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Mobile Phone Based Clinical Microscopy for Global Health Applications

Abstract Top
Light microscopy provides a simple, cost-effective, and vital method for the diagnosis and screening of hematologic and infectious diseases. In many regions of the world, however, the required equipment is either unavailable or insufficiently portable, and operators may not possess adequate training to make full use of the images obtained. Counterintuitively, these same regions are often well served by mobile phone networks, suggesting the possibility of leveraging portable, camera-enabled mobile phones for diagnostic imaging and telemedicine. Toward this end 1we have built a mobile phone-mounted light microscope and demonstrated its potential for clinical use by imaging P. falciparum-infected and sickle red blood cells in brightfield and M. tuberculosis-infected sputum samples in fluorescence with LED excitation. In all cases resolution exceeded that necessary to detect blood cell and microorganism morphology, and with the tuberculosis samples we took further advantage of the digitized images to demonstrate automated bacillus counting via image analysis software. We expect such a telemedicine system for global healthcare via mobile phone – offering inexpensive brightfield and fluorescence microscopy integrated with automated image analysis – to provide an important tool for disease diagnosis and screening, particularly in the developing world and rural areas where laboratory facilities are scarce but mobile phone infrastructure is extensive.



ntroduction Top
Light microscopy is an essential tool in modern healthcare. The advent of digital imaging has only enhanced this diagnostic role, as sample images are now frequently transferred among technologically-advanced hospitals for further consultation and evaluation, a role important enough that a medical communication standard (DICOM [1]) has been widely adopted for the handling of digital images. Unfortunately, much of the power of light microscopy, especially fluorescence imaging and the opportunity for remote consultation and electronic record keeping, remains inaccessible in rural and developing areas due to prohibitive equipment and training costs. This is especially problematic since the diagnosis, screening, and monitoring of treatment for many diseases and infections endemic to such areas – e.g. tuberculosis (TB), malaria, and sickle cell disease – depend on light microscopy as a screening tool or a definitive diagnostic test [2], [3], [4], [5], [6].

A recent convergence of technologies is making it possible to change the way microscopy is performed in developing countries. Given the ubiquity of mobile phone networks, the fact that many mobile phones are now equipped with digital cameras, the increase in computational power of mobile phones, and the advent of inexpensive high-power light emitting diodes (LEDs), we believe that these technologies can be combined to create an inexpensive and powerful tool for light (and especially fluorescence) microscopy in developing regions. While the concept and practice of telemedicine has existed for decades, it has only recently begun a shift to wireless platforms [7], [8], [9], and new avenues are now opening for developing mobile phone enabled medical technology [9], [10], [11]. An additional advantage to using a phone-based microscope is that mobile phones are essentially computers that can be used for digital image processing as well as electronic medical record keeping and communication.

Our initial device development efforts have been aimed at using the digital imaging capabilities, mobile connectivity, and computational power of a camera-enabled mobile phone to capture high-resolution microscopy images and perform subsequent image transmission or analysis. It has been previously demonstrated that a camera-enabled mobile phone can be used to capture images from the eyepiece of a standard microscope [11] and that microscopy images can be wirelessly transmitted for subsequent analysis [12]. However, our goal was to demonstrate the feasibility of creating an entirely integrated and portable mobile phone microscopy system. With the growing use of fluorescent stains in sample preparation to increase diagnostic sensitivity and specificity, we furthermore sought to incorporate fluorescent imaging capabilities into our mobile microscopy system and test the use of digital image processing for image analysis.

Here we report the development of a high-resolution microscope attachment for camera-enabled mobile phones that is capable of both brightfield and fluorescence imaging. We demonstrate the ability to use this system to capture brightfield digital color images of malaria parasites in thin and thick blood smears, sickled red blood cells in peripheral blood smears, and, using fluorescence, tuberculosis bacilli in Auramine O-stained sputum smears. Furthermore, we demonstrate the potential for improving diagnostic efficiency by using simple image processing software to label and count tuberculosis bacteria in a captured image, relieving healthcare workers of the time-consuming and error-prone task of counting by eye. We believe that by integrating these technologies, healthcare workers in remote regions equipped with microscopy-enabled mobile phones could take diagnostic images of patient samples (blood, sputum, etc.), perform on-board image analysis and/or wirelessly transmit those images off-site for medical record keeping, epidemic tracking, or further analysis by clinical experts.

