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On sigmoidoscopic examination 8h9 treatment buy generic rumalaya line, there is a hard non-obstructing mass of 4 cms about 3 cms above the anal verge symptoms miscarriage discount rumalaya 60pills without a prescription. The cause of hypotension is possibly a) intrathoracic and abdominal bleed b) fracture rib c) intracranial bleed d) neurogenic shock Ans (a) 53) On prenatal ultrasound examination symptoms qt prolongation proven 60 pills rumalaya, the diagnostic feature of congenital diaphragmatic hernia is a) absence of gas bubble under the diaphragm b) mediastinal shift with normal heart axisc) peristalsis in the thoracic cavity d) a cyst behind the left atrium Ans (c) 54) A 40 year old male symptoms 3 weeks into pregnancy order rumalaya 60 pills overnight delivery, Kallu, a chronic smoker, presents with claudication and a medial leg ulcer. The diagnosis is a) Peutz-Jeghers’ syndrome b) Carcinoid c) melanoma d) villous adenoma Ans (a) 61) the commonest site of carcinoma prostate is a) Transitional zone b) Central zone c) Peripheral zone d) Anterior zone Ans (c) 62) Dissociative sensory loss is seen with a) Tabes dorsalis b) Syringomyelia c) Ans (b). The best method to detect this would be a) right side chest Xray b) Left sided chest Xray c) Left lateral decubitus chest Xray d) Right lateral decubitus chest Xray. The diagnosis is a) Seborrheic dermatitis b) Contact dermatitis c) Psoriasis d) Porphyria cutanea tarda Ans (d) 73) An 8 year old boy presents with a well defined annular lesion over the buttock with central scarring that is gradually progressing over the last 8 months. The diagnosis is a) myopia b) pseudomyopia c) hyperopia d) emmetropia Ans (b) 81) A 16 year old boy complains of pain in the right eye. The diagnosis is a) phakomorphic glaucoma b) phakolytic glaucoma c) phakotoxic glaucoma d)phakoanaphylactic uveitis Ans (d) 84) A 60 year old male patient operated for cataract 6 months back now complains of floaters and sudden loss of vision. The diagnosis is a) vernal conjunctivitis b) phlyctenular conjunctivitis c) trachoma d) viral conjunctivitis Ans (a) 86) A 25 year old lady presents with severe sudden onset of pain, corneal congestion, photophobia and deep anterior chamber in the right eye. On examination, both the lacrimal duct systems are normal, but there was a large cornea and corneal haziness. The diagnosis is a) megalocornea b) keratoconus c) congenital glaucoma d) Hunter’s syndrome Ans (c). The next line of management is a) tracheostomy b) microlaryngoscopy c) broad spectrum antibiotics d) systemic steroids Ans (b) 94) A 28 year old female presents to the casualty with gradually increasing respiratory distress since 4 days. The next line of management is a) tracheal resection and end to end anastomosis b) tracheal dilatation c) systemic steroids d)laser excision and stent insertion Ans (d) rd 0 95) A 30 year old male, following excision of the 3 molar for dental caries presents with trismus, fever of 39. The diagnosis is a) fracture neck of femur b) anterior dislocation of the hip c) posterior dislocation of the hip d) trochanteric fracture of the femur Ans (c) 97) An 8 year old boy presents with a gradually progressing swelling and pain since 6 months over the upper tibia. On Xray, there is a lytic lesion with sclerotic margins in the upper tibial metaphysis. The test done by the orthopedician is a) apprehension test b) sulcus test c) Ans (a) 100) Regarding bone remodelling, all are true except a) osteoclastic activity at the compression site b) osteoclastic activity at the tension site c) osteoclastic activity and osteoblastic activity are both needed for bone remodelling in cortical and cancellous bones d) osteoblasts transforms into osteocytes Ans (fi While doing this the child started crying and does not allow his father to touch his elbow. The diagnosis is a) pulled elbow b) radial head dislocation c) Annular ligament tear d) Fracture olecranon process Ans (a) 102)The structures piercing the clavipectoral fascia are all except: a) Cephalic vein b) Thoraco acromial artery c) Lateral pectoral nerve d) Lateral pectoral artery Ans (d). Ans (b) 107) During sigmoidoscopy, if the rectum is inflated with gas, increased peristalsis is seen in a) Whole intestine b) Distal colon c) Proximal colon d) Whole colon Ans (fi The diagnosis is a) Malignant hyperthermia b) Neuroleptic malignant syndrome c) Tardive dyskinesia d)akathesia Ans (b) 128) A patient on cisapride for Barrets ulcer suffers from pneumonia. Which of the following is the correct statement a) Increase the dose of cisapride needed b) Increase the dose of erythromycin needed c) Increased risk of Ventricular arrythmias present d) Decreased bioavailability of cisapride Ans (c) 129) A 60 year old male comes to the casualty with acute retention