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1
Q

Treatment for tonsillitis

A

Phenoxymethylpenicillin for 10 days

Clarithromycin or erythromycin in penicillin allergy

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2
Q

Treatment of quinsy

A

IV antibiotics penicillin or metronidazole, can give steroids

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3
Q

Causes of ABRS

A

Strep pneumoniae
H influenzae
Staph aureus

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4
Q

Management of AVRS

A

Self limiting
Analgesics
Nasal irrigation
Intranasal steroids

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5
Q

Risk factors of candidiasis

A 
HIV
Xerostomia
Dentures
Malnutrition
Advanced malignancy
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6
Q

Management of candidiasis

A

Mild to moderate use of clotrimazole

Severe use fluconazole

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7
Q

What is strawberry cervix

A

Trichomoniasis - also has yellow green discharge

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8
Q

What is seen in BV

A

Positive whiff test
clue cells
pH <7.4
thick white discharge

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9
Q

Management of uncomplicated genital thrush

A

Intravaginal cream or pessary fluconazole

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10
Q

Initial presentation for headache

A 
Nausea and vomiting
Visual disturbance
Photophobia
Neck stiffness
Fever
Rash
Weight loss
Sleep disturbance
Temporal region tenderness
Neurological deficits
Contacts with similar symptoms
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11
Q

Features of migraine without aura

A 
5 attacks
Lasts 4-72 hours
Unilateral location
Pulsating
Nausea, vomiting, photophobia and phonophobia during
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12
Q

Migraine with aura features

A

Visual symptoms - zigzag lines
Sensory symptoms - pins and needles
Motor weakness

Aura spreads over 5 mins
Aura lasts 5-60 mins
Unilateral
Accompanied by headache

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13
Q

Management of migraine

A 
Headache diary
Avoid triggers
Ensure no COCP
Analgesia
Triptan e.g. sumatriptan
Anti-emetic e.g. metoclopramide

Arrange follow up 2-8 weeks

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14
Q

Preventative treatment for a migraine

A

Propranolol, amitryptiline

Not gabapentin

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15
Q

Tension type headache

A

Generalised pressure or tightness
Spread to neck
Pericranial tenderness
Exacerbating environmental factors

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16
Q

Cluster headache

A

Unilateral periorbital pain
Ipsilateral autonomic symptoms
Nasal congestion, rhinorrhoea, eyelid oedema
Pain sharp, pulsating, burning or pressure like
Brief attacks last less than 3 hours

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17
Q

Management of cluster headaches

A

Red flags refer
Verapamil preventative
Do not offer paracetamol, NSAIDs, opioids or triptans

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18
Q

Management of SAH

A

Enteral nimodipine
Tranexamic acid
Fluid therapy
Clipping/coiling

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19
Q

Investigations for syncope

A 
12 lead ECG
Refer to cardio in 24 hours if any abnormalities
Capillary blood glucose
Urinary pregnancy test
CT head if first fit or head injury, red flags
Routine bloods
Urinalysis
CXR
Echo
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20
Q

Management for sprains and strains

A 
Protection
Rest for first 48-72 hours
Ice - apply ice in damp towel 15-20 mins every 2-3 hours
Compression
Elevation

Paracetamol
NSAID

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21
Q

When is HPV vaccine offered?

A

11-14 years

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22
Q

When is pneumococcal offered?

A

65 years

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23
Q

When is shingles vaccine offered?

A

70 years single dose

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24
Q

What is incubation period of chickenpox?

