit is on the radial (thumb) side while in postaxial polydactyly, it is on the ulnar (little finger) side of the hand.
Osler's nodes are painful, red, raised lesions found on the hands and feet and is seen in infective endocarditis
Janeway lesions are nontender, macular lesions, most commonly involving the palms and soles and seen in infective endocarditis.
Splinter hemorrhages appear as narrow, red to reddish-brown lines of blood that run vertically under nails. Splinter hemorrhage can be associated with infectious endocarditis, systemic lupus erythematosus, and trauma
Washes hands or uses alcohol rub
Explains what he/ she is going to do and ask for permission to examine
Positions and exposes the child appropriately
Makes sure that the room is adequately lit
Looks for the following general points
General well being
Interest in the surroundings
Size of the child
Degree of breathlessness
Environment (Equipment)
Looks for the following specific points
Head - size and shape
Hands and fingers
Difference in colour between limbs
Makes sure that the child is not left exposed
Thanks the child / parent for co operation
Task: INSPECTION OF THE CHEST
Introduce yourself to the child and carer and ask for permission to examine
For inspection, the room should be well lit. Ensure that the lights are turned on and the windows are open
The child should be undressed appropriately to the waist.
In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chair
Examine the younger child on the parent's lap.
Look tangentially from foot end of the bed in supine patients and from the sides in sitting patients.
Look for the following and comment
Shape of the Chest - symmetrical or asymmetrical
Symmetry of chest expansion
Pulsations - Observe for apical impulse, parasternal, suprasternal, epigastric pulsations.
Spine for scoliosis
Make sure that the child is not left exposed
Thank the child / parent for cooperation
Common asymmetrical chests
Pectus carinatum: also called pigeon chest, deformity of the chest characterized by protrusion of the sternum and ribs. It may occur as congenital abnormality or in association with genetic disorders such as Marfan's syndrome, Morquio syndrome, Noonan syndrome, Trisomy 18, Trisomy 21, homocystinuria, and osteogenesis imperfecta.
Pectus Excavatum: also called funnel chest, deformity of the anterior wall of the chest producing sunken appearance of the chest. It may occur in rickets, Marfan's syndrome and spinomuscular atrophy.
Harrison's sulcus: horizontal indentation of the chest wall at the lower margin of the thorax where the diaphragm attaches to the ribs. It may occur in conditions with increased pulmonary blood flow or chronic asthma.
Scars: lateral thoracotomy scar results from closure of patent ductus arteriosus, tracheoesophageal fistula repair and Blalock Taussig shunt. Central sternotomy scar is seen after open heart surgery and lobectomy. Children can have drainage scars in epigastrium, subclavian/axillary scars from pacemakers and scars following cardiac catheterization in the groin and neck.
Apical impulse will be shifted peripherally due to cardiomegaly, collapse of left lung or fluid in the right pleural cavity
Parasternal pulsations can occur due to right ventricular enlargement or enlarged left atrium pushing the right ventricle.
The most common cause of suprasternal pulsations is dilated aorta due to aneurysm or markedly increased blood flow.
Epigastric pulsation may be seen in thin children, right ventricular hypertrophy and abdominal aneurysm.
Scoliosis should be looked for in the standing and not in sitting position
Washes hands or uses alcohol rub
Explains what he/ she is going to do and ask for permission to examine
Positions and exposes the child appropriately
Makes sure that the room is adequately lit
Looks tangentially from foot end of the bed in supine patients and from the sides in sitting patients
Looks for the following points and comments
Shape of the Chest
Symmetry of chest expansion
Apical impulse, parasternal, suprasternal, epigastric pulsations
Spine for scoliosis
Makes sure that the child is not left exposed
Thanks the child / parent for co operation
Task: PALPATION OF THE CHEST
Introduce yourself to the child and carer and ask for permission to examine
The child should be undressed appropriately to the waist.
Position the older child so that they sit over the edge of the bed or lie down on the couch
Examine the younger child on the parent's lap.
Warm your hands for palpation
Be gentle with palpation
Apical Impulse:
Place the palm of the whole hand flat over left chest wall to get a general impression of the point of maximal impulse.
Next, lay the ulnar border of the hand on the chest parallel to rib space where the impulse was felt and try to locate the apex.
Finally palpate with the fingertip of the index or middle finger to localize the apical impulse and define its character.
Use the left hand to palpate the carotid artery to time the apical impulse.
With the finger of the right hand still in place over the apex beat, palpate the manubriosternal joint (angle of Louis) which is present just below the suprasternal notch and is felt as a prominence with the left hand. It corresponds to the second intercostal space. Slide the index finger and count down the next few intercostal spaces until you locate the intercostals space that is level with the apex beat. Look at the position of the apex with reference to the midclavicular line.
If the apical impulse is not readily palpable in the supine position, ask the child to lie on their left side.
If the apex beat is not still palpable, try on the right side in case of dextrocardia.
Parasternal pulsation and heave:
With the fingertips, palpate over the left sternal edge to find the parasternal pulsations.
With the child lying in supine position, place a pencil lateral to the left sternal edge and look tangentially for lifting of the pencil.
Next, place the base of your hand just lateral to the left sternal edge and palpate for a parasternal heave.
If parasternal heave is present, try suppress it by exerting pressure with base of the hand.
Thrills are best felt with fingertips. Time the thrill with carotid or brachial pulse. Palpate the following areas.
Apex of the heart
3rd to 5th intercostal space along the left sternal border
Pulmonary area (left second intercostal space)
Aortic area (right second intercostal space)
Suprasternal area
Make sure that the child is not left exposed
Thank the child / parent for cooperation
Apical impulse is the farthest inferior and lateral maximal cardiac impulse on the chest wall. It results from the heart rotating, moving forwards and striking against the chest wall during systole. Apical impulse is normally felt in the 4th left intercostal space on the midclavicular line. It may be difficult to palpate in obese children and in pericardial effusion.
Displaced apex
Tension pneumothorax and pleural effusion (push apex away from the lesion)
Pulmonary fibrosis and collapse (pull towards the side of the lesion)
Left ventricular hypertrophy - apex is displaced down and out
Right ventricular hypertrophy - apex is displaced outwards
Skeletal abnormalities
Quality of apical impulse (normal apex lifts the palpating fingers briefly)
Sustained (increased amplitude and duration) - pressure overload (aortic stenosis)
Hyperdynamic or forceful (increased amplitude but not duration) - volume overload (mitral incompetence and aortic incompetence)
Tapping - palpable first heart sound of mitral stenosis
Parasternal pulsations
Palpable 2nd heart sound reflects pulmonary hypertension.
Parasternal heave is present in right ventricular hypertrophy or left atrial enlargement pushing the right ventricle.
There are three grades of parasternal heave
Grade I - heave identified by lifting of the pencil alone and not the heel of the hand
Grade II - easily identified, can be suppressed with pressure
Grade III - lifts the heel of the hand and cannot be suppressed with pressure
Thrill is a palpable murmur that felt like a purring cat. While describing the thrill, describe the site and phase of cardiac cycle. When thrill is present, the accompanying murmur is by definition at least 4/6 in intensity.
