By H. Kirk. Bennington College. 2019.
The first edition of this book was published by the Marine Hospital Service effective kamagra effervescent 100mg erectile dysfunction medicine from dabur, forerunner of the United States Public Health Service discount 100 mg kamagra effervescent erectile dysfunction doctors austin texas, in 1881 discount kamagra effervescent online erectile dysfunction statistics race. The Marine Hospital Service was established by the Federal Government in 1798 to provide medical care to sick and disabled American merchant seamen. The first permanent Marine hospital was authorized on May 3, 1802 to be built in Boston. The Service was just a loosely knit group of hospitals for merchant seamen until 1870 when it was reorganized and the administration of the hospitals centralized in Washington, D. His title was changed to Supervising Surgeon General (later Surgeon General) in 1875. Under Woodworth, the Marine Hospital Service began its transformation into the disciplined and broad-based Public Health Service (the name it received in 1912) of the future. Even before the establishment of the Marine Hospital Service, Federal legislation had been enacted in 1790 which required every American flag vessel over 150 tons with a crew of ten or more to carry a medicine chest. Since merchant ships typically did not carry a physician, there was obviously a need to provide some kind of basic medical instruction for the seamen that went beyond the simple directions that frequently accompanied medicine chests. Although there was no Government-issued manual for this purpose for almost a century after the passage of the 1790 law, merchant seamen could consult works published by private physicians, such as Joseph Bonds’ The Master-Mariners Guide in the Management of His Ship’s Company, with Respect to Their Health, being Designed to Accompany a Ship’s Medicine Chest (Boston, 1847). Bond explained his reasons for preparing his book as follows: “My apology for the undertaking is, that in the medicine-chests for the use of the vessels belonging to our posts, I have never seen books of directions that are suitable. This little work is to supply the deficiency which must have been felt by every shipmaster, having no other guide in the management of disease than the small book of directions usually accompanying medicine chests. Hamilton explained the purpose of the handbook as follows: “This book is issued only to vessels subject to the payment of hospital dues, and is intended to be one to which the master or other officer in charge of a vessel iii may refer for information upon the occasion of an injury to any of the crew or the appearance of sickness among them, to aid in obtaining a knowledge of the act of preventing disease, to give the necessary information as to the means of obtaining hospital or dispensary relief, and to serve as a guide to the proper use of the medicine chest required by law to be kept on board. It began with a brief discussion of disease prevention, followed by a list of all of the medicines and supplies that should be in the ship’s medicine chest. The longest portion of the book was a discussion of various accidents and illnesses and how to treat them. Also included in the work was information on the ports where Marine Hospital Service or contract physicians were available to treat seamen. Finally, an appendix provided information on the nature and purposes of the Marine Hospital Service and the laws related to it. Examples of items to be carried in the medicine chest were adhesive plaster, bandages, castor oil, calomel, chloroform liniment, fluid extract of ginger, opium, quinine, saltpeter, salicylic acid, sodium bicarbonate, surgeon’s needles, and a tooth forceps. The ship’s master was admonished to inspect the medicine chest carefully before starting out to sea to be sure that it was furnished with all of the items on the list. The many injuries and diseases discussed included fractures, dislocations, malarial fevers, dysentery, yellow fever, cholera, scurvy, syphilis, delirium tremors, and smallpox. The case of yellow fever may be cited as an example of a treatment regimen for a disease. If the patient was vomiting, a nitre mixture (consisting of saltpeter, water, and an alcoholic solution of ethyl nitrite) would also be given. The handbook goes on to discuss three cardinal rules to observe in treating yellow fever. First, insure that the patient gets sufficient rest by giving Dover’s powder (which contained opium) and inducing the patient to remain in bed. Third, strengthen the patient by means of weak whiskey and water, beef tea, quinine, and other stimulants. The handbook proved to be so useful that a second edition, revised and expanded appeared in 1904. Containing 101 pages, the second edition was more than twice the size of the original 45-page publication. The work continued to be revised and new editions issued over the course of the twentieth century. In addition to the two editions previously noted, the National Library of Medicine holds editions published in 1929, 1947 (reprinted with additions and changes in 1955), 1978, and 1984. By the 1929 edition, the book’s title had changed to The Ship’s Medicine Chest and First Aid at Sea. With the 1978 edition, the title was slightly altered to The Ship’s Medicine Chest and Medical Aid at Sea, perhaps to emphasize the fact that medical care going beyond what we normally think of as first aid would often be required aboard ships. Although designed for use aboard merchant ships, the work has also found use over the years in other situations, such as on fishing vessels and in backwoods areas. For over 100 years it has filled a need for reliable medical information in cases where medical care by a health professional is not available. Chief Historian United States Public Health Service v Editorial Board and Other Contributors Editor-in-Chief Rear Admiral Joyce M. Ryan, Lake Carriers Association, Cleveland Ohio for sharing old editions of The Ship’s Medicine Chest and Medical Aid at Sea and related books. Concern for the health of merchant mariners has, from the beginning, been a part of our nation’s history. In the 1700’s, legislation mandated that a Medicine Chest be carried on each American Flag vessel of more than 150 tons, provided it had a crew of ten or more. By 1798, a loose network of marine hospitals, mainly in port cities, was established by Congress to care for sick and disabled American merchant seamen. Called the Marine Hospital Service, later the Public Health and Marine Hospital Service, and finally the Public Health Service, these federal entities continued to provide healthcare to merchant seamen until 1981. The Ship’s Medicine Chest and Medical Aid at Sea has been a part of much of this maritime history. The Public Health Service published the first Medicine Chest in 1881 under the title, Handbook for the Ship’s Medicine Chest. The early editions of the Medicine Chest provided step-by-step instructions on how to treat a variety of illnesses that might be expected underway when the ship was days from shore, and had limited communication with land. The master or designated crewmember had to independently manage whatever injury or illness might occur. Fortunately, for the health of all merchant seamen and others at sea, the world has changed. Modern technology allows for nearly continual “real-time” communication between the ship and shore. In today’s world, serious medical problems underway will be managed via communication with shore-based physicians and other medical resources. More sophisticated tele-medicine capabilities, often including video as well as audio components, are also continually being expanded. As a result of these changes in technology and medical practice, this edition has limited the “how to” aspects of medical management. Instead, it identifies when medical consultation may be needed, and describes how to do a basic physical exam and then how to communicate these medical findings to shore-based experts. As in any aspect of treatment or consultation, effective communication is key to quality healthcare.