Results Top
System Design and Characterization

Both the brightfield and fluorescence instruments are designed to work with a typical camera-enabled mobile phone (Figure 1a,b). The system uses standard, inexpensive microscope eyepieces and objectives; magnification and resolution can be adjusted by using different objectives. For this study, we used a 0.85 NA 60X Achromat objective and a 20X wide field microscope eyepiece, resulting in a system field-of-view of ~180 µm diameter, an effective magnification onto the camera face of ~28X, and a measured spatial resolution of ~1.2 µm. The effective magnification figure requires care in interpretation as the image can take on greater magnification via digital enlargement. Resolution is a more fundamental parameter, and we estimated it to be ~1.2 µm, based on the full width at half maximum (FWHM) of the system point-spread function (PSF, see Materials and Methods). This is a factor of three larger than the nominal Rayleigh resolution limit of 0.4 µm for the system, to be expected since the (purposefully inexpensive) objectives used are uncorrected for field curvature and other aberrations, reducing resolution away from the field radius of best focus. Imperfections and aberrations in the mobile phone lens will also contribute to the non-diffraction limited performance. Despite these limitations, the mobile phone camera was able to capture high-resolution images of blood and sputum samples useful for diagnosis.

Ambient light (without a condenser) was typically sufficient for brightfield imaging, but we also used a white LED for illumination in darker conditions. For fluorescence microscopy we utilized a simple and inexpensive trans-illumination geometry incorporating an LED excitation source and filters in the optical train (Figure 1a). High-power LEDs are now available in a wide range of emission bands, allowing for the matching of excitation wavelength with a variety of potential fluorophores. As others have also noted, the low cost, high robustness to mechanical shock and environmental conditions, low power requirements, ambient operating temperatures, and ~50,000 hour lifetimes of LEDs make them particularly suitable for use in portable systems and systems designed for use in developing areas where replacement parts may be unavailable or unaffordable [2], [13], [14]. In our fluorescence system, illumination was provided by a high-power blue LED, emitting within the excitation range of the fluorescent Auramine O stain commonly used for detection of TB bacilli in sputum samples. Sensor integration time for the phone was unavailable, so the limiting system sensitivity could not be determined. Whereas an epi-illumination geometry is generally used to minimize background from the illumination source in fluorescence microscopy, we found that the Auramine O-stained TB fluorescence was more than sufficiently bright for bacillus identification using our trans-illumination geometry, which in turn reduces the complexity and cost of our system- an important consideration given the resource-poor settings where it could be of use.

Malaria is a parasitic disease endemic to many parts of the developing world and is a major global health concern. Diagnosis of malaria is usually performed via observation of parasites in a Giemsa-stained “thick” peripheral blood smear; subsequent speciation is obtained (if desired) from a follow-up examination of a similarly stained thin blood smear at higher magnification and resolution for parasite morphology and species identification [3], [15]. Additionally, it has previously been demonstrated that malaria can be effectively diagnosed from e-mailed smear images [16]. Figures 2a and 2b show color, brightfield images of thick and thin Giemsa-stained smears of malaria-infected red blood cells, respectively, captured on the mobile phone microscope. The quality of the malaria images could be improved by use of a higher NA objective; however, especially for the thick smear (more widely used for screening) the current images are already suggestive of the potential for diagnostic utility.

Sickle cell anemia, another disease that disproportionately affects the developing world, can be diagnosed via blood smears displaying abnormally (sickle) shaped red blood cells (RBCs). Diagnosing and identifying sickle cell patients early in life would enable the implementation of preventive measures to decrease the complication rate and overall disease burden of this life-threatening illness. Our system provides enough image resolution and contrast for the direct observation of sickled cells in blood smears taken from patients with hemoglobin SS disease (Figure 2c), with no additional contrast-enhancing techniques (e.g. staining or phase contrast). If needed, however, significant additional contrast can be achieved by the simple expedient of applying an illumination source at an oblique angle to the sample (data not shown). This mobile phone microscopy system could prove to be particularly useful for point-of-care screening of newborns for sickle cell disorders, to identify and treat patients before the onset of symptoms in resource-poor nations, a process already mandatory in the United States and other developed countries [17], [18], [19].

Fluorescence Imaging of Tuberculosis and Automated Image Analysis

TB is a major world health concern, and treatment entails monitoring of patients over long (6–9 month) periods. While the standard for initial diagnosis is the use of brightfield imaging of a Ziehl-Neelsen stained sputum smear, fluorescent stains are increasing in popularity due to reduced toxicity in preparation, improved ease of reading, and possibly increased accuracy of the resulting diagnosis [2], [20]. Their adoption in the developing world for both diagnosis and monitoring of TB is, however, hindered by a lack of fluorescence microscopy equipment [2], [6], [14] generally due to the cost of the equipment and cost of maintenance.

