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This may be just inserting drains into the toxaemia may well kill the baby purchase cheap levitra plus online erectile dysfunction kuala lumpur, or even the mother! The condition may then improve sufficiently to perform a laparotomy much more safely later buy levitra plus 400 mg impotence after 50. Organs on the back of the As soon as the patient is draped generic levitra plus 400mg with visa erectile dysfunction causes cycling, and anaesthetized, and the abdominal wall are seen through the posterior parietal peritoneum. The primary objective of the operation is the pelvis, this may be due to gas-forming organisms. Always lift up bowel from behind with (appendicitis, salpingitis, perforated peptic ulcer, your fingers, never pull it! Occasionally you will be able to lift a whole ruptured ovarian lutein cyst) clump of bowel out of the abdomen, and be able to work pale straw-coloured fluid on it outside, whilst packing away the rest of the incision. If it is walled off from the rest of the abdominal porridge-like material cavity and this is unaffected by sepsis, just drain it and (ruptured dermoid cyst) leave the remaining abdomen alone or you will spread sticky mucous fluid infection into a clean peritoneal area. Generalized peritonitis, particularly of some days peritonitis by adding more organisms to the bacterial soup duration, will always have distended loops of bowel already present and you increase the chances of a faecal present. Do not waste sucker; or else, mobilize the bowel out of the abdominal time at this stage by repairing the perforation: do this after cavity, and drain the contents into a bowl holding the open you have freed all the bowel. This is messy, but as You may need to sacrifice an impossibly matted segment long as you take care to avoid spillage of contents into the of bowel (11. If then you do perforate it, you wont spill its a small hole on the anti-mesenteric border of the bowel, contents. Physiology takes the anaesthetist is inexperienced, or the patient is a child precedence over anatomy. You should know where this might If the peritonitis is localized, pack off the affected area be from: and then lavage or mop out the infected space. You do not need to use saline: 10l of warm (3);If you find localized pus, try to minimize its spread sterile water is preferable to 500ml of saline! Otherwise you may damage the viscera or bowel, simply in a vain attempt to make the abdomen Inspect the abdominal cavity thoroughly, unless you are look clean! All necrotic tissue must be removed; this may multiple intra-abdominal collections, because the area to entail resection of bowel. Trendelenburg for pelvic sepsis, and pack away the suction, and irrigate it with liquid to keep it open. If the intra-abdominal tension remains high, First, you will have to find it, and this may not be easy. Look for signs of (1);you expect to have to look inside again within 48hrs, inflammation (pus or adhesions), of perforation, e. For this (2) there is gross faecal soiling or sepsis requiring repeated reason, keep these books in theatre! Remember damage control a septic abdomen, even wearing 2 pairs of gloves: laparotomy. The decision how to proceed depends on the no amount of soap or perfume will remove the odour, condition. Review the charts carefully each You should not have to pull the abdominal wall together day for complications. Go back and decompress the general state of alertness, the abdominal girth, the bowel bowel. If there is generalized peritonitis, (1) Abdominal sepsis (may lead to septic shock). Intra-abdominal sepsis is an extremely output (if possible 2hrly for the first 48hrs). Use a Pauls difficult diagnosis to make, particularly post-operatively, tubing (condom catheter) in a young male; remember and you will often wish you had made it earlier. Direct your attention to the the fluid balance is stable (at least for 48hrs, usually source of the problem, rather than randomly extracting 3-6days). The common error is not to infuse enough fluid loops of bowel and dividing adhesions unnecessarily. If the Re-open a patient with severe generalized peritonitis initial fluid resuscitation was inadequate, there may still be routinely after 48hrs in order to: a deficit to make up. Start them (4) check bowel anastomoses for patency, when the postoperative diuresis begins. If there was major blood loss during the corners of the abdominal cavity, operation (>2l), especially if previously anaemic and this (6). Look at the clinical response, rather than by the Make sure you do not fail to treat tuberculosis. Do not wait for a complete burst abdomen; return to theatre for closure of any residual defect with interrupted sutures. If fever persists, there may be a postoperative wound, chest or urinary