Negative sputum smears at the times shown in Table 5 indicate good treatment Monitoring the patient during treatment progress 100 mg kamagra effervescent fast delivery finasteride erectile dysfunction treatment, which encourages the patient and the There are two main objectives: health worker responsible for supervising the • To monitor and record the response to treatment order 100 mg kamagra effervescent with mastercard erectile dysfunction and diabetes medications, treatment buy kamagra effervescent master card young erectile dysfunction treatment. If a patient has a positive sputum smear for whom bacteriological monitoring is possible. For was poorly supervised and patient adherence was patients with sputum smear-negative pulmonary poor. Page 174 Module 6 • Sometimes, there is a slow rate of progress with sputum is sent to the laboratory for culture and sputum smear conversion, for example, if a patient sensitivity, and the patient then starts the had extensive cavitation and an initial heavy bacillary continuation phase. Where there are no facilities the end of the second month, the initial phase is for culture and sensitivity testing, the patient prolonged for a third month. The patient then starts continues treatment right until the end of the re- the continuation phase. Recording treatment outcome in smear-positive patients Cure Patient who is smear-negative at, or one month Previously treated sputum smear-positive prior, to the completion of treatment and on at least one previous occasion. Treatment Patient who remains or becomes again smear third month), during the continuation phase of failure positive at five months or later during treatment Died Patient who dies for any reason during the treatment (at the end of the fifth month) and at course of the treatment the end of treatment (at the end of the eighth Treatment Patient whose treatment was interrupted for 2 Interrupted months of more month). If the patient is sputum smear-positive (default) Transfer Patient who has been transferred to another at the end of the third month, the initial phase of out reporting unit and for whom the treatment outcome is not known treatment with four drugs is extended by another month and sputum smears examined again at the end of the fourth month. If the patient still has Recording standardized treatment outcomes positive smears at the end of the fourth month, At the end of the treatment course in each Module 6 Page 175 individual patient with sputum smear-positive treatment. Further management depends on the nature of the Table 6 shows the standardized definitions of adverse reaction and is shown in Table 7. Routine laboratory Joint pains Pyrazinamide Aspirin Burning sensation Isoniazid Pyridoxine 10 mg monitoring is not necessary. Urgent liver drug-induced function tests and Health personnel can prevent some drug-induced acute liver failure) prothrombin Visual Ethambutol Stop ethambutol, side effects, for example isoniazid-induced impairment (other seek further advice causes excluded) peripheral neuropathy. The public heath priority of a National These patients should receive preventive treatment Tuberculosis Programme is to cure smear-positive with pyridoxine 10 mg daily along with their anti- cases, while avoiding drug resistance. In many countries, a significant proportion usually at the same dose but sometimes at a reduced of patients stop treatment before the end, for dose. For these patients, the supervisor right drugs, in the right doses, at the right intervals. Directly observed treatment is also Preventative measures to decrease the duration applicable in out-patient settings. The supervisor of treatment interruption may be a health worker or a trained an supervised At the time of registration of a tuberculosis patient community member. There may be an incentive starting treatment, it is important to set aside of some sort for community members to be enough time to meet with the patient, and supervisors of directly observed treatment. It is partner/spouse, parents, work place, or place of important to ensure confidentiality and that study, in order to contact the patient. Also, it is directly observed treatment is acceptable to the important to identify potential problems which patient. Directly observed therapy is always recommended in the following cases: Recommendations to help prevent the patient • two months initial phase of treatment for all new from stopping treatment too early smear-positive cases; • Be kind, friendly and patient. Contacts are • Thell the patient about local arrangements for usually limited to household contacts and to friends supervision of treatment: for example, admission sharing a similar level of contact to that of to a ward or hostel, or daily attendance at a centre household contacts. Close or household contacts near home for first 2 months, or supervision by can be generally considered to have had at least four volunteers or other persons in his village. If there is a local calendar different from the standard Managing close contacts international calendar, give the patient the date in Figures 1, 2, and 3 on the next page show how the local calendar. This will help in determining the right advice to provide about continuing the full treatment. Aspects of prevention to be discussed include: • contact tracing; • management of close contacts; and • immunization. Contact tracing Studies in the United Kingdom show that up to 10% of tuberculosis cases are diagnosed by contact tracing. Here tuberculin testing is less useful, as many adults will be tuberculin positive (especially if previously immunised). It is important to examine all adults living in the family home, particularly the grandparents, one of whom may be the infector. Controlled trials in several Western Heaf head will be released and protrude 2mm into countries, where most children are well nourished, the skin. Discrete induration of three or The tuberculin skin test 0 fewer needle sites is acceptable. Heaf test (or multiple puncture test), and Induration around each needle site merging with 2. Heaf gun, disposable Heaf heads (paediatric and Individuals who have not previously received standard). The immunised there is no evidence of the characteristic vaccine must be given strictly intradermally with scar. If the skin is visibly dirty it should be swabbed with spirit Those individuals with a Heaf grade 2, or Mantoux and allowed to dry. The Heaf grades 3 or 4, and Mantoux tests of 15 mm needle can usually be seen through the epidermis. If little resistance is felt when injecting, (For a further guide on skin testing and screening the needle is too deep – stop injecting, withdraw of high-risk groups such as new immigrants and and recommence at the correct depth. In Since chemotherapy treatment of tuberculosis has some specialized hospitals, a negative pressure already been discussed, this section will concentrate ventilation system may be available for nursing mainly on infection control issues. The negative psychological effects of isolation can be minimized by careful planning prior to Respiratory precautions prevent the spread of admitting the patient. Isolation of the patient is usually should be given to providing some recreation: recommended for a minimum of two weeks after radios and books or magazines the patient would commencing chemoprophylaxis. Three negative sputum smear toys from any patient in an isolation room as there specimens at a minimum of 24 hours apart and is a low, theoretical risk of cross-infection. Papers resolution of the cough are required before allowing should be discarded as household rubbish and toys the patient home. It is not necessary to heat treat books Out-patient clinics following use by a known infected patient. The coordinated to minimize cross infection to other mattress and pillows should be protected by patients. Any therapeutic overlay or potentially infectious or known infectious patients pressure relieving equipment must also be washable attend other departments, for example X-ray. When sputum samples are obtained in the clinic A comfortable washable chair and footstool to this should be done in a well ventilated area away allow the patient to sit out of bed should be from other vulnerable patients (see further notes provided, as should a washable chair for visitors. The movement of furniture in and out of the room during the isolation period should be minimised Page 185 In-patient treatment because everything in the room may be considered Isolation potentially infected until cleaned and disinfected. Equipment for monitoring the patient’s clinical Module 6 Page 185 condition should be available in each room and to be disposed of as contaminated and potentially kept there until he is discharged. Ideally, the patient should have his own en suite Patient clothing should be washed at normal toilet or a commode within the isolation room to temperatures. If soiled, place in a water soluble or reduce the cross infection risks in communal toilets water-soluble membrane bag to protect care staff or bathrooms. This should have hot and cold or bin with a lid to place soiled items in and do running water, liquid soap for staff use and paper not open them until reaching the laundry - lift the hand towels for staff use.