A

1-3 weeks

Infectious 1-2 days before rash appears

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25
Complications of chickenpox
Varicella pneumonia in smokers | Fetal varicella syndrome if pregnant, causes skin scarring, eye defects, microcephaly
26
Describe chickenpox rash
Small erythematous macules on scalp, face, trunk Intensely itchy Crusting within 5 days of onset
27
Treatment of chickenpox
Self limiting Aciclovir if immunocompetent Paracetamol for pain or fever Calamine
28
What is shingles
Reactivation of varicella zoster from ganglion
29
RFs of shingles
``` Increasing age Immunocompromised Co-morbidities Female sex Statin use ```
30
What are the complications of shingles?
Post herpetic neuralgia - chronic debilitating pain Ramsay Hunt CNS involvement
31
Describe shingles rash
Maculopapular rash, cluster of vesicles | Limited to dermatomal pattern
32
What is the management of shingles
Aciclovir | Admit to hospital if needed
33
What is Hutchinson's sign
Rash on tip, side or root of nose - nasociliary nerve | Can cause eye inflammation and permanent corneal denervation
34
Presentation of EBV
``` Low grade fever Fatigue Malaise Sore throat Tonsillar enlargement Lymphadenopathy Mild hepatomegaly and splenomegaly ```
35
What are the investigations
EBV serology if ill for at least 7 days Monospot test in adults or immunocompromised If second monospot negative consider CMV, HIV Check LFTs
36
Management of EBV
Hospital admission if stridor, dehydration, splenic rupture Paracetamol, ibuprofen relieve pain and fever
37
Management of scleritis
High dose steroids or antibiotics
38
Presentation of uveitis
Painful watery red eye | Cloudy view, irregular pupils
39
Management of acute angle glaucoma
Lie patient flat Beta blocks Pilocarpine
40
Causes of aphthous ulcers
``` Genetics Smoking Iron, b12 deficiency Luteal phase of menstrual cycle Trauma Anxiety ```
41
Malignancy considered instead of aphthous ulcers
Solitary ulcer or swelling of oral mucosa | Persists for more than 3 weeks
42
Signs of high risk serious illness in a child
``` Pale, mottled, ashen, blue No response to cues Appears ill Does not wake High pitched cry Grunting Reduced skin turgor Bulging fontanelle Neck stiddness Status epilepticus Focal neurological signs or seizures ```
43
What is a stroke
Sudden onset of rapidly developing focal or global neurological disturbance lasts more than 24 hours
44
What is a TIA
Less than 24 hours of neurological dysfunction, caused by focal brain, spinal cord or retinal ischaemia Without acute infarction
45
Causes of haemorrhagic stroke
Intracerebral haemorrhage e.g. aneurysm | SAH
46
Long term complications of stroke
``` Motility issues Sensory problems Pain Incontinence Fatigue Dysphagia Skin problems Sexual dysfunction Cognitive Financial ```
47
What is acute vestibular syndrome
Symptoms of stroke of posterior circulation Vertigo, nystagmus, nausea and vomiting New gait unsteadiness
48
Management of stroke
Stroke thombolysis | Do not start antiplatelet treatment until haemorrhagic stroke ruled out
49
Management of TIA
Aspirin 300mg stat PPI Urgent assessment within 24 hours
50
Bell's palsy
Acute unilateral facial nerve weakness or paralysis with rapid onset
51
Complications of Bell's
Eye injury Corneal ulceration Dry mouth Intolerance to loud noises if stapedius affected
52
What does forehead sparing suggest in a facial palsy
Upper motor neurone lesion such as a stroke
53
Management of Bell's
Prednisolone | Antiviral treatments alone not recommended
54
Causes of hypothalamic amenorrhoea
Functional disorders e.g. exercise, ED Chronic conditions e.g. thyroid Kallmann syndrome - x linked,failure of migration of GnRH cells
55
What are pituitary causes of amenorrhoea
``` Prolactinomas Pituitary tumours Sheehan's Destruction of pituitary gland Post contraception ```
56
Ovarian causes of amenorrhoea
PCOS Turner's 45 XO Premature ovarian failure
57
Genital tract abnormalities causing amenorrhoea
Ashermann's adhesions Imperforate hymen Transverse vaginal septum MRKH agenesis
58
What is average freq for cycle
28 days | >38 days infrequent
59
Av duration of period
5 days, >8 days prolonged
60
Av vol loss during menses
40ml
61
Differentials for HMB
``` Pregnancy - miscarriage or ectopic Endometrial or cervical polyps Adenomyosis Fibroids Malignancy Coagulopathy Endometriosis ```
62
What are fibroids
Leiomyomas | Benign smooth muscle tumours arising from myometrium
63
RFs for fibroids
``` Obesity Early menarche Increasing age FH AfroAmericans ```
64
Management of fibroids
