ࡱ> GIDEF#` vbjbj 4"O("""8ZF.N*&&"HHHHHH}$xhemHHmmHHm:HH}m}  H pm" <0N Mx   HڴhBTHHHU4HHHNmmmm...DS$/...zh Physical Diagnosis Exam Two Material Skin, Hair and Nails Study Questions What questions should be asked during the ROS for dermatological problems? Have there been any changes in moles, birthmarks, or spots on the body? Any color changes, irregular growth, pain, scaling or bleeding? Any recent growth of flat pigmented lesion? Any red, scaly or crusted areas of the skin that does not appear to be healing Have you ever had skin cancer? If so, where? Treatment? Outcome? What are the most common symptoms of skin disorders? Skin lesions (location, distribution, arrangement, type, color) Skin color changes (pallor, cyanosis, jaundice, rashes, bruises) Pruritis itching (from renal ds, IDDM, dry skin, lymphomas, leukemias) Changes in hair (color, texture, thickness, distribution) Changes in nails (color, texture, thickness) List the important questions when obtaining the history for lesions? When, where, how, any change since pt. first noticed the lesion Palliative/Provocative Qualitative (description) Radiation (distribution) Severity (Effect Quality of Life?) Timing (pattern) Past Hx, Family Hx, Occupational Hx, Psychosocial Hx, ROS What features would you note while inspecting a skin lesion? Anatomic location and distribution (localized or generalized?) Arrangement (linear, clustered, annular, arciform, dermatomal?) Appearance and type (see question 6 for types) Uniformity % Thickness % Symmetry % Color What features would you note while palpating a skin lesion? Temperature, texture, moisture, mobility Turgor ( hydration level Tenting ( if dehydrated Nonpalpable (circumscribed, flat, change in skin color) Macule, Patch Fluid filled (circumscribed, superficial elevations) Vesicle, Bulla, Pustule Elevation (from small to large) Papule ( Nodule ( Tumor ( Plaque ( Wheal Define what is meant by a primary lesion and list the various classifications. Primary lesion ( developed on normal skin Comado (Blackhead) % Burrow Cysts % Abscess Furuncls % Milia (whitehead) Define secondary lesion types and list the classifications. Secondary lesion ( change of primary due to infection, meds, scratching, etc Loss of skin surface Erosion, ulcer, fissure, excoriation (scratch), atrophy, sclerosis Material on the skin surface Crust, scale List miscellaneous lesions and their cause. Theres a giant list of these and I dont have the time to write them out right now. Sorry they should be in your book if ya need em! If I have time, Ill type em up and email them out. What are the possible variations in skin color and list causes of each? White (! melanin) Albino (congenital inability to form melanin) Tinea Versicolor (superficial fungal infxn of skin; scaly macule) Decreased visibility of oxyhemoglobin: Syncope: ! blood flow in superficial vessels Anemia: ! oxyhemoglobin Edema: nephritic syndrome Brown (melanin) sunlight, pregnancy, Addison s Ds, pituitary tumor Grayish Tan/Bronze (hemosiderin) Hemochromatosis Blue (cyanosis) visible in toes/toenails from ! deoxyhemoglobin Peripheral (capillary) ( anxiety, cold exam room Central (artery) ( advanced lung ds Red (oxyhemoglobin) Dilation of vessels, fever, alcohol, blushing Yellow (bilirubin) Conjunctiva (most evident), liver ds, RBC hemolysis Orange (Carotenemia - ! carotene) Palms, soles, and faces (most evident) Myxedema, hypopituitary, anorexia What are some of the vascular and purpuric lesions of the skin? Vascular ** blanching occurs only when blood is not outside vessel** Spider angioma: fiery red, central body, radiating legs Cherry angioma Erythemia Purpuric Petechia/Purprua Ecchymosis: excessive hematomas List clinical features or manifestations of Lymes Ds. Vector: ticks Agent: spirochete Borrelia burgdorferi Starts as a macule at site of bite and spreads as annular erythematous plaque Erythematous Migrans is the clinical hallmark Common symptoms include: Fatigue % Arthralgia % Fever/chills Myalgia % Headache % Stiff neck What is Koebner s phenomenon? Koebner s phenomenon is associated with lesions that develop in areas of previous skin damage. This may indicate recurrence of cancer if present on a surgical scar from prior cancer