In contrast buy 100mg kamagra effervescent amex erectile dysfunction medicine in uae, fewer than 5 in 10 respondents are aware of the term in Barbados (43%) buy kamagra effervescent 100 mg on line erectile dysfunction treatment with diabetes, Nigeria (38%) and Egypt (22%) buy kamagra effervescent 100mg cheap erectile dysfunction hypothyroidism. Percentage of all respondents who answered “yes” to “Have you heard of…Antibiotic Resistance? The survey findings show some notable socio-demographic differences in relation to awareness of the term antibiotic resistance: Respondents with a higher level of education are more likely to have heard of the term antibiotic resistance (77%) compared to those with further (64%), basic (60%) or no education (49%). This is significantly higher than those aged 16-25 (63%) and those aged 65+ (63%). Those who stated they were aware of the term antibiotic resistance were asked from which sources they had heard about it. The source cited by the largest number of respondents in all 12 countries surveyed is a doctor or nurse (50%), followed by the media (41%), and then a family member or friend (23%). Percentages of responses from all respondents to “Where did you hear about the term antibiotic resistance? Percentages of all respondents who answered “true” to the question “Antibiotic resistance occurs when your body becomes resistant to antibiotics and they no longer work as well” by country surveyed. The survey shows some significant differences in findings between countries surveyed in relation to the statement which is best understood—Many infections are becoming increasingly resistant to treatment by antibiotics. Respondents in Mexico (84%), Viet Nam (83%) and the Russian Federation (81%) are the most likely to correctly identify this as a true statement (Figure 25). In contrast, 30% of respondents in Sudan think that this statement is false, while 43% of respondents in Barbados and 30% of respondents in Egypt state they do not know the answer to this question. Percentages of responses from all respondents to “Many infections are becoming increasingly resistant to treatment by antibiotics” by country surveyed. Levels of awareness and understanding around ways to address antibiotic resistance In order to explore levels of awareness and understanding around ways to address the problem of antibiotic resistance, respondents were asked whether they felt the following actions would help address the problem: People should use antibiotics only when they are prescribed by a doctor or nurse Farmers should give fewer antibiotics to food-producing animals People should not keep antibiotics and use them later for other illnesses Parents should make sure all of their children’s vaccinations are up-to-date People should wash their hands regularly Doctors should only prescribe antibiotics when they are needed Governments should reward the development of new antibiotics Pharmaceutical companies should develop new antibiotics Across the 12 countries included in the survey, the majority of respondents agreed that all of these actions would help address the problem, with People should wash their hands regularly (91%) and Doctors should only prescribe antibiotics when needed (89%) coming out on top (Figure 26). People should not keep and use antibiotics later was the least commonly agreed to, though a significant majority (70%) still thought this has a part to play. Percentages of all respondents who answered “yes” to “Do you think the following actions would help address the problem of antibiotic resistance? However in Viet Nam, 13% of respondents disagree with this statement, compared to an overall average of 6%. Additionally, almost one quarter (23%) of survey respondents in China neither agree nor disagree with this statement. Percentage of responses from all respondents to “People should use antibiotics only when prescribed” by country surveyed. The multi-country average was 73%, with respondents in China, the Russian Federation and Serbia most likely to agree that this action has a part to play, at 83%, 81% and 81% respectively. Respondents in Indonesia are least likely to agree, at 64%, and the highest proportion of respondents disagreeing with this statement was in Viet Nam at 16%. Percentage of responses from all respondents to “Farmers should give fewer antibiotics to animals” by country surveyed. Figure 29Respondents in Barbados are the least likely to agree that this action has a part to play, at 50% compared to the multi-country average of 78%, though this is still half of all respondents. Percentage of responses from all respondents to “Governments should reward the development of new antibiotics” by country surveyed. Of note however, is that 14% of respondents in Viet Nam disagree with this statement, compared to the 12-country average of 5%, and 14% of respondents in China neither disagree nor agree, compared to the multi- country average of 6%. Percentage of responses from all respondents to “Doctors should only prescribe antibiotics when needed” by country surveyed. Percentage of responses from all respondents to “Pharmaceutical companies should develop new antibiotics” by country income classification. People’s opinions on the scale of the problem of antibiotic resistance and whether it will impact them personally In order to understand how serious respondents believe the issue of antibiotic resistance is and whether it will have an impact on them, survey participants were asked whether they agree with a series of statements connected to the issue: Antibiotic resistance is one of the biggest problems the world faces Medical experts will solve the problem of antibiotic resistance before it becomes too serious Everyone needs to take responsibility for using antibiotics responsibly there is not much people like me can do to stop antibiotic resistance I am worried about the impact that antibiotic resistance will have on my health, and that of my family I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly Responses to this question reveal a mix of views around this area, with some slightly paradoxical findings: 88% of respondents in all countries included in the survey think that everyone should take responsibility for using antibiotics responsibly, but 64% of respondents also 36 Antibiotic Resistance: Multi-country public awareness survey think that medical experts will solve the problem of antibiotic resistance. It is also important to note that 57% agree that There is not much people like me can do to stop antibiotic resistance with only 18% disagreeing with this statement, and therefore indicating that they believe they do have a part to play. Everyone needs to take responsibility for using antibiotics responsibly 88 4 8 I am worried about the impact that antibiotic resistance will have on my