Tranexamic or mefanamic acid Hormonal contraception to control menorrhagia Ulipristal can reduce size Hysterectomy, myomectomy
65
What is endometriosis
Extrauterine implantation and growth of endometrial tissue
66
What is adenomyosis
Deposits of endometrial tissue in the myometrium of the uterus
67
Clinical features of endometriosis
``` chronic pelvic pain dysmenorrhoea irregular periods dyspareunia infertility/sub ```
68
Investigations and management for endometriosis
Laparoscopy USS, MRI Pain management Excision or ablation
69
Diagnosis and management of adenomyosis
Same symptoms as endometriosis Symetrically enlarged tender uterus Transvaginal US Only curative is hysterectomy NSAIDs, COCP, uterine artery embolisation
70
Pathogenesis of PCOS
Insulin resistance Hyperinsulinaemia Reduction in sex hormone binding globulin LH higher than FSH so no surge and ovulation Excess androgens
71
Features of PCOS
``` Oligo/amenorrhoea Infertility/sub-fertility Acne, hirsutism Obesity Sleep apnoea Anxiety/depression Acanthosis nigricans ```
72
Risk of cancer in PCOS
Risk of endometrial Endometrial hyperplasia can occur Pts to have withdrawal bleed every 3-4 months and tv uss in any abnormal bleeding or absent bleeding
73
Management of PCOS
``` COCP Weight loss Hair removal techniques Topical ointments for acne Smoking cessation, exclude other causes of infertility Healthy lifestyle ```
74
Complications of PCOS
``` T2DM Gestational diabetes CVD Sleep apnoea Depression/anxiety ```
75
Causes of post-coital bleeding
``` Infection Cervical ectropion Polyps Vaginal cancer Cervical cancer Trauma, abuse Atrophic change ```
76
Causes of IMB
``` Pregnancy related Spotting in ovulation Adenosis, vaginitis Infections, STIs, polyps Fibroids, cancer, endometriosis Tamoxifen, smear, missed COCP, drugs ```
77
Types of HRT
Unopposed oestrogen or combination of oestrogen and prog Given oral or transdermal Topical HRT for vaginal dryness
78
Risks of HRT
Combined has increased risk of breast cancer Increased risk from ovarian cancer Oral has increased risk of VTE Risk of fragility fractures reduced
79
contraception post menopause
hrt not contraception Women under 50 fertile 2 years after last period over 50 fertile 1 year after last period so still need contraception
80
Premature ovarian insufficiency
``` younger than 40 not on contraception menopausal symptoms no periods elevated FSH can be genetic or autoimmune ```
81
Contraindications to HRT
``` Current, past or suspected breast cancer Oestrogen dependent cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia Previous idiopathic or current VTE Active or recent arterial thromboembolic disease Active liver disease Pregnancy Thromophilic disorder ```
82
Complications of HRT
Oestrogen causes fluid retention, bloating, breast tenderness Leg cramps PMS like symptoms Vaginal bleeding problems
83
What is croup
Upper respiratory viral illness leads to inflammation of larynx and airways below the glottis
84
Causes of croup
parainfluenza adenovirus coronavirus rhinovirus
85
clinical features of croup
viral prodrome coryzal symptoms of runny nose, dry cough fever lasts 24-48 hrs Sudden onset barking cough, stridor, resp distress
86
Score to assess croup
Westley score
87
Management of croup
Dexamethosone and anti-pyretics
88
organic causes of constipation in children
``` anorectal malformations anal fissure hirschsprung's hypothyroid coeliac CF Lead toxicity ```
89
Red flag symptoms of constipation in kids
``` Commence from birth delay in passing meconium ribbon stools leg weakness abdominal distention and vomiting abnormal anus limb deformity ```
90
What is SCFE?
Slipped capital femoral epiphysis | Metaphysis displaces anteriorly and superiorly leading to slipped plate
91
viral induced wheeze usually due to
rhinovirus
92
what does a tense or sunken fontanelle mean
raised icp - hydrocephalus dehydration
93
what do you look for on newborn exam in eyes
erythema, discharge position of eyes red reflex
94
When is red reflex absent
congenital cataracts retinoblastoma retinal detachment vitreous haemorrhage
95
what are the two tests on the hips
barlows and ortolani's adduct hips with pressure on knee with thumb for barlow ortalani - flex hips and knees to 90
96
what reflexes are present in a baby
rooting - brush cheek and turn stepping - pretends to walk when touch flat surface moro - drop back once or twice, extension of legs and head, arms jerk up palmar grasp sucking - sucks anything which touches roof of mouth
97
scabies caused by
sarcoptes scabiei
98
presentation of scabies
female burrows leaves eggs in skin causes wavy silver lines papules, nodules, pustules
99