operation. List causes of contact dermatitis. Contact dermatitis is an inflammatory reaction of skin because of an allergen Detergents % Acids/Alkali % Plants % Drugs/medications Poison Ivy % Sun exposure % Solvents What features differentiate eczema from psoriasis? Eczema ("Dermatitis")PsoriasisFound onFlexorsElbows, knees, scalp, nailsResult ofInflammation of skinOverproduction of skinIndicatorsAuspitz Sign, Pitting Nails, OnycholysisAppearanceVesicules w/ crustingYellowish-tan "oil spot" **Psoriasis is one of the most common noninfectious skin disorders What is the Auspitz Sign? Auspitz sign is a classical sign for psoriasis Scales: scraped, scratched, or picked off skin) Petechia underneath: micro-hemorrhage List some causes for candidiasis? ***oral candidiasis is most common cause of white lesions in the mouth*** Prolonged antibiotic use Corticosteroids (inhalers) How is the hair loss pattern of 2ndary syphilis described? The hair is missing patches like it is  moth eaten List the fungal tinea infections by location of involvement. Tinea capitis & & & & & . Head % Tinea faciale & & & & & . Face Tinea unguium & & & & Nails % Tinea manuum & & & & Hand Tinea barbae & & & & & Beard % Tinea cruris & & & & & & Groin Tinea pedis & & & & & & Foot Tinea corporis & & & & . Body ( ring worm ) The initial episode of herpes simplex may have prodromal symptoms including: Recurrent painful vesicular eruptions First: small cluster of vesicles Second: these break; yellow-brown crusts form Third: Healing ensues in 10-14 days What is the herpes zoster and what are its features? Causative Agent: Chicken pox and shingles Groups of vesicles and bullae on erythematous bases are present along peripheral nerves Usually distribution occurs along spinal and cranial nerves What are features of dysplastic moles? AKA Clarks Nevi Larger than most acquired nevi (more than 5 mm) Flat macules to slightly raised plaques w/ pebbly surface Variability in pigmentation and borders w/ irregular contour May occur as hundreds of lesions on sun-exposed and non-sun-exposed skin What are the risk factors associated with skin carcinoma? Male, Over age 50 Fair, freckled, ruddy complexion w/ light colored hair and eyes Overexposure to UVB sunlight, frost, wind, radium or x-rays Geographic location: near equator or high altitudes Exposure to skin carcinogens or family hx of skin cancer Precancerous dermatoses (actinic keratosis) **Skin cancer is most common occurring: 1.4 million cases/yr** List the three most common dermatological cancers and differentiate them. Basal cell carcinoma **most common skin cancer 75-80%** Spreads through direct extension (to the tissues that are adjacent) Slowest growing Best prognosis (except for rodent) Squamous cell carcinoma **2nd most common and aggressive** Manifests as scaly lesion and then ulcerates Fast growing Most common to effect the mucosa of lips, ears, and eyelids (most common to effect actinic keratosis) Metastasis by direct extension, blood system, and lymphatics Malignant melanoma (ABCDs) A = asymmetry of shape B = Border irregularity C = Color variation D = Diameter larger than 6 mm Why are actinic keratoses clinically significant? It is pre-cancerous. What is seborrheic keratoses and what features may assist with differentiating this from a malignant melanoma? Seborrheic keratoses (aka Seborrheic warts) are common benign skin tumors seen in light skinned individuals and increasingly with aging Solitary or multiple lesions that occur in areas exposed to UV light Lesions are well defined, raised and have a fissured surface Malignant melanoma A = asymmetry of shape B = Border irregularity C = Color variation D = Diameter larger than 6 mm What is the most accurate method for diagnosing potentially malignant lesions? BIOPSY Define these types of alopecia: areata, androgenetic and efflucium. Androgenetic genetic passed from either/both parents, can be either gender but more common in males Miniaturization: changes long terminal hairs into fine terminal hairs Affects the frontal hair line and crown of the head most often Hairs on head and body are affected by various hormones Females: testerone or androstenedione Males: dihydrotesterone (androgen) Changes hair