Using fluorescence illumination, we were able to capture images of Auramine O-stained M. tuberculosis-positive sputum smears (Figure 3a). The resolution of the system was high enough to allow easy identification of individual TB bacteria in the sample, as well as to observe the standard rod-shaped morphology. While we subtracted the background intensity from all images as a matter of course, bacilli were bright enough that background subtraction was not in fact required for reliable identification.



Current standards for the diagnosis of TB using the non-fluorescent Ziehl-Neelsen stain require the screening of upward 100 fields-of-view of ~180 µm in diameter [21], cumbersome with our system and similarly tedious by eye on a conventional microscope. One of the principal advantages of using the fluorescent Auramine O stain rather than the absorptive Ziehl-Neelsen stain for TB screening is that a lower power (20X) objective may be used [2], with resultantly larger fields of view and thus a reduction in the number of fields (by a factor of 25) which must be examined to cover the same slide area. Such objectives have the added advantage of being less expensive; however, they also have lower light-gathering power making them more challenging to use for fluorescence applications. In our testing we found that a 20X 0.4 NA objective (with a theoretically 5.7X lower light collection efficiency than the 0.85 NA objective) was more than adequate for acquiring images of Auramine O-stained TB bacilli (data not shown). In order to take full advantage of the objective field of view, a sufficient number of detector pixels are required. While our phone had ~3.2 Megapixels (Mp), camera-phones are well on the way to the ~4–8 Mp required to image the entire field at maximum resolution.

In addition to the capture and transmission of data, the fact that mobile phones are essentially embedded computer systems offers the opportunity for significant post-processing of images. To demonstrate the diagnostic potential of image processing in this application, we carried out automated bacillus counting of the fluorescent TB images (Figure 3b). For reasons of simplicity we implemented the automated particle count on a laptop computer onto which we had transferred the images, but phone computational resources are sufficient for such tasks to be performed on-phone, providing both an immediate efficiency gain in slide analysis as well as the longer-term potential for automated microbe and pathogen identification.

Discussion Top
We have developed a microscope attachment for a camera-enabled mobile phone such that it can be used as a platform for high-resolution clinical light microscopy. The system can reliably capture images of malaria-infected red blood cells from both thin and thick blood smears, as well as images of sickled red blood cells. Additionally, we have demonstrated that mobile phone cameras can be adapted for high-resolution LED-based fluorescent microscopy, using fluorescence imaging of Auramine O-stained sputum smears as a test case.

Microscope-enabled mobile phones have the potential to significantly contribute to the technology available for global healthcare, particularly in the developing world and rural areas where mobile phone infrastructure is already ubiquitous but trained medical personnel, clinical laboratory facilities, and clinical expertise are scarce. By using existing communication infrastructure and expanding the capability of existing mobile phone technology, mobile phone microscopy systems could enable greater access to high-quality health care by allowing rapid, on- or off-site microscopic evaluation of patient samples. As an example, mobile phone microscopy as demonstrated here could provide a rapid, point-of-care method for monitoring TB patients. Such a system would support the World Health Organization's DOTS program, which was established to guide TB eradication efforts by emphasizing, among other factors, the role of quality-assured technology, standardized treatment, and enhanced recording and reporting [4]. With the advent of new 2-minute rapid-staining protocols [22], [23], sample evaluation could potentially be performed in real time while a patient is still in the presence of a healthcare worker, rather than requiring days or weeks. Since we are developing a technology that makes the current and long-standing internationally accepted standards for disease screening in developing countries more portable – rather than creating an entirely new diagnostic assay – we anticipate that a relatively fast time to adoption by clinicians and health workers may be possible.

Not only could such a mobile phone microscopy system help alleviate the problems of inadequate access to clinical microscopy in developing and rural areas, but it would provide those areas remote access to digital record keeping, automated sample analysis, expert diagnosticians, and epidemiological monitoring – the latter enhanced by the ease of location-tagging patient data by cellular triangulation or GPS location data. Combining the mobile phone microscopy system with automated sample preparation systems could address challenges associated with use by minimally-trained health workers and the time involved in imaging multiple fields of view [24]. While future field studies are planned to evaluate the reliability and ease of use of mobile phone microscopy, our present system serves as a proof of principle that clinical imaging of hematologic and infectious diseases is possible with conventional mobile phone camera technology combined with a custom microscopy attachment.

