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By D. Tyler. University of Hawai`i, Hilo.

Studies in China have found that the eggs need oxygen (they do not tolerate anaerobic conditions) and survive for three to four months at 4°C buy cheap tadalis sx 20 mg online erectile dysfunction treatment new jersey. The miracidium emerges from the mature egg and pen- etrates small planorbid snails buy 20 mg tadalis sx overnight delivery erectile dysfunction protocol amino acids, mainly of the genera Gyraulus discount 20 mg tadalis sx mastercard erectile dysfunction klonopin, Segmentina, Helicorbis, Hippeutis, and Polypylis. In mollusks, the miracidium passes through the sporocyst stage and two generations of rediae. The second generation of rediae gives rise to large numbers of cercariae, which emerge from the snails and encyst as metacercariae on aquatic plants. The studies in China have found that almost 4% of the metacercariae encyst in the water. The definitive hosts, humans or swine, become infected by consuming aquatic plants or water with metacercariae. In the intestine, the metacercaria is released from its envelope, and after about three months, the parasite reaches maturity and reinitiates the cycle by oviposition. Geographic Distribution and Occurrence: The infection is common in south- east Asia (Waikagul, 1991). The parasitosis occurs in Bangladesh, central and south- ern China, India, the Indochina peninsula, Indonesia, and Taiwan. Cases have also been reported, many of them among immigrants, in the Philippines, Japan, and sev- eral Western countries. Prevalence is very variable but generally low in humans and is thought to be higher in the areas where swine are raised. In several areas of Chekiang and Kiangsi Provinces, China, the prevalence can be as high as 85%; in contrast, in other areas of the coun- try infection rates ranging from less than 1% to 5% are found. Approximately half of all human infections are believed to occur in China (Malek, 1980). A study conducted in an endemic area of Thailand found that the preva- lence of infection in humans was similar to that of the swine population. In some areas of China with high rates of human infection, the parasitosis in swine has not been con- firmed. This would seem to indicate that, at least in some areas, humans are the par- asite’s preferred host. The Disease in Man and Animals: This parasite produces few or no symptoms in most hosts. Perhaps because it is the largest trematode affecting man, traumatic, toxic, and obstructive effects have been attributed to it, with epigastric pain, nausea, diarrhea, undigested food in the feces, and edemas of the face, abdomen, and legs. Yet a clinical study of a group of mostly young persons in Thailand who were elim- inating F. The severe disease described in the lit- erature seemingly corresponds to cases with a large parasite burden (Liu and Harinasuta, 1996). By and large, the health of the pigs is not affected, and the symptoms of the disease occur only in cases of massive parasitosis. Source of Infection and Mode of Transmission: The source of infection for humans and swine is aquatic plants and water containing metacercariae. Epidemiological research in China suggests that between 10% and 13% of persons and from 35% to 40% of swine are infected more from drinking water contaminated with metacercariae than from eating plants. Endemic areas offer the ecological con- ditions necessary for the growth of both the intermediate hosts and the edible aquatic plants. In central Thailand, these conditions occur in flooded fields, where edible aquatic plants are cultivated near dwellings. These fields receive human excreta directly from the houses, which are built on pillars. Human and animal excreta pro- mote the development of mollusks and plants and provide the infective material (the parasite’s eggs) for the host. The hosts are the snails Hippeutis umbilicalis and Segmentina trochoideus in Bangladesh, in addition to Polypylis hemisphaerula in China, Thailand, and Taiwan (Gilman et al. It has also been found that Helicorbis umbilicalis is an intermediate host in Laos (Ditrich et al. The epi- demiologically important aquatic plants, whose fruits, pods, roots, bulbs, or stems are eaten by humans, are “water chestnuts” (Eliocharis spp. Certain parts of these plants are eaten raw, and the teeth and lips are often used to peel the pods and bulbs. In areas where people customarily boil the plants or their “fruits” (water chestnuts) before eating them but give them raw to swine, the infection rate is much higher in these animals than in humans. In general, the preva- lence of human infection is higher in areas where the aquatic plants are cultivated and lower in distant towns, since metacercariae attached to the plants are not resistant to desiccation when some time elapses between harvest and marketing. The pig is con- sidered a reservoir of the parasite that could maintain the infection in the human pop- ulation even if the sanitary elimination of human excreta were achieved. In Muslim countries, such as Bangladesh, swine do not play any role as a reservoir; man is prac- tically the only reservoir and only source of infection for snails (Gilman et al. The infection can be imported by patients into regions where intermediate hosts exist; one study found that 3 of 93 Thai workers in Israel were infected by F. The eggs are very similar to those of Fasciola gigantica and Fasciola hepatica; experts say that the eggs of F. There are no reports on attempts at immunological diagnosis, but the