patterns: from C-shaped to M-shaped hairline Telogen effluvium - result from stress (childbirth, severe illness, thyroid disease, drugs) Hair follicles are shunted into the resting phase or telogen phase Reversible if condition is resolved  Areata genetic or autoimmune etiology Devoid of hair follicles in certain areas w/ sharply defined patches w/ no hair This is permanent Which features would you note while examining the head? Inspection Size, shape, position, movements, masses Note alopecia, lesions, prominent vessels Palpation For tenderness and further define inspection Auscultation Any prominent vessels, Subocciptal A. (occlusion (bruits) or giant cell aritis) What are some common abnormalities/variations of the nails and possible causes? Beau's LinesParonychiaLeukonychiaCharacteristicsTransverse depressionsInflammation of folds"White Spots"From under proximal nail foldsproximal & lateralgrow slowlyRed, swollen, tenderCause ofAcute/Severe IllnessFrequent immersion in H2OTrauma/Manicures*can estimate time of illnessMee's LinesClubbingPsoriasisCharacteristicsTransverse white linesDistal Phalynx is rounded/bulbousSmall pitsFrom under proximal nail foldsProximal fold is spongyOnycholysisCurves w/ LunulaNOT w/ asthma/emphysemaThickening Of nailsCause ofAcute/Severe IllnessChronic hypoxiaOverproduction*can estimate time of illnessNOT w/ asthma/emphysemaof skinTerry's NailsOnycholysisCharacteristicsWhite nails w/ distal bandPainless separation ofof reddish-brownnail plate from bedLunulae may not be visibleCause ofAging/Chronic DiseaseTrauma/Illness In which type of alopecia does miniaturization occur? Androgenetic (common baldness) Head, Face, and Neck Study Questions What symptoms may warrant an examination of the head, face and/or neck? Pain Headaches Stiff Neck Thyroid symptoms Dizziness (vertigo) Cranial Nerve symptoms/deficits What are the components of the exam of the head? Inspection Size, shape, position, movements, masses Note alopecia, lesions, prominent vessels Palpation For tenderness and further define inspection Auscultation Any prominent vessels, Subocciptal A. occlusion (bruie) or giant cell aritis Cranial Nerve Exam What is mircrocephaly? Craniosynostosis (oxycephaly)? Microcephaly Congenitally small skull caused by cerebral dysgenesis that yields cognitive deficiencies Macrocephaly Hydrocephalus: enlarged head, bulging fontanels, dilated scalp veins, bossing of the skull and sclerae visible above the iris Cranosynostosis (Premature suture closing) Sutures involved determine shape of the head What is caput succedaneum vs cephalohematoma? Cephalohematoma Birthing trauma; sub-periostial hemorrhaging Leads to misshapen skull but does NOT cross suture lines Resolves in several months to couple years Caput Succedaneum Most common birthing trauma due to forceps Usually occurs over the occiput and crosses suture lines Resolves in 2-3 days What is torticollis (AKA Wry Neck) and the features of this disorder? Condition which the head is tilted to one side & chin is rotated to the other shoulder In newborn, a hematomas of the SCM as a result of birth injury can cause it If webbing is present think Turners Syndrome & other congenital anomalies Describe the facial appearance of a patient with myxedma, hyperthyroidism, Graves Ds, acromegaly, Cushings Syndrome, Parkinsons Ds, Nephrotic Syndrome. Adult Facies include coarsening of the skin and enlargement of bones of face Myxedema: occurs in severe hypothyroidism dull, puffy facies edema is often pronounced around the eyes & does not pit with pressure hair and eyebrows are dry, coarse, and thin and the skin is dry will sometimes have a scalloped tongue or swollen tongue Nephrotic Syndrome: fluid retention state Diffuse edema and pale face Swelling usually appears first around the eyes Eyes may become slitlike when edema is severe Cushings Syndrome Increased adrenal hormone production Round or moon shaped face with red face Excessive hair production Thin erythematous skin Hirsutism: females that develop male hair patterns Parotid Gland Enlargement Unilateral: neoplasia Parkinsons Decreased facial mobility (mask like) Head bent slightly forward and will peer upward toward the observer Oily and droopy skin Graves