Materials and Methods Top
All mobile phones were Nokia N73 camera phones, equipped with a 3.2 megapixel (2048×1536 pixel) CMOS camera with a 5.6×4.2 mm sensor, yielding an ~2.7 µm pixel spacing. The phone and optical components were mounted using an optical rail system, and laid out as in Figure 1a. A functional, handheld prototype is shown in Figure 1b.

The imaging system consisted of a 20X wide field microscope eyepiece (Model NT39-696, Edmunds Optics) separated by 160 mm from a microscope objective (60X 0.85NA DIN Achromat objective, 160 mm tube length, Model NT38-340, Edmunds Optics). The eyepiece was separated from the camera phone by approximately the focal length of the camera (5.6 mm). For fluorescence imaging, the illumination source was a Luxeon III 455 nm LED (Model LXHL-LR3C, Philips Lumileds) attached to a 3×3 inch microprocessor heat sink with silver conductive epoxy and driven at 700 mA to provide ~275 mW nominal optical output power. Directly mounted to the LED was a 5° spot lens (OP005, Dialight), followed by a 25.4 mm focal length biconvex lens placed approximately 11 cm from the spot lens and acting as a condenser. Resultant excitation intensity at the sample was 2.0 mW/mm2. An excitation filter (D460/50x, Chroma) was placed between the spot and condenser lenses, and an emission interference filter (Chroma D550/50 m) was placed as close as practical to the objective back focal plane. Focus was adjusted by moving the sample position.

Brightfield images were captured using the phone's default camera settings, with the flash disabled. Fluorescent images were captured in the cameras “Night” mode, with the flash disabled. Night mode slightly increases exposure time of the camera to a maximum of 0.2 s, but likely performs software-based contrast adjustments on the image as well. We were not able to manually set the exposure time; however, single images provided adequate signal-to-noise for easy viewing and analysis. For all fluorescent images, we subtracted a background image (captured from a sample area with no fluorescent signal) from the sample image; such subtraction is of low computational overhead and, though we did not do so in these experiments, would be simple to implement in a user-transparent manner as part of the overall image acquisition algorithm. After background subtraction, the JPEG sample image was split into its red-green-blue layers and only the green channel retained. No significant signal was observed in the other channels, despite the demosaicing and JPEG compression implemented on the phone. Images filled a ~4.8 mm diameter area of the sensor; surrounding blank image areas have been cropped from Figures 1c, 1d, 2, 3a, and 3c for display purposes.

To characterize the resolution of the system, 100 nm fluorescent beads (Fluoresbrite Plain YG Microspheres, Polysciences, Inc.) were diluted 10,000-fold in deionized water and allowed to dry on a 200 line-pair/mm Ronchi ruling. After acquiring a best-focus image of the beads, the emission filter was removed to capture a brightfield image of the Ronchi ruling without refocusing, which we used for calibrating scale (data not shown). We defined resolution as the FWHM of the measured PSF, which in this case was 1.2 µm. This value for resolution should be a slightly conservative estimate since the bead diameter was not deconvolved from the result. The resolution was obtained by averaging the FWHM of seven different beads spread randomly in the field of view. Unfortunately due to lack of information on the phone algorithms for both demoisaicing of the color pixel array and JPEG compression, determining the theoretical system resolution is not possible. The optical magnification of 28X is the product of the 2.7 µm pixel size and 95 nm/pixel scale obtained using the Ronchi ruling. The system field-of-view was measured directly from an image of the Ronchi ruling.

Automated counting of samples performed on a computer using ImageJ [25]. Image threshold was set at three standard deviations above the pixel mean value; bacilli were required to have an area of at least one PSF, 1.57 µm2, or 125 pixels, with no upper size limit. While more sophisticated algorithms can be envisioned, the count derived in this manner matched that we performed by eye.

Malaria and sickle cell samples were obtained from patients confirmed to have each disease. TB samples were culture confirmed.