Washes hands or uses alcohol rub
Explains what he/ she is going to do and ask for permission to examine
Positions and exposes the child appropriately
Warms hands before
Palpates gently
Apical Impulse
Places the palm flat over left chest wall to get a general impression
Keeps the ulnar border of the hand parallel to rib space
Palpates with the fingertip to locate the apical impulse
Palpates the carotid artery to time the apical impulse
Counts the intercostal space and localises the site of apical impulse
Looks for apical impulse on right side if it could not be localised on the left
Spine for scoliosis
Parasternal pulsation and heave
Palpates the left sternal edge with the fingertips to find parasternal pulsations
With the child lying in supine position, places a pencil lateral to the left sternal edge and looks tangentially for lifting of the pencil.
Palpates the left sternal edge with the base of hand for parasternal heave
Palpates with fingertips at apex, pulmonary area, 3rd to 5th left intercostal space along sternum, aortic area, suprasternal area and carotids (1 point per area)
Times the thrill with carotids or brachial pulse
Makes sure that the child is not left exposed
Thanks the child / parent for co operation
Defines the location of apical impulse and its character
Task: AUSCULTATION of heart sounds
Introduce yourself to the child and carer and ask for permission to examine
Undress the child appropriately to the waist.
Ask older children to lie down on the couch.
Examine the younger child on the parent's lap or while lying down if possible.
Begin with the bell of the stethoscope over the apex. Apply the stethoscope gently, as firm pressure will cause the skin to stretch over the bell and act as diaphragm. Next, listen with the diaphragm of the stethoscope.
Palpate the right carotid or brachial artery at the same time as auscultating to time the cardiac events. If the murmur coincides with the carotid pulse, it is systolic.
If a murmur is identified at the apex, inch towards the axilla to look for radiation
Roll the child onto the left lateral position and listen in full expiration with the bell for middiastolic murmur of mitral stenosis.
Ask the child to roll back to the supine position and inch the diaphragm of the stethoscope towards the left lower sternal edge or the tricuspid area (fourth left intercostal space).
While listening with the diaphragm, move onto the pulmonary area (left sternal edge in the second interspace) and then to the aortic area (second right intercostal space). With an older co-operative child, always listen again along the left sternal edge as the child breathes out and learns forward (early diastolic murmur of aortic regurgitation).
Listen over the suprasternal notch and carotids - radiation suggests aortic stenosis
Last but not the least, always listen at the back
Make sure that the child is not left exposed
Thank the child / parent for cooperation
The diaphragm of the stethoscope is designed to amplify high-pitched sounds; the bell does not amplify sound but transmits low-pitched sounds better than the diaphragm.
Auscultation of the heart reveals the first and second heart sounds, each of which has two components. The first heart sound and second heart sound are produced by the closing of the atrioventricular valves and semilunar valves respectively. The first sound is usually audible as a single sound and occurs at the beginning of systole i.e. the beginning of the carotid pulse. The second heart sound is often split with the aortic component preceding the pulmonary component (especially during inspiration), due to the lower pressures in the pulmonary circulation resulting in a slight delay in pulmonary valve closure with respect to the aortic valve. This splitting is accentuated by inspiration because increased right heart filling delays closure of the pulmonary valve further. The second sound occurs at the beginning of diastole.
While auscultating, listen to the sounds in the following sequence
First heart sound
Second heart sound
Additional heart sounds - S3 and S4
Additional sounds - opening snap, ejection click
In each region, focus on systole and diastole separately and note the quality as well as loudness of sounds and murmurs.
For the first heart sound, comment if it is normal or loud. For the second heart sound, one should comment whether it is normal or loud and whether the split is normal, wide, narrow or reversed and changes of the split with respiration.
The third heart sound is a low-pitched early diastolic sound best heard at the apex with the bell. It is produced during passive ventricular filling and often heard as a gallop rhythm. The fourth heart sound is a late diastolic sound with a slightly higher pitch than S3, produced by the rapid influx during atrial systole .
While describing a murmur, it is helpful to describe the following
Timing in cardiac cycle - systolic/ diastolic
Location of maximal intensity - where on precordium
best heard by - bell/diaphragm
loudness (commonly graded out of 6)
Duration - beginning and end with respect to systole and diastole
Character - pitch and quality (high or low; harsh, blowing or rumbling)
Radiation - extent and direction
Changes with lying/sitting (venous hum disappears on lying down with legs elevated)
Changes with respiration and valsalva manoeuvre (dynamic auscultation)
It is important to remember that innocent murmurs are common in children. They are symptom free, systolic, short, soft murmurs, heard over a small area and vary with position (sitting/ standing). They have musical character or are vibratory. The S2 is normally split.
- Washes hands or uses alcohol rub
- Explains what he/ she is going to do and ask for permission to examine
- Positions and exposes the child appropriately
- Warms the diaphragm of the stethoscope if it is cold
- Auscultates the apex with the bell of the stethoscope gently
- Listens at the apex with the diaphragm of the stethoscope.
- Palpates the right carotid or brachial artery while auscultating the apex
- Auscultates the axilla for radiation
- Rolls the child onto the left lateral position and listens in full expiration with the bell
- Listens to the tricuspid, pulmonary and aortic area
- Listens over the suprasternal notch and carotids
- Listens at the back
- Makes sure that the child is not left exposed
- Thanks the child / parent for co operation
- Describes the heart sounds and murmur
Percussion has a limited role in cardiovascular examination but may alert you to reasons why the apex may be shifted such as pleural effusion.
May help with liver/spleen site/size, especially if there is over-inflation of lungs cause of apparent organ enlargement
Limited role in assessment of cardiac size
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text:
15 is a better age of sexual consent than 18
|Voting Style:
|Point System:
|7 Point
|5 years ago
|Post Voting Period
|3,367 times
|Debate No:
Round 1 - Acceptance, definitions
Rounds 2, 3 - Introduce and counter arguments
Round 4 - No new arguments, conclusions
PRO will argue that the age of consent should be 15
CON will argue that the age of consent should be 18
For this debate I have chosen CON.
No semantics. This debate encompasses whether - as a matter of law, morals, practicality, or any other reasonable and relevant reason - it makes more sense for the age of sexual consent to be 15, or 18 in the USA. If you wish to clarify or add any definitions please do so in round 1.
PLEASE - Only accept if you plan to actually follow through with all 4 rounds, I've not actually been able to engage in a real debate yet because of flaky opponents.
Guidelines for the Policy
The Proposed Policy
All males and female that have had their fifteenth birthday shall be able to legally have sex with all adults. However, impregnation of a girl who has not yet finished her higher education (18 in USA) should not feel the need to get pregnant and if she is impregnated by someone over 18, this is a huge social issue and shall be dealt with in the following manner:
Incest, rape and blackmailed sex shall be dealt with as laws apply, apart from that the age of consent is now 15, any part of the laws and policies stating '18' shall be replaced with '15'. Any 15+ year old male that engages with sex with a female under 15 and is caught can, and will, be prosecuted as an adult for pedophilic rape, since sexually he will now be considered an adult.
That is all for the policy.
Age of sexual consent: the minimum age at which a person is considered to be legally competent to consent to sexual acts.[3]
Sexual: relating to the instincts, physiological processes, and activities connected with physical attraction or intimate physical contact between individuals.[4]
[1] http://www.teengrowth.com...
[2] http://puberty101.com...
