By H. Mezir. Belhaven College. 2018.
Turn the palmar flap medially discount 30mg lansoprazole with visa gastritis or gastroenteritis, and close racquet incision (35-15H); preserve the insertion of the skin without tension buy generic lansoprazole 15mg gastritis with duodenitis. Provided an above-knee amputation stump avoids the This is easier than amputating through the mcp joint purchase lansoprazole 15 mg free shipping gastritis tratamiento. An amputee will also have to learn to balance with the hip Proceed as for the distal phalanx below, but amputate instead of the foot muscles. Join these 2 incisions to make a dorsal flap at the level of the joint, and a palmar flap 1cm distal to the flexor crease (35-15D). Dissect back the fibro-fatty tissue to find the digital vessels and nerves, the extensor expansion, and the flexor tendon in its sheath. If you cannot preserve tendon insertions, divide them and let them retract; never suture the extensor to the flexor tendon over the bone stump because of the quadriga effect where the flexed amputated finger reaches the palm before the other fingers, and so weakens the grip of the hand. Separate the nerves from the vessels, and divide the nerves proximal to the vessels. Preserve the articular cartilage, which provides a shock pad and close the wound. If < of the nail remains, a patient will be troubled later by the irregular hooked remnant, so excise the whole nail bed. If you have to remove some of the pulp, do not make a flap; place a non-stick dressing and allow the wound to heal on its own. If you can preserve the pulp, flex the terminal joint and make a transverse incision across its dorsal surface 6mm distal to the joint (35-15A). Continue the incision as far as the sides of the phalanx, and deepen it down to the bone. Cut the phalanx with bone avoids the condyles of the femur, the longer it is the better. Trim protruding condyles and the anterior part of the phalanx to make a less bulbous stump; then fold the flap and close the wound (35-15B). Rasp away and make (3),cuts little muscle and no bone, so it is quick, there is the end of the bone smooth. Cover the If you have a choice, disarticulating the knee is better than stump with a crepe bandage and then apply a plaster cap. Good prostheses are now available This will relieve pain, and its weight will help to prevent a for disarticulated knees and are easier to use than for flexion contracture developing. Enclose the distal leg as far as the knee in a polythene bag, so as to isolate it If the wound becomes septic, open it up and debride any from the field of operation. Raise the leg so that you If bone protrudes through the stump, re-fashion it can prepare the upper thigh and groin. Put a drape behind making sure the muscles are long enough to cover the it and another one in front. If there is insufficient viable skin on one If the patient has to wait a long time for a prosthesis, side, make the other flap longer rather than amputating pad the stump well, make a cast round it and fit it snugly higher up. This will facilitate walking until Mark incisions for the anterior flap on the medial side of the permanent prosthesis is ready. The combined If you have to amputate both legs above the knees, length of the two flaps should be 1 times the diameter of consider the possibility of getting short stumpy the thigh at the site of bone section. This may be preferable to a wheel chair, and they will be easier to balance with than Reflect the flaps to the site of section. The centre of gravity end of the anterior flap so as to expose the femoral artery will however be closer to the ground, and two short sticks in its canal under the sartorius muscle. Pull down the femoral make, because they do not have jointed knees, and need nerve, cut it clean and allow it to retract. Ask your assistant to raise the leg while you cut across and Cut a long, broad anterior flap, and a shorter posterior flap bevel the posterior muscles distal to the site of section, in (35-19A). Start the anterior flap on the medial side 1cm proximal to Trim away any excessively bulky muscle masses. Extend it 10cm below this, crossing the Find, clamp, and tie the profunda femoris artery on the leg c. Find the sciatic nerve under proximally to end at a point on to the lateral side of the the hamstring muscles, separate it from its bed without knee opposite to where you started. Do not fashion an anterior flap if it might Reflect the anterior flap upwards with its underlying fascia have an inadequate blood supply. Cut this at its insertion onto medial flaps, the latter 2cm longer than the former, the tibial tuberosity. Now expose and divide the biceps femoris tendon and the iliotibial tract on the lateral aspect of the knee. Find the common peroneal nerve deep to the biceps femoris tendon, cut it clean proximally so it retracts above the level of the amputation. Then reflect the short posterior flap and complete division of the capsule and ligaments of the knee round the whole circumference of the joint below the menisci. Detach the heads of gastrocnemius from the femoral condyles, and remove the lower leg. Draw the patellar tendon posteriorly through the intercondylar notch of the femur, and suture it to the anterior cruciate ligaments under some tension (35-19E). Suture the sartorius and the iliotibial tract to the fascial part of the extensor mechanism. Remove the tourniquet (if present), control bleeding, drain and close the stump with the suture line lying posteriorly (35-19F). Then bring the patellar tendon round so you can fix the undersurface of the patella to the bony stump of the femur.