health, and that of my 75 8 16 family Medical experts will solve the problem of antibiotic resistance before it becomes too serious 64 10 26 Antibiotic resistance is one of the biggest problems the world faces 63 12 25 I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly 63 15 21 There is not much people like me can do to stop antibiotic resistance 57 18 26 0% 20% 40% 60% 80% 100% Agree Disagree Neither agree nor disagree Figure 32. Percentage of responses from all respondents to statements surrounding attitudes towards antibiotic resistance. There are some significant variations in the findings between the countries surveyed and socio-demographic groups in relation to some of these statements, which are explored further below. In contrast, only 33% of respondents in Serbia and 27% of respondents in Barbados agree that antibiotic resistance is one of the biggest problems in the world, with more than one quarter in each country disagreeing and almost half neither agreeing nor disagreeing with this statement. Percentage of responses from all respondents to “Antibiotic resistance is one of the biggest problems the world faces” by country surveyed. Medical experts will solve the problem of antibiotic resistance before it becomes too serious Findings suggest that this statement produced a lot of uncertainty from respondents, particularly in Barbados where 56% of respondents neither agree nor disagree with this statement (Figure 34). More than one third of respondents in the Russian Federation (36%), Serbia (35%) and South Africa (36%) are also uncertain. In contrast, 89% of respondents in Sudan agree that experts will solve the problem, as well as 81% of Nigerian respondents. Percentage of responses from all respondents to “Medical experts will solve the problem of antibiotic resistance before it becomes too serious” by country surveyed. Survey findings differ significantly by income level of the respondents’ countries, with 71% of those in lower income countries strongly agreeing to this statement in comparison to 56% of respondents in higher income countries (Figure 35). Percentage of responses from all respondents to “I am not at risk of getting an antibiotic-resistant infection, as long as I take my antibiotics correctly” by country income classification. The majority of respondents (62%) think that antibiotics are widely used in agriculture in their country. Respondents in Serbia (53%), Indonesia (52%) and Barbados (40%) are least likely to agree with this statement. Percentage of responses from all respondents to “Do you think antibiotics are widely used in agriculture in your country? These findings can both help shape future public awareness efforts and aid evaluation of the impact of these efforts. Although antibiotic resistance occurs naturally, overuse and misuse of antibiotics in humans and animals is accelerating the process. Steps can be taken at all levels of society to reduce the impact and limit the spread of resistance, including the public, who can help by preventing infection through good hygiene and vaccination, only using antibiotics when prescribed by a certified health professional, taking the full course, and never sharing or using left-over antibiotics. For this reason, it is critical that people understand the problem, and the way in which they can change their behaviour. They show that although people recognize the problem, they do not fully understand what causes it, or what they can do about it. Antibiotic use The results of the survey questions on antibiotic use demonstrate how frequently antibiotics are taken, with a considerable majority of respondents (65%) across the 12 countries reporting having taken them within the past six months. This rises to 76% in Egypt, the country with the highest number of respondents reporting having taken antibiotics in the past six months, including 54% having taken them within the past month. Even in Barbados—the country in which respondents reported the lowest use in the past six months—the number stands at 35%. This prevalence is highly relevant to public campaigns on antibiotic resistance—both because high levels of use contribute to the problem, and because it demonstrates just how many people it could impact in a short time frame if the antibiotics they are taking become increasingly ineffective.
A large part of the symptomatology is due to secondary infections in weakened patients purchase kamagra effervescent 100mg overnight delivery erectile dysfunction what is it, most of them children purchase kamagra effervescent online from canada erectile dysfunction doctor washington dc. In a case in an adult from Nigeria buy kamagra effervescent uk sudden onset erectile dysfunction causes, the most prominent patho- logical feature was severe hepatic fibrosis and functional disorders related thereto (Attah et al. Laboratory examinations find hyperleukocytosis with eosinophilia and hypochromic anemia, with abnormal values in liver function tests. Autopsy reveals the presence of grayish-white nodules on the surface of the liver. Subclinical human infections undoubtedly occur, as attested to by solitary hepatic granulomas found in nine individuals autopsied during a study in the former Czechoslovakia. In seven of the nine cases, only one parasite larva was found in the lesions (Slais, 1973). Biopsy reveals granulomatous lesions with cellular reac- tion to a foreign body (Aftandelians et al. Experimental infection in primates of the genus Macaca or in wild rats is asymptomatic. In gerbils, on the other hand, the infection is manifested by a symptomatology similar to that in man (Banzón, 1982). Although hepatic capillariasis does not have a high mortality rate, it could contribute to the control of rodent populations (McCallum, 1993). Intense infections can cause rhinitis, tracheitis, and bronchitis, which may end in bronchopneumonia caused by a secondary bacterial infection. Source of Infection and Mode of Transmission: Man is the only known definitive host of C. The main source of infection for humans seems to be infected fish, and the manner of infection is the ingestion of undercooked fish. Contamination of bodies of water with the excreta of humans or the birds that serve as hosts ensures perpetuation of the cycle. Given that the infection can be transmitted experimentally from one gerbil to another, with the parasite at different intestinal stages of develop- ment, direct person-to-person transmission may also occur (Banzón, 1982). The infection is transmitted by ingestion of embryonated eggs that have been released from the liver of rodents and disseminated through the external environment by carnivores. In the peridomestic environment, the disseminating agents can be cats and dogs that hunt rodents. The eggs can also be released by cannibalism among rodents or by death