[3] http://en.wikipedia.org...
[4] http://oxforddictionaries.com...
I would like to thank my opponent for accepting this debate!
My opponent appears to start in round one (acceptance and definitions,) by asserting his position as a definition in the form of a proposed policy (Policy) and guidelines for that policy (Guidelines). Therefore, as a matter of definition, I of course must reject his Proposal and the Guidelines therein. I do however accept the definitions he contributes for "Age of sexual consent" and "sexual".
It's unclear whether my opponent meant to submit his Proposal and Guidelines as the full position he wishes to defend. In an attempt to not disregard his efforts completely, and because many of the clauses present in the Proposal are relevant to the debate, I will likely touch on many of the issues he has presented. However, since posted in Round 1 – reserved exclusively for acceptance and definitions – and thus rejected as a definition, it is up to my opponent to re-introduce any topics he feels are relevant that I may not formally introduce this round.
Point 1: Age of Majority
The age of majority is "the chronological moment when minors cease to legally be considered children and assume control over their persons, actions, and decisions, thereby terminating the legal control and legal responsibilities of their parents or guardian over and for them." [1] While this is not the same as age of consent, and perhaps often gets confused with age of consent, it is significant due to the ramifications (such as pregnancy!) that consensual sex can bring upon a minor that the parents of that minor would ultimately be responsible for. This is a primary reason why age of consent should in fact match up with the age of majority – which is almost universally 18, including in the USA. A parent should not be held responsible to provide financially for their daughter's pregnancy or child if they don't agree with it and had no part in it. But if the daughter is legally able to consent to sex as a matter of personal choice at an age younger than 18 then the parent has no right to restrict that particular choice, nor do they have a right over the girl's body to force an abortion, not even a right to force an adoption of the child. With the divergence between age of consent and age of majority the parents become responsible for a whole additional human being without any legal say in the matter.
Point 2: Prevent unwanted pregnancies
Pregnancy is the #1 reason girls drop out of school.[2] It's imperative that students finish high school, and an unwanted pregnancy contributes toward them quitting early and not receiving a diploma. With a lower age of consent it stands to reason that the frequency of teenage sexual encounters would increase, and as a direct result so would the frequency of teenage pregnancy.
Point #3: Maturity
Research suggests that the human brain does not fully develop until age 21-22 in females, and age 30 in males. [3] Furthermore, "Studies in both humans and other animals have suggested that the dopamine system peaks in activity during adolescenese. If this is true, the abundance of dopamine might lead to different considerations of short-term and long-term rewards and consequences" in teenagers. [4] Because of this it is possible that teenagers may not properly consider consequences when engaging in sexual activity, lending credence to a higher age of consent in order to protect them from sexual exploitation from adults.
In conclusion, I would like to briefly address a few points from my opponents Proposal should he choose to formally introduce these points in the debate during his next two rounds:
• It is illogical to create a divergent legal system wherein sex between an adult and a 15 year old is legal, however an adult impregnating a 15 year old is not. Pregnancy is an unpredictable effect of sex and is likely under more control of the younger party (typically being female) due to birth control options available as well as personal knowledge of their menstrual/fertility cycle.
• It is unreasonable to state that when the elder male party is over 18 that he would be financially responsible for the child or for the abortion at the family descrition, the that if the elder male was under 18 then abortion would be mandatory. In fact, stating at all that abortion would be mandatory is completely unreasonable, or at very least a topic for another debate all in itself.
• If the law is concerning "safe sex" only then a detailed definition would
need apply, and it is up to my opponent to prove that such safe sex is reliable and could be verified in a court of law. Also it should be noted that birth control is against some religions and therefore could not be considered a mandatory pre-requisite under the law.
[1] - http://en.wikipedia.org...
[2] - http://www.aclu-wa.org...
[3] - http://www.education.com...
[4] - http://www.abqtrib.com...
I am not impressed with the response. The point #2 is contradictive of my policy. My policy made it so that pregnancy till high school is over shouldn't be legal. So... It's not a real point to raise.
I shall now rebut my opponent and reinforce my proposed policy plan.
That age of majority concept is firstly irrelevant and secondly isn't a well established fact since maturity is, somewhat, subjective as much as it is objective so cannot be used as the full backing for an entire contradiction to the age of consent being 15. The fact of human life is that at 13, most boys begin puberty[1] and at 10, most girls[1]. Thus, by 15 the body is pretty much ready to have sex especially for females but socially they would be unready to be pregnant for school purposes so that's just an illogical argument for con.
The fact I think I simply want to state (which counters almost all points raised by con) is that it is possible to have an age of consent for sex that is different to the age when one becomes an 'adult'. the reason is that sex is merely a pleasurable experience that can be very safe and enjoyable for both parties (or more parties, but let's not get sidetracked). An adult is, I would say, a human that has reached a stage f maturity whereby they are fully capable of being independent and responsible in society. However, despite a 15 year old having not quite reached this stage of maturity, they are entering the world of 'higher education' where, in most countries, external examinations occur for the individual. They already begin building the reputation, via school reports and commendations, for their future success in university and the working world. They clearly have a reasonable level to decide and use their bodies in a sensible manner (hence most universities analysing students' success form this age onwards). However, they are not fully finished on their journey into adulthood but have reached what I would call an 'intermediate stage of maturity' whereby they are mature enough to consent to sex but not mature enough to independently make decisions in all sectors of life.
Yes, this is safe sex, I don't understand how you can think a 15 year old should have unsafe sex... I didn't quite understand that argument you put at the end.
[1] http://kidshealth.org...
Point #1: Age of Majority – Carried from R2
Despite the connection evident in my R2 argument connecting Age of Majority as being a practical consideration regarding the most appropriate Age of Consent, my opponent has labeled the Age of Majority as irrelevant without providing any suggestions or rationale whatsoever as to why he refutes the case I have clearly laid out in R2. Instead he says that age of majority is not a well-established fact, which makes little sense. The Age of Majority in the USA is, factually, 18 at a minimum[1]. While I agree that maturity is somewhat subjective that is not my point, and this debate is not about changing the Age of Majority – I simply am pointing out that the Age of Majority is one legitimate reason why 18 is a more suitable Age of Consent than 15. This is not based on physical maturity, nor social appropriateness of pregnancy in high school as my opponent seems to suggest. It simply is a practical matter that delineation of responsibility is best handed off in full at 18, and the lines should not be blurred before then by a 15 year old being able to make legal choices which may result in pregnancy. Therefore my R2 Point #1 regarding Age of Majority still stands.
Point #2: Prevent Unwanted Pregnancies – Carried from R2
My opponent seems to think that pregnancy can be separated from sex and independently made illegal, and this is not so. If he believes it to be so then the burden of proof is on him and I will address his argument in my conclusions in R4. I clearly and pre-emptively stated in the first point of my R2 conclusion that it is illogical to separate sex and pregnancy into two divergent legal matters. Pregnancy is not a choice by either party – it happens largely based on chance. The factors that contribute toward pregnancy having a much higher chance of occurrence – ie, knowledge of fertility cycle, knowledge of and proper administration of birth control - are all within the control of the [typically younger] female partner. It does not make sense that an older male would NOT face any punishment for having sex with a 15 year old female, but he WOULD face financial and criminal punishment if - by sheer chance and a degree of control on the part of the younger female - she DID get pregnant! That's simply nonsense. If two parties willingly consent to sexual relations there is ALWAYS a chance of pregnancy, that chance cannot be separated from the original consent to engage in sex. The fact that a 15 year old has a fully sexually developed physical body does not mean they have control over pregnancy, and at 15 we both recognize that pregnancy is not beneficial. The only way to reduce the occurrence is to reduce the occurrence of the sex that leads to it, and a 3 year higher age of consent would logically restrict the occurrence of sex and thus the occurrence of pregnancy. My R2 Point #2 regarding the reduction of teenage pregnancies still stands.
