By F. Felipe. Franklin Pierce Law Center.
As frontotemporal dementia progresses cheap 1mg propecia with visa hair loss in men vest, differences between these types lessen: people with the behavioural variant develop language problems and those with language problems develop behaviour changes purchase 1 mg propecia with mastercard hair loss essential oil recipe. In the later stages purchase propecia 5mg on line hair loss eyebrows, the symptoms of frontotemporal dementia become more similar to those of Alzheimer’s disease propecia 5 mg without a prescription hair loss cure quotations. There are some differences – for example, day-to-day memory loss and problems judging distance or seeing objects in three dimensions develop later in frontotemporal dementia, whereas changes in behaviour, such as agitation or aggression, develop earlier. Supporting a person with frontotemporal dementia can be a 12The progression of Alzheimer’s disease and other dementias challenge as they may be younger and will have changes in behaviour and communication. Each person’s experience of frontotemporal dementia will be different, but on average people live for six to eight years after symptoms begin. We 9am–5pm Thursday–Friday provide information 10am–4pm Saturday–Sunday and support, improve care, fund This publication contains information and general research, and create advice. It should not be used as a substitute for lasting change for personalised advice from a qualifed professional. Please refer to our website for the latest version and for full terms and conditions. Except for personal use, no part of this work may be distributed, reproduced, downloaded, transmitted or stored in any form without the written permission of Alzheimer’s Society. Within a decade of its development, 9 methicillin resistance to Staphylococcus aureus emerged. Most of the resistance was secondary to production of beta-lactamase enzymes or intrinsic resistance with alterations in penicillin-binding proteins. Staphylococcus aureus is the most frequent cause of nosocomial pneumonia and surgical- wound infections and the second most common cause of nosocomial bloodstream 12 infections. Other risk factors include intravascular catheters, tracheostomy, gastrostomy, indwelling urinary catheters and decubitus ulcers. Another important consideration is careful evaluation of culture and sensitivity reports. Infection is often confused with colonization and can lead to unnecessary utilization of antimicrobial agents. Potential anatomical sites of colonization include the anterior nares, axillae, upper extremities, urinary tract and perineum. Consultation with an infectious-disease specialist is advised regarding management when there is question as to infection versus colonization. However, some strains remain sensitive to minocycline and recently, strains acquired outside of health-care settings remain susceptible to agents, such as clindamycin and gentamicin. Clindamycin, co-trimoxazole, fluoroquinolones or minocycline may be useful when patients do not have life-threatening infections caused by strains susceptible to these agents. For serious infections caused by strains that are susceptible to rifampin, adding this agent to vancomycin or fluoroquinolone may contribute to improved outcomes. The infecting strain always should 17 be tested for susceptibility prior to initiating any of these therapies. Enterococci are generally not particularly pathogenic in humans and have traditionally been classified as relatively harmless commensals. Enterococci alone rarely colonize or cause infection of the respiratory tract or cause primary cellulitis, unlike other gram-positive organisms such as Staphylococcus 19 aureus. Though over a dozen different species of enterococci have been identified, two species, Enterococcus faecalis and Enterococcus faecium, are the most prevalent in human infections. Enterococcus faecalis, which comprises 85%-90% of all human enterococcal infections, is typically considered the most pathogenic. The remaining 5%-10% of enterococcal infections are due to Enterococcus faecium, which is increasingly resistant 19 to vancomycin and is now considered a major nosocomial pathogen. Enterococci typically are associated with causing urinary tract infections, intra-abdominal and pelvic sepsis, surgical wound infections and bacteremia, in descending order of frequency. However, they now are emerging as highly-resistant 19 organisms and nosocomial pathogens. Enterococci have been identified as the third most common cause of nosocomial, 20 hospital-acquired pneumonia. Enterococci are intrinsically resistant to a number of antibiotics and antibiotic classes. They do not possess exotoxins or enzymes that allow invasion and destruction of tissues. They can, however, readily acquire resistance genes that are capable of transfer to other bacteria. Resistant enterococcus can be isolated from patients who have been institutionalized for long periods of time. Other risk factors for acquiring a resistant enterococcal infection include severity of underlying illness, presence of invasive devices, prolonged antibiotic use and prior colonization. Those at higher risk include immunosuppressed hosts such as renal dialysis, transplant and oncology patients. Treatment of serious infections due to beta-lactam resistant gram-positive organisms. Treatment of serious infections due to gram-positive organisms in patients with serious beta-lactam allergies. Prophylaxis for endocarditis for certain procedures based on American Heart Association recommendations. Routine surgical prophylaxis unless the patient has a severe allergy to beta- lactam antibiotics. Treatment of one positive blood culture for coagulase-negative staphylococcus if other blood cultures drawn at the same time are negative (i. Continued empiric use in patients whose cultures are negative for beta-lactam resistant gram-positive organisms. Prophylaxis for infection or colonization of indwelling central or peripheral intravenous catheters. Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis. Treatment of infection due to beta-lactam sensitive gram-positive microorganisms in patients with renal failure (for ease of dosing schedule). Enterococcus has developed intrinsic resistance to many antibiotics, including cephalosporin antibiotics. They exhibit low-level resistance to aminoglycosides, which can be overcome by adding a cell-wall active agent such as ampicillin or vancomycin. These combinations can provide a bactericidal effect, sometimes referred to as a synergistic effect. Resistance to beta-lactams occurs secondary to either enzyme production or altered penicillin-binding proteins. Beta-lactamase producing strains for Enterococcus faecalis, which are typically rare, can be treated with ampicillin/sulbactam + an aminoglycoside. Enterococcus faecium, which produce an enzyme different from penicillinase that is not inhibited by penicillin, are now commonly resistant to many beta-lactams although there are reports of success with combination 20, 26 therapy using double and or triple combination regimens. Enterococci develop 19, 27 resistance via three phenotypes, which are outlined in Table 2. Steps may include: • A comprehensive antimicrobial utilization plan that includes education of all staff (medical, nursing and other ancillary services). A comprehensive group of individuals, which may consist of infection control, infectious disease, medical, surgical, nursing, microbiology, pharmacy, epidemiology, quality assurance, administration staff and all other pertinent entities, should develop its own protocols for each individual institution. For line-related bacteremia, simply removing the intravenous device may be sufficient. Surgical debridement and drainage may be adequate for cases of soft tissue infections, surgical site infections and abscesses. Urinary tract infections may respond spontaneously or with removal of indwelling catheters. For severe infections such as endocarditis and meningitis, utilization of bactericidal antibiotics is advised.
Coverage:Staphylococci; Peds: 10-30m g/kg/day po divided q6h $34 150 discount propecia 1mg without prescription hair loss 23,300m g cap Streptococci;m anyoralanaerobes generic 1 mg propecia free shipping kingsley hair loss cure. Peds: 15-30-50m g/kg/day po divided q8h $12 250m g tab Usefulin:intra-abdom inalinfections;C 1 mg propecia for sale hair loss 4 months postpartum. See Online Extras forinstructionson com pounding H eavilyconcentratesin urine (>100xserum levelifhealthykidneys) discount propecia 1 mg free shipping zinc cure hair loss. Adult:600m g po q12h $802 Usefulin:m ulti-drug resistantinfections(including pneum onia,skin and softtissue,etc. Coverage:The onlyoraluse isfortreatm entofClostridium difficile colitis(drug of Peds: 40m g/kg/day po divided q6h $234 125,250m g cap choice ifsevere infection,orifsecond recurrence ofC. M :Essentiallyno oralabsorption (used po for 2010 localeffectin bow el);how ever,dialysispatientsm ayrequire a random vancom ycin leveliftoxicitysuspected. U Upper Respiratory Tract Infection (Common Cold): Lasts 7-14 days U Flu: Lasts 7-14 days U Acute Pharyngitis (“Sore Throat”): Lasts 3-7 days, up to ≤10 days U Acute Bronchitis/”Chest Cold” (Cough): Lasts 7-21 days U Acute Sinusitis (“Sinus Infection”): Lasts 7-14 days You have not been prescribed antibiotics because antibiotics are not effective in treating viral infections, can cause side effects (e. When you have a viral infection, it is very important to get plenty of rest and give your body time to fight off the virus. If you follow these instructions, you should feel better soon: f Rest as much as possible f Drink plenty of fluids f Wash your hands frequently f Take over-the-counter medication, as advised: ® U Acetaminophen (e. Aleve ) for fever and aches U Lozenge (cough candy) for sore throat ® ® ® ® U Nasal spray (e. Pg 15 We asked some clinicians: “How do you deal with patient expectations around antibiotics? An information I really think I need Q Here is an information hand-out and a script with hand-out something. I don’t want Q all of the sudden you feel a lot worse, you can fill it prescription option ii to have to come back! It’s pretty typical to cough for several weeks after a I’ve been coughing for Bronchitis Q chest cold due to a virus. I think I’d like an Actually, antibiotics cause a lot more side effects than Antibiotic harms: we realize. Strep throat can only be I have examined you and I am happy there is no sign of serious illness, which would need an antibiotic today. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. It represents one of the biggest threats to global health today, and can affect any one, of any age, in any country. Antibiotic resistance occurs naturally, but misuse of antibiotics in humans and animals is accelerating the process. This survey provides a snapshot of current public awareness and common behaviours related to antibiotics in a range of countries. Both these actions can result in improper use of antibiotics, and therefore contribute to the resistance problem. Respondents in Sudan, Egypt and China were particularly likely to state that they should stop taking antibiotics when they feel better, with 62%, 55% and 53% of survey participants respectively choosing this response. The majority of respondents across the 12 countries surveyed correctly identify conditions such as bladder/urinary tract infections (72%) and skin/wound infections (72%) as treatable with antibiotics. However, the majority also incorrectly believe that viruses such as colds and flu (64%) can be treated with antibiotics. However, 57% state that there is not much that people like them can do to stop antibiotic resistance, when in fact, everyone can be part of the efforts to address this problem. The general public can help by: o preventing infections by regularly washing hands, practicing good food hygiene, avoiding close contact with sick people and keeping vaccinations up to date o only using antibiotics when prescribed by a certified health professional o always taking the full prescription o never using left-over antibiotics o never sharing antibiotics with others. The majority of respondents across the 12 countries included in the survey correctly believe that many infections are becoming increasingly resistant to treatment by antibiotics (72%). However, a majority also believe, incorrectly, that antibiotic resistance occurs when their body becomes resistant to antibiotics (76%), whereas in fact bacteria, not humans, become antibiotic resistant. These bacteria may then infect humans and the infections they cause are harder to treat than those caused by non-resistant bacteria. Further evidence of misunderstanding is suggested by the fact that 44% of respondents think that antibiotic resistance is only a problem for people who take antibiotics regularly. A total of 9,772 respondents from 12 countries completed the 14 question survey, either online or during face-to-face street interviews, depending on the appropriate methodology to gather a representative sample of adults for that country. A global action place to tackle the growing problem of resistance to antibiotics and other antimicrobial medicines was endorsed at the World Health Assembly in May 2015. Objective 1 of the plan is to improve awareness and understanding of antimicrobial resistance throughout the world through effective communication, education and training. Antibiotic resistance is accelerated by the misuse and overuse of antibiotics, as well as poor infection prevention and control. Steps can be taken at all levels of society to reduce the impact and limit the spread of resistance. The general public can help by taking actions such as preventing infections to avoid the need for antibiotics, only using antibiotics when prescribed by a certified health professional, always taking the full prescription, never using left-over antibiotics and never sharing antibiotics with others. At present, relatively little is known about the general public’s knowledge of antibiotic resistance at a global level. This aim of this survey was to improve understanding of current public awareness and common behaviours related to antibiotics. It provides a snapshot of the current situation which will assist with efforts to track the impact of awareness-raising efforts across the world. The results reported here will inform future engagement efforts, to ensure campaigns targeting the public address key gaps in knowledge and correct common misunderstandings. A total of 9 772 respondents in 12 countries completed the 14 question survey either online or during a face-to-face street interview. The language of the survey was translated and localized where necessary, within a consistent framework to ensure overall comparability of results. The decision regarding which methodology to use (online or face-to-face) was taken on a case by case basis, to ensure a representative sample per country. Online research has grown rapidly over the past ten years and is now well established in all developed nations as well as a growing number of developing countries. It offers cost and time benefits while delivering similarly robust data sets compared to other methodologies and providing a level of anonymity that can help counter research bias stemming from assumed expectations. Although restricting the sampling to those using the internet results in a different bias, in those countries where this approach was still likely to attain a broadly nationally-representative sample of adults for the survey, the research was conducted through online channels.