of urine since 12 hours. His son gives a history of taking some drugs by the patient since 2 days as he is suffering from depression. The diagnosis is a) Acute mania b) Acute psychosis c) Schizophrenia d) Psychosexual disorder Ans (a) 131) Rathi, a 26 year old female diagnosed to be suffering from depression now for the past 2 days had suicidal tendencies, thoughts and ideas. The diagnosis is a) Schizophrenia b) Acute psychosis c) Acute mania d) Delirium Ans (b) 133) A 60 year old male suffering from auditory hallucinations is says that people staying upstairs are talking about him and conspiring against him. He dropped a police complaint against them but the allegations were proved to be wrong. The treatment of choice is a) Estrogen b) Progesterone c) Estrogen-Progesterone d) None. The diagnosis is (a) corpus luteum cyst b) ectopic pregnancy c) Incarcerated abortion d)Threatened abortion Ans (c) 160)Kamla, a 48 year old lady underwent hysterectomy. On the seventh day, she developed fever, burning micturiton and urinary dribbling. The diagnosis is a) uretero-vaginal fistula b) vesico-vaginal fistula c) Urge incontinence d) Stress incontinence Ans (a) 161)A patient treated for infertility with clomiphene citrate presents with sudden onset of abdominal pain and distension with ascites. The probable cause is a) Hyperstimulation syndrome b) Uterine rupture c) Ectopic pregnancy rupture d) Multi fetal pregnancy Ans (a) 162) A woman at 8 months of pregnancy complains of abdominal pain and slight vaginal bleed. Which one of the following is true a) 95% of all children weigh between 12 and 18 Kg b) 95% of all children weigh between 13. Ans (a) 187) Malaria incidence in a village in the year 2000 is 430, 500, 410, 160, 270, 210, 300, 350, 4000, 430, 480, 540. If a missile enters the body just above the pubic ramus through the anterior abdominal wall, it will most likely pierce which of the following structures a. On examination there was distension of abdomen and the stools were maroon colored. When the following aminoacids are separated by running them on agarose gel, at pH 7, which one of them will migrate slowest to the anodic end a. On examination there was an abdominal mass, which showed calcification near the left kidney. Echo cardiography of the heart showed normal cardiac morphology with asymmetric septal hypertrophy. Under the National Polio Eradication Program, a case of Acute Flaccid Paralysis is confirmed as Polio, under the following circumstances except a. In a group of persons taking part in a controlled trial of an antihypertensive drug, the Blood Pressures were measured before and after giving the drug. Kalloo 45 years old, having a 10 year history of alcoholism, presents with complaints of confusion, ataxia, ophthalmoplegia and peripheral neuropathy. Lalloo, 60 yrs of age, a known case of cirrhosis liver, presents with increased levels of Alpha feto protein, hepatomegaly 3 cm below costal margin. A patient with choriocarcinoma, is not responding to the usual doses of methotrexate. Arterial embolisation Ans:(b) Ref:Synopsis of Emergency pediatric Medicine p687, Nelson p1527 40. On examination there is a single enlarged painless lymphnode in the left supraclavicular area. Kalloo 45 years presents with a swelling in the thyroid gland and a lymphnode in the neck. On examination there were two symmetrical ulcers on vulva, which were well defined with a firm base. Carcinoma endometrium with involvement of inguinal nodes belongs to which stage a. Scanty, foul smelling, painless discharge from the ear is a characteristic feature of which of the following lesions a. A man was diagnosed to have myositis ossificans progressiva at the age of 20 years. A child was taken to the doctor by his mother, complaining that there is decrease in his school performance. Which of the following is the commonest infection which causes blind ness in adult men a. All the following anatomical changes will predispose to primary angle closure glaucoma except a. On examination direct pupillary reflex is absent and consensual reflex is present. Basanti, an 8 year old girl, presents with recent onset of genu valgum and difficulty in walking. Left to right shunt, Right ventricular hypertrophy, Pulmonary hypertension, Right to left shunt b. Left to right shunt, Right ventricular hypertrophy, Right to left shunt, Pulmonary hypertension d. Pulmonary hypertension, Right to left shunt, Right ventricular hypertrophy, Left to right shunt Ans:(a) Ref:Old Ghai p239,242 105. The doctor wants to sent a stool sample to a lab in the periphery which is 16 18 hrs away. Laparotomy of a lady with a suspected ovarian tumor showed bilaterally enlarged ovaries with smooth surfaces. Conjugated bilirubin in blood was 38mg/dL, and there was urine urobilinogen and bile pigments. Fothergill can lead to second trimester abortions but not in first trimester, and the fibrosis of cervix after amputation can lead on to dystocia 118. A five year old male child presents with complaints of fever and abdominal distension. An excretory urogram showed a filling defect towards the lower renal infundibulum 1.