Statistics show that of risks of gender number inequality generic lansoprazole 15mg on line gastritis and diarrhea, where boys are perinatal mortality decreases with the number of weeks of valued more than girls buy lansoprazole 15 mg mastercard gastritis y diarrea, who are therefore eliminated buy discount lansoprazole 15mg on-line gastritis diet juicing. At around 36wks this trend reverses Increasing population also brings pollution, and land because mechanical factors, especially cephalo-pelvic degradation. If everybody has 4 children, such equal dies, the baby will also, even if it is born alive in a good distribution will not help. The baby will also often die without the breast standard of living, reduce their waste and the poor should milk and the special attention which is nearly unique to the have fewer children. The deaths of both mothers and babies mortality, women will still want many children as an are largely due to the material, political, and socio- insurance for the future. Many politicians also believe that economic conditions and traditions under which they live. But Sweden (7million) has probably more Despite the challenges of pregnancy and childbirth, influence than Bangladesh (145million). If China had not an important task in many communities is to reduce had a population policy, they would have had 350million the frequency with which pregnancy occurs. They would development cannot be combined with women having probably be begging for food aid. Facilitating Because so much obstetrics must be delegated, free access to family planning, however, is a task the instruction and supervision of those to whom you governments often do not see as a priority because there delegate it is critical. A sound is a to concern yourself with what they do, and to instruct them dangerous instrument in a recently pregnant uterus, because you can where you can. Use these to grasp a Fallopian tube while For example, as the main cause by far for maternal performing a tubal ligation or operating for an ectopic gestation. The great danger with a curette is that you may push it through the wall of the uterus, especially a recently pregnant uterus. Use this for evacuating a hydatidiform mole (it causes much less bleeding than dilatation and non-suction curettage), and for terminating a pregnancy which has lasted <12wks. The in-between sizes are very useful for removing retained products of conception from the uterus, best with the help of an electrical suction machine. They are also very useful for non-septic incomplete miscarriages seen at the out-patient department if there is no suction machine there. You need several sets of cups and tubes because you should be able to do 2-6 vaginal examinations in a weekend. Good simple maintenance of this basic equipment can make the difference between life and death for mothers and babies. Use these for clamping the (digitally) cut edges of the uterus during a Caesarean Section (the faster you become the less you need them), and for repairing a ruptured uterus. Introduce the catheter via the foetal rectum, inflate the balloon and then traction is very easy. This is so useful that you should really try lip which fits over the lower end of the wound and keeps the bladder out to get one. It is a piece of wire with teeth on it, hooks at each end on this speculum presses it downwards, and so keeps the vagina open. Use this to bring the uterine fundus up against the abdominal wall when you perform a mini-laparotomy. Hypergonadotropic High Low Ovary None 10% This percentage drops as the woman becomes older. Hyperprolactinaemic Low Low Pituitary Bromocriptine/ After 1yr of normal sexual intercourse on random days, 5% cabergoline a couple should conceive. However, this data is based on (65%) statistical probability and may not apply in the N. Nonetheless, in normal circumstances, groups 1&3, but it is nevertheless a good idea to advise the it is reasonable to start investigations after 1yr. You must contraceptive pill (for growth/maintenance of the breasts, start with the husband! Always enquire about previous to prevent osteoporosis and to have monthly periods if pregnancies! Failure to ovulate is typically associated with irregular Warn of the increased incidence of multiple pregnancies. She may be If she does not ovulate, increase the dose by 50mg sufficiently educated and motivated to do this, particularly amounts each month, to a maximum of 200mg od for if she is a member of the hospital staff or a teacher. Absence of this rise, especially if her periods are randomly on all infertile patients. This test will of course not work if she has a pregnancy, and abnormal uterine bleeding. It may make (1);Perform a post-coital examination: examine the mucus the ovaries tender and temporary cystic, and can simulate from inside the cervix. With clomiphene treatment, especially in high Ideally only if your laboratory can determine prolactin doses, later than day 7 of the cycle, this test is not reliable. Occasionally a woman is sterile as (4);With vaginal ultrasound, easily follow a follicle in the result of tuberculous endometritis; sterility is its most growth and disappearance. She also runs an increased chance of an successful treatment before the sperm count improves. Often the woman is not Sometimes, you can make the diagnoses by histology from responsible, but she may well be sent away by the man if a D&C scrapings on the 1st day of her period, or by seeing pregnancy does not appear. Beware, though, of vague that there is little point in investigating these patients if stories of men who say they have a child in a town 400km they cannot be reliably referred. Sometimes these stories are backed up by his family easy to open Fallopian tubes which are only closed at the to spare the man embarrassment.