Disease Hyperthyroidism Prominence of eyes and retraction of lids with staring expression Describe the different facial appearances in children. Fetal Alcohol Syndrome Increased risk for growth deficiencies, microcephaly, and mental retardation Short palpebral fissures Congenital Syphilis Hutchinsons teeth (wide square teeth with spots on the bottom) Cretinism Umbilical hernia, dry and cold extremities Screaming Facial Nerve Palsy LMN: Lesion is on same side as facial changes in LMN lesion; whole side of face droops, eyes do not close on side of problem UMN: Lesion is on opposite side as facial/body findings; hemiplasia, eyes will close but with some weakness, flattening of labionasal folds Downs Syndrome Battered-Child Syndrome Perennial Allergic Rhinitis Open mouth and edema and discoloration Graves Disease with Opthalamus How would you clinically differentiate between jaundice and carotenemia? Jaundice Sclera/Conjunctiva of the eye is key for diagnosis ! Bilirubin History Carotenemia Usually is diffuse; most evident in palms, soles & face ! Carotene NOT evident in conjunctiva How would you palpate the lymph nodes in the neck and face? Just like we do in lab & pads of fingers! What features differentiate inflammatory lymph node enlargement vs metastatic? Inflammation is usually tender Metastatic is not tender and are fixed Lymphoma is large and non-tender Cannot really tell the problem from only lymph node itself except Supraclavicular Think neoplasia if Supraclavilcular nodes are involved VIP b/c Virchows nodes are in this area and enlargement of this area is a good indicator of malignancy (especially left sided: most common is lung cancer) Most common Primary site is LUNG Secondary is the BRAIN (requires advanced imagine) What features are noted about a mass (swelling)? **Anything under VICTANE can cause a possible mass** Location, distribution & duration Present for 7 days think inflammation/illness Present for 7 months think neoplasia Present for 7 years then congenital anomaly Age of individual Infant: 50% are neoplasia or congenital anomaly Child/Adolescent/Young Adult: lymph node enlargement is most common Over age 40: any new mass think Neoplasia Size, shape (configuration if a lesion) Irregular shape is BAD Number & pattern of arrangement (lymph nodes) If infection present, lymph node enlargement is normal Margins and surface contour Consistency, tenderness, temperature, mobility How would you palpate the lobes of the thyroid gland? Place index fingers just below cricoid cartilage around the neck Ask pt. to swallow and feel for glandular tissue rising under finger pads Isthmus is often palpable, lobes are more difficult What features are noted about an enlarged thyroid gland? How is swelling arising from the thyroid gland distinguished from other tissue? Palpation Size % Consistency % Nodules? Tenderness? % Auscultation  could have a bruit Benign vs. Malignant (pg 205) Symptoms of dysfunction (pg 203-206) Lab Tests Metabolic will be evident in complete panel (T3, T4, TSH) Neoplasm requires imaging and Iodine Uptake test as well as biopsy Good indicators of malignancy Single nodule Hard, fixated to surrounding tissue Supraclavicular lymph nodes associated with it What features differentiate hypo and hyperthyroidism? Hyperthyroidism vs. Graves? Hypothyroidism Fatigue, lethargy, weakness, muscle cramps Weight gain w/ cold intolerance Dry, coarse, cool skin Bradycardia and hypothermia (later stage) More likely to develop paraesthesia Hyperthyroidism Anxious, could see postural tremors Very sensitive to warm Excessive perspiration, lose weight/thinning of body Graves Ds X-Opthalamus Risk factors of benign vs malignant thyroid nodules? CharacteristicBenign NoduleMalignant NoduleAge of OnsetAdultAdultGenderFemaleMalePt HxSymptoms presentPrevious x-ray treatment to head/neckFamily HxBenign Thyroid dsNoneSpeed of enlargementSlowRapidChange in voiceAbsentPresentNumber of nodulesMore than oneOneLymph NodesAbsentPresentRemainder of thyroidAbnormalNormal  List common masses in the posterior and anterior triangles and neck and midline. Posterior triangle Lymph nodes % External Jugular V./Carotid A. SCM, scalene & tra%&JKL  B C