parasite has shown cross- reactions in tests for Fasciola hepatica, the larva of Taenia solium, and Trichinella spiralis. Control: The simplest way to prevent human parasitosis is to refrain from eating fresh or raw aquatic plants, peeling them with the teeth, or drinking water from con- taminated areas, but this recommendation requires changing a habit, which is diffi- cult to achieve. Studies conducted in China have shown that immersing contami- nated plants in boiling water for 1 to 2 minutes is sufficient to kill the parasite. Other measures to combat the parasitosis, in addition to health education, are to use mol- luscicides, to treat the affected population, to treat the human excreta in septic tanks or with quicklime, to prevent the fertilization of fields with human feces, and to pro- hibit swine raising in endemic areas. Larval stages of medically important flukes (Trematoda) from Vientiane province, Laos. Etiology: The agent of this infection is Gastrodiscoides (Amphistomum) hominis, a bright-pink, pear-shaped trematode 5–14 mm long by 4–66 mm wide; it lives in the cecum and ascending colon of swine and humans, although it has also been found in monkeys and field rats (Soulsby, 1982). The anterior part of the parasite is conical, but the posterior opens into a disc with a suction cup. The eggs leave the host without embryonating and take 16 to 17 days, at 27°C to 34°C, to form the first juvenile stage (miracidium) and hatch (Neva, 1994). In experiments in India, miracidia were able to produce infection in the planorbid snail Helicorbis coenosus, which may be the natural intermediate host. Details of development in the snail are not known, but judging from the cycle of other members of the same family, they are presumed to form oocysts, one or two generations of rediae, and cercariae. Depending on the ambient temperature, the cercariae begin to emerge from the snails 28 to 152 days after infection. Like those of other species of Gastrodiscidae, the cercariae are thought to encyst on aquatic plants and develop into metacercariae. Geographic Distribution and Occurrence: This parasitosis occurs primarily in India (states of Assam, Bihar, Orissa, and West Bengal) and in Bangladesh, but has also been recorded in the Philippines, the Indochina peninsula, and in animals in Indonesia (Java), Malaysia, Myanmar, and Thailand. The geographic distribution may be wider, since the parasite was found in a wild boar in Kazakhstan. Human infection rates vary and can be very high, as in a village in Assam, India, where 41% of the population, mostly children, had the parasite’s eggs in their stools.

Subsequent licensing requires: satisfactory treatment success no brain scan evidence of intracranial metastases (refer to malignant brain tumours order tadalis sx 20mg amex erectile dysfunction at age 21, page 35 of Chapter 1 20 mg tadalis sx mastercard erectile dysfunction vacuum pumps pros cons, neurological disorders) order 20mg tadalis sx with amex erectile dysfunction treatment after prostatectomy. Group 1 Group 2 car and motorcycle bus and lorry Excessive sleepiness Must not drive. The effects of any cancer treatment The effects of any cancer treatment must also be considered – the generally must also be considered – the generally debilitating effects of chemotherapy debilitating effects of chemotherapy and radiotherapy in particular. In-car, on-the-road assessments (Appendix G, page 133) are an invaluable way of ensuring, in valid licence holders, there are no features liable to present a high risk to road safety, including these examples: visual inattention, notable distractibility, impaired multi-task performance. The following are also important in showing there is no impairment likely to affect driving: adequate performance in reaction times, memory, concentration and confdence. Impairment of cognitive functioning is Impairment of cognitive functioning is not usually compatible with the driving not usually compatible with the driving of these vehicles. Mild cognitive disability may be compatible with safe disability may be compatible with safe driving – individual assessment will driving – individual assessment will be required. Licence holders wishing to drive after surgery should establish with their own doctors when it would be safe to do so. Any decision regarding returning to driving must take into account several issues, including: recovery from the effects of the procedure anaesthetic recovery from the effects of the procedure any distracting effect of pain analgesia-related impairments (sedation or cognitive impairment) other restrictions caused by the surgery, the underlying condition or any comorbidities. Drivers have the legal responsibility to remain in control of a vehicle at all times. Such a judgement may be necessary for any of a range of conditions that may temporarily affect driving, including, but not limited to: postoperative recovery (see ‘Driving after surgery’, page 112) severe migraine limb injuries expected to show normal recovery pregnancy associated with fainting or light-headedness hyperemesis gravidarum hypertension of pregnancy recovery following Caesarean section deep vein thrombosis or pulmonary embolism. Drivers taking prescribed drugs subject to the drug-driving legislation will need to be advised to carry confrmation that these were prescribed by a registered medical practitioner. Some prescription and over-the-counter medicines can affect driving skills through drowsiness, impaired judgement and other effects. Prescribers and dispensers should