management of scabies
all contacts treated premethrin dermal cream hot washes cream applied overnight head to toe, and then again one week later
100
where is eczema common
On flexural or skin creases
101
management of eczema
keep skin hydrated emollients, moiturisers tacrolimus if not controlled by maximal corticosteroids
102
treatment of acne
keep face clear blue light therapy benzoyl peroxide topical antibiotics e.g. erythromycin topical retinoids e.g. tretinoin
103
presentation of psoriasis
itchy, well demarcated circular pink elevated lesions distributed symmetrically fissuring in plaques nail changes pitting, onchyolysis
104
management of psoariasis
topical therapies, corticosteroids and vitamin D analogues phototherapy biological therapies e.g. infliximab third line
105
what is vitiligo
patchy loss of melanin | due to emotional stress, childbirth, skin trauma or exposure to chemicals
106
causes of erythema multiforme
herpes simplex mycoplasma pneumonia fungal infections penicillins
107
causes of erythema nodosum
IBD Strep infection, scarlet fever Sarcoidosis, TB
108
treatment of eczema herpeticum
painful itchy blistered rash complication of atopic dermatitis treatment is antivirals
109
management of urticaria
aggravating factors minimised topical anti-pruritic agents e.g. calamine H1 antihistamines e.g. certirizine
110
presentation of SCC
Indurated nodular keratinising crusted tumour non healing ulcer small nodules
111
presentation of BCC
slow growing, locally invasive, arises from hair follicles indurated edge, ulcerated centre
112
subtypes of malignant melanoma
superficial nodular lentigo acral on hands, feet and nailbed
113
changes of melanoma
ABCDE | Diameter >6mm
114
cause of impetigo
bullous or non staphlococcus aureus and strep pyogenes due to poor hygiene break in skin protective layers
115
presentation of impetigo
tiny pustules evolve into honey coloured plaques if non bullous in bullous rupture spontaneously, likely to occur on atopic eczema
116
management of impetigo
stay off school, avoid sharing towels no scratching fusidic acid 3x day for one week hydrogen peroxide cream if not unwell refer if widespread, recurring, systemically unwell
117
management of atopic dermatitis
avoid irritant use of PPE simple emollients topical corticosteroids e.g. ciclosporin
118
what is rosacea
chronic relapsing disease of facial skin, recurrent episodes of flushing erythema, papules, telangiectasia
119
causes of flushing in rosacea
heat, alcohol, caffeine, spicy foods, stress
120
management of rosacea
reassurance facial massage topical metronidazole oral abx e.g. doxycycline if severe papulopustular laser treatment for telangiectasia
121
different types of ringworm
``` tinea corporis - trunk cruris - groin and natal cleft pedis - athlete's foot manuum - infection of hand and scaling in palmar creases capitis - scalp; patches of broken hair unguium - nail yellowing ```
122
presentation of ringworm
``` itching, rash hair loss secondary infection with cellulitis or impetigo webs of toes macerated oncholysis annular scaly plaques, raised edges overlapping concentric circles ```
123
management of ringworm
``` keep skin cool keep dry do not scratch do not share towels cover feet treatment with topical antifungal e.g. miconazole ```
124
what is otitis externa
inflammation of outer ear; auricle, external auditory canal
125
RFs for otitis externa
humidity swimming old age obstruction e.g. wax
126
causes of ear infections
``` bacterial or fungal staph aureus p aerugonisa fungal herpes zoster rh ```
127
presentation of otitis externa
``` ear canal erythema oedema, exudate pain moving tragus hearing loss, discharge oedematous canal ```
128
what is malignant otitis externa
``` spreads into mastoid or temporal bones due to p aeruginosa or s aureus pain and headache can have FN palsy temp, vertigo, hearing loss pain, oedema ```
129
what is chronic otitis externa
lack of earwax hypertrophic skin pain on manipulation constant itch in ear
130
management of acute otitis externa
clean, syringe, dry swab | analgesia for symptomatic relief
131
what is chronic suppurative otitis media
chronic inflammation follows slowly resolving AOM effusion of glue like fluid behind intact membrane
132
presentation of acute otitis media
pain, children pull at ear, irritability, vomiting high temp, pinna may be red red bulging tympanic membrane with fluid behind hearing loss, otalgia and fever in adults
133
management of acute otitis media
rule out complications e.g. mastoiditis, FN If abx needed 5-7 day course amoxicillin erythromycin or clarithromycin in pregnant women
