ࡱ>  _bjbj]q]q a??ʫIIIII]]]]8| ]##"###%%%GI%%%"%%-II##%X---%<I#I#\-%--vRII6͏]-|x}Tn-6-6&I\%%% :   Rotation: UltrasoundRotation Duration: 4 wksMonth(s): 3-4Institution: Stanford, VACall Responsibility: noneNight(s): covered by Night floatResponsible Faculty Member(s): R. Brooke Jeffrey Jr., M.D. F. Graham Sommer, M.D. Terry Desser, M.D. Bruce Daniel, M.D. Aya Kamaya, M.D. Juergen Willmann, MD PhD Lewis Shin, MD Ray Hsu, MD Richard Barth, M.D. (OB ultrasound)Location: Stanford hospital (2 months) VA DRC (1 month) Johnson Perinatal Diagnostic Center, 3rd floor SUH UCSF- optional fourth-year electivePhone Numbers: Stanford Hospital: Ultrasound reading room: 498-2401, 723-3499 Ultrasound lab: 723-3498 OB ultrasound: 725-7030 VA Hospital: 650-493-5000 ( +extension) front desk: 64489 Technologist: 63824, 63020 Reading room: 65250, 63886 Technologists/Technical Staff: Diane Orluck, RDMS, Chief Technologist Amber Gee, Alex Karanany Amanada Nelson Carol Walters Christy Hill Ke Chen Lan Zhang Lillie Utley Marianne Johnson Rebecca Wong Pam Daniel, Sarah Brandon, Shirley Furuichi, Xin YuanTraining Level: Stanford-years 1, 3 VA-year 2Goals & Objectives- A note about goals and objectives- The goals and objectives outlined in this document are based upon the six core competencies as defined by the ACGME. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This conceptgraded and progressive responsibilityis one of the core tenets of American graduate medical education. This document should provide you a framework for the stepwise progression of your knowledge and skills. ROTATION 1: FIRST YEAR-Stanford Hospital Ultrasound This rotation involves interpretation of basic sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also, introduction to color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some ultrasound-guided aspirations and biopsies will be performed on the ultrasound rotation and others on the interventional rotation. Patient Care Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: Knowledge Objectives: Be familiar with all departmental US protocols found in reading room binder. Know the key types of ultrasound examinations. Understand indications, contraindications, and patient preparation for sonographically-guided procedures. Demonstrate basic knowledge of EPIC, Nuance Radwhere voice recognition software, centricity RIS, GE centricity PACS, and the Siemens KinetDX ultrasound workstation. Become familiar with ultrasound machinery and transducers. Become familiar with the use of Color Doppler and harmonics. Learn the basics of ultrasound analysis. Skill Objectives: Become facile with scanning, using PACS and utilizing available information technology to manage patient information. Observe and assist in US-guided aspirations and biopsies under direction of faculty or fellow. Perform basic sonography with minimal assistance, including US of the chest, abdomen, pelvis, and lower extremities. Procedure Log: Log at least 20 DVT cases, some of which should be upper extremity cases. Coordinate activities in the reading room, including assisting the staff MD on providing direction for the technologists, consultation for other clinicians, and answering the phone. Gather clinical and radiological data on patients referred for ultrasound exam. Develop diagnostic plan based on the clinical presentation and prior imaging. Understand the clinical questions to be addressed by the study by calling the referring physician if necessary. Review ultrasound requisitions to be sure that the correct type of study has been ordered to answer the clinical question. Perform exams responsibly and safely, assuring that the correct exam is ordered and performed. Review images with the ultrasound technologists as studies are completed to insure that sufficient, diagnostic images have been obtained. Request additional images as needed. Develop hands-on scanning skills and learn the operation of the ultrasound instrument. Demonstrate the ability to use the internet as an educational instrument: PubMed, RSNA site, Google, Stat DX. Generate differential diagnoses based in imaging findings and clinical data. Behavior and Attitude Objectives: Work with the health care team in a professional manner to provide patient-centered care. Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. Active participation with faculty in patient workup. Graduated responsibility in performing radiologic procedures. Medical Knowledge Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to: Knowledge Objectives: Understand clinical application of ultrasound. Identify relevant anatomic structures on US images. Diagnose common pathologic conditions in the abdomen and pelvis and understand their pathophysiology. Understand the elements of key ultrasound examinations including gallbladder, liver, renal, pelvic, FAST for ER, chest for fluid, extremity for DVT. The goal at this level is to begin to understand the basics and what it takes to master them. Learn the pathophysiology and diagnostic criteria of the diagnoses listed in appendix A. in preparation for a call Skill Objectives: Perform basic sonography with minimal assistance, including US of the chest for fluid, abdomen for gallbladder or liver disease, pelvis for fibroids or ectopic, and lower extremities for thrombosis. Demonstrate sufficient knowledge of medicine and its proper application to generate meaningful differential diagnoses. Demonstrate a clinically appropriate diagnostic treatment plan. Demonstrate the proper use of radiological equipment. Behavior and Attitude Objectives: Recognize limitations of personal competency and ask for guidance when appropriate. Practice-Based Learning and Improvement Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to be able to: Knowledge Objectives: Assess US images for quality and suggest methods of improvement. Skill Objectives: Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. Facilitate the learning of students and other health care professionals. Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills. Keep a log of clinical and interpretive questions that arise during readout of cases, and research answers to at least 2 questions per week. Demonstrate knowledge of and apply the principles of evidence-based medicine in practice. Demonstrate critical assessment of the scientific literature. Use internet and online and print resources to answer clinical questions. Behavior and Attitude Objectives: Incorporate formative feedback into daily practice. Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. Participation in body imaging journal club. Preparation of cases for multi-disciplinary conferences. Participation in ultrasound conference. Demonstrate the ability to use all relevant information resources to acquire evidence-based data. Demonstrate understanding of the principles of research project design and implementation. Systems Based Practice Goal: Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: Knowledge Objectives: Understand how their image interpretation affects patient care. Demonstrate knowledge of funding sources for research and clinical care. Demonstrate knowledge of reimbursement methods. Demonstrate knowledge and sensitivity to workflow and resource utilization issues. Demonstrate knowledge of the regulatory environment. Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff. Learn about the AIUM accreditation standards for Ultrasound laboratories. Skill Objectives: Provide accurate and timely interpretations to decrease length of hospital and emergency department stay. Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted. Practice cost-effective use of time and support personnel. Demonstrate ability to design cost-effective care plans. Review of literature, including ACR Appropriateness Criteria. Behavior and Attitude Objectives: Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. Attendance and participation in multi-disciplinary conference. Interaction with department administrators. Membership and participation in local and national radiological societies. Professionalism Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: Knowledge Objectives: Understanding of the need for respect for patient privacy and autonomy. Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate faculty and/or fellow. Demonstrate knowledge of issues of impairment. Skill Objectives: Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. Behavior and Attitude Objectives: Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career. Demonstrate honesty with patients and staff. Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors. Demonstrate positive work habits, including punctuality and professional appearance. Interpersonal and Communication Skills Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to: Knowledge Objectives: Know the importance of accurate, timely, and professional communication. Skill Objectives: Produce concise and accurate reports on most examinations, provide a clear report based on standard radiologic terminology. Communicate effectively with physicians, other health professionals. Obtain informed consent with the utmost professionalism. Obtain pertinent clinical information and clear understanding of diagnostic question to be answered by communicating directly with clinicians if necessary. Communicate relevant clinical history to ultrasound technologists. Provide direct communication to referring physicians, and documenting communication in report for all significant positive findings. Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives, and possible complications. Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel. Demonstrate findings to clinicians when they come to ultrasound department to review study. Behavior and Attitude Objectives: Work effectively as a member of the patient care team. ROTATION 2: Second Year- VA This rotation involves interpretation of intermediate sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also, introduction to color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some ultrasound-guided aspirations and biopsies will be performed on the ultrasound rotation and others on the interventional rotation. Patient Care Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: Knowledge Objectives: Be increasingly familiar with all departmental US protocols. Know the majority of types of ultrasound examinations, see below. Understand indications, contraindications, and patient preparation for sonographically-guided procedures. Increased familiarity with machines and transducers: optimizing Doppler settings. Skill Objectives: Demonstrate advanced knowledge of EPIC. Become increasingly facile with Scanning, using PACS and utilizing available information technology to manage