consider any risk of medications, single or combined, in terms of driving – and advise patients accordingly. Advice for individual driving safety should be considered carefully for all antidepressants antipsychotics – many of these drugs will have some degree of sedating side effect via action on central dopaminergic receptors. Older drugs (chlorpromazine, for example) are highly sedating due to effects on cholinergic and histamine receptors. Newer drugs (olanzapine or quetiapine, for example) may also be sedating; others less so (risperidone, ziprasidone or aripiprazole, for example) opioids – cognitive performance may be reduced with these, especially at the start of use, but neuro-adaptation is established in most cases. Driving impairment is possible because of the persistent miotic effects of these drugs on vision. Also refer to Chapter 4, psychiatric disorders (page 79), and Chapter 5, drug or alcohol misuse and dependence (page 88). According to Section 92 of the Road Traffc Act 1988: A relevant disability is any condition which is either prescribed (by Regulations) or any other disability where driving is likely to be a source of danger to the public. A driver who is suffering from a relevant disability must not be licensed, but there are some prescribed disabilities where licensing is permitted provided certain conditions are met. A driver with a prospective disability may be granted a driving licence for up to 5 years, after which renewal requires further medical review. Sections 92 and 94 of the Road Traffc Act 1988 also cover drivers with physical disabilities who require adaptations to their vehicles to ensure safe control. See Appendix F, disabilities and vehicle adaptations (page 132) and Appendix G, Mobility Centres and Driving Assessment Centres (page 133). A serious neurological disorder is defned for the purposes of driver licensing as any condition of the central or peripheral nervous system that has led, or may lead, to functional defciency (sensory, including special senses, motor, and/or cognitive defciency), and that could affect ability to drive. A short-term licence for renewal after medical review is generally issued whenever there is a risk of progression. Further information relating to specifc functional criteria is found in the following chapters: Chapter 1, neurological disorders (page 16) Chapter 4, psychiatric disorders (page 79) Chapter 6, visual disorders (page 96) Chapter 8, miscellaneous conditions – excessive sleepiness (page 108). The following two boxes extract the paragraphs of the Motor Vehicle (Driving Licences) Regulations 1999 (as amended) that govern the way in which epilepsy is ‘prescribed’ as a ‘relevant’ disability for Group 1 or Group 2 drivers (also see Appendix A, the legal basis for the medical standards, page 115). Group 1 car and motorcycle (2) Epilepsy is prescribed for the purposes of section 92(2) of the Traffc Act 1988 as a relevant disability in relation to an applicant for, or a holder of, a Group 1 licence who has had 2 or more epileptic seizures during the previous 5-year period. Group 2 bus and lorry (8A) Epilepsy is prescribed for the purposes of section 92(4) b) of the Traffc Act 1988 in relation to an applicant for a group 2 licence who: a) in the case of a person whose last epileptic seizure was an isolated seizure satisfes the conditions in paragraph (8C) and (8D) or b) in any other case, satisfes the conditions set out in paragraph (8D) and who, for a period of at least 10 years immediately preceding the date when the licence is granted has: i. Withdrawal of epilepsy medication This guidance relates only to epilepsy treatment. During the therapeutic procedure of epilepsy medication being withdrawn by a medical practitioner, the risk of further epileptic seizures should be noted from a medicolegal point of view. If an epileptic seizure does occur, the patient will need to satisfy driving licence regulations before resuming driving and will need to be counselled accordingly. It is clearly recognised that withdrawal of epilepsy medication is associated with a risk of seizure recurrence. A number of studies have shown this, including a randomised study of withdrawal in patients in remission conducted by the Medical Research Council’s study group on epilepsy drug withdrawal. This study showed a 40% increased risk of seizure associated with the frst year of withdrawal compared with continued treatment. The Secretary of State for Transport’s Honorary Medical Advisory Panel on Driving and Disorders of the Nervous System states that patients should be warned of the risk they run, both of losing their driving licence and of having a seizure that could result in a road traffc accident. The Advisory Panel states that drivers should usually be advised not to drive from the start of the withdrawal period and for 6 months after treatment cessation – it considers that a person remains as much at risk of seizure during the withdrawal as during the following 6 months. One specifc example is withdrawal of anticonvulsant medication when there is a well-established history of seizures only while asleep. In such cases, any restriction on driving is best determined by the physicians concerned, after considering the history. It is important to remember that the epilepsy regulations remain relevant in cases of medication being omitted as opposed to withdrawn, such as on admission to hospital. For changes of medication, for example due to side effect profles, the following general advice is applicable: When changing from one medication to