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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 !