As youll find you spend much time operating on hernias purchase lansoprazole 15 mg gastritis diet alkaline, it is worth teaching an assistant to learn this procedure 30mg lansoprazole with amex gastritis vs ulcer. The hernial sac is closely related to the spermatic Their repair (herniorrhaphy) is usually simpler generic 30mg lansoprazole with amex gastritis test, unless they cord, and lies in the same fascial planes. A special variety of direct hernia in which the patient has a narrow defect in the conjoint tendon, or in the transversalis fascia (18-10). This is a Busoga (or Gill-Ogilvie) funicular type of hernia; it is not uncommon in certain areas (hence the name, Busoga, in Uganda) and may predominantly affect women. Recurrence is a problem with any inguinal hernia, especially if the patient is old and has weak muscles. Preventing recurrence needs care and skill, but curing a hernia that has recurred needs even more skill. Recurrence is less likely if you: (1) Repair a hernia early, before it has grown too large. If you leave the neck or fail to define the sac all round, a hernia is much more likely to recur. A few direct inguinal hernias bulge through a weakness in (7) Use non-absorbable sutures. Because of the is usually related to haemorrhage, and both will weaken way they arise, the spermatic cord lies behind an indirect your repair. The external (superficial) inguinal ring is an opening in the Women less often have indirect hernias, and seldom have external oblique aponeurosis just above and lateral to the pubic spine. An indirect hernia presents a bulge in the This aponeurosis forms the anterior wall of the inguinal canal: groin, sometimes with a dragging feeling. As the spermatic cord passes down the inguinal canal, the muscle and tendon of the into the scrotum. The patient may say that he felt internal oblique and transversus arch over it, to form the conjoint tendon. Often the hernia has been Divide the inguinal canal into thirds: in the lateral, the internal oblique present since childhood (congenital). An operation, forms its lateral wall; in the central it forms its roof; in the medial (as part of the conjoint tendon), it forms its floor. A hernia deforms this which will remove the risk of strangulation, and possibly normal anatomy, but you can always see that this was its original state. The inferior epigastric vessels leave the femoral artery and vein, and run longitudinally on the medial side of the internal inguinal ring. Direct hernias bulge medial to them, through the posterior wall of the inguinal canal, while indirect ones pass lateral to them through the This is expensive and difficult to get; it is unlikely to be internal ring. The inguinal ligament is attached to the antero-superior iliac understood that the hernia must be completely reduced spine laterally, and to the pubic tubercle medially. At its medial end a before application, and it is likely to be very small curved ligament, called the lacunar ligament, joins it to the pubic uncomfortable in a hot climate. A few of its fibres continue laterally along the upper border of the keeping the hernia orifice closed. Ordinary direct hernias, which seldom strangulate In an infant, the 2 inguinal rings overlie one another; in the adult they separate, although not always in some people. They may cause no symptoms, and remain the you will meet two very constant vessels, but you can easily control same size for long periods, and so may not need surgery. A, coverings of the spermatic cord, which also become the coverings of an inguinal hernia. The abdominal wall muscles are: B, external oblique; the linea semilunaris is the curved lateral tendinous edge of the rectus abdominis. Testicular atrophy is one of the complications of herniorrhaphy, Suggesting a femoral hernia (18. Take note of previous scars to see if it to the femoral vessels, whereas the inguinal hernia is is a recurrent hernia. If there is a history of a inguinal swelling that comes Suggesting inguinal lymphadenopathy: the swelling is and goes, make a determined effort to demonstrate the constant, and below the inguinal ligament. Suggesting filariasis: a thickened oedematous spermatic Review the situation later, and wait until you have actually cord, with no cough impulse (34. Suggesting a varicocoele: a soft swelling feeling like a bag of worms in the spermatic cord, which fills from below, unlike the hernia which fills from above. Do not confuse them with inguinal passing through the internal and external rings, and lying antero- hernias. A, enormous swellings of similar sizes in an superiorly to the vessels of the cord. It will show up the tissue planes as the result of progressive lymphatic obstruction. Look for microfilariae or Do not use it in children, or if the patient is tense and schistosoma eggs in skin snips. For small hernias it can be a disease or malignancy, the risks may outweigh the little shorter, and for large ones a little longer (18-7A). Find and tie securely or diathermy the superficial epigastric and superficial external pudendal vessels. In a teenager, or young adult with a small indirect If they bleed later, a postoperative haematoma results. If it does produce pain, all you need do is excise Apply straight haemostats to all bleeding points, the sac and narrow the internal ring as it is usually a and secure haemostasis. If it is large, repair the defect superficial fascia down to the shining fibres of the external with a darn. For bilateral hernias, discuss whether the patient wants both operated at the same time; recovery will be slower Clear the upper skin flap from the underlying aponeurosis and the risk of urinary retention greater. Persuade a smoker to stop; if the operation external ring, and identify the line of the inguinal canal.
