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 The Philippine Health Agenda
Framework 2016-2022 under the
Duterte Administration. The new
health system framework aims for:
1. Financial Protection: Filipinos,
especially the poor are protected
from high cost of health care.
2. Better Health Outcomes: Filipinos
attain the best possible health
outcome with no disparity.
3. Responsiveness: Filipinos feel
respected, valued and empowered in
all of their interaction with the health
system.
 The Department of Health said that the
new health agenda framework will be
attainable through the ACHIEVE
strategy:
A Advance health promotion, primary care and quality with Public-Private Partnerships
C Cover all Filipinos against financial health risk
H Harness the power of strategic HRH
I Invest in eHealth and data for decision-making
E Enforce standards, accountability and transparency
V Value clients and patients
E Elicit multi-stakeholder support for health
 RH Law, otherwise known as
Republic Act 10354 or the
Responsible Parenthood and
Reproductive Health Act
 Here are the 10-point Socioeconomic
Agenda of the Duterte
Administration:
Road to Success by: JONAS MARVIN ANAQUE
1. Continue and maintain current
macroeconomic policies, including
fiscal, monetary, and trade policies.
2. Institute progressive tax reform and
more effective tax collection,
indexing taxes to inflation. A tax
reform package will be submitted to
Congress by September 2016.
3. Increase competitiveness and the
ease of doing business. This effort
will draw upon successful models
used to attract business to local
cities (e.g., Davao) and pursue the
relaxation of the Constitutional
restrictions on foreign ownership,
except as regards land ownership, in
order to attract foreign direct
investment.
4. Accelerate annual infrastructure
spending to account for 5% of GDP,
playing a key role.
5. Promote rural and value chain
development toward increasing
agricultural and rural enterprise
productivity and rural tourism.
6. Ensure security of land tenure to
encourage investments, and address
bottlenecks in land management and
titling agencies.
7. Invest in human capital
development, including health and
education systems, and match skills
and training to meet the demand of
businesses and the private sector.
8. Promote science, technology, and the
creative arts to enhance innovation
and creative capacity towards self-
sustaining, inclusive development.
9. Improve social protection programs,
including the government’s
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Conditional Cash Transfer program,
to protect the poor against instability
and economic shocks.
10. Strengthen implementation of the
Responsible Parenthood and
Reproductive Health Law to
enable especially poor couples to
make informed choices on
financial and family planning.
RABIES PREVENTION AND
CONTROL PROGRAM
Vision: To Declare Philippines Rabies-
Free by year 2020
Goal: To eliminate human rabies by the
year 2020
Program Strategies:
To attain its goal, the program employs the
following strategies:
1. Provision of Post Exposure
Prophylaxis (PEP) to all Animal Bite
Treatment Centers (ABTCs)
2. Provision of Pre-Exposure
Prophylaxis (PrEP) to high risk individuals
and school children in high incidence zones
4. Health Education
Rabies prevention
 RA 9482 or “The Rabies Act of
2007”, rabies control ordinances
shall be strictly implemented.
 March as the Rabies Awareness
Month
What Breeds Have the Strongest Bite?
Road to Success by: JONAS MARVIN ANAQUE
 September 28 as the World Rabies
Day.
 Stop walking or moving.
 Stay still and be calm.
 Do not panic or make loud noises.
 Avoid direct eye contact with the
dog.
 Say "No" or "Go Home" in a firm,
deep voice.
 Stand with the side of your body
facing the dog.
 Avoid facing a dog directly since it
can appear aggressive to the dog.
 keep your body turned partially or
completely to the side.
 Slowly raise your hands to your
neck, with your elbows in.
 Wait for the dog to pass or slowly
back away.
 Do not run from a dog.
 Remain motionless (e.g., "be still
like a tree") when approached by an
unfamiliar dog or attempt to sit.
 Avoid retrieving objects from the
dog's mouth
 Do not disturb the dog while the
animal is eating.
 Curl into a ball with your head
tucked and your hands over your ears
and neck if a dog knocks you over.
 Immediately let an adult know about
stray dogs or dogs that are behaving
strangely.
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- Kangal dogs
Post-exposure prophylaxis (PEP)
 extensive washing and local
treatment of the wound as soon as
possible after exposure;
 a course of potent and effective
rabies vaccine that meets WHO
standards; and
 the administration of rabies
immunoglobulin (RIG), if indicated.
Categories of contact with suspect
rabid animal
Category I – touching or feeding
animals, licks on intact skin
Category II – nibbling of uncovered
skin, minor scratches or abrasions
without bleeding
Category III – single or multiple
transdermal bites or scratches, licks on
broken skin; contamination of mucous
membrane with saliva from licks,
contacts with bats.
 Head is the most fatal site for dog
bite
 Legs are the most common site for
dog bite
 Rabies vaccine is an artificial active
 given on days 0, 3, 7, 14, 30, and 90,
 avoid gluteal area
 Rabies vaccine should be
administered in the deltoid muscle
 In both pre-exposure and post-
exposure immunization, the full 1.0
mL dose should be given 9
intramuscularly
 Sanofi Pasteur created both
antirabies and antidengue vaccine
 antirabies horse serum
 HRIG is from human serum
Road to Success by: JONAS MARVIN ANAQUE
Examples of active vaccines are PCEC (Purified Chick Emb
the new cheap drug VEROWELL
 - It will give 2 years immunity against rabies if the do
Postexposure Prophylaxis for Non-immuniz
Treatment Regimen
Wound All postexposure prophylaxis should begin wi
cleansing cleansing of all wounds with soap and water. I
such as povidine-iodine solution should be use
Post-exposure
RIGprophylaxis
If possible, the full dose should be infiltrated a
measures
remaining volume should be administered IM
from vaccine administration. Also, RIG shoul
None same syringe as vaccine. Because RIG might
production of antibody, no more than the reco
Immediate vaccination and
local treatment of the wound
Vaccine HDCV or PCECV 1.0 mL, IM (deltoid area ),
14.
Immediate vaccination and
administration
* Aof
5thrabies
dose on day 28 may be
immunoglobulin; local
treatment ofrecommended
the wound for immunocompromised
persons.
Postexposure Prophylaxis for Previously
Immunized Individuals
Treatment Regimen
Wound All postexposure prophylaxis
cleansing should begin with immediate
thorough cleansing of all wounds
with soap and water. If available,
a virucidal agent such as
povidine-iodine solution should
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Postexposure Prophylaxis for Previously
Immunized Individuals
RESTV species, found in Philippines and
the People's Republic of China, have been
found to infect humans but they do not cause
illness or death

Treatment Regimen Diagnosis

***antibody-capture enzyme-linked
immunosorbent assay (ELISA)
be used to irrigate the wounds.

RIG RIG should not be administered. Principles of Primary Health Care

1. 5 A's = Accessibility, Availability,

Vaccine HDCV or PCECV 1.0 mL, IM
(deltoid area), one each on days
0 and 3.
Ebola: Mapping the outbreak
From the section of WEST Africa
Ebola crisis
The hunters breaking an Ebola ban
on bushmeat- FRUIT BATS
Primary source = fruit bats or flying
foxes , old world bats
Affordability & Acceptability,
Appropriateness of health services.
2. Community Participation
 heart and soul of PHC
Four Cornerstones/Pillars in Primary
Health Care
1. Intra and Inter-sectoral Linkages
2. Use of Appropriate Technology
3. Support mechanism made available
4. Active Community Participation

Other sources:
community is the patient in CHN,
1. Chimpanzees the family is the unit of care or
2. Gorillas service
3. fruit bats
4. monkeys
5. antelope Herbal Medicine (LUBBY SANTA)
6. porcupines Herbal USES
7. symptomatic humans Medicine
Ebola outbreak in West Africa was first Lagundi Skin diseases
reported in March 2014, ( Vitex Headache,
Negundo) Asthma,fever,cough&colds
discovery in 1976. SHARED Rheumatism
The total number of reported cases is more Eczema
than 28,607. Dysentery
Ulasimang Lowers uric acid
Virus is named after the ebola river Bato

Road to Success by: JONAS MARVIN ANAQUE

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(Peperonia  5 years renewable Cotract of
Pellucida) copar
Bawang Hypertension and Toothache Entry Phase
( Allium • Self Awareness and Leadership
Sativum) HAT Training (SALT)
Bayabas Anti septic, Anti-diarrheal Community Organization and Capability
( Psidium Building Phase
Guajava) • Development of management
systems:
Yerba Buena Rheumatism and other body
(Delineation of the roles, functions and
(Mentha aches, analgesics
task of officers)
Cordifolia)
• A-R-A-S
Sambong (Action- Reflection- Action-
(Blumea Diuretic- kidney stones Session)
Balsamifera) Community Action Phase
Akapulko Fungal infection, skin
diseases • PIME of health services
(Project Implementation Monitoring and
Evaluation)
Niog Niogan Anti-helminthic every 6
(Quisqualis months 2 hours p supper
Measles 9m0s.- At least 85% of IMMUNIZATION SCHEDULE
Indica) No to lee than 4 y/o
11m0s. measles can be  Give every child a dose of Vitamin A
Tsaang Gubat Diarrheaprevented by every six months from the age of 6
(Carmona immunization at this months.
Retusa) age.  Give every child mebendazole every
Ampalaya DM Type 2- obesity 6 months from the age of one year.
(Momordica
Charantia) 6 weeks DPT+HIB-1** Hep B1 OPV1
RTV1**** PCV1*****
COPAR COPAR 10 weeks DPT+HIB-2 Hep B2 OPV2 RTV2
PCV2
 A social development approach that aims
to transform the apathetic, individualistic
and voiceless poor into dynamic,  9 months Measles ***
participatory and politically responsive  12 months MMR
community.  18 months DP
****Rotavirus Vaccine is available as
 2 dose or 3 dose schedule
Social Mobilization

 Process of generating and sustaining the ORAL HEALTH

active and coordinated participation of  Advise mother to bring the child to a
all sectors at various levels to facilitate dentist
and accelerate improvement  every 6 months for dental check-up

Road to Success by: JONAS MARVIN ANAQUE

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FOR PROPHYLAXIS IN HIV 3. Reporting/Tally Forms
CONFIRMED OR EXPOSED CHILD: 4. Output Reports...
 ANTIBIOTIC FOR
PROPHYLAXIS: Oral
Cotrimoxazole Rubeola (measles)
Communicable just before the rash
OPV (Oral Polio Vaccine) appears to 4-5 days after rash
“Sabin vaccine” appears=highly contagious
 polio vaccine that is taken by mouth
and contains the three serotypes of • The first sign of measles is usually a
poliovirus in a weakened live state— high fever (often >104o F [40o C])
called also Sabin oral vaccine that typically lasts 4-7 days.
Measles- Subcutaneous • Koplik spots—bluish-gray specks or
Cold Chain under EPI “grains of sand” on a red base—
develop on the buccal mucosa
o 6months- Regional Level opposite the second molars
o Not more than 5days- • First 24 hours
Health centers using – Fever, malaise, cough,
transport boxes. coryza, conjunctivitis
 Most sensitive to heat: Freezer (-15 • In 48 hours
to -25 degrees C) – “Koplik spots” (small,
o OPV irregular, red spots with
o Measles minute bluish-white center)
Schedule for Receiving Vitamin A first seen on buccal mucosa
Supplement Middle East respiratory syndrome
coronavirus (MERS-CoV)
 Post Partum Mother • a viral respiratory disease caused by
 200,000 IU a novel coronavirus (MERS‐CoV)
Within one month that was first identified in Saudi
 After delivery of each child only Arabia in 2012.
Republic of Korea is the largest outbreak
outside of the Middle East
Home Based Mother’s Record (HBMR)
 Tool used when rendering prenatal Source of the virus
care containing risk factors and originated in bats and was transmitted to
danger signs camels sometime in the distant past.
• camels - major reservoir host for
MERS-CoV and an animal source of
MERS infection in humans
• No vaccine or specific treatment is
Fundamental or building block of FHSIS? currently available.
= Individual treatment record or Family • avoid contact with camels, drinking
treatment record raw camel milk or camel urine, or
eating meat that has not been
Composition of FHSIS properly cooked.
1. Family Tx Record
2. Target Cx List