infection, deep vein thrombosis or there is further intra-abdominal sepsis. If there is a mass which was not present previously, get an abdominal radiograph: it may be a retained swab! If there is diarrhoea, especially with the passage of mucus, suspect a pelvic abscess (10. If this is upper small bowel fluid (thin yellow), it may produce disastrous fluid and Fig. C, pelvic abscess fistula, and the output is <500ml/day, it should close pointing into the vagina. Use low-pressure suction to keep the fistula wound dry, and make sure feeding continues and you correct potassium losses. Localized septic collections (these are rarely true (3);A laparotomy during which the abdominal cavity was abscesses) in the abdominal cavity can be the result of: contaminated (10. Generalized peritonitis: they are one of its major (4) A ruptured liver abscess (15. Some primary focus of infection, such as appendicitis Suspect that there is a subphrenic abscess if there is a or salpingitis. If loops of the bowel the right or left subphrenic space, or under the liver in the pass through the abscess, they may become obstructed, right or left subhepatic space in the lesser sac. This is dangerous and misleading: do it with harm; missing a subphrenic abscess and doing nothing is ultrasound guidance. A subphrenic abscess, pyelonephritis, pyonephros or perinephric abscess can all cause similar tenderness posteriorly. If the patient is thin and the pus is superficial, you may feel a tender indurated mass under the costal margin in front (right subphrenic space), in the right flank (right subhepatic space), or posteriorly. He had shoulder-tip pain, but he also said he had pain when he put the tongue out, so it was first thought that he might be hysterical. The following day the abdomen started to distend, and aspiration of the abdominal cavity withdrew greenish fluid. A laparotomy was done, and an ulcer on the greater curve of the stomach was found and repaired.

Pick up the linea alba with straight forceps 400 mg levitra plus erectile dysfunction doctors in south jersey, and cut gently with the knife in the midline till you see the posterior rectus sheath and peritoneum purchase levitra plus 400 mg line erectile dysfunction female doctor. Lift this up with 2 straight forceps best 400mg levitra plus erectile dysfunction doctor in chennai, feel it with your fingers, making sure you have not also picked up underlying bowel. It is a good idea to release one of the forceps, and re-apply them to let anything caught the first time slip away. Cut into the peritoneum with the knife (11-2A) and so allow air to enter the peritoneal cavity; the viscera will then fall away, allowing you to put in 2 fingers to check if there are any adherent underlying structures, tent up the peritoneum and divide it with blunt-ended scissors (11-2B). Do not hesitate to open the You cannot do good work if loops of bowel are always abdomen from top to bottom e. Sterilizeable light handles are very useful; umbilicus: it leaves a neater scar than going round it, otherwise make sure someone else in the theatre knows but remember to clean it thoroughly beforehand. Alternatively use a You can also get a little more length by incising between head-light. If you cannot see working on a lateral organ through the midline, make a exactly where the midline is between the rectus muscles, long incision. Do not become cross with midline, below the arcuate line, the peritoneum is attached him when the position of the retractor slips if he cannot only to transversalis fascia. You will never get below the umbilicus and cut through the anterior rectus adequate exposure in the pelvis unless the body is tilted in sheath, and underlying muscle; you should have diathermy the Trendelenburg position. Similarly, if you are working available to control bleeding from vessels in the muscle on the upper abdomen (as when exposing the oesophagus), layer. You can extend the incision in a table or by putting a pillow under the back will also help. Anchor each pack by its tape or corner to a large If the bleeding is annoying, rather than brisk, haemostat hanging outside the abdomen. Make sure the scrub nurse checks and counts the packs and instruments with you at the end of the operation. If you have diathermy, consider applying it to the Avoid leaving loops of bowel hanging outside the abdomen bleeding point with a fine-tipped dissecting forceps. Keep the bowel If there is a constant ooze during the operation: covered with warm wet packs. Take note of the smell, look at of 10% calcium gluconate after every 4th unit (500ml) of the fluid, gently divide adhesions, minimize the risk of blood. Limit your exploration to what is easily at least 2 units of fresh blood to replace clotting factors. Decide carefully (1);Do not stab blindly with a haemostat in a pool