Point #3: Maturity – Accepted
I did not see any arguments by my opponent refuting the age of full development for the human brain and the suggestion that due to a non-fully developed brain teenagers may not properly consider consequences of sexual activity. Therefore I will assume for now that this point has been accepted by my opponent.
R3 Final Thoughts
Finally, my opponent has misunderstood me regarding safe sex, somehow drawing an absurd conclusion that I've suggested unsafe sex should be practiced. I never stated that I think a 15 year old should have unsafe sex. This is in fact against my entire argument that a 15 year old should have NO sex. I simply said that it was up to my opponent to define "safe sex" as pertinent to his proposal, should he wish to officially introduce any element of that proposal as an argument, which he has failed to do. Since he has not introduced this argument there is nothing for me to refute here! I simply made a helpful suggestion that should he choose to introduce the argument he should save his time unless he can provide a legally compelling rationale that accounts for religious rejection of birth control, as it is an obvious problem to his idea of separating safe-sex from unsafe-sex let alone separating sex from pregnancy!
[1] - http://contests.about.com...
My debate essentially can be broken down into two questions to be answered by con:
If someone is physically mature to have sex and enjoy it safely, without getting pregnant or retaining STD's, why should we ban them from this?
If, at age 15, people can enjoy a sexual relationship, or just sex itself, but would be devastated to be pregnant and if contraception and sex education are pillars of our modern society why should we use the fact that they COULD get pregnant as reason to not allow it safely?
I will address Pro"s final two questions in reverse order, as the first is dependent on the second:
Because, at age 15, people would be devastated to be pregnant we should not allow them legal sexual relations for the following reasons:
Therefore, although someone is physically mature enough to have and perhaps enjoy sex, we should not immediately allow it because:
Pro has failed to contest Point #1 (logical demarcation of responsibility coinciding with Age of Majority), and Point #3 (Lack of maturity and brain development at age 15.) Additionally, Pro has provided a weak and erroneously presumptive argument for Point #2 (preventing unwanted pregnancies.) He has failed to formally submit any of his ideas erroneously introduced in R1, and has also failed to provide answers or even argument for important questions that have been raised throughout the debate. His entire stance is based upon an imaginary situation that is very far removed from reality, and he has failed to ground his reasoning in a realistic context. His citation is weak and lacks substance. His arguments have been sloppy and lack structure.
Vote Con! I have provided ample reason why 15 as the Age of Consent rather than 18 - 1) would result in an increase of unwanted teen pregnancies as a function of increased teen sex, 2) blurs the lines of responsibility between what a legal minor can choose to do and what their parents are ultimately legally responsible for, and 3) is not taking the psychological or educational well-being of the younger party into consideration. I have provided key citation where necessary, and I have responded to every point my opponent has raised. I have kept my arguments structured and able to be easily referenced and read. I thank my opponent for this debate, as well as all those who may read and/or vote on it in the future.
[1] http://womenshealth.gov...
I think I can see why we disagree.
You seem to think that an age of consent must include EVERY SINGLE THING that goes with what is being consented to. However, no law does this. The age of consent for alcohol, in most non-Muslim countries, is 18 (Muslim states tend to prefer the age of 21). Nonetheless it is true to say that anyone, especially those 18+, whom die of liver cancer, whom abuse their children and wife due to alcohol abuse and whom are unable to stop require legal intervention. This is the key flaw in the entire con's debate.
You basically have one contention only: That if we allow 15 year olds to engage in safe sex, with regulated frequency for a healthy life, we are therefore legalising pregnancy. However, in my policy I laid out a clear legal system by which this issue is avoided or dealt with appropriately. I took the very well-implemented and founded laws of the current American (a significantly regarded somewhat democratic) society and merely replaced any dealings with age of 18 with '15'. However, due to an overlap in age, for many educational and thus practical reason, I stated that there shall be an extra policy as follows; If the male is 15-17, abortion will be mandatory. The reasoning behind this is that we can't have underage pregnancy causing overpopulation. Since you didn't state if this age would be relevant to a less economically developed country, I was unsure of how much regulation would be required in terms of population overgrowth. Thus, this policy was made to be applicable to most states/countries in the world today.
In conclusion, the only rebuttal of my opponent the entire debate is irrelevant, safe sex is very necessary to prevent both STD spreading and underage pregnancy (there was not one piece of justified evidence in order to validate the point that the age of legal pregnancy must be equal to the age of sex, it is like stating that countries where the legal age of consent is under 18, for example it is 16 in the U.K., yet 18 remains the age for pornography are flawed laws, you would be arguing the laws of well-established democracies and this, you did not do). My points remain, as I shall now re-iterate, that at 15 the majority of humans are fully physically and mentally ready for a sexual relationship, however I accept that educationally they are not at the stage where having a child should be allowed to mess up their future prospects so severely as to reduce their efficiency at high school, thus safe sex should indeed be mandatory, I assumed this was self explanatory from my proposed policy but nonetheless I hope to have explained why this should be the case. I have also stated how the enjoyment of sex is a great form of pleasure, in moderation, and the only real way to teach the kids who are bound to be having strong urges to do it regardless of legality, is to introduce them into the activity itself in a 'safe zone' in which contraception is a MUST! (They can enjoy the riskier sides of sex, if they so wish, when they are legally considered fully grown adults, which in most countries is at 18).
Vote pro.
Have a nice day. And a nicer tomorrow.
|Agreed with before the debate:
|0 points
|Agreed with after the debate:
|0 points
|Who had better conduct:
|1 point
|Had better spelling and grammar:
|1 point
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|3 points
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|2 points
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subset: commoncrawl


text:
What's Your Selfie Technique?
Oh, don't pretend like you don't have one!
I feel like every corner I turn on the Internet, Old Gregg is there.
For example, recently on Reddit a user shared a picture of two bay leaves and a cup of coffee — which the waiter brought instead of Baileys and coffee — and a top comment was, "You ever drunk bay leaves out of a shoe?" followed by quote after quote from the Mighty Boosh skit. And when people were posting three fictional characters that best described themselves, a viral meme circulated in which all three of someone's characters were Old Gregg.
Even you all brought up Old Gregg when I did a post on fishy face masks over the summer, which is when I first considered doing an Old Gregg costume tutorial here on xoVain.
And here we are.
For those unacquainted, Old Gregg is a big scaly man-fish who drinks Baileys out of a shoe and invites strangers to clubs where people wee on each other. He's kind of needy and desperate for love, but aren't we all, really?
If you haven't watched the skit, you absolutely have to. The first time you do, you'll be confused and perhaps frightened, but it gets better with every viewing, so play it again.