Road to Success by: JONAS MARVIN ANAQUE

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• Cover your nose and mouth with a
tissue when you cough or sneeze,
then throw the tissue in the trash.
• Avoid touching your eyes, nose and
mouth with unwashed hands.
• Avoid personal contact, such as
kissing, or sharing cups or eating
utensils, with sick people.
Diphtheria
• Diphtheria is an acute infection
caused by
• bacteria Corynebacterium
diphtheriae.
• The throat infection causes a gray to
black, tough, fiber-like covering,
which can block your airways
Tetanus
• caused by the bacterium Clostridium
tetani, the spores of which are
widespread in the environment
• present with trismus (“lockjaw”),
which is the inability to open the
mouth secondary to masseter muscle
spasm.
• Nuchal rigidity and dysphagia are
also early complaints that cause risus
sardonicus, the scornful smile of
tetanus, resulting from facial muscle
involvement
• generalized muscle rigidity with
intermittent reflex spasms in
response to stimuli (eg, noise, touch).
• Tonic contractions cause
opisthotonos (ie, flexion and
adduction of the arms, clenching of
the fists, and extension of the lower
extremities).
ZIKA-
• The Zika virus was detected for the
first time in a rhesus monkey
• Virus was named after a forest
in Uganda in 1947. A year later, it
was isolated in an Aedes mosquito
from the same region.
• The first human cases appeared in
the 1970s in Africa (Uganda,
Road to Success by: JONAS MARVIN ANAQUE
Tanzania, Egypt, Central African
Republic, Sierra Leone, Gabon and
Senegal) and then in some countries
in Asia (India, Malaysia, the
Philippines, Thailand, Vietnam and
Indonesia).
• In 2007, an actual epidemic broke
out in Micronesia (Yap Islands in
the Pacific Ocean), causing 5,000
infections.
• In 2013 and 2014, 55,000 cases of
Zika were reported in French
Polynesia. The epidemic then spread
to other islands in the Pacific,
namely New Caledonia, the Cook
Islands and Easter Island.
• The Zika virus was detected for the
first time in the northwest of Brazil
in May 2015 and it quickly spread to
other regions of the country. Brazil
has declared the highest number of
Zika cases ever recorded with
between 440,000 and 1,300,000
suspected cases reported.
• The virus has been present in
Colombia, El Salvador, Guatemala,
Mexico, Panama, Paraguay,
Suriname, Venezuela and Honduras
since October 2015.
Fighting the disease
Treatment
There is currently no vaccine for preventing
Zika virus infection and no specific
medication for treating the disease.
Treatment involves taking pain killers to
relieve the painful symptoms. However,
aspirin should be avoided until infection by
the dengue virus has been ruled out because,
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in this case, the anticoagulant effect of the
drug could cause bleeding.
Diagnosis
As soon as symptoms appear, blood and
urine samples are taken to confirm the
diagnosis using an RT-PCR (Reverse
Transcriptase-Polymerase Chain Reaction)
method to detect the presence of the virus's
genes.
Prevention
The only way of protecting against the Zika
disease is to protect yourself from mosquito
bites both day and night, especially in the
early morning and early evening when
mosquitoes are most active, using physical
and chemical methods — wear clothes that
cover up your skin (long sleeves, pants), use
suitable repellents on your clothes and areas
of exposed skin, and use insecticide-
impregnated mosquito nets and electric
insecticide diffusers indoors.
Pregnant women living in high-risk areas
must protect themselves from mosquito bites
using the above methods, particularly during
the first six months of pregnancy when the
risk of birth defects is at its highest.
Pregnant women wishing to travel to areas
affected by the Zika epidemic must weigh
up the risks beforehand with their family
physician.
mosquito breeding sites control, for example
stagnant water in flower pots, gutters and
old tires, must be removed. It is particularly
advisable to empty any water containers
located around your home after each spell of
rain.
 title of the agenda is Transforming
our world: the 2030 Agenda for
Sustainable Development.
17 goals
Road to Success by: JONAS MARVIN ANAQUE
Goal 1: No Poverty
Goal 2: Zero Hunger
Goal 3: Good Health and Well-being (health
related)
Goal 4: Quality Education
Goal 5: Gender Equality
Goal 6: Clean Water and Sanitation(health
related)
Goal 7: Affordable and Clean Energy
Goal 8: Decent Work and Economic Growth
Goal 9: Industry, Innovation and Infrastructure
Goal 10: Reduced Inequalities
Goal 11: Sustainable Cities and Communities
Goal 12: Responsible Consumption and
Production
Goal 13: Climate Action
Goal 14: Life Below Water
Goal 15: Life on Land
Goal 16: Peace, Justice and Strong Institutions
Goal 17: Partnerships for the Goals
 Anthrax
 (Splenic fever, Siberian ulcer,
Charbon, Milzbrand)
 Anthrax is a zoonotic disease caused by
the spore forming bacterium Bacillus
anthracis.
 Anthrax is most common in wild and
domestic herbivores (eg, cattle, sheep,
goats, camels, antelopes)
 B anthracis spores can remain viable in
soil for many years.
 Raw or poorly cooked contaminated
meat is a source of infection for zoo
carnivores and omnivores; anthrax
resulting from contaminated meat
consumption has been reported in pigs,
dogs, cats, mink, wild carnivores, and
people.
 GI anthrax (including pharyngeal
anthrax) may be seen among human
populations after consumption of
contaminated raw or undercooked meat.
 people may develop a highly fatal form
of disease known as inhalational anthrax
or woolsorter’s disease. Inhalational
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anthrax is an acute hemorrhagic
lymphadenitis of the mediastinal lymph
nodes, often accompanied by
hemorrhagic pleural effusions, severe
septicemia, meningitis, and a high
mortality rate.
 B anthracis was used successfully as a
weapon of terrorism in 2001, killing 5
people and causing disease in 22.
Probably because of the method of
delivery (via mail), no known animal
disease resulted from this attack.
Weaponized spores represent a threat to
both human and animal populations.
 Pathogenesis:
 After wound inoculation, ingestion, or
inhalation, spores infect macrophages,
germinate, and proliferate. In cutaneous
and GI infection, proliferation can occur
at the site of infection and in the lymph
nodes draining the site of infection.
 Lethal toxin and edema toxin are
produced by B anthracis and
respectively cause local necrosis and
extensive edema, which are frequent
characteristics of the disease.
 incubation period is 3–7 days (range
1−14 days).
 The disease in horses may be acute.
Signs may include fever, chills, severe
colic, anorexia, depression, weakness,
bloody diarrhea, and swellings of the
neck, sternum, lower abdomen, and
external genitalia. Death usually occurs
within 2–3 days of onset.
Road to Success by: JONAS MARVIN ANAQUE
 by species but resembles, for the most
part, anthrax in cattle.
 Specific diagnostic tests include
bacterial culture, PCR tests, and
fluorescent antibody stains to
demonstrate the agent in blood films or
tissues
 Treatment, Control, and Prevention:
 The nonencapsulated Sterne-strain
vaccine is used almost universally for
livestock immunization. Vaccination
should be done at least 2–4 wk before
the season when outbreaks may be
expected. Because this is a live vaccine,
antibiotics should not be administered
within 1 wk of vaccination.
 Oxytetracycline given daily in divided
doses also is effective. Other
antibacterials,
including amoxicillin, chloramphenicol,
ciprofloxacin, doxycycline, erythromyci
n, gentamicin, streptomycin, and
sulfonamides also can be used, but their
effectiveness in comparison with
penicillin and the tetracyclines has not
been evaluated under field conditions.
 Cognitive behavioral therapy (CBT) is
an effective treatment for depression
 approach of CBT is educational. The
therapist uses structured learning
experiences that teach patients to
monitor and write down their negative
thoughts and mental images.
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 CBT lasts 14 to 16 weeks.
 Cognitive therapy is based on
the cognitive model, which states
that thoughts, feelings and behavior
are all connected, and that
individuals can move toward
overcoming difficulties and meeting
their goals by identifying and
changing unhelpful or inaccurate
thinking, problematic behavior, and
distressing emotional responses
 Cognitive behavioral for
 Addiction
 Anxiety disorders
 Bipolar disorder
 Low self-esteem
 Phobia
 Schizophrenia
 Substance abuse
 Suicidal ideation
 Behavior therapy is
effective treatment for attention-
deficit/hyperactivity
disorder (ADHD) that can improve
a child's behavior, self-control, and
self-esteem. ... behavior
therapy must be initiated before
prescribing ADHD medicine.
 Metrorrhagia (bleeding between
menstrual periods) - first sign of
cervical cancer.
Road to Success by: JONAS MARVIN ANAQUE
 reducible hernia protruding mass
spontaneously retracts into the
abdomen.
 Atropine increases heart rate.
 A mechanical ventilator indicated to
a patient can't maintain a safe PaO2
or PaCO2 level.
 goal of treatment for a patient with
angina pectoris is to reduce the
heart's workload, thereby reducing
the myocardial demand for O2 &
preventing MI.
 Drainage of more than 3L of fluid
daily from a NGT may suggest
intestinal obstruction.
 Ecstasy is also known as
(MDMA /Molly)- methylenedioxy-
methamphetamine (MDMA)
 popular in the nightclub scene and at
all-night dance parties ("raves"), but
the drug now affects a broader range
of people who more commonly call
the drug Ecstasy or Molly.
 MDMA's effects last about 3 to 6
hours
 sildenafil (Viagra®)
 MDMA acts by increasing the
activity of three brain chemicals:
dopamine, norepinephrine, and
serotonin.
 Effects include euphoria, increased
energy, distorted perception,
involuntary teeth clenching,
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dangerously high body temperature,
and depression.
 After a corneal transplant avoid lying
on the affected site , soapsuds and
sex
 Persistent bleeding after open heart
surgery may require the
administration of protamine sulfate
to reverse the effects of heparin
sodium used during surgery.
 The risk of cancer is nearly doubled
in frequent users of
ACETAMINOPHEN.
 A triage nurse gathers information
upon a patent's arrival to a hospital
emergency room, including name,
age, symptoms and the current
medical condition of the patient.
 Dopamine—causes a surge in
euphoria and increased
energy/activity
 Norepinephrine—increases heart rate
and blood pressure, which are
particularly risky for people with
heart and blood vessel problems
 Serotonin—affects mood, appetite,
sleep, and other functions. It also
triggers hormones that affect sexual
arousal and trust. The release of large
amounts of serotonin likely causes
the emotional closeness, elevated
mood, and empathy felt by those
who use MDMA.
Road to Success by: JONAS MARVIN ANAQUE
 deer ticks = LYME'S DISEASE.
 REVERSE TRIAGE is system of
categorization of patients in a mass
casualty situation based on decisions
as to which can most safely be
DISCHARGED rather than on
priority for treatment.
 About 50% of people who
experience a systemic allergic
reaction will have a recurrent
reaction when re-stung.
Priming IV Tubing
 Prime all lines very slowly. When a line is
primed quickly, minute amounts of air are
left in the line.
 When priming all lines, invert each port and
hit with a pen to dispel the air bubble. If this
is not done there will be air in the line.
If you see a small bubble of air here or there, that
isn’t a big thing but patients can get anxious, so
get them out of the line by flicking the tubing with
your finger.
Remember that air rises so hold the portion of the
tube that is towards the end higher than where the
bubble is so the bubble will move along. If you see
bubble in the “Y” connectors along the line, turn
them upside down to get the air bubbles to dislodge
and move along.
Finishing the skill of priming an IV line requires you
secure the IV tubing to the patient. Make sure you
don’t tape over the transparent dressing that is on
the insertion site or you will have trouble
removing the line without damaging the dressing.
 If there is air in primed tubing, stretch the
line and strum very rapidly or stretch the
line around a pen and wrap the line forcing
the air upward. Air always rises therefore
while strumming or wrapping make sure that
you are forcing the air where you want it to
go. You can also use a sterile syringe to
aspirate air through a port.
 Spike bags upright and keep the tubing
upright. If the bag must be placed in a
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horizontal position, clamp off the tubing
below the drip chamber with your fingers to
prevent air from getting in the neck of the
drip chamber. If air gets into the neck of the
drip chamber it is very hard to dispel. Using
the roller clamp will not prevent air from
getting into the neck if the bag is horizontal.
 If the tubing is dripping, just raise your arm
above the drip chamber. This will stop the
dripping and is easier and quicker than using
the roller clamp.
 Tubing is usually changed every 96 hours
and the drop factor for tubing can change by
the manufacturer. The drop factor is always
listed on the box.
 DROPLET PRECAUTIONS for
Meningitis, and pertussis
 Contact precaution for MERS and
EBOLA
 PROGNATHISM - INITIAL
MANIFESTATION of
ACROMEGALY.
 Shick test for susceptibility to
diphtheria: A + shicks means no
immunity or suceptible; (antigen
test)
 Moloney test – for sensitivity of
diptheria
 Triad of ADHD: Inattention,
Hyperactivity, Impulsivity
 Latanoprost eye solution control the
progression of glaucoma or IOP
 Burns: Emergent Phase
 *Fluid shifts: IV to IS
 *Electrolyte imbalances:
Hyponatremia & Hyperkalemia
Road to Success by: JONAS MARVIN ANAQUE
 *Acid-Base imbalance: Metabolic
acidosis
Administering Oral Inhalation Therapy
 Shake the inhaler immediately
before using it. Remove the cap
from the mouthpiece.
 Ask client to clear their throat.
 Ask the client to breath out slowly
until no more air can be expelled
from the lungs then hold their
breath.
 Place the mouthpiece in the
mouth holding the inhaler upright.
Close the lips tightly around the
mouthpiece.
 Squeeze the inhaler as client
breathes in deeply through the
mouth. This is often difficult to
do.
 Tell client to hold breath up to a
count of five seconds.
 Before breathing out remove
inhaler from the mouth. Wait at
least two minutes between puffs,
unless there are other directions.
 Repeat process if two puffs are
ordered.
 If you have two or more inhalers
always use the steroid
medication last. Then rinse mouth
out with water.
 Clean mouthpiece of inhalers
frequently and dry it thoroughly.
 Remove gloves, wash your
hands with soap and water, and
dry thoroughly.
 NLE POINTERS
Anaphylaxis may cause respiratory
(bronchoconstriction) and shock
(vasodilation). It's considered a crisis.
 Mastoidectomy is required in 50% of
cases of MASTOIDITIS.
 Pure-tone audiometry is a behavioral
test used to measure hearing
sensitivity.
 The most common cause of corneal
ulceration is prolonged or improper
use of contact lenses.
 A person with Antisocial Personality
Disorder lacks superego and needs
immediate gratification.
 After a patient undergoes a femoral-
popliteal bypass graft, the nurse must
closely monitor the peripheral pulses
distal to the operative site and
circulation.
 Osteoarthritis is also known as
Degenerative Joint Disease. It
commonly affects the weight-bearing
joints (spine, hips and knees).
 Colonoscopy is the "screening" for
colorectal cancer.
 Biopsy is the confirmatory.
 Veracity: habitual observance of
truth in speech or statement;
TRUTHFULNESS.
 The closest predisposition to Type 2
DM (NIDDM) is obesity.
 Dyspnea and sharp, stabbing pain
that increases with respiration are
symptoms of pleurisy, which can be
Road to Success by: JONAS MARVIN ANAQUE
a complication of pneumonia or
tuberculosis.
 GERD is also known as chalasia.
 Z-Track Injection
 adult, the most commonly used
needles are 1’(inch)or 1/2, 22 to 25
gauge thick
 Preparation
 Verify doctor’s order on the patient’s
chart.
 Hand washing.
 Use a proper needle. Rule of thumb
in needle selection for IM injection
are as follows:
 Aspirate the prescribed medication
into the syringe. Draw 0.2-0.5 cc of
air (depending on the hospital
policy) to create an air lock. (Air-
lock technique is used with this
procedure.)
 Replace the needle with a new one
after preparing the drug so that no
drug remains outside the needle
shaft. This prevents tracking the drug
into the subcutaneous tissue during
injection.
 Pancolitis refers to inflammation of
the entire colon.
 hallmark of Ulcerative colitis
is bloody diarrhoea / rectal
bleeding.
 Recurrent Ulcerative colliotis treat
with sulfasalazine
 Tracheoesophageal fistula:
 NLE POINTERS
•Distal esophagus arises from
trachea; proximal esophagus
ends blindly.
• Stuff swallowed ends up in
trachea.
• Food regurgitates in mouth.
 Gastroesophageal reflux disease:
GERD or chalasia:
 Caused by:
• Smoking, alcohol, caffeine,
chocolate, hiatal hernia.
 Findings:
• Chest pain, cough, asthma,
heartburn, acid injury to
enamel, Barrett's esophagus.
 Achalasia:
• Incomplete relaxation of
LES.
• Absent ganglion cells of
myenteric plexus.
• No peristalsis.
 Causes:
• Chagas disease.
• Abnormal barium swallow:
beak-like (bird-beak) tapering
at distal end of esophagus.
 Congenital pyloric stenosis:
• Projectile vomiting.
• Hypertrophy of muscles in
pyloric sphincter.
 Findings in small bowel disease:
• Colicky pain: pain occurs in
intervals.
• Diarrhea.
• Anemia: malabsorption of
iron, folate, vitamin B12.
 Findings in large bowl disease:
• Diarrhea.
Road to Success by: JONAS MARVIN ANAQUE
• Pain.
• Iron deficiency.
• Hematochezia: massive blood
loss.
 Inflammatory bowel disease:
 Ulcerative colitis:
• Most common.
 *Rectum and sigmoid
• Ulcerations.
 Crohn's disease:
• Granulomatous,
ulceroconstrictive disease.
• Discontinuous spread
throughout entire GI tract.
 Irritable bowel syndrome:
•Alternating bouts of diarrhea
and constipation.
 **Diverticulitis – LLQ pain
 Barrett's esophagus:
• Complication of GERD.
• Glandular metaplasia in distal
esophagus.
• Ulceration, glandular
dysplasia; adenocarcinoma
risk.
 Colon cancer:
• Increasing age.
• Low-fiber diet.
• Smoking.
• Familial polyposis, ulcerative
colitis.
• Common location:
rectosigmoid.
• Test: fecal occult blood test,
colonoscopy, barium enema.
• Constipation and diarrhea
with or without bleeding.
 NLE POINTERS
• Spreads to: liver (common),
lungs, bone, brain.
 Colorectal
cancer –
primary
diagnostic test
is colonoscopy
 Acute appendicitis:
• Children: lymphoid
hyperplasia.
• Adults: fecalith obstruction
of proximal lumen.
• Initial colicky periumbilical
pain.
• Nausea, vomiting, fever.
• Tenderness at McBurney's
point (Blumberg's sign).
• Laboratory: neutrophilic
leukocytosis.
• Diagnosis: CT scan.
• Complications:
periappendiceal abscess;
pylephlebitis.
• Treatment: appendectomy.
 Mental health stigma types: social
stigma and perceived stigma or self-
 Stigma is when someone views you
in a negative way because you have
a distinguishing characteristic or
personal trait that's thought to be, or
actually is, a disadvantage (a
negative stereotype)
 Stigma can lead to discrimination.
 Pyschiatric nursing, approach,
disorder, drugs, approach, LITHIUM
THERAPHY, collaborative and
management, diagnostic and
screening.
√ Geriatrics Nursing, Drugs,
Road to Success by: JONAS MARVIN ANAQUE
Management and approach
√ Nursing Research
√ Maslow
√ PALMAR
√ Meniers, parkinsons, GBS, ALS,
drugs, surgery, limit, diet, exercise
and management
√ MaskuloSkeletal Disorder ( gouty,
osteo, rheumatoid) drugs, diet,
exercise and management
√ Gait, posture, strain and braces
√ pediatric bones disorder
√ BURNS
√ EENT disorders, drugs, surgery,
management and diet
√ Nursing Theories
√ RAPE management
 STEP 1 – Making preparations to offer
medical care to rape survivors
 STEP 2 – Preparing the survivor for the
examination
 A person who has been raped has
experienced trauma and may be in an
agitated or depressed state. She often
feels fear, guilt, shame and anger, or any
combination of these.
 Ensure that a trained support person or
trained health worker of the same sex
accompanies the survivor throughout
the examination.
 STEP 3 – Taking the history
 STEP 4 – Collecting forensic evidence
• Documenting injuries and
collecting samples, such as
blood, hair, saliva and sperm,
within 72 hours of the incident
 NLE POINTERS
• **place evidence in a paper  Close your office door or find a quiet
bag not in a zip lock plactics space, and meditate for five minutes.
to prevent deterioration
 Distract yourself from your anger
 STEP 5 – Performing the physical and
• visit your favorite website, play
genital examination
a song that you like, daydream
 STEP 6 – Prescribing treatment about a hobby that you enjoy,
or take a walk.
 STEP 7 – Counselling the survivor