134
presentation of suppurative otitis media
chronically draining ear > 2 weeks history of AOM hearing loss
135
what is mastoiditis
suppurative infection from middle ear spreads to mastoid air cells common in young children or immunocompromised
136
common organisms in mastoiditis
strep pneumoniae strep pyogenes staph h influenzae
137
presentation of mastoiditis
intense otalgia pain behind ear external ear may protrude forwards boggy tender mass behind ear
138
management of mastoiditis
hospital referral high dose cephalosporins IV tympanostomy tube insertion mastoidectomy
139
what is otitis media with effusion and management
``` glue ear, collection of fluid in middle ear no inflammation may be due to impaired eustachian tube dysfunction hearing loss aural discharge loss of light reflex crackling, popping tinnitus ``` do tympanometry audiometry active observation should resolve in 6-12 weeks if persist, hearing loss severe, tympanic membrane structurally abnormal then refer
140
cause of BPPV
Loose calcium carbonate crystals | When head moves, otoconia move causing motion of fluid
141
RFs of BPPV
head injury recumbent position ear surgery inner ear pathology
142
what is vestibular neuritis
vestibular neuropathy due to reactivation of type 1 herpes simplex virus in vestibular ganglion hearing not affected
143
what is labyrinthitis
vestibular nerve and labyrinth affected which contains peripheral sensory organs for balance and hearing hearing loss, vertigo, nausea and vomiting
144
what is meniere's
disorder of inner ear due to change in fluid volume vertigo, tinnitus, fluctuating hearing loss sense of aural pressure fluctuating episodic pattern
145
management of meniere's
reassure keep medication accessible if sudden attacks stop driving if vertigo when driving cyclizine for vomiting consider betahistine to reduce freq of attacks
146
causes of vertigo
``` inner ear, labyrinth, vestibular nerve brainstem/cerebellum BPPV Vestibular neuronitis Meniere's Migraine, stroke, TIA ```
147
management of chronic sinusitis
``` admission if orbital or intracranial involvement avoid allergic triggers no smoking good dental hygiene saline solution and irrigation intranasal corticosteroids - fluticasone ```
148
removal of earwax
ear drops, sodium bicarbonate, olive oil irrigation if symptoms persist microsuction do not use irrigation if increase risk of trauma or infection
149
what is acoustic neuroma
tumour of vestibulocochlear CN 8 nerve From schwann cells of nerve sheath slow growing, benign, life threatening unilateral or asymmetrical hearing loss or tinnitus progressive as tumour spreads - facial pain or numbness
150
management of acoustic neuroma
microsurgery | radiotherapy and observation
151
what is a cholesteatoma
abnormal accumulation of squamous epithelium and keratinocytes in middle ear and mastoid air spaces erodes into neighbouring structures chronic negative middle ear pressure causes tympanic membrane to be retracted forms pocket progressive conductive hearing loss, as lesion grows get vertigo, headache, FN palsy
152
complications of cholesteatoma
``` recurrent ear infections conductive hearing loss vertigo sensorineural loss due to erosion into inner ear mastoiditis ```
153
management of cholesteatoma
surgery removal | incision behind ear and auditory meatus
154
what is otosclerosis
fixation of stapes footplate to oval window | impairs movement of stapes and transmission of sound into inner ear
155
presentation and management of otosclerosis
progressive hearing loss and tinnitus audiometry and CT improve hearing loss through bilateral hearing aids sodium fluoride and bisphosphonates stapedectomy
156
What is generalised anxiety disorder
syndrome of ongoing worrying, anxiety in an excessive and inappropriate manner
157
symptoms of GAD
Nervousness, trembling, muscle tension, sweating
158
RFs for GAD
female, FH, physical or emotional stress, hx of abuse of trauma, other anxiety disorder
159
Management of GAD
Use of GAD 7 questionnaire assess severity enquire about comorbidities and treat discuss other stressors, help, active monitoring Offer low intensity psychological interventions non facilitated self help, guided self help, groups High intensity CBT, drug treatments, SSRIs If pregnant need high intensity interventions first Refer to specialist if not improving, risk of self harm neglect or suicide risk
160
who is at risk of suicide
``` Male, under 30, living alone/single Previous attempt Substance abuse or alcohol abuse Family history Recent initiation of treatment ```
161
what are the characteristics of acute stress reaction
