MEDICINE FOR FINALS DR INDER MAINIE MAY 2002. CARDIOVASCULAR INTRODUCTION MAY I EXAMINE YOU? 45...

MEDICINE FOR FINALS

DR INDER MAINIE

MAY 2002

CARDIOVASCULAR INTRODUCTION MAY I EXAMINE YOU? 45 DEGREES INSPECTION (SOB, SCARS, MALAR

FLUSH, ANKLE OEDEMA) ALWAYS LOOK AROUND THE BED,

INHALERS, OXYGEN, DIET DRINKS ETC

EXAMINATION LOOK AT THE HANDS FINGER CLUBBING CYANOSIS SPLINTER HAEMORRAGES PALE

PULSE RATE RHYTMN CHARACTER BRACHIAL/CAROTID VOLUME COLLAPSING PULSE

CAUSES OF IRREGULAR IRREGULAR PULSE

ATRIAL FIBRILLATION, VE’S, ATRIAL FLUTTER WITH VAR BLOCK, CHB

CAUSES OF AF ISCHAMIC HEART DISEASE RHEUMATIC HEART DISEASE THYROID NO CAUSE CARDIOMYOPATHY WPW INFECTION ASD

COLLAPSING PULSE AORTIC REGURG LOOK FOR CORRIGAN’S

SIGN PDA PAGETS PREGNANCY RUPTURED ANEURYSM OF AORTIC SINUS FEVER ANAEMIA

RADIO-FEMORAL DELAY COARCTATION OF THE AORTA ASK WHILE EXAMINING THE PULSE

CAN YOU CHECK FOR THIS

BLOOD PRESSURE ALWAYS REMEMBER TO ASK IF

YOU CAN CHECK THE BLOOD PRESSURE

JVP INTERNAL JUGULAR BETWEEN THE TWO HEADS EQUAL TO PRESSURES IN THE

RIGHT ATRIUM a WAVE = ATRAL CONTRACTION v WAVE= ATRIAL FILLING DURING

VENTRICLAR SYSTOLE,TRICUSPID VALVE IS CLOSED

CAUSES OF A RAISED JVP HEART FAILURE –ELEVATION, SUSTAINED

HJR PE – ELEVATED PERICARDIAL EFFUSION-ELEVATED,

PROMINENT Y DESCENT CONSTRICTIVE PERICARDITIS-ELEVATED

KUSSMAULS, PARADOXICAL RISE ON INSPIRATION

AF NO a WAVES TRICUSPID STENOSIS- GIANT a WAVES TRICUSPID REGURG- GIANT v WAVES COMPLETE HEART BLOCK- CANNON WAVES

APEX BEAT LOOK FOR STERNOTOMY SCARS LOOK FOR THORACOTOMY SCARS POSITION AND CHARACTER CHECK FOR HEAVES OR THRILLS

HEART SOUNDS PALPATE THE CAROTID

SIMULTANEOUSLY COMMENT ON I AND II OR

ADDITIONAL MURMURS

MURMURS STENOSIS- APEX LEFT LATERAL USE

THE BELL REMEMBER CHANGES IN BREATHING INSPIRATION RIGHT HEART

MURMURS GET LOUDER EXPIRATION LEFT SIDE MURMURS

GET LOUDER PANSYSTOLIC MURMUR APEX, AXILLA EARLY DIASTOLIC AORTIC REGURG

3RD ICS SIT FORWARD ON EXP

GRADING OF MURMURS 1. FAINT 2. FAINT BUT EASILY DETECTED 3. POMINENT BUT NOT LOUD 4. LOUD THRILL 5. VERY LOUD 6. LOUD WITHOUT CONTACT