ξqbbVqAqb(h]hDX5B*CJOJQJaJphh]CJOJQJaJhT&h]CJOJQJaJ%h]hDXB*CJOJQJaJphhwuCJOJQJaJhT&hwuCJOJQJaJ%hwuhDXB*CJOJQJaJphhzLCJOJQJaJhh]D5CJOJQJaJhhDX5CJOJQJaJhhzL5CJOJQJaJ"hzLhzL5:CJOJQJaJ%&KL K  S  B C  5 8^8gdwu & Fgdwu & FgdDX$a$gdDXu5 F > m HJHz8Pp8^8gd} & Fgd & Fgd}^gd0.B & Fgd0.B & FgdDX8^8gd] & Fgd] < = H l m x "468<FHJ$&XZıııwbwPP" jhT&h]CJOJQJaJ(h}hDX5B*CJOJQJaJph%h}hDXB*CJOJQJaJphh]CJOJQJaJh0.BCJOJQJaJh0.Bh0.BCJOJQJaJ%h0.Bh0.BB*CJOJQJaJphh0.Bh0.BB*CJaJphh0.Bh]CJOJQJaJhT&h]CJOJQJaJhT&h}CJOJQJaJZzPwx(*VX #Nyӵn[%hohDXB*CJOJQJaJph%hhB*CJOJQJaJphhT&hB*CJaJph" jhT&h]CJOJQJaJ%h}hDXB*CJOJQJaJphh}CJOJQJaJ" jhT&h}CJOJQJaJhT&h}CJOJQJaJhT&hCJOJQJaJhT&h]CJOJQJaJ@$ANz9:t & FgdW & FgdIBh^hgdW & Fgdo & FgdIB & Fgd} & Fgd} & Fgd} & FgdDXh^hgd & Fgd & Fgdyz9:Z\RTv$*LNH^dfz|HѾxxe%h[hDXB*CJOJQJaJph" jh0.BhWCJOJQJaJh0.BhIBCJaJh0.BhIBCJOJQJaJh0.BhWCJaJh0.BhWCJOJQJaJ%hWhDXB*CJOJQJaJphhWCJOJQJaJhT&hoCJOJQJaJ%hohIBB*CJOJQJaJph#F,v$N8|H & FgdX& & FgdDX^gdW^gdW & FgdIB & FgdIB & FgdW & FgdWHPRTbv׮׮׮ןqbRqbCh0.Bh7HCJOJQJaJh0.BhT&6CJOJQJaJh0.BhT&CJOJQJaJh0.BhoCJOJQJaJ%h7HhDXB*CJOJQJaJphh[CJOJQJaJh0.BhX&CJOJQJaJ%h0.BhX&B*CJOJQJaJph+h0.BhX&6>*B*CJOJQJaJph(h0.BhX&6B*CJOJQJaJph%h0.BhX&B*CJOJQJaJphTB !!H" & Fgd0.B8^8gd7H & FgdT& & Fgd7H & FgdDXgd[ & FgdX& & FgdX&@BTVXrtv !ɹyyyymZٛmZNh0.BCJOJQJaJ%h7HhDXB*CJOJQJaJphh7HCJOJQJaJ%h0.BhT&B*CJOJQJaJphh0.BhT&B*CJaJphh0.Bh7HCJOJQJaJh0.BhT&CJOJQJaJh0.BhT&>*CJOJQJaJh0.Bho>*CJOJQJaJh0.Bh7H>*CJOJQJaJ+h0.Bh7H5>*B*CJOJQJaJph!!!!!!!!!!! """0"2"6"F"H"J"L"N""""" ##ѶѪumYH h]th'7CJOJQJ^JaJ&h]th'75CJOJQJ\^JaJh'7CJaJ&h]th'75CJOJQJ\^JaJh'7CJOJQJ^JaJ%h'7hDXB*CJOJQJaJphh0.BCJOJQJaJh0.Bh0.BCJOJQJaJh7HCJOJQJaJh0.BCJOJQJaJ%h0.Bh0.BB*CJOJQJaJphh0.Bh0.BB*CJaJphH"J"L"N"""""" ##R#rvkd$$Ifl*F &!''x ' @6    44 lap$If & FgdDX8^8gd7H #P#R#T#h#####$$$#$R$S$U$V$$$$$;%<%]%ޱ֥zk_L%hzLhDXB*CJOJQJaJphh]KCJOJQJaJh]th'7CJOJQJaJ%h]KhDXB*CJOJQJaJphh'7CJOJQJaJh]tCJOJQJaJh0.BCJOJQJaJ h]th]KCJOJQJ^JaJ&h]th'75CJOJQJ\^JaJh'7CJaJ h]th'7CJOJQJ^JaJ h]th0.BCJOJQJ^JaJR#T#h###$Ifvkd$$Ifl F &!''x ' @6    44 lap####$$Ifvkd$$Ifl F &!''x ' @6    44 lap$$#$9$R$$Ifvkd$$Ifl F &!''x ' @6    44 lapR$S$V$$$$$%;%<%wog__V^gd]K & Fgd'7 & Fgd'7 & FgdDX ^`gd]tgd'7vkd$$Ifl F &!''x ' @6    44 lap <%^%%%%%2&&&'''\((((|))*3* & Fgd*Gp & Fgd*Gp8^8gd*Gp & Fgdzv & Fgd]tgdzL^gdzLgd]t & FgdzL^gd]t & FgdDX]%^%%%%%%&&2&&&&'H'L'̽s[sH9-h]tCJOJQJaJh]thzvCJOJQJaJ%h*GphDXB*CJOJQJaJph.h]KhzL56>*B*CJOJQJaJphhzLCJOJQJaJ+h]KhDX5B*CJH*OJQJaJph(h]KhDX5B*CJOJQJaJph%hzLhDXB*CJOJQJaJphh]thzLCJOJQJaJh]thzL>*CJOJQJaJ%h]th]tB*CJOJQJaJphhDXB*CJOJQJaJphL'N'R''''''''(("($(((Z((((((((((((|)W*X***L+οοοvjWv%h]KhDXB*CJOJQJaJphh*GpCJOJQJaJh]th*GpCJOJQJaJ%h*GphDXB*CJOJQJaJphhzvCJOJQJaJh]th0.BCJOJQJaJh]tCJOJQJaJh]thzvCJOJQJaJh]th]tCJOJQJaJ%h0.Bh]tB*CJOJQJaJphh]th]tB*CJaJphf 3*W*X***+L+M++++/,x,y,,,-A-u--- & F gd/8^8gdR` & FgdR` & Fgd/gd]t & Fgd*Gp & Fgd0.B & FgdDXgd*Gp & Fgd*GpL+M+s+++x,y,,,,,,.-@-----..5.h.λwhwhwhwhS=S+h]th/56B*CJOJQJaJph(h]th/6B*CJOJQJaJphh]th/CJOJQJaJh]th]tCJOJQJaJ%h/h/B*CJOJQJaJph%h/hDXB*CJOJQJaJphh]thR`CJOJQJaJ%hR`h/B*CJOJQJaJph%hR`hR`B*CJOJQJaJph%hR`hDXB*CJOJQJaJphhR`CJOJQJaJ-.h..../W////50S0j0000011p11 & Fgdh^gdDXh^hgd/ & Fgd/ & Fgd/ & FgdDX^gd/h....///4/7/9/V/W/50J0R0S0T0j0k00000000011ʺ٢ʍʍʍʁn^Oh]thDXCJOJQJaJhhB*CJOJQJaJph%h/hDXB*CJOJQJaJphh/CJOJQJaJ(h]th/5B*CJOJQJaJph.h]th/56B*CJH*OJQJaJphh]th/6CJOJQJaJh]th/CJOJQJaJ+h]th/56B*CJOJQJaJphh]th/5CJOJQJaJ1p111111y2z22222222222@3A3B3H3I3ѶvfQ?"h]K>*B*CJOJQJaJph(h]Kh]K>*B*CJOJQJaJphhhB*CJOJQJaJphhR`CJOJQJaJh]th]KCJOJQJaJ(h]th]K5B*CJOJQJaJphh]th]K5CJOJQJaJh]thhCJOJQJaJhR`CJOJQJaJhhCJOJQJaJh]thR`CJOJQJaJ%h]KhDXB*CJOJQJaJph1=2z2222222B3I3J333;4z444495 & Fgd]t & Fgd]t & Fgd]t & Fgd]t & Fgd]tgdh & FgdDX^gdR` & Fgd]K & Fgd]K & FgdhI3J33395M5555666666667777778񯣔qaN%h<hDXB*CJOJQJaJphh]tB*CJOJQJaJphhhB*CJOJQJaJph%h<hhB*CJOJQJaJphh]thhCJOJQJaJhhCJOJQJaJh]tCJOJQJaJ%j{h]thhCJOJQJUaJh]th]t5CJOJQJaJ%hh]tB*CJOJQJaJphh]th]tCJOJQJaJ955555'6w6666666"7,7Y7f7778 & FgdDXh^hgd]t & Fgdh & Fgdh & Fgdh & Fgdh^gdh p^p`gd]t & Fgd]t & Fgd]t8 88!8-8.8>8U8k8MG$Ifkd $$Ifl\dh&'@' ' ' ($644 lap( $$Ifa$8-8.8>8y8z8{888888899 9B9C9D9G9H9h9i9y9999:::A:B:K:::::::::::::%;&;';M;N;O;m;n;w;;;;;;;ͺh/CJOJQJaJ%h/h/B*CJOJQJaJph%h/hDXB*CJOJQJaJphh<CJOJQJaJh<CJOJQJ^JaJh<CJaJ h<5CJOJQJ\^JaJ;k8y8z8{8888hb$Ifkd $$Ifl\dh&'@' ' '$644 lap( $$Ifa$888888qkbbb $$Ifa$$Ifkd $$Ifl\dh&'@' ' '$644 