and decompo- sition of their cadavers. For man, the source of direct infection is the soil, and the source of indirect infection is contaminated hands, food, or water. There are more than 30 described cases of spurious infections due to the ingestion of raw liver of rodents or other mammals, such as squirrels, monkeys, and wild boars, infected with unembryonated eggs. In such cases, the eggs of the parasite pass through the human digestive tract and are eliminated with the feces without causing true infection. Children probably acquire the infection by ingesting dirt or water and food contaminated with eggs. Coprologic examination confirms the diagnosis, though a series of them may be necessary. A specific diagnosis of hepatic capillariasis is suspected from the presence of fever, hepatomegaly, and eosinophilia in a patient in an endemic area. Confirmation can be obtained only from liver biopsy and identification of the parasite or its eggs. Diagnosis of pulmonary capillariasis can be obtained by confirmation of the pres- ence of eosinophils or the typical eggs in the sputum, or by biopsy of pulmonary tis- sue in which larvae or aspirated eggs can be found. Control: In endemic areas, intestinal capillariasis can be prevented by refraining from eating raw or undercooked fish. Patients should be treated with thiabendazole, both for therapeutic reasons and to decrease the dissemination of parasite eggs. Hepatic capillariasis is a geohelminthiasis in which the eggs develop to the infec- tive stage in the soil; they then penetrate the host orally through contaminated food or water or, in the case of man, via contaminated hands that are brought to the mouth or handle food. Consequently, individual prevention consists of carefully washing suspected foods and avoiding eating them raw; boiling both water and suspected foods; and washing hands carefully before eating. Since the infection is common in young children, who often eat dirt, and in homes in which rats abound, supervision of children’s hygiene and rodent control can be important. Young animals, which are the most susceptible and have the largest parasite burden, must be separated from adults. Any infection must be treated as soon as possible to prevent contamination of the environment with the eggs. Individuals can avoid infection by following strict hygiene rules to prevent infections with geohelminths. Recherche de trois infestations parasitaires chez des rats capturés à Marseille: Évaluation du risque zoonosique. Human intestinal capillariasis in an area of nonendemicity: Case report and review. Evaluation of a nematode (Capillaria hepatica Bancroft, 1893) as a con- trol agent for populations of house mice (Mus musculus domesticus Schwartz and Schwartz, 1943). Imported Opisthorchis viverrini and parasite infections from Thai labourers in Taiwan. The finding and identification of solitary Capillaria hepatica (Bancroft, 1893) in man in Europe. Etiology: Cutaneous larva migrans is a clinical description more than an etiologic diagnosis. The principal etiologic agent is the infective larva of Ancylostoma braziliense, an ancylostomid of dogs, cats, and other carnivores. Experimental infec- tions have been produced in human subjects with other animal ancylostomids, such as A. Since cases of cutaneous larva migrans have been seen occa- sionally in areas where these latter parasites are prevalent, it is assumed that they can also infect man in nature. Cutaneous infection caused by the larvae of Strongyloides stercoralis, which progresses more rapidly than that caused by the larvae of ancylostomids, is currently called “larva currens,” but it is also known as cutaneous larva migrans. In addition, some authors extend the validity of this term to gnathostomiasis (Díaz-Camacho et al. Also, a case of invasion of human skin by Pelodera strongyloides,afree-living soil nematode related to S. The name “cutaneous larva migrans” has even been applied to the larvae of some arthropods that can colonize human skin, such as Gasterophylus and Hypoderma (Cypess, 1982). In individuals who have suf- fered previous infections, the human ancylostomids A. Here consideration is given only to the canine ancylostomes, with particular focus on A. Man is an aberrant host, in which the infective larvae cannot complete their devel- opment cycle and become adults. Its life cycle is similar to that of the other ancylostomes (see the chapter on Zoonotic Ancylostomiasis).
In addition discount kamagra effervescent online master card erectile dysfunction 40 over 40, evaluation for disorders associated with celiac disease that could cause persistent symptoms generic 100mg kamagra effervescent with visa impotence at 52, such as microscopic colitis purchase kamagra effervescent overnight delivery impotence therapy, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients. A “ strong ” confdence in the estimate of the efect and would likely change recommendation is made when the benefts clearly outweigh the estimate. This results from injury to the • Some (−1) or major (−2) uncertainty about directness small intestine with loss of absorptive surface area, reduction of • Imprecise or sparse data (−1) digestive enzymes, and consequential impaired absorption of micronutrients such as fat-soluble vitamins, iron, and potentially • High probability of reporting bias (−1) B12 and folic acid (3). In addition, the infammation exacerbates Increase grade if symptoms of malabsorption by causing net secretion of fuid • Strong evidence of association—signiﬁcant relative risk of >2 (<0. The failure of absorption of adequate based on consistent evidence from two or more observational calories leads to weight loss, and the malabsorption results in studies, with no plausible confounders (+1) abdominal pain and bloating (3). A lower rate probably ap- (Strong recommendation, high level of evidence) plies to second-degree relatives (18). Some data suggest Irritable bowel syndrome an increase in absorption, leading to the need for increased insu- Down’s and Turner’s syndromes lin doses. This antigen was initially produced Recommendations by extraction from the liver or purifcation from human red cells (1) Immunoglobulin A (IgA) anti-tissue transglutaminase and, most recently, by recombinant protein production. The reduction or cessation of dietary gluten leads to a decrease in the levels of all these celiac-associated antibodies Summary of the evidence. While little is known about the precise accuracy in the primary-care setting and referral cohorts has dynamics of the reduction, a weakly positive individual may be- been extensively studied (9). The higher the titer of the test, the greater the likelihood of tive by serology (57). There are recognized diferences in test been in use for several decades, there is a wide variability in their