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Int J of smoking among school adolescents in Khartoum Community Med Public Health 2016; 3:538-541 symptoms concussion 60pills rumalaya with amex. Smoking among among secondary school male students in Jeddah medications kidney disease purchase rumalaya 60 pills with mastercard, secondary school students in Kota Tinggi medications bad for liver discount rumalaya online amex, Johor medications 319 buy online rumalaya, Saudi Arabia: a survey study. Cigarette smoking habits among adolescents in cigarette smoking among adolescents in China. East Mediterr Health J influences on adolescent smoking by developmental 1999; 5:440-449. In this study, we reviewed the determined based on tumour subtype, location, and size. Specifcity-sensitivity values Design: Retrospective study according to histopathological group were as follows: Seting: Thoracic Surgery Department of Kocaeli 76. The 5-year survival rate is approximately the diagnostic accuracy is quite high in these cases. Only 16% of lung cancer cases are diagnosed in diagnosis via minimally invasive methods must the early stages[1]. Surgical treatment of lung cancer has a In this study, 162 patients who underwent lung relatively low prevalence rate (20%). There was no statistical cases, extension of bleeding time due to aspirin usage diference between the male and female patients in was observed. When lesions were surgery and control coagulometric measurements evaluated according to location, 56 (34. When classifed according of the patient’s radiologic images was used to evaluate to size, there were 88 (53. After determining the path of the needle, 3 5 groups were included in logistic regression analysis ml of 1% lidocaine was injected subcutaneously into between localizations. The same pathologist observed this process (21%) cases had pneumothorax and 11 (6. Complications such as were observed in the emergency department for 6 pneumothorax and haemorrhage were evaluated hours; they were discharged after examined control during the same stage. Normality of distribution of the data was evaluated using the Kolmogorov-Smirnov Test. Numerical variables showing normal distribution are shown as means ± standard deviation. Numerical variables not showing normal distribution are shown as median (25th – 75th percentile). The efective magnitude thoracic needle biopsy 34 Transthoracic Needle Aspiration Biopsy Experience of 162 Cases Operated for Non-Small. Specifcity-sensitivity values according to followed in the Department of Thoracic Surgery with histopathological group were as follows: 76. Subtypes of Number of cases In particular, determination of histological subtype is adenocarcinoma n (%) important for treatment planning. Biopsy techniques Acinar 30 (35) with a high diagnosis rate and low complication rate Solid 22 (25) are considered to be optimal[6]. In these respects, it is Lepidic 18 (21) clear that the value of transthoracic biopsy is quite Mucinous 5 (6) Papillary 3 (4) high. The pneumothorax rate in our cases was 21% and At this time, targeted inhibitors are used against tube thoracostomy was applied to 3% of these cases. No to determine adenocarcinoma subtype, the number additional surgical intervention was required. Of our 86 post-operative In a previous study, the malignancy potential for adenocarcinoma cases, 30 (35%) were acinar, 22 5 10 mm lesions was 6 28% and 64% 82% for 20 (25%) were solid, 18 (21%) were lepidic, 5 (6%) were mm-sized lesions[9]. Since the malignancy potential mucinous, 3 (4%) were papillary, and 8 (10%) were of small lesions is relatively low, surgery is not “other” tumours. Number of passes has a signifcant efect with high malignancy potential, exclusion of small on diagnosis because obtaining insufcient material cell lung cancer is very important. Thus, when the pathologist on our team obtained increases the false-negative rate[11] because, in wide sufcient material for malignancy distinction, the consolidation, it is difcult to distinguish malignant process was considered complete. While the same cells within the primary lesion from atelectasis and approach is used by many clinics, the determination infamed areas[11]. Fassina A, Corradin M, Zardo D, Cappellesso R, areas were determined according to this evaluation. Cytopathology 2011; 22:306biopsy to determine whether sufcient material has 312. In our cases, a pathologist was present guided transthoracic needle biopsy of lung lesions: during the biopsies. The role of bronchoscopy and clinical characterization