Ethics Statement

Use of these patient samples was approved by the institutional review board of the University of California, San Francisco. Written informed consent was obtained for all patient samples.


spcl tankz to Dr.Neelesh Bhandari (edrneelesh@gmail.com)

Telepathology

“The images can either be analyzed on site or wirelessly transmitted to clinical centers for remote diagnosis. The system could be used to help provide early warning of outbreaks by shortening the time needed to screen, diagnose and treat infectious diseases,” University of California in San Francisco (UCSF)/UCB Bioengineering Graduate Group graduate student David Breslauer adds

Ophthalmology(salakya)

Ophthalmology is the branch of medicine which deals with the diseases and surgery of the visual pathways, including the eye, brain, and areas surrounding the eye, such as the lacrimal system and eyelids. The term ophthalmologist is an eye specialist for medical and surgical problems. Since ophthalmologists perform operations on eyes, they considered both a surgical and medical specialty.
The word ophthalmology comes from the Greek roots ophthalmos meaning eye and logos meaning word, thought or discourse; ophthalmology literally means "the science of eyes". As a discipline, it applies to animal eyes also, since the differences from human practice are surprisingly minor and are related mainly to differences in anatomy or prevalence, not differences in disease processes. However, veterinary medicine is regulated separately in many countries and states/provinces resulting in few ophthalmologists treating both humans and animals.




History

The eye, including its structure and mechanism, has fascinated scientists and the public in general since ancient times. The majority of all input to the brain comes from vision. Many of the expressions in the English language that mean to understand are equivalent vision terms. "I see", to mean I understand.
Many patients when told that they may have an eye problem will be more concerned about diseases that affect vision than other, more lethal diseases[citation needed]. Being deprived of sight can have a devastating effect on the psyche, as well as economic and social effects, as many blind individuals require significant assistance with activities of daily living and are often unable to continue gainful employment previously held while seeing[citation needed].
The maintenance of ocular health and correction of eye problems that decrease vision contribute greatly to the ability to appreciate the longer lifespan that all of medicine continues to allow. Given the importance of vision to quality of life, many ophthalmologists consider their job to be rewarding, as they are often able to restore or improve a patient's sight. As detailed below, advances in diagnosis and treatment of disease, and improved surgical techniques have extended our abilities to restore vision like never before.


Sushruta
Sushruta wrote Sushruta Samhita in about fifth Century BCE in India. He described about 72 ocular diseases as well as several ophthalmological surgical instruments and techniques. Sushruta has been described as the first Indian cataract surgeon.[1][2] Arab scientists are some of the earliest to have written about and drawn the anatomy of the eye—the earliest known diagram being in Hunain ibn Is-hâq's Book of the Ten Treatises on the Eye. Earlier manuscripts exist which refer to diagrams which are not known to have survived. Current knowledge of the Græco-Roman understanding of the eye is limited, as many manuscripts lacked diagrams. In fact, there are very few Græco-Roman diagrams of the eye still in existence. Thus, it is not clear to which structures the texts refer, and what purpose they were thought to have.


Pre-Hippocrates
The pre-Hippocratics largely based their anatomical conceptions of the eye on speculation, rather than empiricism. They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by Alcamaeon and others, that this fluid was the medium of vision and flowed from the eye to the brain via a tube. Aristotle advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He, and his contemporaries, further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.

Alexandrian studies
Alexandrian studies extensively contributed to knowledge of the eye. Aëtius tells us that Herophilus dedicated an entire study to the eye which no longer exists. In fact, no manuscripts from the region and time are known to have survived, leading us to rely on Celsius' account—which is seen as a confused account written by a man who did not know the subject matter. From Celsius it is known that the lens had been recognised, and they no longer saw a fluid flowing to the brain through some hollow tube, but likely a continuation of layers of tissue into the brain. Celsius failed to recognise the retina's role, and did not think it was the tissue that continued into the brain.


Ophthalmic surgery in Great Britain
The first ophthalmic surgeon in Great Britain was John Freke, appointed to the position by the Governors of St Bartholomew's Hospital in 1727, but the establishment of the first dedicated ophthalmic hospital in 1805 — now called Moorfields Eye Hospital in London, England was a transforming event in modern ophthalmology. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology by Sir Stewart Duke-Elder established the site as the largest eye hospital in the world and a nexus for ophthalmic research.

fever

Fever

See complete list of charts.
A fever is defined as a temperature 1° or more above the normal 98.6°. Minor infections may cause mild or short-term temperature elevations. Temperatures of 103° and above are considered high and can signal a potentially dangerous infection. Contact your doctor in case of a high fever or if a lower fever doesn't resolve with simple treatments.

SYMPTOMS DIAGNOSIS SELF-CARE

1. Is the person an infant or child? See "Fever In Infants and Children."

2. Does your fever come and go and does your temperature stay between 97° and 102°? Go to Question 8.*

3. Have you had a fever for weeks along with tiredness and a sore throat?

You may have MONONUCLEOSIS. See your doctor.