performance between the various commercially available test kits, diagnostic accuracy (43). However, it was with the advent test is regarded as an overall positive result; however, the increased of auto-antibodies, frst directed against reticulin, then endomy- sensitivity comes at the expense of a reduction of specifcity ( 59 ). Subsequent biopsy is also useful for the diferential diagnosis of malabsorptive studies demonstrated that a biopsy at the time of diagnosis in disorders ( 82,83 ). Other causes of villous atrophy in duodenum quent the “triple test” criteria are met by unselected populations. The rate of duodenal biopsy Intestinal tuberculosis was signifcantly lower among black, older (70 years and older), Infectious enteritis (e. A targeted duodenal bulb biopsy from Acquired immune deﬁciency syndrome enteropathy either the 9- or the 12-o’clock position in addition to biopsies of Table 4. Summary of histologic classiﬁcations frequently used for celiac disease Marsh modiﬁed (Oberhuber) Histologic criterion Corazza Increased intraepithelial lymphocytesa Crypt hyperplasia Villous atrophy Type 0 No No No None Type 1 Yes No No Grade A Type 2 Yes Yes No Type 3a Yes Yes Yes (partial) Grade B1 Type 3b Yes Yes Yes (subtotal) Type 3c Yes Yes Yes (total) Grade B2 a>40 intraepithelial lymphocytes per 100 enterocytes for Marsh modiﬁed (Oberhuber); >25 intraepithelial lymphocytes per 100 enterocytes for Corazza. Care must be taken when interpreting duodenal bulb original diagnosis of celiac remains in question biopsies to allow for the normal surface architectural changes that (e) Patients with Down ’ s syndrome overlie Brunner’s glands and the acute infammatory changes of (4) Capsule endoscopy should not be used for initial diagnosis peptic duodenitis. Expert opinion suggests that only a single biop- except for patients with positive-celiac specifc serology sy specimen should be obtained with each pass of the biopsy for- who are unwilling or unable to undergo upper endoscopy ceps (5); however, there is no evidence that supports that recom- with biopsy. We recommend multiple biopsies of the duodenum evidence) including one or two biopsies of the bulb (either 9- or 12-o’clock (5) Capsule endoscopy should be considered for the evalua- position) and at least four biopsies of post-bulbar duodenum. The added yield of duodenal bulb biopsies is follow-through are neither specifc nor sensitive and are likely to be small in such circumstances. Other disorders have been associated with lymphocytic symptomatic patients referred for small-bowel biopsy due to sus- duodenosis, including Helicobacter pylori (H. D-xylose is a pentose absorbed unchanged from the small Knowledge of the pathogenesis, epidemiology, and natu- bowel ( 131 ). The D-xylose test involves measurement of serum ral history of non-celiac gluten sensitivity is quite rudimentary xylose or measurement of excreted xylose in urine afer ingestion (142,146–148). The test is abnormal in patients with malab- gluten sensitivity does not have a strong hereditary basis, is not sorption due to mucosal disorders but remains normal in those associated with malabsorption or nutritional defciencies, and is with maldigestion of pancreatic origin ( 132 ). Sensitivity ( < 65 % ) not associated with any increased risk for auto-immune disorders and specifcity (<74%) for either 1-h plasma test or 4-h urine or intestinal malignancy. The added diagnostic sensitivity of extending the challenge to 8 weeks is unknown. In one study positive tissue transglutaminase serology was seen not sufciently specifc to be useful for positive diagnosis (8). If a patient is unwilling or unable must be noted that patients who develop severe symptoms to undergo testing to make this distinction, then their further following gluten ingestion are not suitable candidates for glu- management becomes less well-defned. Although gluten challenge with a diet containing non-celiac gluten sensitivity is symptom-based, without data to at least 10g of gluten per day for 6–8 weeks has long been the elicit major concerns for a long-term sequel of inadequate therapy norm, there are few data to indicate the diagnostic efcacy of ( 146,147 ). There is evidence that compliance The principal sources of dietary gluten are wheat, barley, and rye. Most physicians do not sources of gluten, in reality this is not possible due to contam- have the knowledge about the diet to adequately counsel patients. Hence the term Registered dietitians are trained to evaluate patients for potential “gluten free” indicates a diet that contains gluten at such a low current and future dietary nutrient defciencies and advise and level as to be considered harmless. The Academy of Nutrition and than 10mg per day is unlikely to cause damage in most patients Dietetics has published evidence-based guidelines for treatment ( 156 ). There is an increased risk for malignan- ments for potential dietary nutrient defciencies, inadequate fber cies (e. Some defciencies may persist even afer a pro- low bone mineral density and risk for fractures. A systematic review supports the role of strict adher- assessment for complications. Of (4) Upper endoscopy with intestinal biopsies is recommended these visits, 175 (56%) were conducted with primary-care providers for monitoring in cases with lack of clinical response and 122 (39%) with gastroenterologists (213). Until more recommendation, moderate level of evidence) evidence is available, annual follow-up seems reasonable. All serologic ogenous group of patients with refractory iron-defciency anemia, markers associated with celiac autoimmunity are gluten-dependent. Copper levels normalize within a month of duces increasing values of antibodies (222). Persistently defciency appears to be a very rare cause of peripheral neu- positive serology was seen in only 1% of patients who under- ropathy (237). Serology is improvement in bone density, especially among patients with strict not accurate to detect lesser degrees of gluten contamination. Intesti- (Strong recommendation, high level of evidence) nal biopsies are the only way to document healing of the intestine. Follow-up biopsy could be considered for assessment of mucosal healing in adults with negative serology and absence Summary of the evidence. It is reasonable despite 6 – 12 months of dietary gluten avoidance ( 218,219,242,243 ). Yes No Adjust diet & Small-bowel biopsy monitor progress (with colonic biopsies if persisting diarrhea) Enteritis with villous atrophy? Ongoing infammatory enteropa- bodies, or cladribine ( 6,115,116,244,252,255,258 – 261 ). Furthermore, T-cell receptor analyses may (4) Consider testing of asymptomatic relatives with a frst- reveal oligoclonal T-cell expansion within the small-bowel mucosa degree family member who has a confrmed diagnosis ( 244,246,253,254 ).