 STEP 8 – Follow-up care of the survivor

 CRISIS management
•
√ Anger Management  CRISIS INTERVENTION

 Anger is a powerful force that  TECHNIQUES OF CRISIS INTERVENTION

can jeopardize your
relationships, your work, and
your health, if you don't learn
to manage it effectively.
 To manage anger,
acknowledge that you have a
problem, keep a hostility log,
and build a support network
based on trust.
 Also, use techniques to
interrupt your anger, listen,
empathize, be assertive with
others, and learn to relax, as
well as laugh at yourself.
 v Catharsis: the release of feelings that
takes place as the patient talks
emotionally charged areas
 v Clarification: encouraging the patient
to express more clearly the relationship
between certain events.
 v Manipulation: using the patient’s
emotions, wishes or values to benefit
the patient in the therapeutic process.
 v Reinforcement of behavior: giving
the patient positive reinforcement to
adaptive behavior.

 Yell "Stop!" loudly in your thoughts. This  v Support of defenses: encouraging the
can interrupt the anger cycle. use of healthy, adaptive defenses and
discouraging those that are unhealthy
 Use physical relaxation techniques
or maladaptive.
like deep breathing or centering
 v Increasing self- esteem: helping the
 Count to 20 before you respond.
patient to regain feelings of self worth.
 Manage your negative thoughts
with imagery and positive thinking