patient information. Perform intermediate sonography with minimal assistance, including US of the chest, abdomen, pelvis, and lower extremities. Procedure Log: Log at least 10 abdomen and 10 pelvis cases. Coordinate activities in the reading room, including assisting the staff MD on providing direction for the technologists, consultation for other clinicians, and answering the phone. Gather clinical and radiological data on patients referred for ultrasound exam. Develop diagnostic plan based on the clinical presentation and prior imaging. Understand the clinical questions to be addressed by the study by calling the referring physician if necessary. Review ultrasound requisitions to be sure that the correct type of study has been ordered to answer the clinical question. Perform exams responsibly and safely, assuring that the correct exam is ordered and performed. Review images with the ultrasound technologists as studies are completed to insure that sufficient, diagnostic images have been obtained. Request additional images as needed. Develop hands-on scanning skills and learn the operation of the ultrasound instrument Demonstrate the ability to use the internet as an educational instrument: PubMed, RSNA site, Google, Stat DX. Generate differential diagnoses based in imaging findings and clinical data. Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected cholecystitis. Learn to perform imaging of the acute scrotum for suspected torsion and epididymitis. Behavior and Attitude Objectives: Work with the health care team in a professional manner to provide patient-centered care. Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. Active participation with faculty in patient work-up. Graduated responsibility in performing radiologic procedures. Medical Knowledge Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to: Knowledge Objectives: Understand clinical application of ultrasound. Identify relevant anatomic structures on US images. Diagnose common and uncommon pathologic conditions in the abdomen and pelvis and understand their pathophysiology. Understand the elements of key ultrasound examinations including gallbladder, liver, renal, pelvic, FAST for ER, chest for fluid, extremity for DVT. Learn to analyze and diagnose IUP, ectopic pregnancy, adnexal mass, pancreatic mass, liver mass, spleen mass, kidney mass, bladder mass, and ovarian mass. Learn appropriate differential diagnoses and methods for further analysis. Learn to analyze and diagnose ultrasound studies of the neck and scrotum, carotid duplex studies. Review and understand at least half of the diagnoses listed in appendix B. Skill Objectives: Perform intermediate sonography with minimal assistance, including US of the chest for fluid, abdomen for gallbladder or liver disease, pelvis for fibroids or ectopic, and lower extremities for thrombosis. Demonstrate sufficient knowledge of medicine and its proper application to generate meaningful differential diagnoses. Demonstrate progress during subsequent rotations. Demonstrate a clinically appropriate diagnostic treatment plan. Demonstrate the proper use of radiological equipment. Behavior and Attitude Objectives: Recognize limitations of personal competency and ask for guidance when appropriate. Practice-Based Learning and Improvement Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to be able to: Knowledge Objectives: Assess US images for quality and suggest methods of improvement. Skill Objectives: Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. Facilitate the learning of students and other health care professionals. Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills. Keep a log of clinical and interpretive questions that arise during readout of cases, and research answers to at least 2 questions per week. Demonstrate knowledge of and apply the principles of evidence-based medicine in practice. Demonstrate critical assessment of the scientific literature. Use internet and online and print resources to answer clinical questions. Demonstrate understanding of the principles of research project design and implementation. Demonstrate the ability to use all relevant information resources to acquire evidence-based data. Behavior and Attitude Objectives: Incorporate formative feedback into daily practice. Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. Participate in journal club, clinical conferences, and independent reading. Participation in body imaging journal club. Preparation of cases for multi-disciplinary conferences. Systems Based Practice Goal: Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: Knowledge Objectives: Understand how their image interpretation affects patient care. Demonstrate knowledge of funding sources for research and clinical care. Demonstrate knowledge of reimbursement methods. Demonstrate knowledge and sensitivity to workflow and resource utilization issues. Demonstrate knowledge of the regulatory environment. Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff. Learn about the AIUM accreditation standards for ultrasound laboratories. Skill Objectives: Provide accurate and timely interpretations to decrease length of hospital and emergency department stay. Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted. Practice using cost effective use of time and support personnel. Demonstrate ability to design cost-effective care plans. Review of literature, including ACR Appropriateness Criteria. Behavior and Attitude Objectives: Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. Attendance and participation in multi-disciplinary conference. Interaction with department administrators. Membership and participation in local and national radiological societies. Professionalism Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: Knowledge Objectives: Understanding of the need for respect for patient privacy and autonomy. Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate faculty and/or fellow. Demonstrate knowledge of issues of impairment. Skill Objectives: Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. Behavior and Attitude Objectives: Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career. Demonstrate honesty with patients and staff. Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors. Demonstrate positive work habits, including punctuality and professional appearance. Interpersonal and Communication Skills Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to: Knowledge Objectives: Know the importance of accurate, timely, and professional communication. Skill Objectives: Produce concise and accurate reports on most examinations, provide a clear report based on standard radiologic terminology. Communicate effectively with physicians, other health professionals. Obtain informed consent with the utmost professionalism. Obtain pertinent clinical information and clear understanding of diagnostic question to be answered by communicating directly with clinicians if necessary. Communicate relevant clinical history to ultrasound technologists. Provide direct communication to referring physicians, and documenting communication in report for all significant positive findings. Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives, and possible complications. Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel. Demonstrate findings to clinicians when they come to ultrasound department to review study. Behavior and Attitude Objectives: Work effectively as a member of the patient care team. ROTATION 3-Stanford Hospital This rotation involves performance and interpretation of advanced sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also, an advanced level of color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some ultrasound-guided aspirations and biopsies will be performed on the ultrasound rotation and others on the interventional rotation. Patient Care Goal: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: Knowledge Objectives: Describe more common and uncommon sonographic artifacts. List indications, contraindications, and patient preparation for sonographically-guided procedures. Continued mastery of material from rotation 2. Normal OB exam and possible abnormalities. Skill Objectives: Become increasingly facile with scanning and utilize available information technology to manage patient information. Perform US-guided aspirations and biopsies with occasional help from faculty or fellow. Coordinate activities in the reading room, including providing direction for the technologists, consultation for other clinicians, and answering the phone. Observe ultrasound-guided biopsy of the thyroid gland. Perform ultrasound localization for ultrasound-guided biopsy of the kidney by the nephrology service. Behavior and Attitude Objectives: Work with the health care team in a professional manner to provide patient-centered care. Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. Medical Knowledge Goal: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to: Knowledge Objectives: Understand clinical application of ultrasound. Identify relevant anatomic structures on US images. Diagnose all pathologic conditions in the abdomen and pelvis and understand their pathophysiology. Understand principles of Doppler studies of abdominal vasculature, especially transplant studies Skill Objectives: Accurately interpret all US examinations, with only the necessary amount of faculty assistance. Begin to perform more complex sonographic examinations such as US of the carotid and visceral arteries, upper extremity arteries and veins, scrotum, and gravid uterus. Demonstrate understanding of the pathophysiology and diagnostic criteria for all of the diagnoses listed in appendix B. Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected cholecystitis. Learn to perform imaging of the acute scrotum for suspected torsion and epididymitis. Behavior and Attitude Objectives: Recognize limitations of personal competency and ask for guidance when appropriate. Practice-Based Learning and Improvement Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to be able to: Knowledge Objectives: Assess US images for quality and suggest methods of improvement. Skill Objectives: Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. Facilitate the learning of students and other health care professionals. Behavior and Attitude Objectives: Incorporate formative feedback into daily practice. Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. Systems Based Practice Goal: Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: Knowledge Objectives: Understand how their image interpretation affects patient care. Skill Objectives: Provide accurate and timely interpretations to decrease length of hospital and emergency department stay, Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and Practice using cost effective use of time and support personnel. Behavior and Attitude Objectives: Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. Professionalism Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: Knowledge Objectives: Understanding of the need for respect for patient privacy and autonomy. Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate faculty and/or fellow. Skill Objectives: Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. Behavior and Attitude Objectives: Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. Interpersonal and Communication Skills Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to: Knowledge Objectives: Know the importance of accurate, timely, and professional communication. Skill Objectives: Produce concise and accurate reports on most examinations. Communicate effectively with physicians, other health professionals. Obtain informed consent with the utmost professionalism. Behavior and Attitude Objectives: Work effectively as a member of the patient care team. ROTATION 4: OB ULTRASOUND ELECTIVE (optional) Can be taken at UCSFnote: this is the ONLY away rotation authorized by our GME office Workflow: The workday begins at approximately 8:30, immediately following morning conference Readouts occur throughout the morning and afternoon. Whenever possible, the resident should preview ultrasound cases with the body imaging fellow before readout. The resident should dictate cases that he/she performed or checked once they have been reviewed with the attending. The resident should field requests for emergency add-on studies and should elicit enough clinical history to insure that the correct study is performed for the condition suspected. He/she should also find out whom to contact with the results, and where any outpatient should be sent when the study is completed. After cases are dictated, a brief summary of the findings should be recorded in the Diagnosis section of the Worksheet for that study on the Ultrasound KinetDx workstation (Ultrasound mini-PACS). First-year residents should also spend time observing the technologists perform diagnostic scans. During the first rotation, they should begin to perform studies of the legs for suspected deep venous thrombosis. Ultrasound conference is held with the attending staff and technologists on Thursdays at 12:30. In OB ultrasound, residents should observe the studies being performed, and sit in on readout sessions. Duties: Required scanning skills: Venous Doppler studies of the extremities: First year residents should learn to perform studies for suspected deep venous thrombosis of the upper and lower extremities. At least 20 cases should be performed. Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected cholecystitis. Testicular ultrasound: Second and third year residents should learn to perform imaging of the acute scrotum for suspected torsion and epididymitis. Guidance for renal biopsies. Second, third and fourth year residents on the ultrasound service should learn to set up the transducer within a sterile drape and with a biopsy guide in order to assist the nephrologists' renal biopsies. Preparing Cases: Studies are reviewed on the KinetDx workstation in the ultrasound reading room. Once a study is reviewed, it should be marked as "Read" on the study list. Brief diagnoses are recorded directly into the KinetDx workstation after the studies are reviewed. The resident should note whether there are prior comparison ultrasound studies. The technologists will often print out the reports of prior studies. If there are prior ultrasound studies, the resident should check whether they are available online for viewing, or whether they need to be re-loaded onto the server manually. If the latter, the resident should note which tape has the study in question and inform the technologists so that they can re-load the study. If there are relevant comparison images from other modalities, these should be brought up onto the PACS workstation in the ultrasound reading area. The resident should note whether there are any outside cases to be reviewed. If so, these should be reviewed on the PACS in the ultrasound reading room. Time allowing, the resident may pre-dictate studies using the Nuance voice recognition software. The studies will then enter status 60, or "dictated." What to do during readout During readout, the resident should articulate the indication for the examination and be able to provide brief patient history. This may mean looking up some history in EPIC before the readout has begun. While the attending reviews the images, the resident should state what his/her impression was of the findings for any cases they have checked or scanned. During the readout, the resident should jot down a brief list of the findings to be included in the dictation on the tracking form for the patient's study so that all findings will be included. The resident should be sure he/she understands what the "bottom line" is for the study BEFORE the case is signed off, so that the report will convey the significance of the findings. Questions are welcome during readout. Conference Schedule/FormatTitleDayTimeLocationAbdominal imaging core conferencesTuesdayNoonLucasUltrasound QA conferenceThursdays12:30, monthlyBallroomMethod of Assessment of Performance: Written