In other words medical entomology is a medical science directly concerned with vectors that affect human and animal health generic lansoprazole 15mg with amex diet bagi gastritis. Old World:- refers to the Eastern hemispher; the world of Europe generic 30 mg lansoprazole otc gastritis symptoms heart, Asia and Africa discount lansoprazole 30mg otc chronic gastritis x ray. Rodents:- comprise a great number of mammals, ranging in size from the rats and mice to as large as the Porcupines and which belong to the order rodentia. In this course we are concerned with the domestic rats and mice, which is one of the serious health hazards in the community. Technical grade insecticides: are an insecticides that exist in its purest commercial form. Vector(s):-In communicable disease terminology, vectors are arthropods or other invertebrates which transmit infection by inoculation into or through the skin or mucous membrane by 8 biting or by deposit of infective materials on the skin or on food or other objects. Namely, Mechanical disease transmission, Biological disease transmission, and hereditary disease transmission. Mechanical disease transmission:- is a type of disease transmission in which the vector is no more than a carrier that transmit pathogens without any change either on the number or form of disease pathogens. Biological disease transmission: In this type of disease transmission certain developmental pattern exists either in the vector or host or in both cases. Propagative: In propagative type of disease transmission only the number of pathogens increases and the developmental stage remain constant. The disease plague and typhus are a good examples of propagative type of disease transmission. Cyclo-developmental: In this type of disease transmission only the developmental stage (form) of the disease pathogen changed (small to big, immature to matured stage, etc. Cyclo-propagative: This type of disease transmission is a combination of both propagative and cyclo-developmental where by the disease pathogen under take a change both in number and developmental form (stage). Transovarian(Hereditary)disease transmission:- is a type of disease transmission where by the causative agent is transmitted to the immature stage ( usually to egg ) from the adult insects and / or other arthropods who carry disease pathogens and when the infected egg complete its developmental stage, it become infective or can transmit the disease to man and other animals. Ticks are very good examples of arthropods that exhibit hereditary disease transmission. Insects of Public Health Importance Introduction Arthropod is the great phylum of invertebrate animals. They were the first animal phylum to overcome the problems of locomotion, respiration, and water conservation in a terrestrial environment. All species under phylum arthropoda have the following characteristics in common Bilaterally symmetrical body sub-divided into segments. Chitin is a tough and rigid substance made up of poly (N-acetyl)-D-glucosamine (C15H20N2O10). The phylum arthropoda from public health point of view can be sub- divided in to five important classes namely Insecta, Arachnida, Diplopoda, Chilopoda and Crustacea. Of all the animal phyla, only the arthropods and the chordates have succeeded extensively in adapting to life in dry air. Insects now inhabit virtually all land surfaces of the globe except the extreme polar regions and the highest mountain peaks. Of these, the predators kill their prey more or less immediately, while parasitoids feed externally or internally in their host for some period before finally killing it. The exoskeleton provides not only strong support and protection for the body but also a large internal area for muscle attachments. The head bears a pair of large compound eyes and as many as three simple eyes, or ocelli, a pair of sensory antennae, and the feeding appendages or mouth parts. The abdomen is composed of no more than 10 or 11 visible segments and lacks appendages except for a pair of cerci and the reproductive external genitalia that may be present near the tip of the anal opening. Adult insects belonging to the diptera have one pair of functional wings and undergo holometabolous life cycle. Generally there are more than 50,000 species of both biting and non-biting diptera and the majority of which have no medical importance, but few of them are the most important disease vectors. Most of the families (including Culcidae, Simulidae, Psycodidae, Glosinidae and Muscidae) which are discuced in the concicative chapters are included under this order. Write the three types of disease transmission and give a short description for each. Mosquitoes are notorious as proven vectors of some of the most devastating human diseases. There is little need to document the impact on human public health of malaria, yellow fever, filariasis, and several mosquito-borne diseases of arboviral etiology. Rift Valley fever and the equine encephalitis are important livestock diseases transmitted 14 by mosquitoes. The Anophelinae and the culicinae are blood feeders but the third subfamily, the toxorhynictinae, do not feed on blood and so do not concern in here. They can be easily identified from other insects by -Mouth parts possession of a mouth part which is conspicuous 15 and forwardly projected proboscis -The presence of scales on their abdomen, legs and thorax - The presence of fringe of scales at the posterior margin of wings. This sperm is enough to fertilize all the eggs that can be laid by the female through out her life time thus only one mating and insemination per female is required. After mating it is a must for a mosquito to have a blood meal for the eggs to be matured. After taking a blood meal they have to take a rest for digestion and egg maturation. The speed of digestion of the blood-meal depends on temperature and in most tropical species takes only 2-3 days, but in colder, temperate countries blood digestion may take as long as 7-14 days.