Road to Success by: JONAS MARVIN ANAQUE

 NLE POINTERS
 v Exploration of solution: examining
alternative ways of solving the
immediate problem.
 Catharsis - . As feelings about the events
are realised, tension is reduced. The
nurse solicits the patient's feelings
about the specific situation, recent
events, and significant people involved
in the particular crisis. The nurse asks
open-ended questions and repeats the
patient’s words so that more feelings
are expressed. The nurse does not
discourage crying or angry outbursts
but rather sees them as a positive
release of feelings.
•
√ CVA
 Pheochromocytoma is the formation
of a benign tumor in adrenal medulla
causing hypertensive crisis.
 DOC: Phentolamine Mesylate
(Regitine) In otitis media, the
tympanic membrane is bright red and
lacks its characteristic light reflex
(cone of light).
 Dopamine is the drug of choice for
shock. (Maybe,CIC)
 Vital Signs
 Assess the client for the
following while in
traction.
 Monitor skin integrity of
the affected part before
Road to Success by: JONAS MARVIN ANAQUE
and after traction
placement.
 Assess the skin, especially
bony prominences for
breakdown.
 Assess neurovascular
status.
 Regularly check the
condition of the traction
equipment: ropes,
pulleys, and weights.
 For the client in skeletal
traction, assess the pin
site for signs and
symptoms of infection.
 Role of the Nurse in
Caring for Patients in
Traction
 RNs shall not apply or set
up skeletal or cervical
traction.
 RNs shall not remove,
add, or lift up on weight
when the patient is in
traction for the treatment
of fractures.
Glucometer Testing
 Puncture the body part as
directed by the delegating RN.
The best practice is to change
the puncture site for each test.
Tip: fingertips are less
sensitive on the sides of the
finger.
 Provide direct pressure to stop
the bleeding if needed
 Remove gloves.
 Wash and dry your hands.
 NLE POINTERS
Gastrostomy Feedings
 Remove the dressing - never
use scissors to cut it off.
 Anchor the tube as instructed by
the delegating nurse.
 Encourage the client to be in a
sitting or semi-reclining position.
 The delegating nurse may ask
you to check gastric contents by
putting on gloves and
withdrawing some of the
contents of the stomach with a
large syringe.
 Administer the formula or the
medication as directed by the
delegating nurse.
 Flush the feeding tube with 30-
60 ml of water before and after
each feeding and after giving all
medications.
 Remove gloves.
 Wash your hands.
 Arteriolosclerosis:
• Hardened arterioles.
• Protein deposition occludes
lumen.
• Caused by diabetes mellitus;
hypertension.
• Onion skin appearance of
arterioles.
 Aneurysms:
• Weak vessel walls followed
by dilation.
• Tendency of vessel wall to
rupture.
 Abdominal aortic aneurysm:
• AORTA is located at the
EPIGASTRIC REGION
 Atherosclerosis weakens wall.
Road to Success by: JONAS MARVIN ANAQUE
• Increased vessel diameter;
lumen fills with debris and
clots.
• Findings: usually
asymptomatic.
 Hypertension:
• BP over 140/90 mm Hg.
 Depends on:
• Diastolic blood pressure.
• Systolic blood pressure.
• Sodium level.
 Essential hypertension:
• 95% cases of hypertension.
• Genetic factors reduce Na
elimination; unknown factors
cause vasoconstriction of
arterioles.
• Obesity, stress.
 Secondary hypertension:
• 5% cases of hypertension.
• Renal artery occlusion.
• Activation of renin-
angiotensin-aldosterone
system.
• Renal artery has beaded
appearance.
 Complication:
• Rupture causes severe back
pain followed by
hypotension.
• most common type of hernia
is the hiatus hernia, in
which the stomach passes,
partly or completely, into the
chest cavity through the hole
("hernia") for
 NLE POINTERS
the oesophagus (which is also
known colloquially as the
"windpipe" or "gullet").
 Complications of hernias
 impossible to return to their normal
state (irreducible).
 swollen and fixed within their sac
(incarcerated).
 cut-off from their blood supply,
becoming painful and eventually
gangrenous (strangulated).
 treatment for hernias surgical repair.
• Irritable Bowel Syndrome is
also known as "IBS", "spastic
colon", and "mucous colitis"
• Cause is unknown but IBS is
often associated with stress or
anxiety
 Treatment might involve:
 reducing or removing anxiety (e.g.
psychotherapy)
 dietary adjustment
 faecal softening agents
 drugs to reduce spasm and / or
reduce sensitivity to pain
 gastric ulcers
 The action of acid, pepsin, and bile
on the lining of the stomach
(mucosa). However, the output of
stomach acid is not usually
increased.
 Taking NSAIDs (non-steroid anti-
inflammatory drugs) or
corticosteroids may be pre-
disposing factors.
 helicobacter pylori is often present.
Road to Success by: JONAS MARVIN ANAQUE
 vomiting and pain in the upper
abdomen soon after eating.
 Complications may include
bleeding, perforation and
obstruction due to scarring.
 Medical treatment may include the
use of antacids to relieve symptoms
and / or anti-secretory drugs to heal
the ulcer(s)
 gastroscope to confirm the diagnosis
of a gastric ulcer
 Effects / symptoms of a peptic ulcer
can include:
 abdominal pain - often just below
the sternum (="breastbone"), can be
a persistent burning pain that
extends to he person's back.In some
cases this pain may begin approx.
20 mins after eating, or it may
awaken the person at night.
 heartburn
 regurgitating food
 vomiting
 bitter taste in the mouth
 Osteomyelitis:
• Bone infection due to: S
aureus (most common).
• Findings: fever, bone pain.
• In sickle cell anemia: S.
paratyphi.
• In foot due to rubber
footwear puncture: P.
aeruginosa.
 Osteoporosis:
• Loss of bone matrix and
minerals.
 NLE POINTERS
• Primary: idiopathic, senile,
postmenopausal (lack of
estrogen).
• Secondary: disease, drugs,
space travel.
• Prevention: vitamin D,
calcium, weight-bearing
exercise.
• Treatment: bisphosphonates,
calcitonin.
 Paget's disease
• Elderly men.
• Idiopathic.
• Osteoclastic resorption of
bone; shaggy-appearing
lesions.
• Increased alkaline
phosphatase.
• Thick weak bone - mosaic
bone.
• Increased osteoclastic bone
resorption causing increased
bone turnover.
• Causes may include
paramyxovirus infection.
• Some findings include: bone
pain and deformity, hearing
loss.
 Osteoarthritis:
• Non-inflammatory joint
disease.
• Universal after 65 years of
age.
• Degeneration of articular
cartilage in weight-bearing
joints.
• Osteophyte formation.
• Bone rubs on bone.
 Findings:
• PIP/DIP enlargement.
 Rheumatoid arthritis:
Road to Success by: JONAS MARVIN ANAQUE
•HLA-DR4 association.
•Type III hypersensitivity
reaction.
• Joint B-cells produce
rheumatoid factor.
• Rheumatoid factors activate
complement, attracting
neutrophils.
• Synovial tissue proliferates
forming a pannus.
• Findings: MCP/PIP involved;
knees, ankles, hips involved;
lungs, hematologic disease,
carpal tunnel syndrome,
rheumatoid nodules,
vasculitis, popliteal cyst.
 Sjogren's syndrome:
• Autoimmune disease;
dominant in females.
• Destruction of salivary and
lacrimal glands.
• Findings: rheumatoid
arthritis, dry eyes, dry mouth.
• Labs: anti-SS-A (Ro) and
anti-SS-B (La) antibodies.
• Confirm with lip biopsy.
 Juvenile rheumatoid arthritis:
•Children younger than 16.
•Still's disease: fever, rash,
polyarthritis;
lymphadenopathy,
neutrophilic leukocytosis.
 Gouty arthritis:
• Multifactorial inheritance.
• Due to underexcretion of uric
acid.
• Recurrent acute arthritis:
podagra (gout in great toe;
painful); fever, pain,
neutrophilic leukocytosis.
• Chronic gout: tophi cause
erosive arthritis.
 NLE POINTERS
 Findings:
• Urate neuropathy, renal
stones, hypertension,
coronary artery disease, lead
poisioning.
 Labs:
• Hyperuricemia.
 Lyme disease:
• B. burgdorferi.
• Ixodes tick transmission;
white-tailed deer is reservoir.
• Early: bull's eye lesion.
• Late: arthritis, Bell's palsy,
myocarditis and pericarditis;
babesiosis (secondary
infection).
• Diagnosis: serologic tests,
biopsy, silver stains.
 Duchenne's muscular dystrophy:
•
Deficiency of dystrophin
gene.
• XR disease.
• Type I and II fiber atrophy.
• Weakening and wasting of
pelvic muscles.
• Death by age 20.
• Labs: increased serum
creatine kinase at birth;
increased serum creatine
kinase in female carriers.
 Myotonic dystrophy:
•AD disease.
•Trinucleotide repeat disorder.
•Findings: facial weakness,
myotonia, frontal balding,
cataracts, testicular atrophy,
cardiac involvement.
• Increased serum creatine
kinase.
 Myasthenia gravis:
Road to Success by: JONAS MARVIN ANAQUE
• Thymus-synthesized auto-
antibodies against ACh
receptors.
 Findings:
• Ptosis, dysphagia, risk for
thymoma.
 Confirmation:
• Tensilon (edrophonium) test.
 Potassium disorders:
• Controlled by aldosterone
(direct relationship), arterial
pH (more pH, less K).
• Hypokalemia: muscle
weakness, U waves on ECG,
polyuria, rhabdomyolysis.
• Hyperkalemia: ventricular
arrhythmias, peaked T waves
on ECG, muscle weakness.
 K loss caused by:
• Decreased intake, GI loss,
renal loss, alkalosis.
 Acid-base disorders:
 Respiratory acidosis:
•Hypoventilation and
CO2 retention.
• Basic blood (increased
HCO3) compensates for
acidic lungs (decreased pH)
by causing metabolic
alkalosis. Very high pCO2.
• Findings: somnolence,
cerebral edema.
 Respiratory alkalosis:
• Hyperventilation with
CO2 elimination.
• Acidic blood (decreased
HCO3) compensates for basic
lings (increased pH) by
 NLE POINTERS
causing metabolic acidosis.
Very low pCO2.
• Findings: light-headedness,
tetany (Ca binds to albumin,
so decreased Ca).
 Pulmonary Embolism:
• Originates in femoral vein,
pelvic vein, or vena cava;
occludes pulmonary artery
branches; sudden death.
 Position to Left side lying
 Metastasis:
• Hepatic portal vein: liver.
• Vena cava: lungs.
 Effects of cancer:
• Cachexia.
• Anemia.
• Hemostasis abnormalities
like DIC, etc.
• Fever.
• Paraneoplastic syndromes.
 Transfusion Reactions: Acute
Hemolytic Transfusion Reaction:
• Intravascular: ABO
incompatibility; type II
hypersensitivity.
• Extravascular: donor RBCs
coated with antibodies;
jaundice.
 Findings:
• Fever, back pain,
hypotension, DIC, oliguria.
 Hemolytic Disease of Newborn:
• Maternal IgGs coat infant
RBCs.
Road to Success by: JONAS MARVIN ANAQUE
 Hemolytic disease of newborn:
ABO HDN:
• Mom = type O; baby = type
A or B.
• Jaundice develops 24 hours
after birth.
• Anemia.
• + Coombs' test on baby
blood.
 Hemolytic disease of newborn: Rh
HDN:
• Mom is RH negative; baby is
Rh positive.
• Mom exposed to fetal blood,
develops anti-D-IgG
antibodies.
• First pregnancy plays no role.
• During second pregnancy,
anti-D-IgG enters placenta
coats baby RBCs.
 Treatment:
•At 28th week of pregnancy,
give mom anti-D globulin (it
covers and eliminates "Rh+"
baby blood before mom's
body officially mounts an
attack against it), which lasts
~3 months.
 Findings:
•Jaundice, kernicterus,
positive direct/indirect
Coombs' test.
• Use blue fluorescent light on
newborn skin.
 Blood urea nitrogen (BUN):
• End product of amino acid
and pyrimidine metabolism.
• Produced by liver.
• Increased in CHF.
 NLE POINTERS
 Azothemia:
• Increased BUN and
creatinine levels.
 Prerenal:
• Causes: decreased CO.
 Renal:
• Causes: parenchymal damage
to kidneys; tubular necrosis,
renal failure.
 Postrenal:
• Causes: urinary tract
obstruction below kidneys.
 Renal function tests:
 Creatinine clearance:
•Correlates with GFR.
•Detects renal dysfunction.
•Increased in pregnancy;
decreased in elderly people,
renal disease, etc.
 Nephrotic syndrome:
• Increased proteinuria.
• Pitting edema, ascites.
• Hypoalbuminemia.
• Infections, eg., S.
pneumoniae.
• Hypertension,
hypercoagulability,
hypercholesterolemia,
hypogammaglobinemia, fatty
casts.
 Wilm's Tumor:
• 2-5 years of age.
• AD disease; chromosome 11.
• WAGR syndrome: Wilm's
tumor, aniridia, genital
abnormalities, retardation.
• Beckwith-Wiedemann
syndrome.
Road to Success by: JONAS MARVIN ANAQUE
• Unilateral palpable mass;
hypertension.
• Metastasis to lungs.
 No to palpation
 Congestive Heart Failure:
 Left-sided HF:
• Blood cannot be ejected into
aorta.
• Pulmonary edema.
• Caused by concentric LVH.
• Alveolar macrophages
contain hemosiderin (heart
failure cells).
• Difficulty breathing.
• Left-sided S3 sound.
• Mitral-valve regurgitation.
• Paroxysmal nocturnal
dyspnea.
 Right-sided HF:
• Blood cannot be pumped into
lungs.
• Prominent jugular veins.
• Right-sided S3 sound.
• Tricuspid valve regurgitation.
• Painful hepatomegaly.
• Pitting edema and ascites.
 Angina pectoris:
 Stable angina:
• Caused by atherosclerotic
coronary artery disease.
• Exercise-induced chest pain.
• ST depression.
• Relieved by resting or
nitroglycerine.
 Prinzmetal angina:
• Coronary artery vasospasm at
rest.
• Vasoconstriction.
• ST-elevation.
 NLE POINTERS
•Nitroglycerine and Ca-
channel blocker.
 Unstable angina:
• Severe atherosclerotic
disease.
• Chest pain even at rest.
• May progress to MI.
• Balloon angioplasty.
• Stents.
 Chronic ischemic heart disease:
• Ischemic damage to
myocardial tissue causes
CHF.
• Findings: CHF, angina,
dilated cardiomyopathy.
 Myocardial infarction:
• Disruption of atheromatous
plaque; platelet thrombus
formation.
• TXA2 plays important role in
platelet thrombus formation.
• Causes of MI: cocaine use,
vasclitis, embolization, etc.
 Transmural / Q-wave:
•Involves full thickness of
myocardium.
 Findings:
•
Sudden retrosternal pain.
•
Not relieved by
nitroglycerine; lasts 45
minutes.
• Radiates to left arm and jaw.
• Sweating, anxiety,
hypotension.
 Complications:
• Arrhythmias, CHF, rupture,
mural thrombus, pericarditis,
ventricular aneurysm, right
ventricular acute MI.
Road to Success by: JONAS MARVIN ANAQUE
• Increased CK-MB; peaks at
24 hours.
• Troponins: cTnl and cTnT.
• LDH 1-2; "flip."
• Inverted T waves.
• Elevated ST segment.
• New Q waves.
 Rheumatic fever:
• Immune disease that follows
group A streptococcal
pharyngitis infection.
• Pericarditis.
• Myocarditis.
• Endocarditis.
• Sterile, verrucoid-appearing
vegetations near valve.
• Mitral and aortic valve
regurgitation.
• Infection.
• Migratory polyarthritis.
• Sydenham's chorea.
• Antistreptolysin O (ASO)
titers; throat culture;
leukocytosis; increased PR
interval; CRP.
 Rubella (German measles):
• RNA togavirus.
• 3-day measles.
• Painful lymphadenopathy.
• Findings: polyarthritis in
adults.
 Varicella-zoster virus:
•DNA herpesvirus.
•Varicella (chickenpox): rash;
+ Tzanck test; Reye
syndrome; pneumonia;
cerebellitis.
• Herpes zoster (shingles).
 Eczema:
• Inflammatory dermatoses.
 NLE POINTERS
• Acute: weeping,
erythematous rash.
• Chronic: dry, thickened skin
due to scratching.
• Atopic dermatitis: type I IgE-
mediated hypersensitivity
reaction in children.
• Contact dermatitis: allergic;
type IV hypersensitivity
reaction.
• Photodermatitis: UV light
reaction.
 Psoriasis:
• Genetic predisposition.
• Undifferentiated proliferation
of keratinocytes.
• Association with
streptococcal pharyngitis.
• Koebner phenomenon: rash
in areas of trauma.
• Plaques, pitting of nails.
• Munro microabscesses:
neutrophils collect in stratum
corneum.
 Hydrocephalus:
• Ventricle enlargement due to
increased CSF volume.
 Communicating/non-obstructive:
•Increased CSF production.
•Obstruction of CSF
absorption by arachnoid
granulations.
 Non-communicating (obstructive):
•CSF can't flow out due to
stricture of aqueduct of
Sylvius, fourth ventricle
tumor, etc.
 Findings:
Road to Success by: JONAS MARVIN ANAQUE
• Seen in newborns (enlarged
head) and adults (dementia,
wide-based gait, urinary
incontinence).
 Cerebrovascular accidents:
 Atherosclerotic (thrombotic)
stroke:
•Most common.
•Platelet thrombus develops
over disrupted plaque: MCA
or ICA near bifurcation.
• Findings: pale infarction,
swelling of brain, gliosis,
cystic area.
• Clinical findings: strokes.
 Meningitis:
• Pia mater (brain cover)
inflammation.
• Fever, nuchal rigidity,
headache.
 Labs:
• Viral: increased CSF protein;
normal CSF glucose.
• Bacterial/fungal: increased
CSF protein; decreased CSF
glucose.
 Encephalitis:
• Brain inflammation.
• Fever, headache, altered
mental status.
 Demyelinating disorders:
 Multiple sclerosis:
• More common in females.
• HLA-DR2.
• CD8 T-cell destruction of
myelin and oligodendrocytes.
 NLE POINTERS
 Findings:
• Sensory and motor
dysfunction, visual and
speech disturbances, ataxia,
tremor, nystagmus, bilateral
internuclear ophthalmoplegia.
 Labs:
• Increased CSF leukocyte,
protein, myelin basic protein;
normal CSF glucose;
oligoclonal bands on CSF
electrophoresis; central
pontine myelinolysis.
 Alzheimer's disease:
• Important role of beta-
amyloid (A-beta) protein
coded by chromosome 21.
• Defective degradation of
APP.
• Apolipoprotein gene E on
chromosome 19.
• Defective tau protein; located
on chromosome 14.
 Findings:
• Cerebral atrophy, dilated
ventricles, NF tangles in
neuron cytoplasm, senile
plaques, amyloid angiopathy.
 Confirmation:
• Postmortem examination of
brain.
 Parkinsonism:
• Altered dopaminergic
pathways.
• Defective control over
voluntary muscle movement.
 Pathology:
• Idiopathic degeneration of
neurons in substantia nigra
Road to Success by: JONAS MARVIN ANAQUE
causing deficiency of
dopamine.
 Findings:
• Muscle rigidity,
resting/rolling pill tremor,
expressionless face, shuffling
gait.
 Treatment:
• Dopamine replacement.
 Huntington's disease:
• AD disease.
• Trinucleotide repeat disorder
involving chromosome 4.
• Atrophy of striatal neurons.
 Findings:
• Chorea, muscle rigidity,
dementia.
 Friedreich's ataxia:
• AR disease.
• Trinucleotide repeat disorder.
 Findings:
• Ataxia, lack of joint
sensation, peripheral
neuropathy, hypertrophic
cardiomyopathy.
 Lou Gehrig's disease (ALS):
• Degeneration of UMNs and
LMNs.
• Mutated chromosome 21.
• Findings: UMN: spasticity,
Babinski's sign; LMN:
muscle weakness causing
respiratory paralysis.
 CNS and alcohol abuse:
• Cortical and cerebellar
atrophy.
• Central pontine myelinolysis.
 NLE POINTERS
• Wernicke-Korsakoff
syndrome due to thiamine
deficiency.
• Findings: ataxia, confusion,
nystagmus, ophthalmoplegia.
• Anterograde and retrograde
amnesia.
 Guillain-Barre syndrome (GBS):
• Autoimmune demyelination
syndrome.
• Associated with M.
pneumoniae pneumonia, C.
jejuni enteritis, CMV, EBV,
and HIV.
• Weakness of ascending motor
neurons.
• Findings: increased CSF
protein.
• Treatment: plasmapheresis.
 Idiopathic Bell's palsy:
• Unilateral facial paralysis due
to LMN palsy.
• Inflamed facial nerve.
• Associated with HIV,
sarcoidosis, Lyme disease.
• Findings: drooping corner of
mouth; can't speak; can't
close eye.
• Causes: eg., vincristine,
hydralazine.
• Deficiency of vitamins:
thiamine, B12, pyridoxine.
 Benign prostatic hyperplasia:
• Digital rectal exam 50%
sensitive.
• DHT is mediator.
• Estrogen is co-mediator.
 Findings:
• Obstruction, hematuria, PSA.
Road to Success by: JONAS MARVIN ANAQUE
 Complications:
• Obstructive uropathy, bladder
infections, prostatic infarcts.
 Prostate cancer:
• Most common cancer in adult
males next to lung Cancer.
• Risk: age, familial, black,
smoking, high saturated fats
in diet.
• DHT is mediator.
 Findings:
•Obstructive uropathy, back
pain, alkaline phosphatase is
increased, spinal cord
compression.
 Diagnosis:
• Screening (DRE/PSA).
 Confirmation:
• Needle biopsy.
 Spreads to:
• Lungs, liver.
 Erectile dysfunction:
• Psychogenic, decreased
testosterone, vascular
insufficiency, neurologic
disease (defect in
parasympathetic S2-S4
(erection) or sympathetic
T12-L1 (ejaculation)), drugs,
endocrine disease, penis
disorders.
 Treatment:
• Sildenafil (Viagra); Yohimbe.
 Cervical cancer:
• Uncommon.
 NLE POINTERS
• Detected early: CIN and Pap.
• Risk: Early age for having
sex, multiple sex partners,
smoking, oral contraceptives,
HPV, immunodeficiency.
• Findings: Malodorous
discharge; postcoital
bleeding.
• Distant metastasis.
• CIN I: mild.
• CIN II: moderate.
• CIN III: severe.
 Oral contraceptive pills:
• Estrogen + progesterone.
• Estrogen: prevents mid-cycle
estrogen surge.
• Progesterone: inhibit LH.
• Hostility to sperm.
 Changes during pregnancy:
• Increased plasma volume and
RBC mass.
• Respiratory alkalosis.
• Increased serum thyroxine
and cortisol.
 Menopause:
• Increased FSH, LH;
decreased estrogen and
progesterone.
• Secondary amenorrhea, hot
flushes, night sweats.
 Increased testosterone (ovaries) or
increased DHEA-sulfate (adrenal
origin) cause:
• Hirsutism or virilization.
 Endometriosis:
• Glands and stroma located
outside uterus.
 Locations:
• Most common is ovaries.
Road to Success by: JONAS MARVIN ANAQUE
 Findings:
• Dysmenorrhea, painful
menses, intestinal
obstruction, ectopic
pregnancy, enlarged ovaries.
 Treatment:
• Laparoscopy.
 Fallopian Tube Disorders:
 Pelvic Inflammatory Disease:
• Causes: N. gonorrhoeae or C.
trachomatis.
• Gives rise to hydrosalpinx.
• Complication: oophoritis.
 Ectopic Pregnancy:
 Causes:
• Most common cause is
scarring from previous PID;
endometriosis, altered tubal
motility, SIN.
 Findings:
• Pain, bleeding, adnexal mass,
hypovolemic shock.
 Complications:
• Rupture, hematosalpinx.
 Diagnosis:
• Beta-hCG, ultrasound,
laparoscopy.
 Placenta previa:
• Implantation over cervical os;
bleeding, painless.
 Abruptio placentae:
• Premature placental
separation; due to smoking,
cocaine, hypertension,
advanced age.
 NLE POINTERS
 Preeclampsia/eclampsia:
• Toxemia of pregnancy.
• Abnormal placentation.
• Decreased natural
vasodilators.
• Increased vasoconstrictors.
• Premature aging of placenta.
• Infarctions, atherosclerosis of
spiral arteries.
 DOC: Mg SO4
 Findings:
• Hypertension, proteinuria,
edema, seizures, renal and
liver disease, HELLP