For most cause categories buy cheap kamagra effervescent 100mg line erectile dysfunction natural cures, extrapolations 45 and over experiencing mild hearing loss or greater order kamagra effervescent us erectile dysfunction forums. The total attributable burden of disability due to alcohol use is much larger (see chapter 4) buy kamagra effervescent 100mg otc erectile dysfunction in diabetes type 2. Although healthy life lost through time spent in states of less than full the prevalences of disabling conditions such as dementia health. From 1991 to 1994, average, poor health resulted in a loss of nearly eight years of the risk of premature death increased by 50 percent for healthy life globally. This once again illustrates the importance of Latin America and the Caribbean taking nonfatal conditions into account, as well as deaths, Middle East and North Africa when assessing the causes of loss of health in populations. East Asia and Pacific In 2001, the leading causes of the burden of disease in low- and middle-income countries were broadly similar to South Asia those for the world as a whole (table 3. Between ed for 36 percent of the world’s total burden of disease and 1994 and 1998, life expectancy for males improved, but injury in 2001 and adults ages 15 to 59 accounted for almost declined again signiﬁcantly between 1998 and 2001 (Men 50 percent. While the proportion of the total burden of disease stantially higher burden of noncommunicable disease than borne by adults ages 15 to 59 was the same in both groups of high-income countries (ﬁgure 3. Other uninten- top four causes of the burden of disease, four nonfatal condi- tional injuries and violence were the third and fourth Table 3. Low- and middle-income countries High-income countries around 85 percent in adults ages 15 and older,the proportion 0–4 in middle-income countries has already exceeded 70 percent. Population aging and changes in the distribution of risk factors have accelerated the epidemic of noncommunicable disease in many developing countries. Injuries were also important older attributable to cancer was 6 percent in low- and mid- for women ages 15 to 44, although road trafﬁc accidents dle income countries and 14 percent in high-income coun- were the 10th leading cause, preceded by other unintentional tries in 2001. The number of cases of lung cancer increased nearly 30 percent since 1990, largely reﬂecting the emergence of the tobacco epidemic in low- and middle- The Growing Burden of Noncommunicable Diseases income countries. The burden of noncommunicable diseases is increasing, Stomach cancer, which until recently was the leading site accounting for nearly half the global burden of disease for all of cancer mortality worldwide, has been declining in all parts ages, a 10 percent increase from estimated levels in 1990. Liver cancer was the third leading site, with The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 | 89 607,000 deaths in 2001, more than 60 percent of them in the compared with other regions. Among women, the leading cause of burden in Latin America and Caribbean countries, cause of cancer deaths was breast cancer. Globally, neuropsychiatric Group I causes also appear in the top 10 causes for this conditions accounted for 19 percent of the disease burden region, with road trafﬁc accidents being the only non- among adults, primarily from nonfatal health outcomes. Of particular note, road trafﬁc accidents were Injuries, both unintentional and intentional, primarily the third leading cause and congenital anomalies were the affect young adults, and often result in severe, disabling seventh leading cause. In 2001, injuries accounted for 16 percent of the Group I causes of the disease burden remained dominant adult burden of ill-health and premature death worldwide. In developed countries, suicides accounted hensive assessment of global population health, and has also for the largest share of the intentional injury burden, where- conﬁrmed the growing importance of noncommunicable as in developing regions, violence and war were the major diseases in low- and middle-income countries. The former Soviet Union and other high-mortality has also documented dramatic changes in population health countries of Eastern Europe have rates of death and disabil- in some regions since 1990. The key ﬁndings include the ity resulting from injury among males that are similar to following: those in Sub-Saharan Africa. In addition, injury deaths are noticeably changed our perceptions of the time frames within which higher for women in some parts of Asia and the Middle substantial changes in the burden of chronic disease can East and North Africa than in other regions, partly occur and of the potential for such adverse health trends because of high levels of suicide and violence. Otherwise, limitations • Sense organ disorders, principally hearing and sight loss, in the evidence base for certain causes or regions might lead contribute signiﬁcantly to disability in all regions of the to their omission, and hence to the conclusion that they world. The gap between serious lack of information on levels of adult mortality and healthy life expectancy and total life expectancy is pro- causes of death in some regions, particularly Sub-Saharan portionately highest for the low-income countries. The key need for countries is to establish a system that registers the most common causes of death for the The analysis presented in this chapter has aimed to pro- entire population without serious biases (such as an empha- duce a comprehensive and detailed assessment of the global sis on urban mortality), in which there is reasonable conﬁ- burden of disease, based on all available relevant data. Recent experience in sparse has used the available evidence and the best available countries such as China, India, and Tanzania suggests that methods to make inferences and to assess the uncertainty sample registration based on a representative set of surveil- in resulting estimates (see chapter 5). The need for internal lance sites, and with appropriate controls and reporting pro- consistency between estimates of incidence, prevalence, cedures, can yield extremely useful information about levels, case fatality rates, and mortality rates for a given disease patterns, and causes of mortality for large populations (Setel and for consistency across diseases and injuries with and others 2005; Yang and others 2005). Low- and middle- known total levels of mortality are crucial strategies for income countries can beneﬁt from the advantages of death making the best use of multiple sources of uncertain and registration without implementing a system of complete potentially biased data. To support such systems, pri- global and regional causes of death have been summarized ority needs to be given to developing a standardized report- in tables 3. In excess of 770 country-years of ing form for verbal autopsies and to implementing valida- death registration data and more than 3,000 additional tion studies to assess the reliability and accuracy of verbal sources of information on levels of child and adult mortali- autopsy methods. As discussed in more than 10,000 data sets relating to population health and chapters 5 and 6, new data and syntheses for major causes mortality. This represents the largest synthesis of global of child death may result in future revisions to the estimates information on population health carried out to date. Similarly, even in high-income countries, few den, even in the face of limited or missing data, to ensure population-based studies of the prevalence of chronic lung that a comprehensive overview is provided to gain a better disease or musculoskeletal conditions have been carried out. Nevertheless, substantial uncertainty ease models used to estimate the burden of disease for some remains about the comparative burden of diseases and causes. This is to become more widespread unless control programs partly an issue of valuation of health states for the construc- are more widely implemented. However, we remain sub- tion of disability weights, and partly an issue of lack of stantially uncertain about the true levels of the disease bur- information on the population-level distribution of out- den from chronic lung disease, heart disease, stroke, mental comes and the severity of health states. Even efforts that substantially reduce have gone further in assessing disability weights for a range uncertainty will be a major advance toward this goal. The burden of disease framework, with 15 years health state valuation data on more than 500,000 health of development and application in numerous countries states from respondents in 71 countries, which Salomon and across the globe, offers the best, indeed the only, approach Murray (2004) used to construct a health state valuation to comprehensively assess the impact of conditions and function. The World Health Survey also included a health exposures that health systems need to deal with if popula- state valuation module, and analysis of the resulting data is tion health is to improve rapidly. In the next for setting and monitoring global health priorities, a more iteration of burden of disease analysis, it should be feasible concerted effort is needed to obtain and critically assess data to use health state valuations based on such survey data, sets on the health of populations in all countries. This must together with descriptions of outcomes associated with dis- be a key focus of future efforts to assess the burden of dis- ease sequelae, to produce updated disability weights that ease. A partic- the Ellison Institute for Global Health (Horton 2005) are ular issue is the measurement of disability weights for low urgently required to provide stewardship and guarantee that severity but highly prevalent conditions, such as anemia and the evidence base for health policy and priority setting will hearing loss, where the current disability weights are small develop at a pace commensurate with need. Virgin Islands Latin America and Antigua and Barbuda, Argentina, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican the Caribbean Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, St. Vincent and the Grenadines, Suriname, Trinidad and Tobago, Uruguay, República Bolivariana de Venezuela Middle East and Algeria, Djibouti, Arab Republic of Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libya, Malta, Morocco, Oman, Saudi North Africa Arabia, Syrian Arab Republic, Tunisia, West Bank and Gaza, Republic of Yemen South Asia Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka Sub-Saharan Africa Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Democratic Republic of Congo, Republic of Congo, Côte d’Ivoire, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, São Tomé and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Tanzania, Togo, Uganda, Zambia, Zimbabwe Other Anguilla, British Virgin Islands, Cook Islands, Falkland Islands, French Guiana, Gibraltar, Guadeloupe, Holy See (Vatican City), Martinique, Montserrat, Nauru, Niue, Pitcairn, Réunion, St. Pierre et Miquelon, Tokelau, Turks and Caicos Islands, Tuvalu, Wallis and Futuna Islands, Western Sahara Source: Jamison and others 2006. Hookworm disease 126 B76 (Ancylostomiasis and necatoriasis) U036 Other intestinal infections B78, B80, B81 127. Respiratory infections 460–466, 480–487, 381–382 J00–J06, J10–J18, J20–J22, H65–H66 U039 1. Abortion 630–639 O00–O07 U048 Other maternal conditions 643–659, 661–665, 667–669, O20–O43, O47–O63, O68–O71, O73–O75, 671–676 O87–O99 U049 D.