of false negative results in lung cancer. Conclusions: Only music has efect on reducing anxiety Main outcome measure(s): Anxiety in parity I group and those with under diploma level of Results: There were signifcant diferences between the mean education. Sedatives or antianxiety drugs are normally experience anxiety due to the risk of normally administered before surgery to decrease unpredictable events that may threaten their the anxiety of patients, although, sedatives usually health. High levels of anxiety lead to some negative have adverse efects including sleepiness and outcomes including elevated blood pressure, respiratory depression, and may possibly interfere increased levels of cortisol, elevated heart rate, with anesthetic agents and can prolong the recovery slower wound healing, reduced immune response, and discharge of patients[3]. High anxiety levels anxiety of surgery, more atention is paid to noncould have a negative efect on the induction pharmacological interventions[3,4]. Previous studies have shown that the were randomly divided into 3 groups: music group, anxiety of being awake during surgery is one of the ear plug group and control group, each including 30 main reasons for choosing general anesthesia[5,6]. The sample size was determined with the studies have evaluated the efect of playing music confdence interval of 95% and the power of 90%. Kushnir et al’s study has assessed the efect was used to evaluate the individuals’ anxiety and to of listening to favorite music just before the cesarean assess how they react to mental pressure. In another designed by Spielberger et al and contains 40 questions, study by Li et al on women undergoing cesarean among which 20 are related to state anxiety which is delivery, it was demonstrated that preoperative music infuenced by the situation and the other 20 are related intervention can decrease anxiety and pain[8]. In a to trait anxiety that is infuenced by the current feeling study by Gonano et al, in orthopedic surgery after of the subjects. The test retest reliability of the test was sedation with propofol, the case group used earplug from r = 0. Ni et al Zarghami defned the internal consistency of the test revealed that music reduced preoperative anxiety and which was Cronbach’s fi = 0. After ensuring the correct spinal anesthesia, while the anesthesiologist is required location of the puncture, spinal anesthesia with a to control the anxiety of patients during surgery. This condition in case of high levels of anxiety with the noise reduction rating of 30 db) was used for may lead to rejection of spinal anesthesia, while spinal individuals. In a study by In the music group, in addition to routine medical Berbel et al, the efects of diazepam and music were care, through a headphone the “Motivation” piece of evaluated in preoperative patients’ anxiety and it was Doctor Arand Ashtian, a sedative musical piece of the shown that the efect of music and diazepam were Iranian Music Therapy Association, was played during similar in patients’ anxiety[12]. In previous studies, the pre-operation interview Headphones or ear plugs were applied after dural and visit, spousal participation in delivery, preparing puncture and went on until the end of surgery and the pamphlet about the surgery, playing music during was only discontinued before starting surgery for surgery and using ear plug were used to decrease the evaluation of anxiety. Therefore, the anxiety levels of the individuals were more studies in this area are needed. March 2018 diference between the scores in three groups in prethe result of the present study revealed that music test, the result of post-test score showed a diference signifcantly reduces the anxiety of pregnant women. The result of Tukey test revealed that the result of this study was consistent with some other the diference was related to the diference between studies. Koelsch et al in 2011 have evaluated the efect the scores of music and ear plug (p = 0. One hundred and sixty seven patients were the results show that only music is efective in randomly divided into broadcast, headphone and score reduction and this efect is signifcant in under control group. It was Table 5 demonstrates that for individuals under 30 revealed that both headphones and broadcast music years of age, there were signifcant diferences between were efective in reducing the anxiety of patients[16]. In a study scores in three groups pre-test, the result of post-test by Merakou et al which evaluated 200 patients who score showed diference among groups. The result underwent cataract surgery, it was demonstrated that of Tukey test revealed that the diference was related meditation music had an efect on preoperative stress to the diference between the scores of music and ear and anxiety and reduced their systolic blood