The concerned departments will be encouraged to develop a diary / log book which gives details of tasks / cases to be seen by the interns cheap propecia 1mg with amex hair loss cure by 2015. Yet 1mg propecia visa hair loss zyrtec, it is the unique combinations of these sectors that give a place its distinct character and asset base discount propecia 5 mg free shipping hair loss cure your child. Creative Minds in Medicine explores the intersections that are taking place between the arts1 and culture and health and human services sectors purchase 1mg propecia free shipping hair loss zantac. The publication reveals how these resourceful collaborations are improving health and wellness outcomes for the broader community as well as serving individual needs. We believe you will have new insights and appreciation for the invaluable contributions produced when arts and health professionals join forces for our community now and in the future. Both of these sectors were formed in response to the industrialization of Cleveland’s economy, which grew rapidly during the 19th and 20th centuries, greatly increasing the area’s urban population and fnancial resources. With those resources, wealthy industrialists funded the development and endowment of numerous cultural organizations, greatly improving quality of life for the growing numbers of Cleveland residents. The resulting growth of the local healthcare industry led to advances in medicine and the establishment of boards of health and other certifcation agencies which, in turn, promoted the creation of more health education resources. These assets, along with Cleveland’s location on key transportation routes, helped the city’s medical community grow into one of the most notable metropolitan healthcare sectors in the world. Meanwhile, Cleveland’s arts and culture institutions have multiplied in number and discipline, expanded in size and reputation, and become renowned attractions for local and international audiences. While Cleveland is known for the strength of its arts and culture and health and human services sectors, the intersections of those sectors are still being explored and developed. This white paper examines the concept of such intersections frst with a brief historical perspective on the development of the feld. The organization of subsequent chapters is based on a number of examples of real-life programs and practices, both national and local, which illustrate the many ways in which arts and culture contribute to healthcare practice and human services delivery: • Arts integration in healthcare environments. The infusion of arts and culture in, or the design of, settings where healthcare and medical treatment are given to individuals. The engagement of individuals and communities in arts and culture activities and therapies for the promotion of broader clinical and general wellness outcomes. The ability of arts and culture to strengthen social ties and serve as a rallying point from which communities can address public health and social equity issues. The enrichment of medical training programs through the integration of arts and culture. The fnal sections of the paper introduce best practices and policy recommendations to further strengthen Cleveland’s arts and health intersections in the future. Community Partnership for Arts and Culture 5 Creative Minds in Medicine Executive Summary The Historical Development of the Arts and Health Field Throughout history, doctors and medical personnel have provided care of patients and treatment of disease. They have worked to apply scientifc methods in light of and sometimes in spite of the different cultural conditions of the period and location in which they work. The tension between the twin concerns of comfort and science has pulled prevailing medical and social thought frst one way and then another over the years. This has occurred primarily as clinical approaches based in science, diagnosis of disease and observation have competed for favor with more humanistic approaches that emphasize individualized care, compassionate doctor/patient interactions and patient empowerment in healthcare decision-making. The patient-centric approach with its stronger connection to the social sciences has emerged more recently, following a period of stricter emphasis on disease-based, standardized treatment in the vein of natural sciences methodology. Over the past 50 years, greater acceptance of “whole person healthcare” practices, which consider each patient’s unique needs, have created fertile ground for the application of arts and culture activities and expressive arts therapies in health and wellness. Over the course of the 20th century, professional psychologists and educators played an important role in integrating the arts with health more fully. And, from the mid-to late 20th century, greater institutional supports for the arts and health intersection began to develop, while today emphasis is being placed on the production of evidence-based research that demonstrates the multiple values of the intersection. Arts Integration in Healthcare Environments Healthcare facilities can range from small neighborhood clinics to huge hospital campuses. Whatever the type of facility, design considerations are typically focused on creating environments that welcome patients and their families, ease navigation to destinations and facilitate positive general wellness and therapeutic outcomes. Florence Nightingale, the founder of modern nursing, was one of the earliest practitioners of medicine that tied a patient’s