REMEMBER LUNG BASES SACRAL OEDEMA HEPATOSPLENOMEGALY FAILURE PERIPHERAL PULSES

MITRAL STENOSIS MALAR FLUSH PULSE- IRREGULR IRREGULAR RAISED JVP TAPPING APEX NOT DISPLACED LEFT PARASTERNAL HEAVE(RIGHT

VENTRICULAR ENLARGEMENT) LOUD 1ST HS OPENING SNAP

MITRAL STENOSIS CAUSES- RHD TAPPING APEX BEAT -DUE TO

ACCENTUATED 1ST HS OPENING SNAP OPENING OF A

STENOSED VALVE – PLIABLE, ABSENT IN DIFFUSELY CALCIFIED VALVE

LOUD 1ST – VALVES ARE MOBILE PRESYSTOLIC ACCENTUATION- SINUS

RHYTMN DUE TO THE ATRIAL SYSTOLE WHICH INCREASES FLOW ACROSS A STENOTIC VALVE

COMLICATIONS LEFT ATRIAL ENLARGEMENT AF PULMONARY HTN TR RHF

SEVERITY NARROWER DISTANCE BETWEEN

2ND HS AND OS LONGER THE DIASTOLIC MURMUR

MITRAL REGURG PERIPHERAL PULSES- NORMAL JERKY

DUE TO REDUCED SYSTOLIC EJECTION TIME SECONDARY TO A LARGE VOLUME OF BLOOD REGURG INTO LEFT ATRIUM

APEX BEAT- DISPLACED 1ST HS SOFT 3RD HS PSM -> AXILLA LOUDER ON EXP

CAUSES OF MR MITRAL VALVE PROLAPSE RHD LEFT VENTRICLAR DILATATION CORONARY DISEASE ANNULAR CALCIFICATION ENDOCARDITIS PAPILLARY MUSCLE RUPTURE CARDIOMYOPATHY CONNECTIVE TISSUE DISORDER TRAUMA MYXOMATOUS DEGENERATION

CAUSES OF PSM MR TR VSD HOCM

AORTIC REGURG PULSE- LARGE VOLUME,

COLLAPSING CORRIGAN’S APEX DISPLACED OUTWARDS,

FORCEFUL EDM- LSE SIT FORWARD

EXPIRATION

Aortic Regurgitation WIDE PULSE PRESSURE FEMORALS- PISTOL SHOTS(TRAUBE’S) TO AND FRO MURMUR (DUROZIEZ’S) CORRIGANS – CAROTID PULSATION QUINCKE’S UVULA PULSATIONS (MULLER’S) ARGYLL ROBERTSON PUPIL MARFANS ANK SPOND, RA

Causes Of Aortic Regurgitation

RF HTN ATHEROSCLEROSIS ENDOCARDITIS SYPHILIS MARFANS RA ANK SPOND TRAUMA AORTIC DISSECTION

SEVERITY WIDE PULSE PRESSURE SOFT 2ND HS 3RD HS AUSTIN FLINT MURMUR LVF LONGER + LOUDER

AORTIC STENOSIS LOW VOLUME SLOW RISING APEX- HEAVING, NOT DISPLACED SOFT 2ND EJECTION CLICK S4 MAY BE HEARD ESM NARROW PULSE PRESSURE REVERSE SPLITTING

CAUSES OF AORTIC STENOSIS

RHEUMATIC DEGENERATIVE CALCIFICATION OF

A BICUSPID VALVE

OTHER CAUSES OF ESM PULM STENOSIS HOCM SUPRAVALVULAR STENOSIS

SYMPTOMS FATIGUE ANGINA DYSPNOEA SYNCOPE DEATH

INVESTIGATIONS ECG CXR ECHO CATH EST BE CAREFUL IF SYMPTOMATIC

TRICUSPID REGURGITATION

CAUSES FUNCTIONAL

PULMONARY HTN CCF

RHD ENDOCARDITIS – DRUG ADDICTS

VSD

PSM AT LSE LOUD P2 OF PULM HTN MAY HAVE CCF LOUDNESS DOES NOT MEAN

SEVERE

CAUSES OF VSD CONGENITAL RUPTURE AFTER MI

50% MAY CLOSE SPONTANEOUSLY COMPLICATIONS ARE

CCF AORTIC REGURG SBE PULM HTN

INFECTIVE ENDOCARDITIS ANAEMIA CLUBBING SPLINTER HAEMORRAGES- EMBOLISM OSLER NODES- INFLAMMATION OF EMBOLI JANEWAY LESIONS PETECHIAE ROTH SPOTS SPLENOMEGALY HAEMATURIA DENTAL FBP- NORMOCYTIC NORMOCHROMIC ESR BLOOD CULTURES ECHO/ TOE