syndrome.
 Hydatidiform moles:
• Benign tumor of chorionic
villus.
• Neoplastic placenta.
• 46XX.
• Findings: preeclampsia, large
uterus, increased hCG;
snowstorm appearance on
ultrasound.
 DOC: Methotreaxate same with
ectopic
 Choriocarcinoma:most dreaded
complication of h mole
• Malignant tumor made of
syncytiotrophoblast and
cytotrophoblast.
• Spreads to: lungs, vagina;
lesions are hemorrhagic.
 Treatment:
 Chemotherapy.
 Breast cancer:
• Mean age: 64 years old.
• Family history, genetics.
• AD disease.
Road to Success by: JONAS MARVIN ANAQUE
• BRCA1 and BRCA2.
• Li-Fraumeni syndrome:
inactivated TP53 suppressor.
• RAS, ERBB2, RB
suppressor.
• Due to: prolonged estrogen
exposure; smoking, radiation,
endometrial cancer.
• Painless mass.
• Skin, nipple retraction.
 •BSE – SUPINE 7 days after
menstruation
 Mammography: screening; cannot
differentiate benign from malignant.
• Spreading: first by
lymphatics, then
hematogenously.
• Spreads to: lungs, bone, liver,
brain, ovaries.
• Treatment: radical
mastectomy; damage to long
thoracic nerve causes
winged-scapula;
lumpectomy; radiation.
 Breast cancer in men:
• BRCA2 mutated;
Klinefelter's syndrome.
• Poor prognosis.
 Atelectasis:
 Resorption atelectasis:
•
Collapsed lung.
•
Air doesn't reach alveoli.
•
Caused due to: mucus,
foreign material,
bronchogenic carcinoma.
• Fever, dyspnea.
• Absent breath sounds.
• Ipsilateral elevation of
diaphragm, and tracheal
deviation.
 Pulmonary edema:
• Altered Starling pressure.
 NLE POINTERS
• Increased hydrostatic;
decreased oncotic pressure.
• Infections, drugs, aspiration,
high-altitude.
 Acute respiratory distress
syndrome:
•
Pulmonary edema due to
alveolar-capillary damage.
• Caused by: sepsis, gastric
aspiration, trauma/shock,
infections, smoke, heroin.
• Cyokines released; leakage of
protein-rich exudate;
decreased surfactant.
 Pneumonia:
 Pulmonary infections:
 Community acquired pneumonia:
•Often due to S. pneumoniae.
•Acute bronchitis; lung has
areas of consolidation.
 Lobar pneumonia:
•
Complete consolidation of
lobe.
• Complications: lung
abscesses, empyema, sepsis.
• Findings: fever, cough,
positive Gram stain,
leukocytosis.
 Community-acquired pneumonia:
•M. pneumoniae.
•C. pneumoniae.
•C. trachomatis.
•RSV, influenzavirus,
adenovirus.
• Insidious onset; fever,
productive cough.
• Flu-like symptoms.
• No consolidation.
 Nosocomial pneumonia:
Road to Success by: JONAS MARVIN ANAQUE
• Severe underlying disease.
• Antibiotic therapy.
• Immunosuppression.
 In immunocompromised hosts:
• AIDS, bone marrow
transplants.
• CMV; P. jiroveci; A.
fumigatus.
 Tuberculosis:
• M. tuberculosis.
• PPD test.
• Primary and secondary
(reactivation) TB.
• Fever, night sweats, weight
loss.
• Miliary spread within lungs
and extrapulmonary sites.
• Granulomatous hepatitis;
Pott's disease (vertebra).
 Silicosis:
• Quartz dust inhaled.
 Emphysema:
• Enlargement of respiratory
unit.
• Causes: smoking, AAT
deficiency.
• Increased compliance;
decreased elasticity.
• Centriacinar emphysema:
common in smokers; upper
lobes.
• Panacinar emphysema: AAT
deficiency; AD disease;
lower lobes.
• Pink puffers; dyspnea and
hyperventilation.
 Chronic bronchitis:
• Productive cough for 2
months - 3 years.
• Smoking, cystic fibrosis.
 NLE POINTERS
•
Hypersecretion of mucus
from bronchi.
• Acute inflammation.
• Dyspnea.
• Cyanosis of skin.
• Blue bloaters; stocky
patients.
• Cor pulmonale (hypertrophy
of right ventricle due to lung
disease).
• Respiratory acidosis.
 Asthma:
• Episodic and reversible
airway disease.
 Extrinsic asthma:
• Type I hypersensitivity; CD4
Th2 cells;
bronchoconstriction, mucus
production, influx of
leukocytes.
• IL4 = isotype switching to
IgE production.
• IL5 = production and
activation of neutrophils.
• Histamine released.
• Late phase reaction: eotaxin
produced; eosinophils cause
airway constriction.
• Charcot-Leyden crystals in
terminal bronchioles.
• Expiratory wheezing,
nocturnal cough, increased
anteriorposterior diameter.
 Intrinsic asthma:
• Non-immune.
• Caused by viral infections,
air-pollutants, drug-
sensitivity, stress, exercise,
smoking.
 Bronchiectasis:
Road to Success by: JONAS MARVIN ANAQUE
• Permanent dilation of bronchi
and bronchioles.
• Cartilage and elastic tissue
destruction.
• Causes: CF, TB, bronchial
obstruction, primary ciliary
dyskinesia.
• Lower lobes.
• Productive cough; copious
sputum.
 Cystic fibrosis:
• AR disease.
• Three nucleotide deletion on
chromosome 7.
• Defective CFTR for chloride
ions.
• Increased Na/Cl in sweat,
causing dehydration.
• Nasal polyps, respiratory
infections and failure.
• Malabsorption.
• Type 1 diabetes mellitus.
• Male infertility.
 Lung tumors:
• Most common cancers:
adenocarcinoma; weak
smoking association.
 Association with smoking:
• Squamous cell carcinoma;
small cell lung carcinoma.
 Metastatic lung cancer:
• Most common.
• Primary site: breast.
• Secondary site: colon, renal.
• Dyspnea.
• Cough, hemoptysis, weight
loss, chest pain.
• Pancoast tumor: Horner's
syndrome.
• Superior vena cava
syndrome.
 NLE POINTERS
 Metastasis sites:
• Most common: hilar nodes.
• Also spreads to adrenal
glands, liver.
 Mediastinal masses:
• Commonly: neurogenic
tumors.
• Thymoma: located in anterior
mediastinum.
 Pleural fluid:
• Moves from parietal pleura to
pleural space to lungs.
 Plural effusion:
• Movement of fluid from
lymphatic vessels into
pulmonary tissue.
 Causes:
•Increased hydrostatic
pressure, decreased oncotic
pressure, lymphatic
obstruction, increased vessel
permeability, metastasis to
pleura.
 Transudate:
•Ultrafiltrate; disturbed
Starling pressures;
protein/serum less than 0.5.
 Exudate:
• Protein-rich, and cell-rich
fluid; pneumonia, infarction,
metastasis; protein/serum
greater than 0.5.
 Spontaneous pneumothorax:
• Idiopathic; hole in pleura.
• Pleural hole.
• Pleural cavity pressure =
atmospheric pressure.
• Trachea deviates to side of
pneumothorax.
Road to Success by: JONAS MARVIN ANAQUE
• Sudden dyspnea, chest pain.
 Tension pneumothorax:
• Ruptured tension
pneumatocysts.
• Trauma to lungs; knife
wound.
• Increased pleural cavity
pressure; compression
atelectasis.
• Absent breath sounds.
• Trachea and mediastinal
structures deviate to opposite
side.
 Treatment:
•Insert needle into pleural
cavity to relieve pressure.
 Syndrome of Inappropriate ADH
(SIADH):
• Causes: small cell carcinoma
of lung, CNS injury, drugs,
pulmonary infections.
• Findings: mental status
dysfunction, hyponatremia.
• Restrict water intake.
 Thyroid gland disorders:
 Function tests:
•Total serum T4:
•Represents bound (to TBG)
and unbound serum T4.
• Increased TBG synthesis
increases T4 and vice versa.
 Serum TSH:
• Best indicator of thyroid
function.
• Increased TSH: primary
hypothyroidism.
• Decreased TSH:
thyrotoxicosis (Grave's
disease); hypopituitarism.
 I-131 uptake:
 NLE POINTERS
•Indicates synthetic activity of
thyroid.
• Increased I-131 uptake:
increased T4 synthesis; also,
hot nodule / goiter.
• Decreased I-131 uptake:
decreased gland activity; also
cold nodule / cancer.
 Thyroglobulin:
• Thyroid marker.
 Hypothyroidism:
 Causes:
• Hashimoto's thyroiditis,
cretinism.
 Findings:
• Weight gain, fatigue, cold
intolerance, constipation,
hypertension, muscular
myopathy.
 Lab findings:
• Decreased T4, increased
TSH; antimicrosomal and
antithyroglobulin antibodies,
hypercholesterolemia.
 Treatment:
• Levothyroxine.
 Excess thyroid hormone:
• Due to: thyrotoxicosis and
hyperthyroidism.
 Findings:
• Increased BMR.
 Graves' disease:
• HLA-Dr3; IgG against TSH
receptor.
• Hyperthyroidism and
thyrotoxicosis.
Road to Success by: JONAS MARVIN ANAQUE
 Findings:
• Exophthalmos, pretibial
myxedema.
 Plummer's disease:
• Goiter.
 Thyrotoxicosis: findings:
• Weight loss, fine hand
tremor, heat intolerance,
diarrhea, anxiety, lid stare,
tachycardia, atrial fibrillation,
hypertension, HF.
 Lab findings:
•Increased T4, decreased TSH.
•Increased I-131 uptake in
Graves' disease and goiter.
• Decreased I-131 uptake in
thyroiditis and patients taking
excess thyroid hormone.
• Hyperglycemia,
hypocholesterolemia,
hypercalcemia,
lymphocytosis.
 Treatment of Graves' disease:
• Beta-blockers; thionamides.
 Nontoxic goiter:
• Enlargement from excess
colloid.
• Deficiency of thyroid
hormone.
• Hyperplasia/hypertrophy.
• Treatment: levothyroxine.
 Types of goiters:
 Endemic:
• Iodide deficiency.
 Sporadic:
• Goitrogens (eg., cabbage),
enzyme deficiency, puberty,
pregnancy.
 NLE POINTERS
 Thyroid tumors:
• Follicular adenoma: most
common benign tumor.
• Papillary adenocarcinoma:
radiation exposure; female
dominant; Orphan-Annie
nuclei; spreads to cervical
nodes, lungs.
• Follicular carcinoma: most
common female dominant
thyroid cancer; spreads to
lungs and bone.
• Medullary carcinoma: MEN
IIa/IIb.
 Parathyroid gland disorders:
 Hypoparathyroidism:
•Hypocalcemia.
•Causes: surgery,
autoimmune, DiGeorge
syndrome, hypomagnesemia.
• Findings: tetany, basal
ganglia calcification,
cataracts.
• Lab: hypocalcemia,
hyperphosphatemia,
decreased PTH.
 Primary hyperparathyroidism
(HPTH):
• Common cause of
hypercalcemia.
• MEN I/IIa association.
 Causes:
• Adenoma.
• Primary hyperplasia.
• Carcinoma.
 Findings:
• Calcium stones, peptic ulcers,
acute pancreatitis,
constipation, osteitis fibrosa
cystica (salt and pepper
Road to Success by: JONAS MARVIN ANAQUE
appearance of skul),
hypertension.
 Lab:
• Increased PTH, Ca;
decreased Ph; normal anion
gap metabolic acidosis.
 Diagnosis:
• Technetium-99-m-sestamibi
radionuclide scan.
 Treatment:
• Surgically remove adenoma.
 Parathyroid gland disorders:
secondary hyperparathyroidism:
• Hyperplasia of all
parathyroid glands.
• Decreased Ca; increased
PTH.
 Adrenal Gland Disorders:
 Hypofunction:
 Acute adrenocortical insufficiency:
• Causes: Waterhouse-
Friderichsen syndrome (N.
meningitides, DIC, adrenal
hemorrhage).
 Chronic Addison's disease:
• Autoimmune.
• Tuberculosis/histoplasmosis.
• Adrenogenital symdrome.
• Metastasis.
• Findings: weakness,
hypotension,
hyperpigmentation.
 Lab:
• ACTH test shows no increase
in cortisol or 17-OH.
• Metyrapone test: increased
ACTH only.
 NLE POINTERS
•Increased plasma ACTH.
•Hyponatremia, hyperkalemia,
metabolic acidosis.
• Fasting hypoglycemia.
• Eosinophilia, lymphocytosis,
neutropenia.
 Hyperaldosteronism:
 Primary:
• AKA Conn's syndrome.
• Findings: Hypertension,
muscle weakness, tetany,
metabolic acidosis.
• Labs: hypernatremia,
hypokalemia, metabolic
alkalosis, decreased plasma
rennin.
 Secondary:
• Compensatory reaction to
decreased cardiac output.
• Increased plasma rennin.
• Activated rennin-angiotensin-
aldosterone system.
 Pheochromocytoma:
• Unilateral, benign adenoma.
• N-methyltransferase converts
NOR to EPI.
• Characteristics: brown,
hemorrhagic, necrotic.
• Findings: hypertension,
palpitations, anxiety, sweats,