evaluation of resident by responsible faculty member monthly Verbal feedback to resident by faculty ACR In-Training Service Exam annuallyRecommended Reading ROTATION ONE: Clinical Sonography: A practical guide. Roger A. Sanders. Boston: Little Brown and Co., 1991.This handbook for technologists is a great place for the beginner to start. The book reviews the controls on the ultrasound machine and describes techniques for performing scans. Ultrasound: the requisites. Alfred B. Kurtz and William D. Middleton. St. Louis: Mosby-Year Book, Inc, 1996. An excellent overview of clinical ultrasound. ROTATION 2/3: Sonography of the abdomen. R. Brooke Jeffrey Jr. and Philip W. Ralls. New York: Raven Press, 1995. A rich source of information on abdominal ultrasound, with particularly good images of gastrointestinal applications. Emergency Imaging. R. Brooke Jeffrey, Philip Ralls, Ann Leung, Michael Brant-Zawadzki. Philadelphia: Lippincott Williams and Wilkins, 1999. A concise overview of diagnostic imaging in the acute setting. Chapters 11 and 12 discuss cholecystitis and appendicitis, and are especially pertinent. Reference Text: Diagnostic Ultrasound, Third Edition. Carol M. Rumack, Stephanie R. Wilson, and J. William Charboneau. St. Louis: Elsevier-Mosby, 2005. This outstanding two-volume text contains beautiful color illustrations and has excellent discussions on the most common ultrasound procedures. The first volume covers material likely to be encountered during the Stanford hospital ultrasound rotation. The second volume is devoted to obstetrics and pediatrics. OB ELECTIVE: Ultrasonography in Obstetrics and Gynecology, Fourth Edition. Peter W. Callen. Philadelphia: W. B. Saunders Company, 2000. An in-depth, comprehensive reference on obstetrical and gynecologic ultrasound. Great for boards. Stat DX RadPrimer As a suggestion, you should do selected readings nightly on topics which have come up on cases seen during the day. This is much more effective than reading texts cover-to-cover and, in general, results in better retention of material because you will be able to associate what youve read with a real case that youve recently seen.  Appendix A: knowledge objectives in rotation one in preparation for call. Pre-call 1Acute Calculous Cholecystitis2Acute Pyelonephritis3Biliary Ductal Dilatation4Choledocholithiasis5Cholelithiasis6Deep Vein Thrombosis7Epididymitis/Orchitis8Hemorrhagic Cyst9Hydrocele10Hydronephrosis11Hydrosalpinx12Ovarian Teratoma13Torsion14Peripheral Arterial Pseudoaneurysm15Peripheral Arteriovenous Fistula16Pyogenic Hepatic Abscess17Portal Vein Gas18Scrotal Trauma19Testicular Carcinoma20Testicular Torsion/Infarction21Tubo-ovarian Abscess22Urolithiasis23Varicocele Appendix B: knowledge objectives for the remainder of the rotations. LiverDiffuse Parenchymal Disease24Acute Hepatitis25Cirrhosis, Hepatic26Diffuse Microabscesses, Hepatic27Lymphoma, HepaticCyst and Cyst-like Lesions28Hepatic Cyst29Caroli Disease30Amebic Hepatic Abscess31Hepatic Echinococcus Cyst32Hepatic TraumaFocal Solid Masses33Hepatic Adenoma34Focal Nodular Hyperplasia35Hepatocellular Carcinoma36Hepatic Cavernous Hemangioma37Hepatic MetastasesVascular Conditions38Portal Hypertension39Portal Vein Occlusion40Budd-Chiari SyndromeBiliary SystemGallstones and Mimics41Echogenic Bile, Blood Clots, Parasites42Gallbladder Cholesterol PolypGallbladder Wall Pathology43Acute Acalculous Cholecystitis44Chronic Cholecystitis45Porcelain Gallbladder46Hyperplastic Cholecystosis47Gallbladder CarcinomaDuctal Pathology48Choledochal Cyst49Cholangiocarcinoma50Ascending Cholangitis51AIDS-Related CholangiopathyPancreasPancreatitis52Pancreatitis, Acute53Pancreatic Pseudocyst54Pancreatitis, ChronicSimple Cysts and Cystic Neoplasms55Mucinous Cystic Pancreatic Tumor56Serous Cystadenoma of PancreasSolid-Appearing Pancreatic Neoplasms57Pancreatic Ductal Carcinoma58Pancreatic Islet Cell Tumors59Solid and Papillary NeoplasmSpleen60Splenomegaly61Splenic Tumors62Splenic TraumaUrinary TractNormal Variants and Pseudolesions63Column of Bertin, Kidney64Renal Ectopia65Horseshoe Kidney66Ureteral Duplication67Ureteral Ectopia68Ureteropelvic Junction ObstructionCalculi and Calcinosis69NephrocalcinosisCysts and Cystic Disorders70Simple Renal Cyst71Complex Renal Cyst72Cystic Disease of Dialysis73Multilocular Cystic Nephroma74Renal Trauma75Perinephric Fluid CollectionsUrinary Tract Infection76Focal Bacterial Nephritis77Emphysematous Pyelonephritis78Pyonephrosis79Renal Abscess80Xanthogranulomatous Pyelonephritis81Tuberculosis, Urinary TractSolid Renal Neoplasms82Renal Cell Carcinoma83Renal Angiomyolipoma84Transitional Cell Carcinoma85Renal LymphomaVascular Conditions86Renal Artery Stenosis87Renal Vein ThrombosisProstate88Prostatic Hypertrophy89Prostatic CarcinomaBladder90Bladder Carcinoma91Ureterocele92Bladder Diverticulum93Bladder CalculiRenal Transplants94Allograft Hydronephrosis95Perigraft Fluid Collections96Allograft RejectionAdrenal Gland97Adrenal Hemorrhage98Myelolipoma99Adrenal Cysts100Pheochromocytoma101Adrenal CarcinomaAbdominal Wall/Peritoneal Cavity102Groin Hernias103Peritoneal Carcinomatosis104Appendicitis105IntussusceptionFemale PelvisCervical and Myometrial Pathology106Adenomyosis, General Uterine107Leiomyoma, General UterineEndometrial Disorders108Hematometrocolpos109Endometrial Polyp110Endometrial Hyperplasia111Endometrial Carcinoma112EndometritisPregnancy-Related