of though if the bowel is very stuck together whether you will blood! Draw each loop out of the wound, looking at Pinch it closed between your fingers while someone gently both sides, and at the mesentery. Finally look at the hernial 2 perforations near each other, it is best to sacrifice a orifices from inside. If necessary, look into the lesser sac segment of bowel and make one anastomosis (11. Intubation is not essential, but chest patient and want to examine them, hand them to someone drainage usually is. As soon as the tube has been inserted, close the will then not be contaminated by infection or malignancy. At the end of If you cannot do an operation through one incision, the operation insert an intercostal water seal drain (36. Keep your original one open until you have and leave it in place for at least 48hrs. This is one of the most critical procedures you will have to undertake, and if you are inexperienced, one which will give you much anxiety. It is one of the few surgical methods which you can usefully practise before you operate on a living human patient. You will usually anastomose bowel end-to-end, but there will be occasions when you will have to do it end-to-side, (as in a Roux loop) or side-to- side (as in a gastro- enterostomy, or cholecysto-jejunostomy) Do not be worried by the complexity of the methods which follow. If you bring only the mucosal surfaces together there will be no strength in the join and a leak is likely. Beware of mucosa pouting out after the first layer; it can easily do this at the mesenteric border. So if it does evert as a dog ear, push the ear back and close it over with the serosal layer. Do the suturing outside the abdominal cavity on a towel, or pack away the rest of the abdominal contents. This starts on the ante-mesenteric border to the mesenteric border C, where it turns round to close the anterior layer the bowel and D meets the beginning of the suture again back at the antimesenteric border. Pitfalls: I, bowel closed longitudinally (which will result in stricture formation). J, bowel cut obliquely in a way which reduces the blood supply to an area on the ante-mesenteric border of one loop. L, mesentery bunched together with a suture which occludes the vessels supplying the bowel. Avoid this disaster by emptying the bowel every time you Note that any sutures which go right through the wall of make an anastomosis. You will need to make sure that the the bowel (and so might leak) are usually infolded by a bowel reaches outside the abdomen, and emptying it does 2nd layer of sutures which go through serosa and muscle not contaminate the peritoneal cavity, the very thing you only; these are called Lembert sutures. Make the Lembert sutures of the 2nd layer bring the serosa If you cant make the bowel reach outside the abdomen, of one loop into contact with the serosa of the other loop. This will not work in Only put them through the outside peritoneal layer, the the distal small bowel or colon because the content is muscle, and the submucosa (the strongest layer of the usually too thick, but that is where it is more important to bowel), and do not go through the mucosa into the lumen empty it! Avoid catgut: it dissolves just when the bowel of the bowel and clean them with swabs held in sponge is healing, and so needs a 2nd layer of sutures for forceps (swab-on-a-stick). Avoid cutting V-shaped needles on bowel content is very fluid, and your anaesthetist is ready to suck as these can produce a leak. The danger is spillage into the mouth, You will need to hold the bowel with stay sutures, and from there into the lungs, especially if the Babcock forceps (4. For any method of anastomosis the bowel crushing clamp with its jaws protruding well beyond the must be viable, which also means that its blood supply edge of the bowel, because bowel widens as you crush it. Crushed bowel dies, so cut the crushed bowel away with the clamp before making an Wait to decide if the bowel is viable or not until you have anastomosis. Cut the bowel strictly transversely, removed the cause (divided an obstructing band, not obliquely (11-5J). As you do this, be sure there is a or untwisted bowel which has twisted on its mesentery). Crushing clamps are thus always used Base your decision on several of these signs, not on one in conjunction with non-crushing ones. You will often have to operate on bowel when it is distended and full of intestinal content: this fluid has Bowel is viable if: millions of bacteria, particularly anaerobes. If you are going to do this, the non-viable bowel must: (1) not be perforated, (2). Use 2 layers of absorbable suture to bring the serosal surfaces of the healthy margins together in the transverse axis, so as to invaginate the non-viable segment into the lumen of the bowel where it can safely necrose.