The rate is considered normal between 50 and 100 beats per minute as defined by the American Heart Association purchase kamagra effervescent 100 mg otc erectile dysfunction on coke. Rates more than 100 beats per minute are suggestive of abnormality buy 100mg kamagra effervescent with visa erectile dysfunction doctors fort worth, particularly in the absence of physical exertion purchase kamagra effervescent amex impotence marijuana facts. If the rate and rhythm appear normal, count for 15 seconds and multiply times four; if the rate is unusually fast or slow, count it for a full 60 seconds. Disposable nasal specula and tongue blades must be available and appropriately disposed of after use. Wash hands before putting on gloves and after taking them off when examining each patient. Skin turgor is the degree of fullness and elasticity observed in the skin, indicating circulation and hydration status. If there are lesions present, identify the location, size, note the configuration of any grouping of arrangement of the lesions, note the color, describe any other qualities and try to identify the type of lesion. Head and Neck: The head is inspected by observing the position of the head and noting any unusual movements, size, shape, and symmetry of the skull. Assessment of muscle function is done by checking for the range of movement by flexion, extension, and lateral rotation from side to side. The patient should be able to do this freely, smoothly and without experiencing pain or dizziness. The midline neck structures are palpated for presence of masses and for enlarged lymph nodes. The thyroid may be examined with the health care provider standing either in front of or behind the patient. However, it is easiest to examine standing behind the patient and using both hands to palpate the thyroid. Ask the patient to swallow and then palpate the thyroid gland as it rises during swallowing. A palpable mass of 5 mm or larger is considered to be a nodule; and, the location and size should be described. Ears, Nose and Throat: Examine the external portions of the ear for position, size, symmetry, and presence of lumps or lesions. If gently palpating the area in front of the ear and manipulating the tip of the outer ear produces pain, the patient may have an external otitis. The internal portions of the ear are examined with the otoscope, using the largest ear speculum that the ear canal can accommodate. This helps to straighten the ear canal and makes it easier to visualize the middle ear structures. The tympanic membrane in healthy people has a translucent pearly, gray appearance. Occasionally, some membranes have white flecks or plaques on them indicating previous healed inflammatory disease. This triangular cone of reflected light is seen in the anteroinferior quadrant of the tympanic membrane (i. Finally, auditory acuity may be assessed by a simple whisper test, testing one ear at a time. Then standing 1-2 feet away from the patient, a phrase or several words are whispered by the examiner. To prevent lip-reading, the examiner may stand behind the patient, or if not feasible, the patient may be asked to close his or her eyes. Other bone and air conduction tests involve the use of a tuning fork and are normally performed when hearing is diminished. Flaring is the expansion of motion of the ends of the nostrils outward and may indicate breathing difficulties. The assessment of the ability to identify fragrances will be discussed in the neurological examination. Localized tenderness with pain in the area of the sinuses coupled with nasal discharge is suggestive of frontal or maxillary sinusitis. The mouth and throat are inspected beginning with an external inspection of the mouth and jaw area. If dentures are present, the examiner asks the patient to remove them, so the entire mouth can be inspected. Use of a tongue blade will facilitate the moving of the tongue and cheek aside to inspect all structures. The patient is asked to repeat "Ah" and the rise of the soft palate and uvula are noted. Visual acuity for distance vision is assessed with the use of the traditional Snellen eye chart. To test for near vision have the patient read a newspaper and note the distance at which the print is readable. Patients with corrective lenses are tested both with and without the lenses which allow for an assessment of the correction. Eyelids and eyelashes are inspected for position, color, lesions, infection, or swelling. The conjunctiva and sclera are inspected by moving the lower lid downward over the bony orbit and having the patient look upward; the examiner observes for the presence of any swelling, infection, or foreign objects and the vascular pattern. In a darkened room, a bright light, such as a flashlight, is directed into each pupil from the side of the eye, one at a time. The examiner observes for a constriction reaction in both the eye being examined as well as in the opposite eye. Eye movement is controlled through the coordinated action of six muscles collectively known as the extraocular muscles. Each of these muscles can be tested by asking the patient to move the eyes in the direction controlled by that muscle. These six muscles move the eye in a lateral (right to left) movement, and in a vertical (up and down) movement, and in a slanting (in an X) movement. So, if the right eye is to be examined, the examiner holds the ophthalmoscope in the right hand. The optic disc is examined for size, shape, color, margins, and the physiologic cup. The retinal vessels are examined for color, arteriovenous ratio, and any crossings of vessels. Chest and Lungs: Assessment of the chest and lungs involves inspection, palpation, auscultation, and percussion. While examining one side of the chest and lungs, the other side serves as the comparison, noting differences and abnormalities. The examiner may begin on the top (superior) and work down to the bottom (inferior), or vice versa, or begin in the front (anterior) and work around to the back (posterior), or 1-10 vice versa. The examiner should always use a systematic approach regardless of where he or she begins the exam.