lap(8888 99qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(99 9>9@9B9qkbbb $$Ifa$$Ifkd-$$Ifl\dh&'@' ' '$644 lap(B9C9D9E9F9G9qkbbb $$Ifa$$IfkdF$$Ifl\dh&'@' ' '$644 lap(G9H9I9U9^9h9qkbbb $$Ifa$$IfkdQ$$Ifl\dh&'@' ' '$644 lap(h9i9y9999VPGGG $$Ifa$$Ifkd$$$Ifl\dh&'@' ' ' ($644 lap(99999:qkbbb $$Ifa$$IfkdW$$Ifl\dh&'@' ' '$644 lap(::::-:A:qkbbb $$Ifa$$Ifkd~$$Ifl\dh&'@' ' '$644 lap(A:B:K:`:p::qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(::::::qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(::::::qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(::::::qhhhh $$Ifa$kd$$Ifl\dh&'@' ' '$644 lap(::: ;$;%;\VMMM $$Ifa$$Ifkd$$Ifl\dh&'@' ' ' $644 lap(%;&;';8;L;M;qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(M;N;O;j;l;m;qkbbb $$Ifa$$Ifkd$$Ifl\dh&'@' ' '$644 lap(m;n;w;;;;qkbbb $$Ifa$$Ifkd8$$Ifl\dh&'@' ' '$644 lap(;;;;;;;<<qldWRFFF $h^ha$gdDXgdh 8h^8`hgd/ & Fgd/gd<kd_$$Ifl\dh&'@' ' '$644 lap(;;;;;<<g<k<m<n<|<}<<<<<<<<<<<ŵ{h{h{h{{Xh{Lh]tCJOJQJaJhhB*CJOJQJaJphf%hhhhB*CJOJQJaJphfhhCJOJQJaJhhh6CJOJQJaJ%h6hDXB*CJOJQJaJphhCJOJQJaJhhDX5CJOJQJaJh6CJOJQJaJhhhDXCJOJQJaJhhh/CJOJQJaJhhh/5CJOJQJaJ<g<<<<==B=l=v=====>>>>>K>X> & FgdVIj & FgdVIjh^hgdVIj & FgdVIj & FgdVIj & FgdVIj & FgdVIjgdh & Fgd6 & FgdDX<=>>> >!>J>K>??????@@ AA=AAAAA첟ьyfyZK?KhhCJOJQJaJh]th<CJOJQJaJh]tCJOJQJaJ%h<h<B*CJOJQJaJph%h<hB*CJOJQJaJph%hVIjhB*CJOJQJaJph%h]thVIjB*CJOJQJaJph%hVIjhVIjB*CJOJQJaJphhhCJOJQJaJhVIjCJOJQJaJh]thVIjCJOJQJaJ%hVIjhDXB*CJOJQJaJphX>>>>?i?????@<@g@{@@@@@=AAA+B & Fgd< & Fgd< & Fgdh^gdVIj & FgdDXh^hgdVIj & FgdVIj & FgdVIjA*B+B,BdBBBB?DFDFFFNGOGPGGGIIIðàuiTuA%hvhB*CJOJQJaJph(hhhB>*B*CJOJQJaJphhBCJOJQJaJhBCJOJQJaJhhhB>*CJOJQJaJhhhBCJOJQJaJhhhB5CJOJQJaJ%hBhB*CJOJQJaJph%hBhB*CJOJQJaJphhvCJOJQJaJhhh<CJOJQJaJhhhhCJOJQJaJ+B,BBC?CRCCCD?D[DDDDDE3EJE}EEEEE#F8F & FgdB & FgdB`gdB & FgdDXh^hgdv8FHFXFFFFF6GOGPGdGGGGGGtHII(IDIkII^gdh & FgdB & FgdB & FgdDX8^8gdB & FgdB & FgdBIIII"J:JJJbJJJK KKKKFLfLLLM7M & Fgd] & Fgd]8^8gd4b & Fgd4b^gdv & Fgd4b & Fgdv & Fgdv & FgdDXh^hgdBIIII"J$J:JJJJJK KKKKKFLL񺫟qeRCh.h]CJOJQJaJ%h]hB*CJOJQJaJphh4bCJOJQJaJh.h4bCJOJQJaJh.CJOJQJaJ%h4bhB*CJOJQJaJphhvCJOJQJaJhhh4bCJOJQJaJhhh4bCJaJ+hhh4b6>*B*CJOJQJaJph+hhhv6>*B*CJOJQJaJphhhhvCJOJQJaJLLLMMMN N&N'N(NYNjNlNNNӾ馓tgQ9Q.h{h]56>*B*CJOJQJaJph+h{h]56B*CJOJQJaJphh]5CJOJQJaJ%h]hB*CJOJQJaJphhzvCJOJQJaJ%h.h]B*CJOJQJaJph.h.h]56>*B*CJOJQJaJph(h.h]>*B*CJOJQJaJph+h.h]5>*B*CJOJQJaJph+h.h]6>*B*CJOJQJaJph7MMM'N(NYNNNNOAOSOOOOP3PaPPPPPQ[Q8^8gd] & Fgd] & Fgd]gd] & FgdDXgdzv & Fgd]NNNNNNNNNNO O!O"O'OAOSOYOOOOOOOOOOPPQQRRRʲʲʲʲʲʲʲʲʲʲওqbh.h.CJOJQJaJh.hzvCJOJQJaJ%hzvhB*CJOJQJaJph%h]hB*CJOJQJaJphh]CJOJQJaJ.h.h]56>*B*CJOJQJaJph+h.h]6>*B*CJOJQJaJphh.h]CJOJQJaJh-Dh]5CJOJQJaJ![QQQQRR&SSSTTLTTTTTUUbUqUUUU & FgdY & Fgd<8^8gdzv & Fgdzv & Fgdzv & FgdDX8^8gd] & Fgd]RR SS$SS@SBSFSTT/T=TLTTTjTwTUUEUaUbUqUUUUҶҶҶҶҪxiYih.hY>*CJOJQJaJh.hYCJOJQJaJh<CJOJQJaJ%hYh<B*CJOJQJaJph%hYhB*CJOJQJaJphhzvCJOJQJaJh.hzv>*CJOJQJaJh.CJOJQJaJh.hzvCJOJQJaJh.h.CJOJQJaJh.h.B*CJaJphUU$V4VXVoVVVVVVWW!W $IfgdV]  & FgdDX^gdY & Fgd< & FgdY U$V4V;VjVnVVVVVVWW"W/WڴxgR=, hY5CJOJQJ\^JaJ)hY5B*CJOJQJ\^JaJphf)hY5B*CJOJQJ\^JaJph hY5CJOJQJ\^JaJ%hYhB*CJOJQJaJph%hYhYB*CJOJQJaJph+hYhY5>*B*CJOJQJaJph+h.hY5>*B*CJOJQJaJphh.hY>*CJOJQJaJh.hYCJOJQJaJ+h.hY6>*B*CJOJQJaJph!W"W/W5W;W $IfgdV] vkd $$IflF3C"2$' ''6    44 lap/W5W*B*CJOJQJaJphhT&hT&5CJOJQJaJhT&CJOJQJaJhoCJOJQJaJ(hT&ho5B*CJOJQJaJph(hT&hY5B*CJOJQJaJph(hT&h_L5B*CJOJQJaJphh6CJOJQJaJh.h_LCJOJQJaJ%h_LhB*CJOJQJaJphhYCJOJQJaJh.hYCJOJQJaJh.CJOJQJaJ\^o}&4~ & FgdT& & FgdT&gdT&gd6 & Fgd_L & FgdY & FgdY & FgdDX^gdY~|Es9:yjyj]yjJjJj;hohoB*CJaJph%hohoB*CJOJQJaJphfhT&5CJOJQJaJhohoCJOJQJaJhoho5CJOJQJaJhoCJOJQJaJhT&CJOJQJaJhT&hT&CJOJQJaJhT&hT&5CJOJQJaJ+hT&hT&5>*B*CJOJQJaJph+hT&hT&6>*B*CJOJQJaJph%hT&hT&B*CJOJQJaJph|)CEs|- & Fgdo & Fgdo & Fgdo & Fgdo & Fgdogdogd6-Ib>@le-dD & Fgdo & Fgdo & Fgdo & Fgdogdo & Fgdo & FgdoDFJ`| @l3,.2bD^bճճգգ՗uuu՗uuuգs՗U%hT&hT&B*CJOJQJaJphhT&hT&B*CJaJphhT&CJOJQJaJhoho5CJOJQJaJ%hohoB*CJOJQJaJphfhohoB*CJaJphhohoCJOJQJaJ hohoCJOJQJ^JaJhohoCJaJ-ular symptoms Meningeal signs may be subtle or absent in the very young or old, and in those who are immunocompromised or comatose Often associated with signs of ICP: Vomiting % Papilledema % Lethargy % LOC Hypertensive HA Extremely high BP Dull, throbbing, occipital HA Present when pt. awakens