headache, chest pain.
• Labs: increased urine VMA
and metanephrine,
hyperglycemia, neutrophilic
leukocytosis.
 Diabetes mellitus:
 Causes:
• Pancreatic, endocrine, or
genetic disease; insulin-
Road to Success by: JONAS MARVIN ANAQUE
receptor deficiency;
infections; impaired glucose
tolerance; gestational
diabetes mellitus.
• Younger patients.
• AD inheritance.
• HLA-DR3 and HLA-DR4
genetic associations.
 Syndrome X:
• Insulin resistance.
• Hyperinsulinemia: increased
VLDL, hypertension,
coronary artery disease.
 Pathology:
• Poor glycemic control:
hyperglycemia.
• Nonenzymatic glycosylation:
combination of glucose with
proteins.
• Osmotic damage: damage to
tissue, retina, vessels.
• Diabetic microangiopathy:
decreased type IV collagen
synthesis.
 Findings:
• Hypoglycemia.
• Diabetic ketoacidosis.
• Hypertriglyceridemia.
• Muscle wasting.
• Labs: hyperglycemia,
hyponaremia, hyperkalemia,
increased anion gap
metabolic acidosis, prerenal
azotemia.
 Gestational diabetes:
• Diabetes of pregnancy due to
anti-insulin effect of human
placental lactogen and
increased placental size.
 NLE POINTERS
• Risk to newborns:
macrosomia, RDS, neural
tube defects, hypoglycemia.
 Hypoglycemia:
 Reactive type:
 Causes:
• Insulin treatment for type 1
diabetes.
• IGT or type 2 diabetes.
• Idiopathic postprandial
syndrome.
 Findings:
• Sweating, trembling, anxiety.
 Fasting type:
 Causes:
• Alcohol, renal failure,
malnutrition, liver disease,
insulinoma, hypopituitarism,
ketotic hypoglycemia in
childhood.
 Findings:
• Dizziness, confusion,
headache, lack of
concentration, motor
disturbances, seizures, coma.
 Reye syndrome:
• Children younger than 4
years.
• Follows chickenpox or
influenza infection.
• Mitochondrial damage.
• Encephalopathy
hepatomegaly.
• Transaminasemia, increased
bilirubin and ammonia.
Road to Success by: JONAS MARVIN ANAQUE
 Preeclampsia:
• Hypertension, proteinuria,
pitting edema during 3rd
trimester of pregnancy.
• HELLP syndrome; hemolytic
anemia, elevated
transanimases, low platelets.
 Fulminant hepatic failure:
 Causes:
• Viral, drugs, Reye syndrome.
 Findings:
• Encephalopathy.
• Decreased transaminases;
increased PT and ammonia.
 Prehepatic obstruction of blood
flow:
• Blood doesn't flow to liver.
• Hepatic artery thrombosis;
transplant rejection;
vasculitis.
• Portal vein thrombosis;
pylephlebitis, polycythemia
vera, carcinoma.
 Intrahepatic obstruction of blood
flow:
• No sinusoidal blood flow;
cirrhosis.
• Centrilobular hemorrhagic
necrosis; LHF, RHF.
• Nutmeg liver.
• Pain, increased
transaminases.
 Liver cirrhosis:
• Liver fibrosis + formation of
regenerative nodules.
• Compressed hepatic arteries
and veins.
 Causes:
 NLE POINTERS
• Alcohol, viral, autoimmune,
metabolic disease.
 Complications:
 Hepatic failure:
• Hypoalbuminemia, hepatic
encephalopathy, portal
hypertension, ascites,
hepatorenal syndrome,
hyperestrinism in males.
 Primary biliary cirrhosis:
• Autoimmune disorder.
• Destruction of bile ducts and
portal triads.
• Pruritis, hepatomegaly,
jaundice.
• Antimicrobial antibodies,
increased IgM.
 Hereditary hemochromatosis:
• AR disease.
• Unrestricted reabsorption of
iron in SI.
• Iron deposits in organs.
• Bronze diabetes.
• Type I diabetes mellitus.
• Malabsorption.
• Cardiomyopathy, joint
degeneration.
• Increased iron, ferritin, TIBC.
 Wilson's disease:
• AR disorder.
• Decreased ceruplasmin
synthesis.
• Increased serum copper;
increased copper in urine.
• Kayser-Fleischer ring.
 Alpha-antitrypsin deficiency:
• AD disease.
• Accumulation of Alpha-
antitrypsin in hepatocytes
causing liver damage.
Road to Success by: JONAS MARVIN ANAQUE
• Hepatitis.
 Laboratory confirmation of
cirrhosis:
• Increased BUN,
hypoglycemia, respiratory
alkalosis, lactic acidosis,
increased PT, hypocalcemia.
 Liver tumors: Benign:
 Cavernous hemangioma:
• Most common.
 Liver cell adenoma:
• Women of child-bearing age.
 Liver tumors: Malignant:
• Metastasis: most common
cancer.
 Heptocellular carcinoma:
• Most common.
• HBV, HCV.
• Focal, muitifocal, infiltrating
cancer.
• Portal and hepatic vein
invasion.
• Fever, enlargement of liver,
ascites.
• Increased AFP; ectopic
production of erythropoietin
and insulin-like factor.
• Spreads to lungs.
 Gallstones (cholelithiasis):
•Most are cholesterol stones.
•Supersaturation of bile with
cholesterol.
• Female, fat, forties; oral
contraceptives, rapid weight
loss.
 Acute pancreatitis:
• Alcohol, gallstones.
 NLE POINTERS
•Activated pancreatic
proenzymes.
• Trypsin plays a role in
activating enzymes.
• Fever, nausea, vomiting,
midepigastric pain radiating
to back, shock, hypoxemia,
Grey-Turner's sign (flank
hemorrhage), Cullen's sign
(periumbilical hemorrhage),
tetany.
• Increased pancreatic amylase,
lipase; neutrophilic
leukocytosis, hypocalcemia,
hyperglycemia.
• Complications: pancreatic
pseudocyst, ARDS,
pancreatic abscess, DIC.
 Chronic pancreatitis:
•Idiopathic.
•Alcohol, Cystic Fibrosis,
malnutrition.
• Repeated attacks of acute
pancreatitis, calcification of
ducts.
• Pain, malabsorption, type 1
diabetes mellitus, pancreatic
pseudocyst.
• Increased lipase, amylase.
 Exocrine pancreatic cancer:
• Smoking, pancreatiris.
• Activated K-RAS gene;
mutant TP16 and TP53
genes.
• Jaundice, epigastric pain,
weight loss, light-colored
stools.
• Increased CA19-9.
• Poor prognosis.
 Kwashiorkor:
• Inadequate protein intake.
• Too much carbohydrate
intake.
Road to Success by: JONAS MARVIN ANAQUE
• Pitting edema; ascites.
• Fatty liver.
• Diarrhea.
• Anemia; deficient immunity.
 Marasmus:
• Inadequate intake of protein
and other food.
• Muscle wasting.
• Growth retardation; anemia;
deficient immunity.
 Anorexia nervosa:
• Self-induced starvation.
• Distorted body-image.
• Amenorrhea; osteoporosis;
lanugo; increased stress
hormones (cortisol, GH, etc.).
 Bulimia nervosa:
• Binging with self-induced
vomiting.
 Obesity:
• BMI over 30 kg/m2.
• Excess fat on waist is more
harmful.
• Genetic predisposition: 50-
80%.
• Defective leptin gene;
syndrome X.
 Obesity causes:
• Depression, cancer, diabetes
mellitus 2, hypertension,
obstructive sleep apnea, and
more.
 Transplantation immunology:
• ABO blood group
compatibility.
• Best chance of success with
matching HLA-A,-B,-D loci.
 Rejection reactions:
 Hyperacute:
 NLE POINTERS
• Recipient ABO
incompatibility or preformed
anti-HLA antibodies react
against donor.
• Type II hypersensitivity
reaction.
• Eg., blood group A person
receives blood group B heart.
 Acute:
• Type IV: CD4 T cells activate
macrophages; CD8
proliferation; donor-graft
destruction.
• antibody-mediated type II
hypersensitivity reaction:
CD4 T cells activate B-cells.
 Treatment:
• Immunosupressive agents;
risk for cervical squamous
cell cancer, malignant
lymphoma, squamous cell
carcinoma of skin.
 Chronic:
• Irreversible reaction that
occurs over months to years.
 Graft-vs-host reaction:
• Donor T cells activate host
CD4/8 T cells.
• Bile duct necrosis, jaundice,
diarrhea, dermatitis.
 Systemic lupus erythematous
(SLE):
• Child-bearing age.
• B-cell activation after
exposure to certain triggers
(eg., procainamide).
• Affects: blood, lymph nodes,
joints, skin, heart, lungs, and
kidneys.
Road to Success by: JONAS MARVIN ANAQUE
• IgG anti-SS-A (Ro)
antibodies cross placenta and
cause neonatal heart block.
 Drug-induced SLE:
• Procainamide, and
hydrazaline.
• Findings: Anti-histone
antibodies; low CNS and
renal involvement.
 Lab findings in SLE:
• ANA in almost all cases.
• Anti-dsDNA antibodies and
anti-Sm antibodies: very
specific.
• Anti-Ro antibodies.
• Anti-phospholipid antibodies:
vessel damage and
thrombosis.
• Anti-cardiolipin antibodies:
may generate false-positive
syphilis test.
 Systemic sclerosis (scleroderma):
• Small vessel endothelial
damage; ischemic injury.
• Excess cytokines cause
excess collagen synthesis.
• Raynaud's phenomenon.
• Tightened facial features;
also affects GI, lungs,
kidneys.
• Calcification of subcutaneous
tissue, dysphagia, esophageal
reflux.
• Lungs, kidneys also affected.
• Serum ANA +.
• Anti-topoisomerase antibody.
• Anti-centromere antibodies.
• CREST syndrome.
 AIDS:
• RNA retrovirus.
• HIV 1: US.
 NLE POINTERS
• HIV 2: developing countries.
• HIV envelope protein gp120
attaches to CD4 T-cell.
• Infects all APCs.
• Macrophages and dendritic
cells are reservoirs for the
virus.
 Tests:
•ELISA (screening), Western
blot (confirmatory test), p24
antigen (indicates active viral
replication).
 Phases:
• Acute, latent, early
symptomatic.
• CD4 T-cell count less than
200 cells/mL.
• Most common infection:
cryptococcosis.
 Leading causes of disease:
• Alcohol and tobacco.
 Tobacco use causes:
• CV disease, lung cancer,
stroke.
• Nicotine is the most addictive
substance in tobacco.
• This also includes chewing
tobacco and second-hand
(passive) smoke.
 Alcohol use:
• Stomach absorption.
• Metabolism in liver and
stomach.
• Alcohol dehydrogenase is the
rate-limiting metabolism
enzyme.
Road to Success by: JONAS MARVIN ANAQUE
 Products of alcohol metabolism:
• Reduced NADH.
• Acetyl CoA.
• Alcohol induction of
cytochrome P-450 increases
alcohol metabolism,
increasing tolerance.
• Females have less gastric
alcohol dehydrogenase.
 Lab findings in alcohol abuse:
• Fasting hypoglycemia:
pyruvate, which is a substrate
for gluconeogenesis, is
converted to lactate.
• Increased anion gap
metabolic acidosis.
• Other findings:
Hyperuricemia,
hypertriglyceridemia, AST
greater than ALT, increased
GGT.
 Other drugs:
 Cocaine:
• Stimulant; mydriasis,
tachycardia, hypertension,
AMI, CNS infarction.
 Heroin:
• Opiate; miotic pupils,
frothing at mouth, nephrotic
syndrome.
 Marijuana:
 NLE POINTERS
• Stimulant; red conjunctiva,
euphoria, delayed reaction
time.
 Complications of IV drug abuse:
• Hepatitis B, HIV, tetanus,
infective endocarditis.
 Overall effects of drugs:
• Cerebral atrophy; damaged
neurotransmitter sites.
 Adverse effects of certain
medications:
 Acetaminophen:
• Damage to liver and kidneys;
production of free radicals.
 Aspirin (also known as
acetylsalicylic acid or salicylate)
overdose:
• Tinnitus, vertigo, altered
mental status, tachypnea,
respiratory alkalosis,
metabolic acidosis with
increased anion gap,
hyperthermia, hemorrhagic
gastritis, fulminant hepatitis.
 Exogenous use of estrogen without
progesterone:
• Cancer, venous
thromboembolism,
intrahepatic cholestasis with
jaundice, myocardial
infarction, stroke.
 Use of oral contraceptives:
• Cancer, venous
thromboembolism, folate
deficiency, hypertension,
hepatic adenoma, intrahepatic
Road to Success by: JONAS MARVIN ANAQUE
cholestasis with jaundice,
cholesterol gallstones.
 Burns
 RACEEE and PASS
 R - RESCUE /REMOVE anyone in
immediate danger
A - Activate the Manual Fire
ALARM
C - CONFINE the fire (close the
door)
E - EXTINGUISH small controllable
fires/or
E- EXIT
E-EVACUATE