The Tutorial
So really, the Old Gregg look isn't terribly difficult to recreate. You need some costume makeup and then all the essential outfit pieces. Here's a shopping list:
The green looks very Kermit in this super-bright room, but in darker spaces it reads more forest green. I was worried that the paint would stain my skin green, but it all came off with face wash in the shower.
The Medusa wig was really long, so I gave it a haircut so it was more in line with Old Gregg's shoulder-length 'do.
After finishing hair and makeup, I put on the rest of my outfit and it all came together.
I just want you to know that I walked around my house and danced for a little bit while wearing this costume. My cats were surprisingly unaffected, but I frightened myself every time I looked in the mirror, so there's that.


text:
Phone: 843-664-8448
Degrees and Certifications:
Mrs. Angelica Rainwater
My name is Angelica Rainwater I am new to Delmae Elementary. I graduated from Francis Marion University with a Bachelor's of Science Degree in Early Childhood Education. This is my first year teaching 1st Grade Language Immersion. I enjoy swimming and bike riding in my free time.


text:
Oh yes it's that time again where national teams come together in a tune before next month's world cup qualifying.
Bias pick alert
Portugal -1 and -1.5 -120 vs Finland (Portugal -1.5 +107 at thegreek for example is ok too knock on wood)
The last time I was picking a friendly matchup, the over between Portugal and Brazilian nicely cashed. Where as recent flame outs between Portugal-Sweden, Portugal-Albania (for fuck's sakes how do they draw 0-0 with Albania) Portugal-Denmark and even Portugal-Germany back in Euro 2008 I've avoided (I believe so, not 100% to lazy too look it up but I usually have a good memory on such things.)
You know why I think Portugal will win? (hopefully by two or more) Because it's a frigging friendly. Since this game is not do or die in any way shape or form the Portuguese players are able to just play freely. Aside from their goalie there isn't a player on the Finnish team who can play for Portugal. Plus Finland (like Portugal) have a relatively new head coach. It's not like these Finnish players will know inside out how the coach wants each player to play within his sytem which should help Portugal break them down at some point during the game.
Come next month when World Cup Qualifiers come around I'm off Portugal again as they will tense up as a 16 year virgin (not that I have any recent experience with the latter)
Game goes off at 4pm EST I believe. Justin.tv should have a stream.
115-101-24 +9.58


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Hill End & Tambaroora Gathering Group
Are you looking for ancestors?
Check out our resources
Here you will find "how-to" guides and general information about Hill End & Tambaroora.
Check our databases
Here is where you will find many records of people from the district. Are your relatives listed?
We are excited to announce our October Long Weekend Market being held on Saturday, 29 September 2018.
Date for the diary: Saturday 20 October – Taste the Past Picnic Lunch. Planning is under way and more details coming soon.
Check out our photos from the 2018 March Gathering.
NEW – Check out the album from our cemetery project.
About HEATGG
The Hill End and Tambaroora Gathering Group is a group of like-minded people who share an interest in the descendants of families of Hill End and Tambaroora in central western NSW. Early in the 1930s a group of women and children started to meet regularly in the Royal Botanic Gardens in Sydney. These were the families of ex residents of the Hill End and Tambaroora goldfields. Since leaving the goldfields they had been missing the closeness and companionship of village life and these meetings went some way towards restoring the support networks that had formerly existed. Read more…
Hill End & Tambaroora were important gold mining towns in the Central West of New South Wales, closely associated with the Turon and Macquarie Rivers. In its heyday in the 1870s the district had a population of over 7000 people. Prior to the Australian goldrush, which commenced in May 1851, the Hill End district had been a sheep and cattle run, leased by William Cummings of Peel. Only weeks after the rush to Ophir, hardy prospectors battled their way up the precipitous Oakey Creek onto flat and open country and were finding good gold where Hill End is today. A village had been born. Read more…


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The 27th CAP-CSA Joint meeting and the UNWTO Regional Ministerial Conference
3 June 2015 - 5 June 2015
Bandos Island Resort
The 27th Joint Meeting of the UNWTO Commission for East Asia and Pacific (CAP) and the UNWTO Commission for South Asia (CSA) & UNWTO Regional Ministerial Conference on Positioning Tourism in a Wider Socio-economic Context will be held in Bandos Island Resort, Maldives from 3 to 5 June 2015 under the garcious support of UnionPay International.
27th CAP-CSA Joint Commission Meeting
The 27th CAP-CSA Joint Commission Meeting is UNWTO´s principal annual event in the Asia Pacific Region, attended last year by around 60 representatives from UNWTO Member States, 7 UNWTO Affiliate Members and numerous international and regional organizations including Japan Association of Travel Agents (JATA), Korea Tourism Organisation (KTO) and USAID.
Key topics this year will include:
- UNWTO´s Programme of Work for the Region
- Asia's use of TripAdvisor as a source of consumers' data
- Other statutory issues related to the UNWTO Asia-Pacific Member States
Please find below the documents related to this meeting.
UNWTO Regional Ministerial Conference
This year the Joint Commission Meeting will take place in conjunction with the UNWTO Regional Ministerial Conference on Positioning Tourism in a Wider Socio-economic Context which is being organised with two main objectives:
- to take stock of the extent to which UNWTO's Open Letter initiative has achieved its main objective of advocating that countries duly recognise the socio-economic contribution of tourism to their national economies;
- and to examine national policies that will engender strategies to ensure that the projected growth in tourism demand will translate into socio-economic benefits for non-tourism sectors of Asia-Pacific economies.
The Ministers of Tourism from across the Asia Pacific region will also discuss and debate the next steps in strengthening government awareness and support to enable advancement of the tourism sector.
Ultimately, through open sharing of national and regional insights, experience and expertise, the Ministerial Dialogue will uncover and unlock valuable individual and cooperative solutions to assist tourism leaders in moving their sector, and national agendas forward.
The preliminary programme for the Regional Ministerial Conference can be found below in 'General Document' section.
