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Visual acuity is a subjective test meaning that if the patient is unwilling or unable to cooperate, the test cannot be done. A patient who is sleepy, intoxicated, or has any disease that can alter their consciousness or mental status, may not achieve their maximum possible acuity.
The 2-4-0 configuration was developed in the United Kingdom in the late 1830s or early 1840s as an enlargement of the 2-2-0 and 2-2-2 types, with the additional pair of coupled wheels giving better adhesion.