intrusion - re-experiencing avoidance - avoid expressing thoughts related to trigger hyperarousal - reckless of arrogant behaviour mood related - negative thoughts
162
What are the kubler ross cycle stages of grief
``` denial anger bargaining depression acceptance ```
163
what is self harm
intentional act of self poisoning or self injury expression of emotional distress includes suicide attempts when there is no attempt
164
what are risk factors for self harm
``` age approx 16-24 socio economic disadvantages stressful life events bereavement by suicide mental health, substance abuse involvement in criminal justice system ```
165
what are the complications of self harm
acute liver failure scarring, tissue/tendon/nerve damage repetitive increase risk of suicide if male, repeatedly self harm physical health problems, suicidal ideation
166
what is the acute management following an act of self harm
``` sensitive, compassion, minimise distress examine for injuries assess emotional and mental state assess any increase in risk of suicide, any protective factors e.g. family to stay for safeguarding concerns ``` consider toxbase, may need to go to A&E if no A&E wound management, refer to mental health ensure follow up in 48 hours, full assessment prevent access to any means support all involved risk assessment, referral to CAMHS if appropriate community mental health, individual care plan
167
what does the PHQ9 tool cover
``` little interest in things feel low or hopeless trouble falling asleep, staying asleep, sleep too much tired/little energy poor appetite, overeating feel bad about self, let down hard to concentrate move or speak slow suicidal ideation ```
168
what is the management of depression
``` assess suicide risk and risk factors factors which may affect course of depression response to treatment in past safeguarding concerns manage comorbidities SSRIs - continue for 6 months sleep hygiene, mindfulness follow up 1-2 weeks after initial appt, then every 2-3 weeks for first 3 months if not at increase risk ```
169
management of OCD
``` Assess degree of issue may have other mental health conditions safeguarding, self harm, self neglect psychological intervention CBT, SSRI Refer to secondary care mental health ```
170
what is anorexia nervosa vs bulimia nervosa
anorexia - restriction of intake to have low body weight, intense fear of gaining weight, denial of malnutrition dry skin, hair loss, bradycardia, postural hypotension bulimia - recurrent binge eating then restrictions compensations - vomiting, purging, laxatives, exercise weight is often in normal limits
171
what is the SCOFF questionnaire
``` Sick Loss of Control lost more than ONE stone in 3 months too Fat Food dominates life ```
172
what interventions for drug misuse
substitution therapy e.g. maintenance or detox with methadone, buprenorphine Goals - abstinence, reduction, maintenance, harm reduction, psychosocial interventions brief interventions, motivational interviewing CBT, groups, family groups
173
What is the model of change
``` cycle of pre contemplation contemplation action maintenance ``` hopefully leave cycle and in remission
174
How to calculate units of alcohol
strength (abv) x vol / 1000 = units
175
recommended alcohol consumption
no more than 14 units a week on regular basis | spread drinking over 3 or more days
176
what is included in CAGE questionnaire
should you cut down on drinking are people annoyed at your drinking do you ever feel guilty drinking in morning - eye opener
177
what management is available for alcoholics
motivational interviewing, promote abstinence psychological interventions assisted alcohol withdrawal as inpatient or outpatient
178
withdrawal symptoms of smoking cessation
``` irritability depression restlessness poor concentration disturbed sleep nicotine craving ```
179
what are the parameters for BMI
<18.5 underweight 18.5-24.9 normal weight 25-29.9 overweight >30 obese
180
what is the time limit for emergency contraception
ulipristal acetate inhibits or delays ovulation via suppression of LH; up to 5 days after UPSI CaIUD toxic effect on sperm and ova, inflammation prevents implantation within 5 days or within 5 days of the earliest estimated date of ovulation whichever latest levonorgestrel - within 72 hours
181
what are the anticipatory medicines in palliative care
analgesics - morphine for pain, breathlessness anxiolytics sedatives e.g. midazolam for distress anti-secretory - hyoscine butylbromide for secretions Anti-emetics e.g. levomepromazine

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