environment to his or her health results. In her Notes on Nursing, she pointed out that environmental factors including ventilation, temperature, light, sanitation and noise affect a patient’s recovery and well-being. Discussions about healthcare environments have continued to include the roles of such factors, with growing emphasis placed on the specifc parts that arts and culture can play from two key perspectives: the infusion of works of art and performances into healthcare spaces; and the specifc role the design feld plays in healthcare environments from structural, aesthetic and practical viewpoints. Over time, arts and culture have come to be valued for more than their decorative uses and are increasingly being integrated with healthcare environments for therapeutic ends. With key partnerships developing between Cleveland’s wealth of arts and culture organizations and its healthcare institutions, more visual artworks and performances are appearing in healthcare settings such as the Cleveland Clinic, MetroHealth and University Hospitals. Additionally, design considerations are directly infuencing health and well-being with medical products shaped by organizations including Nottingham Spirk and Smartshape; biomedical art and game applications from students at the Cleveland Institute of Art; specially designed fashion from businesses such as Downs Designs; and architectural elements in facilities like the Hospice of the Western Reserve. Research has shown that arts integration in healthcare environments can yield lower levels of stress and the use of pain medication among patients; reduce medical errors and work-related injuries among staff; and yield cost reductions, lower rates of staff turnover, and enhanced public perceptions of healthcare institutions/facilities. Community Partnership for Arts and Culture 6 Creative Minds in Medicine Executive Summary Participatory Arts and Health The inherent ability of arts and culture to connect, inspire and engage at both individual and community levels has direct implications for the roles it can play when intersecting with the health and human services feld. For individuals undergoing medical treatment, participation in arts and culture activities has been shown to play an important role in boosting confdence, alleviating stress and improving clinical outcomes. Expressive arts therapists are trained healthcare professionals who apply the disciplines of visual art, music, dance, literature and theater to alleviate or treat specifc diseases or disabilities for the health benefts of participants. For example, visual and literary arts help grieving children and adolescents express their emotions following loss; music therapy decreases pain, anxiety, depression, and shortness of breath, and it improves mood in palliative medicine patients; dance allows military veterans to tell their stories nonverbally and cope with post-traumatic stress disorder; writing and reciting poetry assists those with Alzheimer’s disease and related dementia to recall memories; and drama therapy lifts mood and reduces pain levels for dialysis patients undergoing treatment. Expressive arts therapies have also yielded measurable outcomes such as stress reduction, pain management and improved motor and social functioning for groups such as military veterans, autistic youth and stroke survivors. As the role of arts in healthcare has shifted over time, from more aesthetic use to practical applications, individual artists have also become more involved in healthcare facilities. Artists are sharing projects and engaging others in their work through arts-by-the-bedside programs and as artists-in-residence. Arts-by-the-bedside programs bring customized performances directly to patients’ bedsides. Artist-in-residence programs bring artists into healthcare settings in a more structured way for specifed periods of time, allowing for the artist to become more integrated into the hospital environment and deepen relationships with those they serve. Whereas expressive arts therapies work toward treating the physical and psychological reactions associated with disease, the interaction of the artist with a patient or the interaction of the patient with a particular artistic medium are seen as ends in themselves. Cleveland’s healthcare institutions use a wide variety of expressive arts therapies to bring about positive clinical outcomes for patients, as do arts and culture organizations like Art Therapy Studio, Beck Center for the Arts and the Music Settlement. Cleveland’s wealth of educational programs focused on the expressive arts therapies offered through sources like the Cleveland Music Therapy Consortium and Ursuline College, as well as the city’s historic role in the development of the feld, set it apart as an expressive arts therapy leader. In addition to expressive arts therapies, general arts and culture activities are also being used to empower individuals in the creation of artwork and are well-suited to meet the emotional, physical and social needs of specifc groups like older adults through Judson, Malachi House, McGregor and Menorah Park. Collectively, Cleveland’s expressive arts therapists and individual artists are key champions of promoting the role arts and culture have to play in the medical feld’s broader movement