pressure. They recommended that music could be used as an alternative method to stabilize blood pressure in patients undergoing cataract surgery[18]. It also down-regulates Age < 30 (years) the activity of the central nucleus of the amygdale, Pre-Test 21. Many studies have shown that listening In patients fi 30 years old, there was a signifcant to pleasant music reduces cortisol levels, a hormone related to anxiety[15,24,25]. In a study by Gonano et al in Austria in 2010 anxiety of subjects and they may tend to have general on 50 patients who underwent orthopedic surgery, anesthesia. In the present study, we tried to assess the after using propofol, patients of intervention group efect of music and using ear plug on reducing the used ear plugs.

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Jones before medicine 1700s order rumalaya with mastercard, performs a comprehensive medications equivalent to asmanex inhaler cheap rumalaya 60pills line, multisystem physical examination and completes a comprehensive history with a complete review of systems and extensive past medical history review 9 treatment issues specific to prisons order cheapest rumalaya and rumalaya. Stouffer recommends a new insulin regimen in addition to symptoms 3 months pregnant order rumalaya 60pills without prescription other medications to manage what might be a postoperative wound infection. Stouffer’s medical decision making is of moderate complexity because he has to consider multiple diagnoses, a moderate amount of data, and the moderate risk of complications that Mrs. Documentation guidelines Medicare recipients account for the majority of patients receiving services in the American health care system. Thus, any change by the third-party payer, Medicare, has dramatic effects on the health care system. One such change that currently is in development is the documentation necessary when submitting a claim for Evaluation and Management services provided to a Medicare patient. The standards are informational items that must be in the patient record to substantiate a given level of service. These guidelines apply only to E/M services and only to patients covered by Medicare and Medicaid. The 1995 Documentation Guidelines are posted on the Evolve website for this text (see Appendix A for free access information). The 1995 guidelines are easier to understand because they are not lengthy or complex. A new set of guidelines was published in July of 1997 for implementation on January 1, 1998. The 1997 set of guidelines was intended to be the standard used when reviewing claims for payment and is also posted on the Evolve website for this text (see Appendix A for free access information). If the physician did not have the documentation required in the guidelines, payment would be adjusted based on what was actually in the medical record. The 1997 Documentation Guidelines specify the information that must be documented in the medical record for an E/M service to qualify for a given level of service. Note that for an examination to qualify as an expanded problem focused examination, the medical record must document that the physician performed at least six of the elements identified by a bullet (•) in. If the medical record documents that only five of the elements identified by a bullet were performed, the examination would have to be reported at the lower problem focused examination level. Although the guidelines will continue to be revised, documentation guidelines will be a part of the standard for the medical record now and in the future for Medicare and Medicaid patients. You can anticipate that, as a coder, you will be required to learn about and follow these documentation guidelines. Chapter 11, learning objective review Review the Chapter Learning Objectives located at the beginning of the chapter, then answer the following questions that relate to each objective (Answers are located in Appendix E): 1 Office, hospital, emergency department, and nursing home locations describe what factor in code assignmentsfi Considering that the patient is otherwise healthy and has a primary care physician caring for him, the dermatologist focuses the history of the present illness on the skin lesions (problem focused history) and focuses the problem focused physical examination on the patient’s trunk. The physician concludes with straightforward decision making that the lesions are sebaceous cysts. The physician advises the patient that the lesions should be monitored for any changes but that no surgical intervention is warranted at this time. The patient also states that she thinks the medications are causing her to have gastrointestinal problems while not relieving her symptoms. The physician performs a detailed history and a detailed physical examination of her cardiovascular, respiratory, and