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This liquefied food is then drawn up by the mouthparts and passed onto the digestive tract purchase levitra plus canada erectile dysfunction at age 35. During daylight hours house flies will rest on floors purchase levitra plus 400 mg overnight delivery erectile dysfunction yahoo, walls and ceilings indoors cheap 400 mg levitra plus free shipping erectile dysfunction at age 27. Outdoors they will rest on plants, on the ground, on fence wires, garbage cans and other similar surfaces. At night they will rest principally on ceilings, electric wires and dangling light cords indoors. In all situations they prefer corners and edges or thin objects such as wires and strings. Night resting places are usually near daytime sources of food and are usually 5 to 15 feet off the ground. Exclusion and Sanitation: - Sanitation is the first measure of defense, even though there are various traps and sprays that are used to kill flies, it is necessary to eliminate the source in order to eliminate them. Killing adult flies will reduce infestation, but elimination of breeding areas is necessary for good management. Trapping-Glue and Outside Window Fly Trap-allows you to use a trap to stick on the window, without using an insecticide. Advantage of fly trap is an excellent trap for the outside, with a unique attractant lure included. Electronic traps: Inside Use electronic fly traps are very efficient and functional: Properly fitting screen doors and windows are essential to exclude flies from homes and other areas where food is prepared. A combination of good sanitation and mechanical exclusion will produce the same effect and keep fly populations under control. Elimination of potential breeding sites will help in the general reduction of fly numbers. Pet faeces should be removed and fresh manure and other compost dug into garden beds. Routine emptying and cleaning of all garbage 145 receptacles will reduce breeding. People traveling to destinations that may include rural areas of Africa, Central and South America, should be aware of possible infection by the immature stages of several exotic flies. The three basic principles of house fly control are sanitation, exclusion and non-chemical measures. Sanitation will provide the best long-term control, followed by exclusion and non-chemical measures, which provide shorter-term management. Exclusion: Flies can be kept outside of homes by the use of window and door screens. Check for openings around water or gas pipes or electrical conduits that feed into the building. Ventilation holes should be screened, as they can serve as entryways for flies as well. Phaenica cuprina Genus 5: Phormia Species - Phormia regina - Black blow fly. General Features of Calliphoridae: Blue or Blow flies All calliphoridae have world wide distribution. Their breeding place is on waste, decaying animal matter, and some lay their egg on flesh and make human food unfit. The female cochliomia hominivorax lay their eggs on wound and result in myiasis particularly on sheep, goat and cattle. Calliphora species also lay their egg on wound and the developing 147 maggot damage the neighbouring tissues example Lucilia illustries. Public Health Importance: Generally calliphorids are responsible to cause myiasis. Prevention and Control of Calliphoridae: Basic sanitation:- By proper disposal of both human and animal wastes, it is possible to control the immature stages of these flies. From the non- residual insecticide the pyrethrins are the best to kill adult flies while flying or resting. Sarchophagidae /Flesh Fly/ Class Inseca Order- Diptera Family - Sarcophagidae Genus-Sarcophaga. When compared to Common House Fly they are larger in size, and have grayish colour. Adults are attracted towards feces and other wastes, in which they normally breed and / or settle. Adults are larviparous and therefore, the immatured larvae laid on flesh, dead body and offals, etc. After the larvae changed to pupa, it dropped on the ground and with favorable condition, the adult comes out of it. Myiasis: is an illness condition that occurs while the larvae of the Diapterans burry it self under the skin. Because particularly when their number is large they can make out door activities difficult. Application of Basic Sanitation: Control of the immatured stages of flesh flies is linked with sanitation. By proper disposal of refuse, the breeding place of the fly can easily be abolished. The pyrethrins used as a space spray to knock-down and kill adults when they are flying or resting in an enclosed space. List the common sources of food, breeding places and resting places of house fly 5. Write all possible factors that affect the distribution, of house fly in a certain environment. Fleas are found throughout most of the world but many genera and species have a more restricted distribution, for example the genus Xenopsylla which contains important vectors of plague (yersinia pestis), and flea-borne endemic typhus (Rickettsia typhi). Some fleas such as ctenocephalides species are intermediate hosts of cestodes (Dipylidium caninum),(Hymenolepis nana, H. Fleas may also be vectors of tularaemia (Francisella tularensis), and the chigoe or jigger flea (tunga penetrans) enters in to the feet of people. Wings are absent, but there are three pairs of powerful and well- 151 developed legs, the hind pair of which are specialized for jumping. The head is roughly triangular in shape, bears a pair of conspicuous black eyes (a few species are eyeless), and short three segmented more or less club-shaped antennae, which lie in depressions behind the eyes. The present account is a generalized description of the life cycle of fleas which may occur on humans or animals, such as dogs, cats and commensal rats. With species which occur on humans or their domestic pets, such as cats and dogs, females often lay their eggs in or near cracks and crevices on the floor or amongst dust, dirt and debris. They are thinly coated with a sticky substance, which usually results in them becoming covered with dirt and debris. Adult fleas may live for up to 6-12 months, or possibly 2years or more, and during this time a female may lay 300-1000 eggs mostly in small bathes of about 3-25 a day. They avoid light and seek shelter in cracks 152 and crevices and amongst debris on floors of houses, or at the bottom of nests and animal burrows. Larvae feed on almost any organic debris including the hosts faeces, and partly digested blood evacuated from the alimentary canal of adult fleas.