Disorders113Ectopic Pregnancy114Interstitial Ectopic Pregnancy115Failed First Trimester Pregnancy116Retained Products of Conception117Gestational Trophoblastic NeoplasmOvarian Cysts and Cystic Neoplasms118Functional Ovarian Cyst119Ovarian Hyperstimulation120Serous Ovarian Cystadenoma/Carcinoma121Mucinous Ovarian Cystadenoma/Carcinoma122Polycystic Ovarian SyndromeNon-Ovarian Cystic Masses123Parovarian CystsVaginal and Vulvar CystsMiscellaneous Ovarian Masses124Ovarian Fibrothecoma125EndometriomasScrotum126Undescended Testis127Testicular and Epididymal Cysts128Testicular Microlithiasis129Tubular Ectasia130Epididymal MassesHead and NeckThyroid and Parathyroid131Differentiated Thyroid Carcinoma132Hashimoto Thyroiditis133Multinodular Goiter134Graves Disease135Parathyroid Adenoma, Visceral Space136Anaplastic Thyroid CarcinomaAdenopathySalivary GlandsParotid SpaceMiscellaneous LumpsCongenitalBreastMusculoskeletalTendon DisordersSubcutaneous and Muscle InjuryArthropathiesNeurovascular AbnormalitiesInfectionArticular and Para-Articular MassesSoft Tissue TumorsVascularCerebrovascular137Carotid Stenosis/Occlusion138Vertebral Stenosis/OcclusionAbdominal Vessels139Takayasu Arteritis140Aortic/Iliac Aneurysm141Aorto-Iliac Occlusive Disease142IVC ObstructionExtremities143Subclavian Steal144Varicose Veins/Incompetent PerforatorLiver Transplants     STANFORD UNIVERSITY MEDICAL CENTER Residency Training Program Rotation Description PAGE   DATE \@ "M/d/yyyy" 10/15/2011  '.8;<=JVlp{s t }     ( o   K M  ' ( ) h|h)9>*OJQJh)9OJQJh|h)9>*OJPJQJ hhZh)9h)9h&0h)9OJQJ h&0h)9OJPJQJmHsHh&0h)9OJPJQJ hD1h)9 h&0h)9h&0h)956.<=Wq?kd$$IflF d&    t06    44 la <<$Ifgd)9l <<$Ifgd)9l   qZCCCCC$If^gd)9l <<$Ifgd)9l kd $$IflF d&    t06    44 la 5 D P t    HH<x$If^Hgd)9l " <x$If^`gd)9l " <x$If^`gd)9l $If^gd)9l      ( U o zcH555$Ifgd)9l  <<$Ifgd)9l <<$Ifgd)9l kd$$Ifl40d&`  t0644 lap o  gP<<$Ifgd)9l kd$$Ifl40d&   t0644 lap $Ifgd)9l   B  ( ) Nkd$$Ifl0d&  t0644 lap  <x$Ifgd)9l $Ifgd)9l ) = fghi%&3l$-DIfM gd)9l $-DIfM gd)9l $@&Ifgd)9l $Ifgd)9l  x<$Ifgd)9l  x<$Ifgd)9l 4p ) = _ fhi%&3:|}>QSUx6ķϘwϘssϘkċaϘh)9OJPJQJh)9OJQJh)9h&0h)96h&0h)95CJaJh&0h)9OJPJQJ h&0h)9h&0h)95OJPJQJh)9OJQJ^Jh&0h)9OJQJ^Jh&0h)9OJQJh&0h)95 hEAh)95B*^JaJph h)95hEAh)956hEAh)95&34:;^=>PQ **$If^*gd)9l # 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kdF$$Ifl,F ''' 3f3f6    44 laXp3f3f #7TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l 78VkdG$$Ifl,\ '''' (644 laXp(8:<?UTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l UVVkdH$$Ifl,\ '''' (644 laXp(VXZ]sTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l stVkdI$$Ifl,\ '''' (644 laXp(tv>mkdJ$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l ¤VkdXK$$Ifl,\ '''' (644 laXp(¤ĤƤɤTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdYL$$Ifl,\ '''' (644 laXp(>mkdZM$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l 4TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l 45Vkd N$$Ifl,\ '''' (644 laXp(579<YTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l YZVkd O$$Ifl,\ '''' (644 laXp(Z\^a~TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ~Vkd P$$Ifl,\ '''' (644 laXp(T$EƀY;Ifgd)9l VkdQ$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdR$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdS$$Ifl,\ '''' (644 laXp(ϥTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ϥХVkdT$$Ifl,\ '''' (644 laXp(ХޥT$EƀY;Ifgd)9l t T$EƀY;Ifgd)9l kdU$$Ifl,F ''' 6    44 laXp >>T$EƀY;Ifgd)9l mkdU$$Ifl,0''D 3f644 laXp3f (TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l ()VkdV$$Ifl,\ '''' (644 laXp()+-0>TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l >?VkdW$$Ifl,\ '''' (644 laXp(?ACFWTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l WXVkdX$$Ifl,\ '''' (644 laXp(XZ\_tTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l tuVkdY$$Ifl,\ '''' (644 laXp(uwy|TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdZ$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd[$$Ifl,\ '''' (644 laXp(ҦӦզצ>mkd\$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l צڦTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l VkdW]$$Ifl,\ '''' (644 laXp( >mkdX^$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l #TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l #$Vkd _$$Ifl,\ '''' (644 laXp($&(+>TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l >?Vkd `$$Ifl,\ '''' (644 laXp(?ACFaTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l abVkd a$$Ifl,\ '''' (644 laXp(bdfiTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd b$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd c$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l §Vkdd$$Ifl,\ '''' (644 laXp(§ħܧݧߧ>mkde$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l Vkde$$Ifl,\ '''' (644 laXp(#TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l #$89NOyzӨԨ+,.BC`a~ȩɩ˩שة"#:;QRrsŪƪ $%?