General Documents
Programme for Regional Ministerial Conference & 27th Joint Commission Meeting
Joint Commission Meeting
4. Report of the Secretary-General
5.1 Implementation of the General Programme of Work for 2014-2015: Global Activities
5.2. Regional Activities
- Presentation by the Regional Programme for Asia and the Pacific
- Activities of the UNWTO Regional Support Office for Asia and the Pacific
- Updates on Tourism Satellite Account development in Asia (by Japan)
(click here for the detailed information in text)
6.1 Committee for Tourism and Sustainability
6.2 Committee on Tourism and Competitiveness
6.3 Committee on Statistics and Tourism Satellite Account
6.4 Committee on Programme and Budget Committee
7. Report on the Survey on the Priority Areas of the Programme of Work for 2016-2017
8. Nomination of the host country for World Tourism Day 2016
9. Preparations for the twenty-first session of the UNWTO General Assembly
11. Place and date of the 28th joint meeting of the two commissions
Consultation Meeting for World Bank and UNWTO
Programme for Consultation Meeting for World Bank and UNWTO
Presentation Files for the 27th Joint Commission Meeting
4. Report of the Secretary-General
5.1. Global Activities
- Technical Cooperation and Services (by Mr Zhu Shanzhong)
- 10 YFP Sustainable Tourism Programme (by Ms Hyeri Han)
5.2. Regional Acticities
- Presentation by the Regional Programme for Asia and the Pacific (by Mr Xu Jing)
- Activities of the UNWTO Regional Support Office for Asia and the Pacific (by Mr Shintaro Hori)
- Asia's use of TripAdvisor as a source of consumers' data (by Ms Sarah Mathews)
- Updates on Tourism Satellite Account development in Asia (by Prof. Kozo Miyagawa)
- (Click here for the full report)
- Presentation by the World Bank on a tourism competitiveness project for South Asia (by Ms Stefania Abakerli)
6. Report on Technical Committees
27th Joint Meeting of the UNWTO Commission for East Asia and the Pacific and the UNWTO Commission for South Asia
For further information, please contact the following persons:
UNWTO Coordinator
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Senior Programme Assistant
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an area of canvas or other fabric extended to the wind in such a way as to transmit the force of the wind to an assemblage of spars and rigging mounted firmly on a hull, raft, iceboat, etc
, so as to drive it along
some similar piece or apparatus, as the part of an arm that catches the wind on a windmill
a voyage or excursion, especially in a sailing vessel:They went for a sail around the island
a sailing vessel or ship
sailing vessels collectively:The fleet numbered sail
sails for a vessel or vessels collectively
(initial capital letter) Astronomy
the constellation Vela
As verb (used without object)
to move along or travel over water:steamships sailing to Lisbon
to manage a sailboat, especially for sport
to begin a journey by water:We are sailing at dawn
to move along in a manner suggestive of a sailing vessel:caravans sailing along
to move along in a stately, effortless way:to sail into a room
As verb (used with object)
to sail upon, over, or through:to sail the seven seas
to navigate (a vessel)
As Verb phrases
sail in/into, Informal
to go vigorously into action; begin to act; attack
to attack verbally: He would sail into his staff when work was going badly
As Idioms
in sail, with the sails set
make sail, Nautical
to set the sail or sails of a boat or increase the amount of sail already set
to set out on a voyage: Make sail for the Leeward Islands
set sail, to start a sea voyage:We set sail at midnight for Nantucket
trim one's sails, Informal
to cut expenses; economize:We're going to have to trim our sails if we stay in business
under sail, with sails set; in motion; sailing:It was good to be under sail in the brisk wind and under the warm sun
As noun, plural canopies
a covering, usually of fabric, supported on poles or suspended above a bed, throne, exalted personage, or sacred object
an overhanging projection or covering, as a long canvas awning stretching from the doorway of a building to a curb
an ornamental, rooflike projection or covering
Also called crown canopy, crown cover
the cover formed by the leafy upper branches of the trees in a forest
the sky
the part of a parachute that opens up and fills with air, usually made of nylon or silk
the transparent cover over the cockpit of an airplane
As verb (used with object), canopied, canopying
to cover with or as with a canopy:Branches canopied the road
As preposition
with the object or purpose of:to run for exercise
intended to belong to, or be used in connection with: equipment for the army;a closet for dishes
suiting the purposes or needs of:medicine for the aged
in order to obtain, gain, or acquire: a suit for alimony;to work for wages
(used to express a wish, as of something to be experienced or obtained):O, for a cold drink!
sensitive or responsive to:an eye for beauty
desirous of: a longing for something;a taste for fancy clothes
in consideration or payment of; in return for: three for a dollar;to be thanked for one's efforts
appropriate or adapted to: a subject for speculation;clothes for winter
with regard or respect to: pressed for time;too warm for April
during the continuance of:for a long time
in favor of; on the side of:to be for honest government
in place of; instead of:a substitute for butter
in the interest of; on behalf of:to act for a client
in exchange for; as an offset to: blow for blow;money for goods
in punishment of:payment for the crime
in honor of:to give a dinner for a person
with the purpose of reaching:to start for London
contributive to:for the advantage of everybody
in order to save:to flee for one's life
in order to become:to train recruits for soldiers
in assignment or attribution to: an appointment for the afternoon;That's for you to decide
such as to allow of or to require:too many for separate mention
such as results in:his reason for going
as affecting the interests or circumstances of:bad for one's health
in proportion or with reference to:He is tall for his age
in the character of; as being:to know a thing for a fact
by reason of; because of: to shout for joy;a city famed for its beauty
in spite of:He's a decent guy for all that
to the extent or amount of:to walk for a mile
(used to introduce a subject in an infinitive phrase):It's time for me to go
(used to indicate the number of successes out of a specified number of attempts):The batter was for in the game
As conjunction
seeing that; since
As Idioms
for it, British
in (def )
As noun, plural patios
an area, usually paved, adjoining a house and used as an area for outdoor lounging, dining, etc
a courtyard, especially of a house, enclosed by low buildings or walls
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text:
"Myrtlebell!" stammered Rose. "No, you can't mean... It can't be. I mean Fuzz just wouldn't... He knows how I feel about...well, I mean...he knows what she..."
"Rose," said Razzmorten with quiet firmness, as he gave her a steely eyed look from beneath his hoary brows. "I think it would be best to see Edward off to bed. He's been through a great lot these past few days and he truly needs your kind support. I believe we have quite enough information to begin a search for his mother and Fuzz, don't you?"
Rose gave a blank look before suddenly seeing how it all was. Just before she had grasped exactly how horrible she should feel, Edward tugged at her skirts with wide eyes.
"I didn't know you knew my momma. Why don't you like her, Rose? Momma is the bestest person in the whole world."
"I didn't know you knew my momma. Why don't you like her, Rose? Momma is the bestest person in the whole world."
Razzmorten saw the frantically helpless expression on Rose's face. Satisfied that she appreciated the hole she had just dug herself, he came to her rescue. "Edward," he said as he knelt down to look him in the eye, "you may not realize it, but there are many women in the world named Myrtlebell. I don't think the Myrtlebell Rose knows is your momma or you know she would like her."
Edward knitted his brow as he considered, then he looked up at Rose.
"That's right, Edward," she said, brightened with relief. "Why, the Myrtlebell I knew could never have a child as bright and sweet as you." She knelt before him. "I'm sorry I upset you. Your mother couldn't be the Myrtlebell I knew."
Edward nodded wisely. "I wonder how somebody named Momma's name could be bad," he said, giving Rose a forgiving smile, "but somebody called Angel could be mean and awful." Then with a huge yawn, he lunged for her with a hug. "I'm really, really tired now."
"Right," said Rose, as she turned to Spark and Lipperella, who had been keenly watching everything as they dropped endless chunks of sukere down dragonet gullets. "Is there some place where Edward could sleep?"
Lipperella nodded and surprised Razzmorten by handing him her dish of sukere as she passed. "Gweltaz, could you do this for me?" he said. "I think it's urgent that I speak with the diatrymas. Kast, you say they refuse to come inside...?"
"They never do. They won't."
"You know about them. You spoke with them, would you take me up there right now and introduce me to them?"
Kast was on his feet immediately, heading for a cramped passage, scarcely larger than the dragon himself, hurrying along so quickly that Razzmorten nearly had to jog to keep up. Presently they came to a spiral stair, carved out of the limestone of the cavern, that led directly overhead to where the diatrymas had bedded down, side by side in the leaves beneath the leaning oaks. At their approach, the diatrymas raised their heads high in unison, but remained resting on their keel bones.