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Another four days later purchase 400mg levitra plus amex erectile dysfunction rap, October 3 generic 400mg levitra plus otc erectile dysfunction icd 0, he had painful spots here and there cheap 400 mg levitra plus zma impotence, that moved from place to place; this is the hallmark of allergic reactions and bacterial infections. Tapeworm stages and Ascaris were again Positive at the bile ducts and gallbladder. And he was started on chromium to stimulate amino acid uptake by cells, as well as sugar. Yet his next tests showed 1, 10 phenanthroline Positive at bone; ferroin Positive at bone; 20-methylcholanthrene Positive at bone; beta propiolactone Positive at bone; hydroxyurea Positive at bone; phorbol Posi- tive at bone. His iron supplies had been changed to useless ferroin by the phenanthroline produced by the parasites. Three days later, October 6, he had done his third liver cleanse with ozonated oil. Two days later, October 8, he seemed very well; his mouth had healed and the plastic had been removed from his front teeth. The dentist had found a large unsuspected filling and extracted the tooth, rather than risk Bruces new-found life. This was the very best sign of all, we could move him to the ninety-nine percent chance of survival category now. His blood test on October 9, showed a brief worsening of his condition, perhaps due to the encounters with parasite reinfection, perhaps due to dental anesthetics [or perhaps the draining of another tumor location with dye]. Then he left for a vacation of three days, but stayed away for two weeks, not entirely unexpected. He promised to be cautious, stay on his supplements and diet, and live in moderation. He had chosen ready made food from a health food store, instead of totally safe home-cooked food. When he returned, he was Positive again for benzene, isopropyl alcohol, and wood alcohol. He had been eating baked cheese dishes in Mex- icothey were probably not truly sterile. He was advised to do an ozonated oil liver cleanse right away, besides the parasite program. In spite of this set back, his cell division regulators pyruvic aldehyde and thiourea were not disturbed from their normal periodicity, no bacterial amines were present to disturb them, there was no Clostridium. Instead, he chose to repeat it at oncesince his flight home was just a day away, and he wanted to leave in perfect health. On his last day, the ultrasound showed that his prostate had shrunk to thirty-seven grams and was still quite normal. His bone scan was not repeated since bone density does not change significantly in five weeks. We had missed getting an ultrasound of his prostate on the day he arrived, and by the time it was done, there were no tumors visible. But he had heard his doctor say, in front of him, to his parents: If we dont do surgery, he will die. If we do surgery, if he survives, he will be paralyzed from the waist down and his brain will be a vegetable. So the surgeon implanted a shunt (plastic tube) in his brain to drain off edema fluid and lower the pressure in the brainhe had already lost significant vision in his left eye. Beside this was a completely calcified pineal gland; it had turned into stone or calcium deposits and appears black on the print. We started on his first day to search for the toxins that came from their home so it could be made ready for Georges return. His plastic glasses frames seeped vanadium; he was to soak and wash them, then re-test them. Other items were obvious; he had been living on semi-food (crackers and sandwiches, fat-free munchies), instead of meats and vegetables to avoid getting high cholesterol! It accumulated in his skin fat and brain, there releasing benzene and phenol to lower the local immunity. The tapeworm test showed five out of five types tested were Positive in his brain. The urethane must be coming from his plastic shunt since there was not a single defective or repaired tooth in his mouth. Three out of three Clostridium tests were Positive, as well as three out of three Streptococcus tests. If only there was clini- cal support available at every minute, day or night, in case the tumorous cyst ruptured and flooded the brain, producing such huge seizures as to stop breathing! The safest approach was to kill