gastrointestinal systems. The physician indicates that the decision-making process is moderately complex, given the number of conditions it is necessary to consider. The patient wants a gynecologic examination and wants to discuss contraceptive options with the physician (think Preventive Medicine Services! The physician collects pertinent past and social history related to the patient’s reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history of her present physical state. A physical examination includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient’s history of not tolerating certain types of oral contraceptives in the past, the physician’s decision making involves a limited number of management options, all with low risk of morbidity to the patient. The patient is dehydrated and has been experiencing dizziness and mental confusion for the past 2 days. Prior to this episode the patient was well but became acutely ill overnight with these symptoms. Given the abrupt onset of these symptoms, the physician has to consider multiple possible causes and orders a variety of laboratory tests to be performed. A comprehensive history is collected, and a comprehensive head-to-toe physical examination is performed. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical examination to reflect the patient’s current status. The patient’s problem is of low severity but requires ongoing active management, with possible surgical consultation. The physician focuses on the problem of the diaper rash for the problem focused history and examination. The man, who is an established patient, has been experiencing severe leg pain of 2 weeks’ duration. In the past 2 days, the patient has experienced fainting spells, nausea, and vomiting. The patient has had multiple other vague complaints over the past month that he dismissed as unimportant, but his wife is not so sure, and she describes his general health as deteriorating. The physician performs a comprehensive multisystem physical examination after performing a complete review of systems and a complete past medical, family, and social history, with an extended history of the present illness (comprehensive history). She describes a feeling of fullness and tenderness over the mass that has become more pronounced in the past 2 weeks. Because the patient is otherwise healthy and has had a physical within the past 6 months, the physician focuses his attention on the breast lump during the taking of a problem focused history and the performance of a problem focused physical examination. The physician orders an immediate mammography to be performed and a follow-up appointment in 5 days. Anesthesia means induction or administration of a drug to obtain partial or complete loss of sensation. Analgesia (absence of pain) is achieved so that a patient may have surgery or a procedure performed without pain. Moderate (conscious) sedation is not reported with anesthesia codes but rather is reported with Medicine codes. The practice of anesthesiology is not limited to administration of anesthesia for the surgical patient. Some types of anesthesia are named for the site of the anesthesia administration, such as sacral, lumbar, and caudal. Other types of anesthesia are named for the category of anesthesia, such as freezing (frost) for cryoanesthesia. Some of the more commonly used anesthesia terms are endotracheal, epidural, regional, and patientcontrolled analgesia. A blood patch procedure is when a cerebrospinal fluid leak is closed by means of an injection of the patient’s blood into the epidural space at or near the area of the dural puncture that was accessed during spinal anesthesia. A device is attached to a pump holding the drug and the patient can depress a handheld button to administer a dose of the drug. In this way, the patient can control the amount of the drug and the frequency of administration. The patient is monitored, and if necessary, sedation is provided; even general anesthesia. The patient is in a deep state of sedation and is not arousable or able to communicate or follow commands. Several different types of medication may be used during general anesthesia, including drugs for analgesia (pain relief), sedation, amnesiacs (to lessen awareness), and paralytics for muscle relaxation to prevent movement or reflexive action by the patient during procedures. Epidural catheters are often placed to facilitate administration of medication into the spinal region. Moderate (conscious) sedation Moderate or conscious sedation is a type of sedation that can be provided by a surgeon or the surgeon’s staff while the surgeon is performing a procedure; it provides a decreased level of consciousness that does not put the patient completely to sleep. This level of consciousness allows the patient to breathe without assistance and to respond to stimulation and verbal commands.