Slowly fades as pt. moves around Acute hypertensive crises: Sudden General Severe pain Change in LOC NV Headache Organic Brain Ds. Visual accommodation problems Seizures Confusion Onset of neurologic deficiencies Papilledema Onset of new headache over 50 y/o Neuroimaging Considerations Worst headache ever Progressive Unresponsive to care New onset after age 50 Association w/ seizures Fever and/or stiff neck     PAGE  PAGE 10 DN0Qmu~ 9 & Fgdo & Fgdo & Fgdogdo & Fgdo & Fgdobdh:V²²²¦{{w{l{jUh}Y0JmHnHuh]K h]K0Jjh]K0JUh ,jh ,UhDXhR`CJOJQJaJhoCJOJQJaJhoho5CJOJQJaJhohoCJOJQJaJhT&CJOJQJaJ%hT&hT&B*CJOJQJaJphhT&hT&B*CJaJph&9:Vjvsh]hgdzL &`#$gdSlgd6 & FgdogdoLauren Montieth Physical Dx Manello - Exam Two Spring 06 12=stuvhDXhR`CJOJQJaJh ,h]KhMCJOJQJaJh]KCJOJQJaJhzLh]KCJOJQJaJstuvgd621h:pDX/ =!"#$% $$If!vh55x 5 #v#vx #v :V l*@6,55x 5 9/ /  /  / / ap$$If!vh55x 5 #v#vx #v :V l @6,55x 5 9/  / / / ap$$If!vh55x 5 #v#vx #v :V l @6,55x 5 9/  / / / / ap$$If!vh55x 5 #v#vx #v :V l @6,55x 5 9/  / / / / ap$$If!vh55x 5 #v#vx #v :V l @6,55x 5 9/ / / /  ap&Dd >  C Abo^|_EZlpnho^|_EZlPNG  IHDRpVxsRGB pHYs.>IDATx^1V0 w-ǃs@ pj.%QB5Ŭ8c[SY~}d~ (o )#$ʮ"eARqDC?txW^>md163R";[6M[Xl& Tv$٥iCdFg11ol^2KW,JwXUܘn_ 8*)O6vT>ِca83Kɢk ۛcP~UTUU&`?> zL Footnote TextCJaJ@&@ zLFootnote ReferenceH*4 @4 zLFooter  !.)@!. zL Page Number4@24 zLHeader  !+P"  z z z z z z z z z zSJ"@*|3<CVK+P,3J976O9 %&KLKSBC5F>m7o}c!o % 8 f  0 B u  > S  3 4 t  'HI4Mu{|'PQRS  CDOe~@gh  Eyz#Zt1_<xy[1mJ#F$a,-$inuv! g !*!e!!"("+"S"""""""$#N#X#####4$5$B$M$Y$Z$j$$$$$$$$$$$$$%% %%9%J%K%L%j%l%n%o%p%q%r%s%t%u%%%%%%%%%%% &"&.&/&0&A&Y&m&n&w&&&&&&&&&&&&&&&&' ' '''9'P'Q'R'S'd'x'y'z'{'''''''''''(#($(%(J(K((() ):)E)n)))))*)*<*=*>*?*@*w****j+++++,/,h,,,, - -!-i-- .W.X..@/k/~//0@0k000001E1_1v11111 2O2d2t222223b3{3|333344#44,5<5T5p55556 6=6I6Q6]666666"7#7r7777,8c88 9S9T9999:@:m:::: ;H;_;;;;<<F<<<======>4>>>x>>>> ?;?J_JlJJJK5K6KVKKKKLm7o}c!o % 8 f  0 B u  > S  3 4 t  'HI4Mu{|'PQRS  CDOe~@gh  Eyz#Zt1_<xy[1mJ#F$a,-$inuv! g !*!e!!"("+"S"""""""$#N#X#####4$5$B$M$Y$Z$j$$$$$$$$$$$$$%% %%9%J%K%L%j%l%n%o%p%q%r%s%t%u%%%%%%%%%%% &"&.&/&0&A&Y&m&n&w&&&&&&&&&&&&&&&&' ' '''9'P'Q'R'S'd'x'y'z'{'''''''''''(#($(%(J(K((() ):)E)n)))))*)*<*=*>*?*@*w****j+++++,/,h,,,, - -!-i-- .W.X..@/k/~//0@0k000001E1_1v11111 2O2d2t222223b3{3|333344#44,5<5T5p55556 6=6I6Q6]666666"7#7r7777,8c88 9S9T9999:@:m:::: ;H;_;;;;<<F<<<======>4>>>x>>>> ?;?J_JlJJJK5K6KVKKKKL0 0 0 0 0 0 07 0 0} 0 00 0 0 0c 0c 0c0 0 0 0! 0o 0! 0 0 00 0 0  0%  0%  0%  0  0  0  0  00  0  0u  0  0 0 0  0>  0  0  0  0  0 0 0  04  0t  0t  0t  04  0  0 0 0  0I 0I 0I 0I 04 040 0  00 0  0| 0 0000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 00 00 0h 0h0 000 0 0z 0z 0z 0z 0z0 0 0 0 0 00 0 0 0 00 0 0y 0y 0y 0y0 0 0 0 0 0 0 00 0 0J 0 0 0 0J 0F 0F 0F 0F 0J 0a 0a 0a 0a0 00 0 0- 0 0 0- 0 0 0 00 0 00 0 0v 0 0 0 0  0  0! 0v 0e! 0e!0 0v 0+" 0+"00 0 0 0 0 0 0N# 0 0#0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000 0 0 00 0 0 0 0 0 0) 0 0) 0) 00000 0  0@* 0w* 0@* 0* 0@* 0j+0 0! 0+ 0+ 0+ 0+ 0+ 0, 0, 0,0 0" 0!- 0i- 0!-0 0#0 0 0@/ 0@/ 0@/ 0@/ 0 0@0 0@0 0@0 0 00 00 00 00 00 0 01 0 01 01 01 0 0d2 0d20 0$ 02 02 020 02 0|3 02 03 03 02 04 04 02 02 02 0T5 020 0% 05 06 06 06 05 0Q6 0Q6 0Q60 0& 060 0' 0#7 0#7 0#7 0#7 07 0,8 0,8 0,80 0(0 0T9 09 09 09 0T9 0m: 0m: 0m: 0T9 0 ; 0T9 0_; 0T9 0T90 0) 0< 0< 0<0 0* 0= 0= 0= 0= 0= 0= 04> 04> 0= 0> 0> 0>0 0+ 0m7o}c!o % 8 f  0 B u  > S  3 4 t  'HI|S  CDOe~h Eyz#Zt1_xy1mJ#F$a,-v! g !*!e!!"("+"S"""X####Y$Z$$$$$%%J%K%n%o%s%t%%%%%.&/&m&n&&&&&&& ''Q'R'y'z'''''''''(#($(%(J(K((() ):)E)n)))))*)*<*w****j+++++,/,h,,,, - -!-W.X..@/k/~//0@0k000001E1_1v11111 2O2d2t222223b3|333344#44,5<5T5p55556 6=6I6Q6]666666"7#7r7777,8c88 9T9999:@:m:::: ;H;<=====P@`@@@@MAgA{AAAABAB]B^BsB|BBBBBBCUCgCCC`EEEE)F,P0000 0 0L 0L 0L 0L 0L0 0 0 0 0 0 00 0 0C 0C 0C 0C 0C 0C 0C0 0 0 0 00 0 0 0 0 0 0P 0 0 0 00 0 0- 0| 0| 0|0 0 0 0; 0 0; 0 00 0 09  0  0  0  0  0  0  09  0  09  0  09  0 0 09  0  09  0  09  0$  0$ 0 0  0  0  0  0  0  0i  0i 0 0  0  0 j004@0. j004@0@tj004@0j00452$j0i0 j0i0 j00 η@ 0 0 0j0 000 0 02 02 02 02 020 0 0 0j 0j 0j0 0j0m0j0m00 0 0 0 0 0 0 0 0 0 0 0> 0> 0> 0 0 0 0 0 0 0  0  0  0 000j00|j00j00 0@0@ 0A 0B 0_B 0_B 0_C 0JC 0JD 0A 0B 0 B 0 @0A 0B 0B 0j00h00h0*0 @ 0j00tj00j00/C.3uvwyj00@0j00@0j00 Tlhdj0 0 A0j00C0t8:^j004&',j00lYp`j00@0j00ܱ@0j00K0!j00L&@10j00@0j00@Y0-YYj0 0!