@abxyʫ˫ݫޫ()LMOh&0h)95CJ\h&0h)9CJh&0h)9B*CJaJphV#$Vkdf$$Ifl,\ '''' (644 laXp($&(+8TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l 89Vkdg$$Ifl,\ '''' (644 laXp(9;=@NTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l NOVkdh$$Ifl,\ '''' (644 laXp(OQSVyTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l yzVkdi$$Ifl,\ '''' (644 laXp(z|~TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkdj$$Ifl,\ '''' (644 laXp(>mkdk$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l ӨTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l ӨԨVkdwl$$Ifl,\ '''' (644 laXp(Ԩ֨بۨTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkdxm$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkdyn$$Ifl,\ '''' (644 laXp(+TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l +,Vkdzo$$Ifl,\ '''' (644 laXp(,.BCEG>mkd{p$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l GJ`TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l `aVkd,q$$Ifl,\ '''' (644 laXp(aceh~TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ~Vkd-r$$Ifl,\ '''' (644 laXp(T$EƀY;Ifgd)9l Vkd.s$$Ifl,\ '''' (3f3f3f644 laXp(3f3f3fTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd/t$$Ifl,\ '''' (644 laXp(ȩTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ȩɩVkd0u$$Ifl,\ '''' (644 laXp(ɩ˩өթשT$EƀY;Ifgd)9l שةVkd1v$$Ifl,\ '''' (3f3f3f644 laXp(3f3f3fةکܩߩTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd2w$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd3x$$Ifl,\ '''' (644 laXp( "TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l "#Vkd4y$$Ifl,\ '''' (644 laXp(#%'*:TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l :;Vkd5z$$Ifl,\ '''' (644 laXp(;MOQT$EƀY;Ifgd)9l QRTVt T$EƀY;Ifgd)9l kd6{$$Ifl,F ''' 6    44 laXpVYrTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l rsVkd|$$Ifl,\ '''' (644 laXp(suwzTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd}$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd~$$Ifl,\ '''' (644 laXp(êŪT$EƀY;Ifgd)9l ŪƪȪʪt T$EƀY;Ifgd)9l kd$$Ifl,F ''' 6    44 laXpʪͪTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l Vkd$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd$$Ifl,\ '''' (644 laXp( TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l  Vkd$$Ifl,\ '''' (644 laXp( $TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l $%Vkd$$Ifl,\ '''' (644 laXp(%')-?TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ?@Vkd$$Ifl,\ '''' (644 laXp(@abdf\Okd$$Ifl,'  644 laXp T$EƀY;Ifgd)9l fjxTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l xyVkd}$$Ifl,\ '''' (644 laXp(y{}TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd~$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd$$Ifl,\ '''' (644 laXp(ʫTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ʫ˫Vkd$$Ifl,\ '''' (644 laXp(˫٫۫ݫT$EƀY;Ifgd)9l ݫޫt T$EƀY;Ifgd)9l kd$$Ifl,F ''' 6    44 laXp>>T$EƀY;Ifgd)9l mkd^$$Ifl,0''D 3f644 laXp3f (TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l ()Vkd$$Ifl,\ '''' (644 laXp()+-1LTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l LMVkd$$Ifl,\ '''' (644 laXp(MOefhj>mkd$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l Oef۬ܬ+,ST}~ҭӭխ;<ijۮܮ12OPfguvݯޯ$%'?@ij !#3h&0h)9B*CJaJphh&0h)9CJh&0h)95CJ\WjnTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l Vkd$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdÎ$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkdď$$Ifl,\ '''' (644 laXp(Ŭ۬TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ۬ܬVkdŐ$$Ifl,\ '''' (644 laXp(ܬެTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdƑ$$Ifl,\ '''' (644 laXp(>mkdǒ$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l +TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l +,Vkdx$$Ifl,\ '''' (644 laXp(,.04STW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l STVkdy$$Ifl,\ '''' (644 laXp(TVX\}TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l }~Vkdz$$Ifl,\ '''' (644 laXp(~TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd{$$Ifl,\ '''' (644 laXp(ҭTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ҭӭVkd|$$Ifl,\ '''' (644 laXp(ӭխ>mkd}$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l Vkd.$$Ifl,\ '''' (644 laXp(";TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ;<Vkd/$$Ifl,\ '''' (644 laXp(<>@DiTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ijVkd0$$Ifl,\ '''' (644 laXp(jlnrTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd1$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd2$$Ifl,\ '''' (644 laXp(ۮܮޮ>mkd3$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l TT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l Vkd$$Ifl,\ '''' (644 laXp(1>mkd$$Ifl,0''D 3f644 laXp3fT$EƀY;Ifgd)9l 1246>>T$EƀY;Ifgd)9l mkd$$Ifl,0''D 3f644 laXp3f6:OTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l OPVkdG$$Ifl,\ '''' (644 laXp(PRTXfTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l fgVkdH$$Ifl,\ '''' (644 laXp(goqsuT$EƀY;Ifgd)9l uvVkdI$$Ifl,\ '''' (644 laXp(vxz~TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdJ$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdK$$Ifl,\ '''' (644 laXp(ïݯTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l ݯޯVkdL$$Ifl,\ '''' (644 laXp(ޯTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdM$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l VkdN$$Ifl,\ '''' (644 laXp( "$T$EƀY;Ifgd)9l $%'?t T$EƀY;Ifgd)9l kdO$$Ifl,F ''' 6    44 laXp?@BD>>T$EƀY;Ifgd)9l mkd,$$Ifl,0''D 3f644 laXp3fDHiTT$EƀY;Ifgd)9l W$$EƀY;Ifa$gd)9l ijVkdݪ$$Ifl,\ '''' (644 laXp(jlnrTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkdޫ$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd߬$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd$$Ifl,\ '''' (644 laXp(°ưTW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd$$Ifl,\ '''' (644 laXp(TW$$EƀY;Ifa$gd)9l T$EƀY;Ifgd)9l Vkd$$Ifl,\ '''' (644 laXp( T$EƀY;Ifgd)9l  !#3t T$EƀY;Ifgd)9l kd$$Ifl,F ''' 3f3f6    44 laXp3f3f346DF>>>T$EƀY;Ifgd)9l mkd$$Ifl,0''D 3f644 laXp3f346FGI]^`mn{|ƱDZɱٱڱܱ 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