4. Do you have a sore throat, a dry cough, tiredness, mild headaches or muscle aches? You may have a COLD or FLU. Get plenty of rest and drink lots of fluids. Over-the-counter- medicines may help relieve your symptoms. See your doctor if your symptoms become severe. Prevent the flu by getting the flu vaccine in the fall.

5. Do you have aches, chills, nausea, vomiting, cramps or watery diarrhea? You may have GASTROENTERITIS, an intestinal infection commonly called the STOMACH FLU. Get plenty of rest. Stop eating and drinking for a few hours to let your stomach settle. Ease back into eating gradually and start with bland foods. Take small, frequent sips of water or clear liquids to avoid dehydration. See your doctor if you have bloody diarrhea, if you've been vomiting for more than 2 days or if you're vomiting blood.

6. Are you short of breath and do you have a cough that produces yellow, green or tan mucus? You may have BRONCHITIS, or a more serious infection, such as PNEUMONIA. Get plenty of rest, drink lots of fluids and take an over-the-counter cough medicine. Bronchitis usually clears on its own in a few days. If your symptoms persist, if you have a high fever or are coughing up blood, see your doctor.

7. Have you lost weight unintentionally and do you have a fever that comes and goes, night sweats or swollen lymph nodes? You may have a serious infection, such as TUBERCULOSIS or AIDS. See your doctor right away.

*8. Do you have a fever between 101° and 103°? Go to Question 15.**

9. Do you have a sore throat and headache? You may have a bacterial infection, such as STREP THROAT. Get plenty of rest, drink lots of fluids and treat yourself with cold and fever-reducing medicines. If you don't feel better in 48 hours, see your doctor. A quick test can determine whether you have strep throat. Antibiotics are effective in treating the bacteria that causes this infection.

10. Do you have stomach pain, nausea and/or vomiting? You may have a severe medical problem, such as APPENDICITIS, DIVERTICULITIS, PANCREATITIS, HEPATITIS or COLITIS. EMERGENCY
See your doctor or go to the emergency room right away.

11. Do you have a rash that's red, tender and warm or a red streak on your arm or leg? You may have an infection of the skin or lymph system, such as CELLULITIS or LYMPHANGITIS. Both conditions need to be treated with antibiotics. See your doctor right away.

12. Do you have an earache? You may have a middle ear infection (OTITIS MEDIA) or an outer ear infection (SWIMMER'S EAR or OTITIS EXTERNA). These infections could lead to complications if not treated. See your doctor right away.

13. Have you been outside under high temperatures and are you feeling nauseous or faint? You may have HEAT EXHAUSTION. Drink cool liquids and rest in a cool location. Lay down and elevate your legs slightly. Recheck your temperature often until it has returned to normal. If your temperature goes higher, have someone take you to the emergency room.

14. Have you recently started taking a new medicine? Your fever may be a side effect of your MEDICINE. Call your doctor.

**15. Is your temperature consistently above 103°? Go to conclusion.***

16. Are you short of breath or are you coughing up mucus or blood? You may have PNEUMONIA or PULMONARY EMBOLUS. See your doctor right away.

17. Are you experiencing pain or burning when you urinate, or do you have back pain? You may have PYELONEPHRITIS, a kidney infection. See your doctor right away.

18. Do you have a severe headache, neck stiffness, drowiness and vomiting, and are your eyes sensitive to light? You may have MENINGITIS, an inflammation of the membranes that cover the brain and spinal cord. EMERGENCY
See your doctor or go to the emergency room right away.

19. Have you been outside in extremely hot weather, and are you hot but not sweating, possibly feeling faint or having some confusion? You may have HEATSTROKE.

EMERGENCY
Have someone take you to the emergency room right away. Get out of the sun and go somewhere shady or air-conditioned.

*** For more information, please talk to your doctor. If you think the problem is serious, call your doctor right away.
This tool has been reviewed by doctors and is for general educational purposes only. It is not a substitute for medical advice. The information in this tool should not be relied upon to make decisions about your health. Always consult your family doctor with questions about your individual condition(s) and/or circumstances. Source: American Academy of Family Physicians. Family Health & Medical Guide.

namami dhanwanthrim adhi dhavam

namami dhanwanthari adhi devam surasure vandhitha padha padhmam loke jwaranara mrithu nasham dhadharamesham vivadhaushadheenam