another and both would be reasonably expected to be equally effcacious, then no period of time off driving is recommended. To be considered a provoked seizure, the seizure must be attributable solely to a recognisable provoking cause and that causative factor must be reliably avoidable. Group 2 bus and lorry entitlement only Licence duration A bus or lorry licence issued after cardiac assessment – usually for ischaemic or untreated heart valve disease – will usually be short-term, for a maximum licence duration of 3 years, and licence renewal will require satisfactory medical reports. The test must be on a bicycle (cycling for 10 minutes with 20 W per minute increments, to a total of 200 W) or treadmill. The patient should be able to complete 3 stages of the standard Bruce protocol or equivalent safely, while remaining free of signs of cardiovascular dysfunction, viz: angina pectoris syncope hypotension sustained ventricular tachycardia. Individuals with a locomotor or other disability who cannot undergo or comply with the exercise test requirements will require a gated myocardial perfusion scan or stress echo study accompanied when required by specialist cardiological opinion. For this reason, exercise tolerance testing and, where necessary, myocardial perfusion imaging or stress echocardiography are the investigations of relevance (outlined above) with the standards as indicated to be applied. If there is a confict between the results of the functional test and a recent angiography, the case will be considered individually. Licensing will not normally be granted, however, unless the coronary arteries are unobstructed or the stenosis is not fow-limiting. The risk of hypoglycaemia is the main acuity (with the aid of glasses or contact lenses if danger to safe driving and can occur with diabetes treated worn) must be at least 6/12 (0.

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The highest incidence of the disease has been recorded in Japan purchase 20mg tadalis sx with visa erectile dysfunction treatment in uae, where various fish dishes are eaten raw or pickled in vinegar buy cheap tadalis sx 20 mg line erectile dysfunction freedom book. The conditions necessary for transmission to humans exist on the Pacific coast of Latin American countries buy 20mg tadalis sx mastercard erectile dysfunction doctor montreal. In Peru and Chile, anisakid larvae have been found in the stomach wall, intestinal wall, and mesentery, and on the surface of the gonads of several species of commercial marine fish. According to Japanese parasitologists, anisakid larvae found in cephalopods such as cuttlefish and octopus are third-stage larvae and so would be infective for man (and for the natural definitive hosts) when the cephalopods are consumed raw or undercooked. Marine fish can become infected second intermedi- ate hosts by eating invertebrates; they can also become paratenic hosts by ingesting the infective third-stage larvae of other fish. Diagnosis: Direct diagnosis by examination of the parasite is the preferred method, but in 50% to 70% of gastric cases, the parasite can be visualized and recov- ered by endoscopy (Deardorff et al. In colonic anisakiasis, it is difficult to see the parasite by endoscopy, but the lesions and X-rays are very useful for diag- nosis. In fact, the parasites were visible on X-ray in four out of six cases (Matsumoto et al. The presence of ascites, dilation of the small intestine, and edema of the Kerckring’s folds found using sonography in patients with acute abdomen who have eaten fish or shellfish recently are indications of intestinal anisakiasis (Ido et al. Most species of anisakids that are dangerous for humans die when exposed to temperatures of –20°C for 24 hours or 60°C for one minute. Since these are the temperatures to which the larva must be exposed, and since there are a few species that are more resistant, it is recom- mended that the fish be cooked at 70°C or frozen to –20°C for 72 hours in order to have a margin of safety. The freezer unit of a good home refrigerator can generally achieve temperatures of –20°C. The requirement that fish be subjected to low temperatures before being sent to market has drastically decreased the infection in the Netherlands. Salting is also effective when concentrated salt solutions that reach all parts of the fish are used. Prohibiting the sale of fish that has not undergone these processes is the most effective measure for controlling anisakiasis in the community. It is also important to eviscerate fish immediately after they are caught to prevent the Anisakis larvae from passing from the intestine to the muscle. Prevalence of larval Anisakis simplex in pen-reared and wild- caught salmon (Salmonidae) from Puget Sound, Washington. A case of abdominal syndrome caused by the presence of a large number of Anisakis larvae. A case report of serologically diagnosed pul- monary anisakiasis with pleural effusion and multiple lesions. Nota preliminar sobre Anisakidae (Railliet and Henry, 1912, Skrjabin and Korokhin, 1945), en algunos peces de consumo habitual por la población humana de Valdivia (Chile). Seroepidemiology of five major zoonotic parasite infections in inhabitants of Sidoarjo, East Java, Indonesia. Etiology: The agents of human ascariasis are the nematode of humans, Ascaris lumbricoides, and occasionally, the nematode of swine, A. The two species are closely related and show only slight morphologic and physiologic differences (Barriga, 1982). Both species can occasionally infect the heterologous host and reach