@Y0-Y-Yj0"0#,@Y0-Y-Yj0$0%dWA0Xj00 j00 @0[ j0&0 @0[ 0 000000 0 0 00 0 0 0 0 0 0 0 0I 0V 0 0  0 0 0 0U 0 00 0! 0: 0h 0h 0h 0: 0  0  0 0 0"0 0#0 0 0 0 0 0 0 0  0  0  0 0\! 0\! 0\! 0\! 0\! 0 0!" 0 0Q" 0Q" 0Q" 0 0" 0"0 0$ 0?# 0v# 0v# 0?# 0# 0?# 0G$ 0G$ 0?# 0$ 0$ 0?# 0?# 0?# 0% 0?#0 0% 0/& 0x& 0x& 0x& 0/& 0& 0& 0&0 0& 03'0 0' 0( 0( 0( 0( 0:) 0) 0)0 0(0 0* 0++ 0++ 0++ 0* 0+ 0+B 0+ 0)j00j0V1W(-h0V1h0V1h01j01j011j01j0100j00j00j00j00j00 j0 0 j0 0 j00j00j0u1 j0u1 j0u1 j000 h0k1 h0k1h00h0*0h0o1h00h0*0j0*0h0*0j00j00j070@00  ZyH!#]%L'L+h.1I38;<AILNRU/W~bv-124689;ABDFGIL_acghjlnp5 H"R##$R$<%3*-1958k8889B9G9h99:A:::::%;M;m;;<X>+B8FI7M[QU!W;WOWWWWW*XbXX\-D9sv.0357:<=>?@CEHJKMNOPQRSTUVWXYZ[\]^`bdefikmoqrstuvwxyu/ !!! Z >Gj[ >Ij\ >k] >!k^ >!k_ >ni` >Tnia >,'kb >+kc >WjW 33?|B|B|B,P ^ 33?BBB,P 8*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsplace =onw:st    '/7B l v   ; = C P  ( V ^ &Ycu|!7BOX@H})/FL`ez"V`w}5?@I !!!e!l!!!+"1"##B$L$M$X$u%z%%%"&-&:&@&' '{''(( **"*(*H*U*j*t*j+y+++++,!,)-4-......@0I000d1p1=3I3h3q3445%55555Q6\6c7e7?8O8e<l<@@AAAA4CGGGIIIIJJJJJKKKNOOOOOO)P,P #  =E3G==xGGGGYNuNOOOOO)P,P::::::::::5Fm7o}o% 8 B u  S  4 I4'SD@h #Tt1_ #a-nv *!")"+"S""""X###5$$$L%u%%%% &&&'9'{''':)))))*@*w****j+++/,,, -!-@/~/@0001E1v111O2223b33334#4,5p5556 6=6]666r7799:@:m::H;_;;<===>>> ?r?@+@@@@AAABBBUCCD2DDD1E`EEE)FEtTjJn1eKU|U_Q+ifS |0W J!W^,'9Y܊P0\$Jq\4x2_b~|Ϋ;hNoQ3p60RqVqftf w-_:t{_$Pue^`B*o(phhH% 88^8`hH. L^`LhH.   ^ `hH.   ^ `hH. xLx^x`LhH. HH^H`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH.  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  ^ `B* o(phhH%  ^ `B*o(phhH% xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH.  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  ^ `B* o(phhH%  ^ `B*o(phhH%88^8`B*o(phfhH"  HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH.  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.^`o(.^`B*o(phfhH" p$ $ ^$ `B*o(phhH%@ @ ^@ `B* o(phhH% ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(.^`B*CJaJo(phhH%  ^ `B* o(phhH% ^`hH. ^`hH. L^`LhH. ^`hH. PP^P`hH.  L ^ `LhH. ^`B*o(ph.^`B*o(phfhH" p$ $ ^$ `B*o(phhH%@ @ ^@ `B* o(phhH%^`B*o(phhH% L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(.^`B*o(phfhH"  $ $ ^$ `o(hH"  @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(.^`B*o(phfhH"  pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(.^`B*o(phfhH% pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`B*o(phhH% 88^8`hH. L^`LhH.   ^ `hH.   ^ `hH. xLx^x`LhH. HH^H`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH.  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH" 88^8`B*o(phfhH" ^`B*o(phhH%  ^ `B* o(phhH% xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`o(.^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH"  ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`o(. ^`o(hH"  pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.88^8`B*o(phfhH" ^`B*o(phhH%  L ^ `LhH.   ^ `hH. xx^x`hH. HLH^H`LhH. ^`hH. ^`hH. L^`LhH.^`o(.^`B*o(phfhH" p$ $ ^$ `B*o(phhH% @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.!W '0`qq\=_0\,'9Y$fS0WK:;hU_Qov:t{ $>EQ3p0Rq)'2_btf weKjJEXO.mI  tLb        P;        V>2 do     0ɘv       B                 6l$`Ъ 1    l3L       Dƪ       ؜        lBtN *D       dpd. zDv-,    R:N        d        tY `     '4W       4        :,8B       \4        Nzu"q3#C#FpVz=Nl ItX[v98i]h]tV] T&X& ,.o.'7<B0.B]D7H]K_LNQDX[na4bVIjSl*Gpwuvs~6j*c} MYzL6&Wo>zv}YIBo#]/R`  CDOe~4$5$B$M$Y$Z$j$$$$$$$$$$$$$%% %%9%J%K%L%j%l%n%o%p%q%r%s%t%u%%%%%%%%%%% &"&.&/&0&A&Y&m&n&w&&&&&&&&&&&&&&&&' ' '''9'P'Q'R'S'd'x'y'z'{''''''''''A.A,B,C,DIJKLMO+P@@@@ @@@(@@@@@8@@@ @"@H@@&@(@T@@J@@@R@@@X@@@@@@@@@$@@8@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana;Wingdings"1hdFdFBf C ( C (!4djOjO3QHX ?DX2$Skin, Hair and Nails Study Questions Lauren MontiethJung-Eunx                      Oh+'0  4@ ` l x (Skin, Hair and Nails Study Questions Lauren MontiethNormal Jung-Eun2Microsoft Office Word@F#@pB@m@m  C՜.+,0  hp|  (jO %Skin, Hair and Nails Study Questions Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./012356789:;=>?@ABCHRoot Entry F`mJData )1TableWordDocument4"SummaryInformation(4DocumentSummaryInformation8<CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q