everything, detoxify, and clear every- thing at top speed, but without bursting the cyst-tumor. He was eat- ing for dear life and was surprised to learn that I considered his low choles- terol-cracker diet to be non-food, hardly to be offered to roaches. He would live in the environmentally safe motel with only borax water for personal and laundry chores. Black Walnut tincture daily and 2 capsules methylene blue powder daily (65 mg each). It would surely still have its dyes locked inside while the neighboring brain tissues were already cleared. Using a dye together with the cerebrum slide to specify the location where the dye was, we immediately found the tumor. We next prepared his brain and liver to receive aflatoxin by giving him 30 capsules glutathione for 5 days and progressed him through Day 2 and Day 3 of the cancer program (he had been repeating Day 1 all this time). At the cerebrum on his eighth day were all the same toxins and para- sites we had originally cleared. For two days in a row he took the complete pro- gram together with 30 capsules B2 each day. The cerebrum cleared up, but the cerebellum did not; would he suddenly buckle, never to walk again? Cysteine and ozonated oil were added; all items were taken at maximum dose and George made not a single complaint. He began to have diarrhea (from the large dose of glutathione), and strange green pea- shaped objects floated in his toilet bowl. On his eleventh day he was switched to 2 freeze dried green black wal- nut hull capsules 4 times a day instead of 10 tsp. The 2-week program he had scheduled at our clinic was done, and the next week father and son did their own cooking. He was encouraged to enroll in the Syncrometer class so he could eventually do his own food testing.

Any redundant tissue that you may have left will probably get smaller as time passes buy levitra plus no prescription impotence from anxiety. Otherwise buy levitra plus in india erectile dysfunction test video, pain is not a major feature best 400mg levitra plus erectile dysfunction rap, unless there is haematuria and clot colic. A good quality intravenous urogram will demonstrate If there are large hydrocoeles, you may have to drain most renal masses. If there is haematuria, perform a cystoscopy Identify, tie, and divide the many large veins that run from (27. The kidney is palpable but haematuria is Either, make a new scrotum from the apron of normal skin unusual. Or, bury the testes in pockets, under the skin on the (4) Other tumours of the kidney and large bowel. These pockets will be easier (5);In children, a neuroblastoma displacing the kidney to make if you stand on the opposite side of the table. You may meet and need to tie the superficial palpable, and the absence of haematuria does not exclude external pudendal vessels and their 2 companion veins. Sometimes the tumour spreads into the and a curative nephrectomy is seldom possible. The tumour arises from embryonal kidney cells and spreads locally through the capsule of the 8 Schistosomes are trematode blood flukes infecting >2. Middle East and Africa causes urogenital disease, though other types cause mainly liver and intestinal disease. The young child presents with a fairly rapidly growing and The adult male fluke encloses the cylindrical female to usually painless mass on one side of the abdomen. The fertilized of cases the mass is present at birth, and in 5% it is female then detaches itself and migrates to narrow veins, bilateral. There is rapid weight loss and fever in 50% of preferentially in the vesical plexus, laying >200 eggs daily cases. The survival figures below are for When these eggs are excreted in the urine, they can hatch a combination of nephrectomy, radiotherapy, in fresh water and attach themselves to certain snails and chemotherapy. These snails can then produce 10 free-swimming forked-tailed cercariae which have an enzyme that allows Stage Definition 5yr them to penetrate human skin, and so continue the Survival life-cycle. The granuloma is accompanied Diagnose the condition clinically, and organize subsequently by fibrosis and impaired collagen synthesis. If this is not available, The eggs can survive 10yrs and so chronic disease is it is acceptable to rely on nephrectomy and chemotherapy. Schistosomiasis affects >200 million people