Meanwhile, Lipperella lead Rose and Edward to a small passage opening into a grotto with several pallets. "Guest quarters for our human friends," she said as she neatly lit a candle with a wee spurt of blue flame from between her lips, revealing the attractive suite.
"My!" said Rose in astonishment that at once made her feel awkward.
"I'll just leave you to tuck him in, then," said Lipperella graciously, as she turned to go back.
"Thank you," called out Rose belatedly.
Edward wasted no time sliding into the most inviting strange bed he had ever seen. Rose found a basin and full pitcher and washed his face and hands. He gave Rose one last smile. He needed another hug. Rose was simply too much like Myrtlebell not to be his chosen nanny. He began to
snore softly even before Rose pulled the coverlet over him. She smiled at him in wonder then silently left his side, returning to the nursery to find the company waiting for Razzmorten to return from his visit to the diatrymas.
snore softly even before Rose pulled the coverlet over him. She smiled at him in wonder then silently left his side, returning to the nursery to find the company waiting for Razzmorten to return from his visit to the diatrymas.
After some time they returned. Razzmorten sat down at once, rubbing the bridge of his nose.
"What did you find, Grandfather?" said Lukus.
"Stunning...absolutely stunning creatures, that's what."
"Comes with the feathers, Wiz," said Hubba Hubba, looking up suddenly from a serious preen.
"They could well be the most intelligent beings I've ever addressed. I truly believe they were making sure that I had all the information I needed to come to a decision, but they were exhausted from their long run, and once they saw that I had what I needed, they politely persuaded me to leave so they could sleep. They also plan on helping us."
"In my dealings with them, I've not known them to forget even the very most minor detail of anything," said Kast. "I daresay you'll be right thankful for their aid."
"They are almost certainly the adar taranus which Razzorbauch released from the rocks when he created the fudge volcano," said Razmorten. "If they be, then they are the ones he is said to have regretted turning loose."
"Certainly," said Lipperella. "As Truth-Bearer, I've had several occasions when I sought them out in secret. Razzorbauch was never comfortable with the truth. Unfortunately they keep to themselves, so that over the years I've seldom seen them."
Ch. 10, Stone Heart
Carol Marrs Phipps & Tom Phipps


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Ward Geene is Editor-in-Chief IGN Benelux for Media Lizard
"During my Bachelor Theatre Film and Television Studies my focus was on computer games and new media. I was looking for a Master that dealt with these subjects, but had more depth: New Media & Digital Culture.
At the time I started with my Master's I was already working in the games industry, writing news for Power Unlimited, one of the biggest game websites. I did an internship there during my Bachelor's and ended up with a small job. I wanted to pursue this career, but knew it was hard to get a fulltime paying job in this industry.
During my Master's I started my own company in new media concepting, but it transformed very fast into a production company for film and festivals. I wanted to quit my small job at Power Unlimited, so I could focus on my own company, but instead of agreeing to let me go Power Unlimited offered me a fulltime job! So I made the difficult choice of leaving my own successful company to pursue my teenage dream.
At Power Unlimited I started as the social media guy, but it didn't take long before I was writing for the magazine and website, went on international trips to test games and became the project manager for the restyle of the website. I became responsible for the digital strategies of the online activities. After two years at Power Unlimited I was running the all-digital, thanks to my knowledge of new media in theory, but also in practice.
After the publisher went bankrupt I moved to Media Lizard, a digital only publisher. Here I became project manager, but soon enrolled in the job of editor-in-chief of IGN Benelux, the Dutch division of the biggest game website in the world. I manage a team of 20 freelancers/volunteers. I have to decide on digital strategies, communicate with game publishers but I also still do a lot of writing for the website.
My deeper understanding of new media gives me an edge and an advantage to a lot of my competition in the field and I believe it has put me in the spot I am right now."
Lindsy Szilvasi works as a Legal Assistant in Trademarks at Google
"I chose New Media & Digital Culture because of the interdisciplinary research trajectory. This Master's programme provided me with the right balance between fascinating courses on contemporary media technology developments, challenging discussions on cultural and political impacts and conducting my own research while interning for an Internet freedom organisation.
I have always been very interested in Internet Freedom and internet policymaking. As a Legal Assistant in Trademarks for Google my job is to process trademark complaints and communicate with trademark owners and advertisers regarding Google's procedures. In addition, I assist with the creation of documentation for existing and new policies and procedures. And finally, I work on special projects, including my own project focusing on workflow and communication improvement, and user education.
The most important skill I have acquired during New Media & Digital Culture is critical thinking. This skill is useful in my professional life as it pushes you to ask yourself urgent questions on how the Internet incorporates the boundaries of social, cultural, and political reflection. I also acquired research skills that help me in my position as Legal Assistant, and the interdisciplinarity of the programme has made me enthusiastic to combine diverse interests and skills to create unique projects.
I feel there are still many things to learn. Curiosity is fuel for creativity, originality and improvement. My job provides me with tools and time to develop my career but also to focus on my personal development. Every day I learn, and get closer towards my ambition to become an Internet policy professional."


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|Manatee County Government Administrative Center Commission Chambers, First Floor 9:00 a.m. - October 10, 2017
Agenda Item #40
Warranty Deed from The V. Raymond Hullinger Family Limited Partnership for property located in Myakka City, Florida; PID 155800006
Contact and/or Presenter Information
Joy Leggett-Murphy, Property Acquisition Division Manager, Property Management Department, Extension 3439
Charles Meador, Real Property Specialist, Property Acquisition Division, Property Management Department, Extension 6289
Action Requested
Enabling/Regulating Authority
Chapters 125 and 127, Florida Statutes. Manatee County Comprehensive Plan Goal 3.3 addresses protection, enhancement, and maintenance of natural land and water resources.
Background Discussion
County Attorney Review
Formal Written Review (Opinion memo must be attached)
Explanation of Other
Reviewing Attorney
Instructions to Board Records
Please record in Board Records only. Please return the original Warranty Deed and Seller's Affidavit of General Partnership, Ownership and Encumbrances to Charles Meador at 1112 Manatee Ave West, Suite 800, Bradenton, Florida 34205
Cost and Funds Source Account Number and Name
Amount and Frequency of Recurring Costs
Attachment: Warranty Deed.pdf
Attachment: Affidavit of General Partnership O&E.pdf
Attachment: Response Memo to CAO Matter No. 2017-0319.pdf
Attachment: Location Map.pdf


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Getty Images
No one does the bachelor life quite like the newly single Flip or Flop star Tarek El Moussa.
The father-of-two has been living rather largely since he split from his wife of seven years, Christina El Moussa — with whom he shares a daughter, Taylor, and a son, Brayden.
EXCLUSIVE: Christina El Moussa's Boyfriend's Dark Past Revealed — See the Court Docs
Tarek is currently renting a home in Newport Beach, CA — that he recently showed off to E! News with a video tour. While the place is amazing, fans seriously can't get over how much he is paying for it, which is detailed in the video below.
Some can't help but wonder if he is trying to show his bombshell ex what she's missing, considering he is not thrilled that she is now dating a man from her past named Doug Spedding.
"Tarek has always had a sense of jealousy over her prior relationship with this person," a source previously told [Entertainment Tonight](http://www.etonline.com/news/219162exclusivechristinaelmoussadatingbusinessmantarekactingoutsourcesays/)_.