COMLICATIONS OF SBE CARDIAC FAILURE RENAL PAIN CEREBRAL ANEURYSMS MYCOTIC ANEURYSMS VALVE ABSCESS

HOCM PULSE JERKY DOUBLE APICAL- LEFT

VENTRICULAR HEAVE WITH PROM PRESYSTOLIC PULSE

PSM- SOFTER ON SQUATTING 4TH HS FAMILY HISTORY

RESPIRATORY INTRO SITTING POSITION SPUTUM CUP BREATHLESS WASTING ASYMMETRICAL BREATHING COUNT RESP

HANDS CLUBBING CYANOSIS TAR BOUNDING PULSE ASTERIXIS TONGUE – CYANOSIS EYES- PALLOR, HORNERS

EXAMINATION LOOK FOR NECK VEINS CERVICAL LYMPH TRACHEA DEVIATION tug PALPATE MOVEMENTS OF BOTH SIDES VOCAL FREMITUS PERCUSSION AUSCULTATION

PLEURAL EFFUSION LOOK FOR DECREASED MOVEMENT TRACHEAL DEVIATION ASPIRATION MARKS STONY DULL DECREASED VOCAL RESONANCE FIND THE UPPER LEVEL BRONCIAL BREATHING SIGNS OF RA, TAR, LYMPH NODES,