toward more patient-centered care. Arts and Health Integration with Community Development, Public Health and Human Services Within their communities, individuals participate in arts and culture activities as observers, creators, facilitators and supporters. Whether through formal or informal outlets, engagement in arts and culture has been shown to mediate greater civic engagement and effcacy among participants. Creative activities such as storytelling, community art projects and public design workshops can help involve stakeholders in decision-making processes and strengthen the Community Partnership for Arts and Culture 7 Creative Minds in Medicine Executive Summary public’s ties to community values. Such activities help strengthen social capital, dense networks between citizens, which has been shown to yield positive outcomes for physical and mental health. In addition to strengthening social ties, arts and culture activities can be rallying points from which communities can address public health issues, which include the prevention of disease through awareness campaigns and the coordination of activities such as vaccinations, motor-vehicle safety, workplace safety, infectious diseases management, nutritional education and prenatal care. Over time, the power of social forces to affect public health has been given more recognition in the feld. As a result, arts and culture activities are increasingly being used to promote public health. Arts and culture activities can help engage audiences in public health issues, spurring discussion and action; provide opportunities to collect qualitative data directly from community members on public health issues; empower communities to change public health behaviors and environments; and encourage different groups to collaborate, effecting changes in attitudes and behaviors relating to public health.
Finally buy discount propecia 1 mg line yves rocher anti hair loss, auditory acuity may be assessed by a simple whisper test generic 5mg propecia overnight delivery hair loss x chromosome, testing one ear at a time purchase propecia 5mg without prescription hair loss 5 years after chemo. Then standing 1-2 feet away from the patient 5mg propecia overnight delivery hair loss research, 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. Over the trachea, the normal breath sounds are called bronchial sounds which are high-pitched, loud sounds with a short inspiratory phase and lengthened expiratory phase. Crackles are discontinuous sounds which are intermittent, brief, nonmusical in nature. Crackles can be either fine, (soft, high pitched and brief in duration) or coarse (somewhat louder, lower pitched, not as brief). Wheezes and rhonchi are more continuous sounds which last notably longer than crackles and have more of a musical quality to them. Wheezes are relatively high pitched with a hissing, shrill-like quality, whereas, rhonchi are more relatively low pitched with a snoring quality. When these continuous sounds are heard, it suggests a narrowing of the air passageways which can be due to a tumor, foreign body, or more generalized situations such as bronchospasm, accumulated secretions or edema of the bronchial mucosa. A stethoscope with both a diaphragm and bell piece will be needed for this examination. Inspection and palpation are performed to determine the presence and extent of normal and abnormal pulsations over the precordium (area of the chest directly over the heart). They may be manifested as the apex beat over the heart area on the chest or as heaves or lifts of the chest as the heart beats. Five prominent areas to become familiar with in describing the heart assessment findings are: right 2nd interspace, left 2nd interspace, left sternal border or right ventricular area, apex or left ventricular area, and the epigastric area. Auscultation is done at the five areas just mentioned as well as in other areas as well. The stethoscope diaphragm is used to detect the high-pitched sounds, like the first and second heart sounds, or S1 and S2, murmurs, and pericardial friction rubs. The bell piece is more likely to detect the more low pitched sounds like the third and fourth heart sounds, or S3 and S4, and other murmurs. The examiner should listen at each of the five areas, paying particular attention to the location and intensity of each sound, and for the presence of any "splitting" of the sounds. Sounds that are heard in between the regular heart sounds may be accentuated by having the patient sit up, lean forward, exhale completely and stop breathing momentarily in expiration. Allow the patient to breathe normally, periodically catching his breath throughout the exam. Abdomen: The abdomen is best assessed with the patient in the supine position (lying on the back) with an empty bladder. Taking the time to make the patient as relaxed as possible will facilitate the examination. Examination for symmetry, distention, masses, skin condition (striae or stretch marks, color, scars, venous patterns, condition of the umbilicus), effect of respirations on abdominal movement, and visible peristalsis is included. Auscultation is employed next before palpation or percussion which may stimulate peristalsis. The examiner should listen with the diaphragm piece in all four quadrants of the abdomen.