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The life cycle of all these ticks is similar treatment pink eye discount rumalaya 60 pills with visa, with small variations among the genera symptoms of hiv rumalaya 60pills generic. The female produces several thousand eggs at a time for a few days symptoms valley fever quality 60 pills rumalaya, and then dies symptoms ear infection buy rumalaya visa. Hexapodal larvae emerge from the eggs; they measure about 1 mm in length, feed on blood for a few days, and molt into nymphs a few days thereafter. The adults mate, the female sucks blood in amounts that can exceed 10 times her body weight for several days—an engorged hard tick is the size of a pea—and falls to the ground, seeks out a protected place, and begins to produce eggs. Hard one-host ticks remain with a host from the larval stage until adulthood; two-host ticks remain with one host during the larval and nymph stages, but molt on the ground and the adults have to seek out another host; three-host ticks molt on the ground and need a different host in each stage—larva, nymph, and adult. These differences are important in the spread of disease and the design of tick control plans. Geographic Distribution and Occurrence: the transmission areas of tick-borne infections are shown in Table 4. The distribution of the ticks themselves is diverse; those of the genus Amblyomma are mainly parasites of small and large mammals distributed throughout the tropical and subtropical areas of the Americas and subSaharan Africa. Ticks of the genus Boophilus are parasites of cattle, and, exceptionally, of other herbivores, and are distributed in tropical to temperate zones throughout the world. Ticks of the genus Dermacentor are parasites of rodents and large mammals ranging from the tropical zone of Latin America to Canada. Ticks of the genus Haemaphysalis are parasites of small mammals and birds and are found throughout the world. Those of the genus Hyalomma are mainly parasites of domestic animals found in the Old World below the 45th parallel North. Ticks of the genus Ixodes are parasites of birds as well as large and small mammals and are distributed worldwide. Rhipicephalus are ticks of a variety of African and Eurasian animals; only Rhipicephalus sanguineus is distributed worldwide. Humans can be infested by 12 species of Argasidae (Argas and Ornithodoros) and 22 species of Ixodidae (4 of the genus Amblyomma,7of Dermacentor,3of Haemaphysalis,2of Hyalomma, and 6 of Ixodes) (Estrada-Pena and Jongejan, 1999). The most common were Amblyomma americanum in the south and near the Atlantic Ocean; Dermacentor variabilis and Ixodes scapularis in the east; Dermacentor andersoni in the west; Ixodes pacificus near the Pacific; and Ornithodoros spp. North Carolina reported human infestations with Otobius megnini, Amblyomma maculatum, Haemaphysalis leporispalustris, Ixodes cookei, Ixodes dentatus, and R. In one locality in Italy, during 1995 and 1996, 240 infested individuals were found, with an average of 1. Eleven percent of the cases occurred in children, 26% in students, 22% in workers, and 24% in retired persons. During the period studied, the prevalence of bites was 5 per 1,000 residents (Manfredi et al. The Disease in Man: Ticks cause damage directly by biting and by sucking blood, since they cause allergic reactions by injecting toxins and transmit infections. It has also been found that ticks cause a depressed immune response (Barriga, 1999), but the importance of that is probably minimal. It may be that the direct damage ticks cause is slight in human beings because the majority of infestations are due to a single arthropod and the patient does not notice it. The case of Amblyomma testudinarium of Japan is noteworthy, since it caused infestations with more than 100 larvae (Nakamura-Uchiyama et al. The mouthparts that remain in the wound when the tick is removed can cause a granuloma that looks like a pustule and lasts for several weeks. Ticks are generally not included among the arthropods that cause allergies; however, there are reports of severe allergic reactions. For example, symptoms have been reported ranging from erythematous reactions to ulcerative lesions caused by Argas reflexus (pigeon tick) (Veraldi et al. A paralysis caused by the female of certain ticks feeding on their hosts has been described in both animals and humans; approximately 20 species have been identified: D. While it is suspected that the paralysis is due to a toxin, it has been identified only in the case of the Australian tick I. The patients experienced an ascending symmetrical flaccid paralysis that causes respiratory paralysis after about a week; the illness ends when the arthropod is removed, but recovery is slow. Transmission of infection is the most serious