RADIATION BURNS, MASTECTOMY

CAUSES OF DULLNESS PLEURAL EFFUSION PLEURAL THICKENING CONSOLODATION COLLAPSE RAISED HEMIDIAPHRAGM

INVESTIGATIONS CXR TAP SEND FOR PROTEIN, LDH, GLUCOSE,

BACTERIOLOGY, CYTOLOGY PH IF EMPYEMA AMYLASE IN NG, PANCREATITIS,

OESOPHAGEAL RUPTURE RHEUMATOID FACTOR

TRANSUDATE NEPHROTIC SYNDROME CARDIAC FAILURE LIVER FAILURE HYPOTHYROID CONSTRICTIVE PERICARDITIS MEIGS

EXUDATE CA SECONDARIES PNEUMONIA PE TB RA SLE LYMPHOMA MESOTHELIOMA

PROGNOSIS POOR IN NG PEURAL FLUID

LOW GLUCOSE LOW pH

HAEMORRAGIC FLUID PE NG TB

REMEMBER OCCUPATION

EG SHIP BUILDING

BRONCHIECTASIS LOOK FOR SPUTUM CUP FINGER CLUBBING BILATERAL COARSE CREPS LATE INSP CREPS

BRONCHIECTASIS DEF - CHRONIC NECROTIZING

INFECTION OF THE BRONCHI AND BRONCHIOLES LEADING TO ABNORMAL, PERMANENT DILATATION OF THE AIRWAYS

CAUSES PNEUMONIA MEASLES PERTUSSIS TB MECHANICAL OBSTRUCTION ASPERGILLOSIS KARTAGENERS CYSTIC FIBROSIS IDIOPATHIC

INVESTIGATION FBP SPUTUM CXR CT

COMPLICATIONS PNEUMONIA PLEURAL EFFUSION PNEUMOTHORAX SINUSITIS HAEMOPTYSIS BRAIN ABSCESS AMYLOIDOSIS

TREATMENT POSTURAL DRAINAGE ANTIBIOTICS NEBS SURGERY

CONSOLIDATION SPUTUM TACHYNOEA REDUCED MOVEMENT ON AFFECTED

SIDE TRACHEAL CENTRAL DECREASED PERCUSSION BRONHIAL BREATHING CREPS

CAUSES PNEUMONIA CARCINOMA PE

FIBROSING ALVEOLITIS TACHYNOEA CLUBBING CENTRAL CYANOSIS BILATERAL BASAL FINE END INSP

CREPS DO NOT DISAPPEAR ON COUGHING

SIGNS HANDS - RA, SYSTEMIC SCLEROSIS FACE - RASH OF SLE MOUTH - DRY OF SJOGRENS PULMONARY HTN - a WAVE IN JVP,

LEFT PARASTERNAL HEAVE AND P2 LOOK FOR CAUSES - DRUGS EG

AMIODARONE

PROGNOSIS 50% SURVIVAL AFTER 5 YEARS INCREASE RISK OF CA

ABDOMEN

EXAMINATION LYING FLAT DO NOT EXPOSE GENITALIA COMFORTABLE LOOK AROUND THE BED

HANDS CLUBBING LEUCONYCIA PALMAR ERYTHEMA DUPUTRYENS HEPATIC FLAP PIGMENTATION SCRATCH MARKS

EXAMINATION NODES TONGUE EYES - JAUNDICE, XANTHELASMA

ANAEMIA SPIDER NAEVIA ACANTHOSIS NIGRICANS GYNAECOMASTIA

EXAMINATION OF ABDOMEN

MOVEMENTS MASS VEINS PERISTALSIS HERNIA

ASK IF THERE IS ANY PAIN

PALPATION KNEEL DOWN ALWAYS LOOK AT THE PATIENT SUPERFICIAL THEN DEEP ALL QUADRANTS

PALPATE MASS - CHARACTERISTICS LIVER - PERCUSSION SPLEEN KIDNEYS LYMPH NODES HERNIAL ORFICES TESTICULAR ATROPHY

PERCUSSION SHIFTING DULLNESS

AUSCULTATE LIVER BRUIT BOWEL SOUNDS RENAL BRUIT

LEG OEDEMAPR

HEPATOMEGALY SIZE TENDERNESS- CHF OR ACUTE

HEPATITIS SURFACE - SMOOTH OR IRREGULAR PERCUSS AUSULTATE- ALCOHOLIC HEPATITIS

OR CA FOR BRUIT

CAUSES CHF CIRRHOSIS SECONDARIES INFECTIVE HEPATITIS MYELOPROLIFERATIVE DISORDERS SARCOID HAEMACHROMATOSIS PBC AMYLOID TUMOURS

CAUSES OF HEPATIC ENCEPHALOPATHY

INFECTION DIURETICS, ELECTROLYTE IMBALANCE DIARROHEA AND VOMITING SEDATIVES GI BLEED ABDOMINAL PARACENTESIS SURGERY

CAUSE OF ASCITES LIVER FAILURE + PORTAL HTN SECONDARY HYPERALDOSTERONISM DECREASED METABOLISM OF

ALDOSTERONE BY LIVER DECREASED METABOLISM OF ADH LOW ALBUMIN LYMPHATIC OBSTRUCTION

HAEMACHROMATOSIS MALE PIGMENTED PALMAR ERYTHEMA AND SPIDER

ANAEMIA JAUNDICE ASCITES HEPATOMEGALY LOSS OF SEXUAL HAIR TESTICULAR ATROPHY JOINT PAIN- PSEUDOGOUT CARDIOMYOPATHY DIABETES

INVESTIGATIONS AUTOSOMAL RECESSIVE MOSTLY HLA-A3 CHROMOSOME 6 TRANSFERRIN INCREASED SERUM FERRITIN RAISED GENE TESTING LIVER BIOPSY

TREATMENT VENESECTION

RISK X200 RISK OF HEP CA

PBC MIDDLE-AGED WOMEN CLUBBING PIGMENTED XANTHELASMA ICTERUS SCRATCH HEPATOSPLENOMEGALY

PBC XANTHOMATA- JOINTS - SKIN FOLDS - AREA OF TRAUMA LOOK FOR OTHER AUTOIMMUNE DISEASES PROXIMAL MUSCLE WEAKNESS –

OSTEOMALACIA PERIPHERAL NEUROPHATHY AMA – M2 OBSTRUCTIVE PICTURE LIVER TRANSPLANTATION

LOOK FOR AUTOIMMUNE CONDITIONS PROXIMAL MUSCLE WEAKNESS

DUE TO OSTEOMALACIA PERIPHERAL NEUROPATHY

PBC ANTI-MITOCHONDRIAL ABS CURE IS TRANSPLANTATION

SPLENOMEGALY DIFF FROM KIDNEY

KIDNEY BALLOTABLE NOTCH CAN’T GET ABOVE DULL TO PERCUSSION MOVES WITH RESP

LOOK FOR LYMPH NODES ANAEMIA JAUNDICE PLETHORIC (PRV) SPLINTER HAEMORRAGES RHEUMATOID

CAUSES CML MALARIA KALA-AZAR PRV MYELOFIBROSIS PORTAL HTN SARCOID AMYLOID ENDOCARDITIS INFECTIOUS MONONUCLEOSIS FELTYS CLL ITP