MORE: Christina El Moussa Stuns in Sexy Bikini Pics — See Them Here
Before Doug, Christina was linked to contractor Gary Anderson and NHL star Nate Thompson.
Watch the video to find out how much Tarek pays for his new place!
More from In Touch
EXCLUSIVE: Christina El Moussa Is Looking to Continue Her TV Career — Without Tarek!
Christina and Tarek El Moussa Pretend Not to Hate Each Other, Walk the Red Carpet Together
EXCLUSIVE: Christina El Moussa's New Boyfriend Is Dating Two Women at Once!


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CNET Prizefight
Speed Test: Kindle vs. Kindle 2Brian Tong and Tom Merritt use three different speed tests to see which Kindle is actually faster. The result might surprise you.
[ Music ] ^M00:00:06 >> Brian Tong: What's up Prizefight fans? I am joined by Mr. Tom Merritt. What's up? It's a little different here today - >> Tom Merritt: Yep. White guy. >> Brian: We're going to do speed tests with the Amazon Kindle first gen versus the new, sexy Kindle 2. Now this is not going to be totally scientific; it's kind of informal, as if we're sitting next to each other, because we are, literally, but we really want to test a few things. We want to test age refresh speed, we want to test how fast they wake up from their sleep mode, and finally we're going to test how long it takes to download the same book. So, I figure we should just jump right into this thing to get it started? >> Tom: Yeah, I mean it's kind of all about style with these two, so find out, is it just style or is there something better in the new one? >> Brian: Ok, so the first test we're going to do is page refresh speed; we're on the same page, are you ready to do this? >> Tom: Ready to go. >> Brian: So are you ready? >> Tom: I'm ready. >> Brian: Ok, let's do this. On "Go". >> Alright. >> Brian and Tom, in unison: One, two, three, go. >> Tom: Close. Let's do another one. >> Brian: It was about the same, let's do a few more. >> Brian and Tom, in unison: One, two, three, go. >> Brian: There you go again. >> Tom: Yeah, it's pretty dead on. >> Brian: And let's try it one more time. >> Brian and Tom, in unison: One, two, three, go. >> Brian: Wow, ok. >> Tom: Not much difference there. >> Brian: No. >> Tom: Those are pretty dead on. >> Brian: I don't think anyone would be able to notice is. >> Tom: Yeah. Any difference is probably caused by us just being a little fraction of a second off. >> Brian: You were a little behind. >> Tom: Plus it's easier to hit the next page on that because you can't not hit the next page on that one. >> Brian: Yeah, you just tap it a little and it'll change. Ok, the next test we're going to do is waking these Kindles up from sleep. We're going to first put them to sleep and then see how fast they actually wake up. So are you ready for this one? >> Tom: Let's put them to sleep. >> Brian: They're a little different. >> Tom: Yeah >> Brian: I have to press two keys to get mine to sleep; you just have to flip a switch. >> Tom: Yeah, there's this switch up at the top; it's also the power switch on this one. >> Brian: Ok, let's try this one, ok? >> Brian and Tom, in unison: One, two, three, go. >> Tom: Faster. >> Brian: Ok, yours was definitely faster. >> Tom: Faster wake up. >> Brian: Let's just try one more time. >> Tom: Yeah, let's put it to sleep again. And that's harder, too, because you've got to press the double buttons. >> Brian: Ok, here we go, ready? >> Brian and Tom, in unison: One, two, three, go. >> Tom: Definitely faster on the wake up. >> Brian: Ok, so, clearly, that one was like twice as fast as that one. >> Tom: Yeah, there was a difference there. >> Brian: So waking up from sleep mode, we're going to give the edge to Kindle 2. >> Tom: Now, for the next one, we're going to buy a book, but I need to swap it out, because both these are mine. That'd be kind of weird - so we've got to have two different accounts. This one's Molly Wood's. >> Brian: What we're going to do is find the same book on both Kindles. We're going to bring in our stopwatch to help us time which Kindle will actually download the book faster. Ok, so we happened to stumble across a book called Boiling Point from Tom Merritt. >> Tom: What? What a fortunate stumble. >> Brian: Yeah, for both of us. So we're going to click to buy on go, right? >> Tom: Yep. >> Brian: Ok, let's do this. >> Brian and Tom, in unison: One, two, three, go. >> Brian: Ok, it's thinking. >> Tom: Oh, it's thanking Molly for her purchase. >> Brian: It's thanking me for a purchase and it's going to actually tell us when the product's actually downloaded; we'll see kind of a cue on both of these. So we're just going to wait to see whose finishes first . . . >> Brian: Is this a long book? >> Tom: It's a couple [inaudible] pages. >> Brian: Mine's finished! >> Tom: You are done. I'm still going. >> Brian: Still going? >> Tom: Done! >> Brian: So we're all done, let's take a look at the stopwatches. I was surprised! >> Tom: Yeah. Which one's mine here? This one? Ok. >> Brian: So I came in at 24:47. >> Tom: 28:67. So pretty much 29 seconds - not that far behind, but you'd think this one would be faster. >> Brian: You would think. This is just one test; we're not going to buy 5 books here, but 4 seconds is not too much difference, but at least in this test, the original Kindle came out on top. >> Tom: Yeah, it could be due to a lot of things. It could be due to what server that one was connected to or the way this one was connecting from just a couple inches away, could be different, who knows. >> Brian: But ultimately, in this Prizefight, it's pretty much with three rounds a tie, because the first one they were even, the second round we gave the Kindle 2, and the third round, the edge was given to the Kindle. So you know, there you go. >> Tom: You know who wins? >> Brian: Who? >> Tom: The reader. >> Brian: [laughter] Stupid. Alright guys, thanks for watching. Come back for another Prizefight. Tom, you know how we end this one, right? >> Tom: Oh yeah. >> Tom and Brian, in unison: Woo-wow! [crashing noise] ^M00:04:10 [ Music ]


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The PEARL Link is your one-click connection to PEARL member companies. Connecting directly through the Link helps you buy or sell electrical equipment with PEARL member companies.
Copyright 2017. Professional Electrical Apparatus Reconditioning League


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Riders Domain offers a variety of motorcycle race suits from different brands, styles and levels of protection. When selecting a motorcycle race suit, many factors should be taken into account including the type of riding you plan to do as well as your physical features to ensure proper fit. A race suit is an investment and one that should be carefully researched for just the right amount of protection and function. Be sure to check out our Motorcycle Race Suit Reviews to find out what customers are saying about the product. If you need assistance choosing the right race suit for your riding style, feel free to call us for help at 1-800-721-8253 or email firstname.lastname@example.com with any questions. We're happy to help!


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A quick note on two important tales:
1) My great love of the cold, frozen north began with Patricia M. Scarry's Pierre Bear.
2) One of my very favorite New Yorker fiction podcasts: Louse Erdrich reads Lorrie Moore's short story "Dance in America." When I first heard it, I listened to it twice in a row. It is really very good. Listen here as soon as you can.
Both of these stories depict home and family life beautifully.
Wednesday, December 01, 2010
"I didn't want anything called Snickerdoodle in my house."
Posted by la_sale_bete at 8:39 PM
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