a certain degree of development inside it. Ascarides are large nematodes: the female is 20–35 cm long and 3–6 mm in diam- eter; the males are smaller and have a curved distal portion. Under ideal conditions of humidity, temperature, shade, and availability of oxygen, a third-stage infective larva develops within the egg in 15 to 20 days; under adverse conditions, this process can take much longer. Once a new host ingests the eggs with food or drinking water, the infective larvae emerge from the egg in the intestine and invade the mucosa of the cecum and colon in a few hours, remain there approximately 12 hours, and migrate to the liver via the portal circula- tion (Murrell et al. The larvae are then carried in the bloodstream from the liver to the heart, and from there to the lungs. After a period of time, they break out of the pulmonary capillaries, enter the alveoli, and migrate through the bronchial tubes and trachea to the pharynx, from whence they are swallowed and carried to the intestine. In the intestine, they complete their maturation and develop into male and female adults. Geographic Distribution and Occurrence: Ascariasis is one of the most wide- spread parasitoses, and both A. It has been estimated that between 644 million and more than 1 billion persons are infected, 42 million of whom are in Central and South America. The estimated worldwide mortality due to ascariasis is 20,000 per year due to intestinal complica- tions; annual morbidity is a million cases, mainly due to pulmonary disorders and malnutrition (Walsh and Warren, 1979). The parasitosis is most prevalent in rural areas, where contamination of the soil and contact between hands or food and lar- vae are more common, and in hot, humid areas, which favor maturation of the eggs. The highest rate of infection is found in children, probably because of their less hygienic habits, but also because an immune resistance is acquired along with the infection. Prevalence rates vary considerably according to differences in environ- mental sanitation, health education of the population, personal and food hygiene, type of soil and climate, and other factors. Studies carried out in slaughter- houses have shown that the prevalence rate is high, ranging from 20% to 70% or more. The highest rate is found in piglets 2 to 5 months old; it declines with age thereafter. Since swine have the same contact with the soil at any age, the difference is believed to represent some level of acquired immunity against the infection. Intestinal infection was verified in 7 of 17 volunteers after each one was administered 25 eggs of A. It is a reasonable assumption that a significant proportion of respi- ratory illnesses observed in people having contact with pigs is caused by A. In developing countries where humans and swine are in close contact and personal and environmental hygiene are deficient, it could be anticipated that the larval phase of A. The Disease in Man and Animals: The course of the disease and the sympto- matology are similar in both humans and swine. In the early age group, not only is the rate of infection higher, but parasite burden is larger. Two phases of the disease are distinguished: the initial phase, pro- duced by migrating larvae, and the latter phase, caused by adult parasites. Invasion of the liver of swine and turkeys by the ascarid larvae produces traumatic microfoci which become inflamed and heal with connective tissue. These microle- sions are more serious and show allergic components in reinfections, but rarely result in clinical signs (Barriga, 1997). In man, there is generally no hepatic component in the migration, although it has been shown that the excreta and secretions of A. The pulmonary phase is characterized by respiratory symptoms attributable to the damage produced by the larvae during pulmonary migration. In intense and repeated larval invasions, the symptomatology consists of fever, irregular and asthmatic breathing, and spasmodic coughing. Aberrant larvae located in the brain, eyes, and kidneys are rare, but can give rise to serious symptoms.

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Head and Neck: The head is inspected by observing the position of the head and noting any unusual movements generic 20 mg tadalis sx otc what causes erectile dysfunction treatment, size discount tadalis sx 20 mg on line erectile dysfunction treatment home, shape proven tadalis sx 20 mg impotence bike riding, 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. Inspection of the chest is performed to assess the skin, respiratory pattern, and overall symmetry of the thorax. Palpation is performed next to identify any tender areas, palpate any observed abnormalities, and to assess respiratory expansion. Percussion is performed over the chest to assess the intensity, pitch, duration, and quality of the underlying tissue. Normal peripheral lung tissue resonates on percussion, the normal tone is loud in intensity, low in pitch, long in duration, and hollow-like in quality. Several areas should be percussed with one side serving as the comparison for the other side. The patient is instructed to breathe through the mouth and inhale more deeply and slowly than normal. The normal breath sounds heard over the lung tissue are called vesicular breath sounds with the inspiratory phase more audible than the expiratory. Over the major bronchi, the normal sounds are bronchovesicular sounds in which the inspiratory and expiratory are equal in duration, and more moderate in pitch and intensity than the vesicular sounds.