It is not acceptable to leave the kidney and to treat with worldwide, and causes up to 200,000 deaths annually. Plain radiographs may show: (1) an enlarged kidney; (2) linear calcification in a dilated ureter, (3) patchy ureteric calcification, (4) secondary ureteric stones; (5);dense calcification in the cystic wall, sometimes with defects in the calcification where a tumour has developed. Appearances are striking: you may see (1) dilated cystic ureters, in active cystitis: (2) thickened pipe-stem ureters, (1) reddened congested oedematous patches especially on (3) ureteric strictures all with possible stones (27. Where the ureter is irreversibly damaged, reconstructive Such pathology may obviously lead to renal failure as well surgery is necessary: this is complicated because excision as infertility, or death from malignant infiltration. Active cystitis usually presents between 5-15yrs with Otherwise the whole ureter needs replacing with an ileal painful micturition, frequency and terminal haematuria. Examine urine or semen carefully for schistosoma eggs, as well as red cells and pus cells (especially in bladder carcinoma where you may find strands of tumour tissue in the urine). You may need a cystoscopic or epididymal biopsy, however, if all the eggs have migrated into the tissues. Treat with a single dose of diethylcarbamazine 6mg/kg with If there is a foreign body in the urethra, try to remove it albendazole 400mg, or ivermectin 150g/kg. If this fails, you can lavage 5-10ml of 1:10000 silver Ideally, identify the foreign body with a cystoscope using nitrate solution into the renal pelvis after passing a ureteric the 0 objective to look down the urethra. Failing this, catheter under direct vision by a cystoscope with the locate it in the penis by palpation and with radiographs. If there is erectile dysfunction, examine the penis for any If necessary, perform a urethrotomy (27. Ask if there is ever a sustained on the urethra through the ventral surface of the penis. The primary much second best, and can be subject to significant treatment of balanitis is better hygiene. If pain & swelling develop with explosive rapidity in the penis or scrotum, and there is severe illness, suspect that there is severe penoscrotal necrosis and infection (6. If a painful perineal swelling develops, this is probably a periurethral abscess (6. The urine is characteristic; if left to stand it separates into 3 layers: a top layer of fat, a pinkish layer of clots, and a bottom layer of debris in the urine. You can see chylomicrons in the urine under the microscope, and microfilariae in 25% of cases. Washing the face regularly and the use of azithromycin every 3 months in children under 12yrs reduces the incidence of trachoma. In the industrial world 02% are blind, but in low-income countries blindness is ten times more common. You can treat cataracts, arrest glaucoma and prevent trachoma and vitamin A deficiency. It is unfortunate therefore that ophthalmology scares most doctors, who imagine that treating the eye must be Fig. This is not true: you can diagnose A,B, flow of aqueous from the ciliary body (15) into the posterior 90% of eye diseases with a torch and an ophthalmoscope. The optic nerve (11) enters the globe at the blind spot and makes the optic disc (10). Danger signs are: haziness of the cornea, the cornea (2) anteriorly at the limbus (20), where the conjunctiva inequality of pupil size (especially if associated with makes a groove known as the fornix. The eye lies within the orbit, a V shaped enclosure, Ask which type has been most affected. Six muscles are attached to the eye and wall of the or optic nerve damage), or slowly (cataract 28. A septum is attached to the rim of the orbit and the Ask about floaters and flashes in the vision. The eyelids protect the Ask about ocular discomfort: conjunctival pain tends to corneal surface are made from skin, muscle, tarsal plate feel like sand or hair in the eye, while very high pressure (28-18) and conjunctiva. The eye itself can be divided into: Optic nerve disease can present with pain on eye (a) the external eye: lids, conjunctiva, sclera, movements and loss of vision. Ask about a family history of eye disease such as glaucoma, cataract, or night blindness.

By X. Trompok. University of Texas at San Antonio.