concern in connection with tick infestation of humans. Since the number of ticks that attack a single animal can be very high, inflammation, pain, and pruritis are intense, due either to the trauma or hypersensitivity, and distract the cattle from feeding, in addition to causing weight loss. Also, the wounds caused by the ticks can ruin the skins for industrial use and attract fly attacks that result in myiasis. The sucking of blood can be significant when the infestation is intense and can also promote weight loss, since the cattle have to expend energy to replace the blood loss. With respect to the transmission of disease, ticks play a role as important for animals as mosquitoes play for humans. Some of the most severe cattle diseases are tick-borne, such as babesiosis (see chapter on Babesiosis), theileriosis, cowdriosis (hydropericardium), and anaplasmosis (Uilenberg, 1997). Source of Infestation: the source of infestation is the environment contaminated with ticks; in the case of hard ticks, the vegetation where the hungry larvae are found in large numbers; in the case of soft ticks, the dwellings with cracks where they can find shelter during the day. While infested animals are the source of contamination of the environment, they are rarely a direct source of infection for man or other animals. Studying them should not be difficult because even the tick larvae measure more than 1 mm, and they are red or dark after feeding. However, the tick is often located on parts of the body where the infested person cannot see it, including behind the ears, where even the doctor can miss it if he or she is not specifically looking for it. When removing a tick, it is important to extract the mouthparts from the skin to prevent the formation of granulomas; to ensure this, the body must be pulled continuously for one minute, without excessive force, in a direction perpendicular to the patient’s skin, until the grip is loosened. It is advisable to remove the tick with tweezers or a plastic sheet to avoid contact with its blood if it should explode, since the fluid may contain pathogenic organisms. Taxonomic identification is rarely necessary but, if it is desired, the specimens should be packaged in 70% alcohol and sent to the Department of Agriculture or university veterinary services. Control: Control of animal ticks is based essentially on the periodic application of acaricides to animals at risk for infestation. An inevitable consequence of this method is the development of strains of ticks resistant to the acaricide. This situation is common in cattle-raising countries with high rates of tick infestation, such as Brazil and South Africa. Modification of the environment to make it unsuitable for the proliferation of ticks is complicated, and not enough is known about their ecology to ensure success. A large number of biological control experiments have been carried out employing the natural enemies of ticks (Samish and Rehacek, 1999), but practical solutions have not been found. Many experiments have also been conducted in an attempt to develop breeds of cattle with a natural resistance to these arthropods, but, despite encouraging results, a meaningful solution has not been found. However, in the short term, the ticks continue to bite and transmit infections; over the long term, that reduction in fertility could be insufficient to decrease the proliferation of arthropods in the pasturelands. The European Union supports a project for the integrated control of ticks and tick-borne disease, with the objective of increasing livestock productivity through the control of ticks, vaccination, and the comprehensive diagnosis of the diseases (Jongejan, 1999). Also, techniques involving remote sensors and geographic information systems are starting to be used to help control these pests (Thomson and Connor, 2000). Rather, efforts are directed at protecting hunters and tourists who enter areas populated with ticks. For this, it is sufficient to wear clothing that covers the body completely, including high boots with pants legs closed around the boot tops. Ticks feeding on humans: A review of records on human-biting Ixodoidea with special reference to pathogen transmission. Attachment sites of four tick species (Acari: Ixodidae) parasitizing humans in Georgia and South Carolina. Tick species parasitizing people in an area endemic for tick-borne diseases in north-western Italy. Amblyomma testudinarium tick bite: One case of engorged adult and a case of extraordinary number of larval tick infestation. Environmental information systems for the control of arthropod vectors of disease. Etiology: the agent of this infestation is Tunga (Sarcopsylla) penetrans,asmall flea. The ovigerous female is an obligate parasite of warm-blooded animals, including swine, man, nonhuman primates, and dogs.