KIDNEYS LOOK FOR AV FISTULA LOOK FOR TRANSPLANTED KIDNEY 3RD NERVE PALSY ASSOC WITH

POLYCYSTIC KIDNEY (BERRY) BP FHX ANAEMIA

ABDOMINAL MASSES EPIGASRTIC -CA STOMACH -CA PANCREAS -AAA

-RETROPERITONEAL LYMPHADENOPATHY

ABDOMINAL MASSES RT ILIAC FOSSA- CROHNS

CA CAECUMLYMPH NODESTRANSPLANTED KIDAPPENDIX ABSCESSOVARIAN NGCARCINOIDAMOEBIAS

CAUSES OF PTOSIS UNILATERAL 3RD NERVE PALSY HORNERS MYASTHENIA CONGENITAL IDIOPATHIC

BILATERAL MYASTHENIA DYSTROPHIA OCULAR

MYOPATHY SYPHILIS CONGENITAL BILATERAL

HORNERS IN SYRINGOMYELIA

HORNERS MIOSIS PARTIAL PTOSIS ENOPTHALMOS ANHYDROSIS

CAUSES PANCOAST TUMOUR CERVICAL SYMPATHECTOMY CAROTID ANERUYSMS SYRINGOMYELIA LESION OF BRAINSTEM TRAUMA

HOLMES- ADIE YOUNG WOMAN DILATED PUPIL PUPIL REACTS SLOWLY DECREASED REFLEXES BENIGN

DILATED PUPIL EYE DROPS 3RD NERVE HOLMES – ADIE LENS IMPLANT DEATH SYMPATHETIC OVERACTIVITY

SMALL PUPIL OLD AGE EYE DROPS HORNERS ARGYLL ROB PONTINE NARCOTICS

DIABETIC EYES BACKGROUND RETINOPATHY PREPROLIFERATIVE PROLIFERATIVE

PAPILLOEDEMA SOL HTN RETINOPATHY BIH INCREASED ICP HEAD INJURY CAUSING CEREBRAL OEDEMA CO RETENTION THYROID VIT A INTOXICATION CENTRAL RETINAL VEIN THRMBOSIS MUTIPLE MYELOMA

OPTIC ATROPHY MS OPTIC NERVE COMPRESSION GLAUCOMA TOXINS ISCHAEMIA HEREDITARY PAGETS VIT B12 DEF

LOWER 7TH LOOK IN THE YEARS PAROTID GLAND ENLARGEMENT TASTE (INVOLVING CHORDA

TYMPANI) HEARING (HYPERACUUSIS DUE TO

STAPEDIUS) URINE - DIABETES

CAUSES OF BILATERAL GUILLAN BARRE SARCOIDOSIS MYASTHENIA MAY MIMIC

UNILATERAL PALSY LLS HERPES CEREBELLOPONTINE TUMOURS POLIO OTITIS MEDIA SKULL FRACTURE

DYSTROPHICA MYOTONICA SHAKING HANDS FRONTAL BALDNESS PTOSIS CATARACTS EXPRESSIONLESS

DYSTROP MYOTON TEST POWER DECREASED REFLEXES ASK ABOUT SWALLOWING URINE - GLUCOSE LOW IQ GYNAECOMASTIA TESTICULAR ATROPHY

DYSTROP MYOTONICA A D CARDIOMYOPATHY CHEST INFECTION

PROXIMAL MYOPATHY DIABETES CUSHINGS THYROID POLYMYOSITIS DRUG CARCINOMA OSTEOMALACIA HEREDITARY

WASTING SMALL MUSCLES OF THE HAND

RHEUMATOID OLD AGE CERVICAL SPONDYLOSIS BILATERAL CERVICAL RIBS MND SYRINGOMYELIA CHARCOT GUILLAN NERVE PALSIES PANCOASTS

NEUROFIBROMATOSIS AXILLA FOR FRECKLES VISUAL ACUITY - GLIOMA ACOSTIS NEUROMA IRIS FOR LISCH NODULES KYPOSCOLIOSIS BLOOD PRESSURE

LOOK FOR 6 OR MORE CAFÉ AU LAIT 2 OR MORE NEUROFIBROMAS AXILLA FRECKLING OPTIC GLIOMA

SPEECH COMPREHENSION

PUT OUT TONGUE SHUT YOUR EYES

ORIENTATION TIME , DATE

SPEECH NAME FAMILIAR OBJECTS ARTICULATION MENTAL SCORE EXPRESSIVE - BROCA

FRONTOPARIETAL RECEPTIVE - WERNICKE’S

SUPERIOR TEMPORAL

PARKINSONS EXPRESSIONLESS- HYPERMYMIA DROOLING PILL ROLLING BRADYKINESIA TONE- COG WHEEL GLABELLAR TAP - CONTINUE

MYERSON’S SIGN WALK MICRGRAPHIA

RHEUMATOID SUBLUXATION OF MCP SWAN NECK BOUTONNIERES Z DEFORMITY SUBLUX AT WRIST NAIL FOLD INFARCTS PALMAR ERYTHEMA

RHEUMATOID ARTHRITIS MUST CHECK FOR NODULES

SEROPOSITIVE AGGRESSIVE PERFORM SIMPLE TASKS EXAMINE OTHER JOINTS

ANAEMIA CHRONIC DISEASE PERNICIOUS ANAEMIA FELTYS NSAIDS

PULMONARY NODULES EFFUSION FIBROSIS CAPLANS BRONCHIOLITIS OBLITERANS

EYES EPISCLERITIS SCLERITIS SCLEROMALACIA SICCA SJOGRENS

ANK SPOND ? MARK POSTURE PROTUBERANT ABDOMEN ASK HIM TO TURN WHOLE BODY

TURNS STAND AGAINST A WALL SCHOBERS TEST

LOOK FOR IRITIS ANTERIOR UVEITIS AORTIC REGURG APICAL FIBROSIS ACHILLES TENDINITIS

GENETIC HLA-B27 40% SEVERE DISEASE

SCLERODERMA TIGHTENING OF HANDS TELANGICTASIA PSEUDOCLUBBING VITILIGO JOINT FOR ARTHRITIS PINCHED NOSE DIFF OPENING MOUTH

ASK ABOUT DYSPHAGIA RAYNAUDS DRY EYES SWALLOWING BREATHING - FIBROSIS

GOUT ASYMMETRICAL LOOK AT 1ST MTP , HELICES,

OLECRANON, ACHILLES NEGATIVE BIFRINGENT DISORDER OF PURINE

METABOLISM

THYROID HANDS - SWEATING, TREMOR,

WARM SCARS PALMAR ERYTHEMA PULSE NODES GOITRE SEAT UPRIGHT EXOPTHALMOS PALPATE ,WATER

EXAMINE FOR SIZE MOBILITY TEXTURE TENDERNESS PEMBERTONS SIGN - RAISE ARMS FOR

COMPRESSION PERCUSS FOR RETROSTERNAL BRUITS - GRAVES

EYES LID LAG VON GRAEF’ SIGN EXOPTHALMOS LID RETRACTION DALRYMPLES SIGN EXTRAOCCULAR MOVEMENTS CORNEAL INVOLVEMENT PROXIMAL MUSCLES SKIN PRETIB MYXOEDEMA

CUSHINGS MOON FACE BRUISES HIRSUTISM PLETHORIC BUFFALO HUMP STRIAE PROXIMAL MUSCLE WEAKNESS

ASK ABOUT STEROIDS DIABETES BP LOOK FOR RA , ASTHMA VISUAL FIELDS

CAUSES STEROIDS PITUITARY ADENOMA- PIT DISEASE ADRENAL CA ADRENAL ADENOMA ECTOPIC CA

ACROMEGALY FACE SWEATING LARGE HANDS CARPAL TUNNEL PROM SUPRAORBITAL RIDGES LARGE NOSE AND LIPS PROTRUSION OF LOWER JAW WIDE TEETH

LOOK FOR MACROGLOSSIA VISUAL FIELDS ACANTOSIS NIGRICANS ORGANOMEGALY JOINTS- CHONDROCALCINOSIS KYPHOSIS BP DIABETES OLD PHOTOGRAPHS

HYPERTENSIVE FUNDUS GRADE 1 – SILVER WIRING GRADE 2 – AV NIPPING GRADE 3 – HAEMORRAGES

(FLAME) +EXUDATES GRADE 4 - PAPILLOEDEMA

DIABETIC EYES BACKGROUND/PREPROLIFERATIVE

– HAEMORRAGES (MICROANEURYSMS) + EXUDATES

PROLIFERATIVE – MALIGNANT RETINOPHATY

NEOVASCULARISATION – NEW VESSELS

GOOD LUCK !