P - PULL the pin
A - AIM the nozzle at the base of the
fire
S - SQUEEZE handle
S – SWEEP from side to side
 **** IMPORTANT NOTES:
R - Rescue
Move patients and assist visitors or
impaired employees away from
immediate danger of fire or smoke IF
YOU CAN DO THIS WITHOUT
PUTTING YOURSELF IN
IMMEDIATE DANGER and IF
THERE ARE OTHER STAFF
AVAILABLE TO COMMUNICATE
THE EMERGENCY AND TURN IN
THE ALARM.
 A - Alert others
Activate manual pull station alarm as
soon as possible. Call #6688 and
state the location, type of fire and
size. Notify co-workers - and make
sure everybody in the area, and in
other departments in your area, know
as well.
 C - Confine
Close all doors and windows. Pack
sheets and towels under doors to
 NLE POINTERS
contain smoke.
If there is oxygen in the area:
Oxygen to a patient can be shut off
by a nurse at the bedside after other
staff have the patient and are
ventilating them.
Oxygen to a zone (a whole unit) can
ONLY be shut off by Maintenance
and Engineering after nursing staff
authorize it (patients on oxygen are
cared for).
Oxygen to the building is only shut
off after the Fire Marshal orders it
and after nursing staff authorize it
(patients on oxygen are cared for).
 E - Extinguish
Select the appropriate fire
extinguisher. Use the P-A-S-S
technique to extinguisher the fire.
(see below for P-A-S-S technique)
 E - Find the EXIT then Evacuate
 "R"- RESCUE/REMOVE:
 *Rescuing patients is every
healthcare worker's primary
concern and is usually performed
simultaneously with activating the
alarm
• Rescue/remove critically ill
patients in their beds.
• Ambulatory patients may
walk to safety on their own
with supervision. •
Rescue/remove semi-
ambulatory patients first,
then non-ambulatory
patients.
 NEVER attempt to enter a room
where a fire is contained without
FIRST checking to see if the door
is warm or hot to the touch.
Road to Success by: JONAS MARVIN ANAQUE
 NEVER open a door if it is hot to
the touch.
 Familiarize yourself with the
institution's policy.
 Some may use additional processes
including, but not limited to: (1)
placing a pillow on the floor outside
the door to signify the room is
empty;
 (2) placing a wet towel along the
bottom of the closed door to prevent
smoke from escaping, if the fire
started in this room; or
 (3) placing a towel on the door
handle to a room where a non-
ambulatory patient remains (not
evacuated).
 Evacuation
 **Horizontal evacuation, which is
the type of evacuation used first,
consists of moving patients down the
corridor, through at least one set of
fire doors to safe area.
 **Vertical evacuation consists of
moving patients down the stairs to a
lower level of safety and ultimately
out of the building.
• NEVER use elevators to
evacuate a fire area.
• Evacuate ambulatory patients
before non-ambulatory
patients.
• Move patient charts with
patients. ALL healthcare
workers must know primary
 NLE POINTERS
and secondary safe areas and
route of evacuation.
 "A"- Alarm: Should you see smoke
or flames, use the fire emergency
call box or pull station. Dial the
institution's emergency number and
give the page operator your name,
the phone number you are calling
from, exact location (building, floor
and room or office number), and
state what you are reporting (sight or
smell of smoke, or sight of fire and
location).
 ***If you discover smoke or flames
in an occupied patient room, call out
to a co-worker to call the emergency
number and activate the fire call
box/pull station while you rescue the
patient.
 Whenever you hear a fire alert, listen
for the building location of the fire
emergency.
• Do not use elevators. Only
use the stairs.
• Close all doors. Reassure all
patients, and visitors.
 If you need to re-open a door, make
sure it is closes and latches securely
behind you.
• Listen for the all-clear code.
You may then resume your
normal activity. Once the fire
emergency has been cleared
you will be notified.
 "C"- Confine/Contain: Fire, smoke
and toxic combustion products must
be confined to the area where the fire
started as much as possible. Closing
Road to Success by: JONAS MARVIN ANAQUE
doors and windows can prevent the
smoke from spreading, cut off the
flow of oxygen to the fire and save
lives. Confine the fire as long as no
one is in danger. Never open a door
if it is hot to the touch. Keep fire
doors closed and automatically
closing fire doors, corridors and
stairwells free of obstructions.
 "E"- Extinguish: Handheld fire
extinguishers (of the appropriate
classification for the type of hazard
likely to occur in the area) are
located throughout the Institution.
 **The most commonly used fire
extinguisher is the ABC type and it
can be used for most types of fires. If
a specialty extinguisher is required in
a particular area, you will be oriented
to its use.
 Never use water on grease or
electrical fires.
 **You should attempt to extinguish
only small, contained fires (no larger
than a waste basket), where your
safety is assured, you have an escape
route behind you, and a staff member
or other healthcare worker is
available to assist.
 The rescuing of those in immediate
danger,.sounding the alarm, and
confining fire and smoke should be
accomplished by other staff members
or healthcare workers. Even if you
extinguish the fire, the fire should
still be reported by. All fire
extinguishers operate in the same
way-
 "P.A.S.S." (Pull, Aim, Squeeze and
Sweep).
 NLE POINTERS
 "P"- Pull: Pull the pin from the fire
extinguisher handle at the top of the
fire extinguisher. (Remember not to
squeeze handles when removing the
pin.)
 "A"- Aim: Take 3 steps back and
then aim the horn or hose at the base
of the fire, not at the smoke or
flames. You want to be about 8 to 10
feet away from the fire.
 "S"- Squeeze: Squeeze the top
handle to the bottom handle to
discharge the extinguishing agent.
"S"- Sweep: Sweep the nozzle from
side to side across base of the fire.
 *log roll yourself when you are in
fire
 The principles of STOP, DROP, and
ROLL are simple
 Stop, do not run, if your clothes
catch on fire.
Drop to the floor in a prone position.
Cover your face with your hands to
protect it from the flames.
Roll over and over to smother the
fire. Don't stop until the flames
have been extinguished.
 If you are near someone whose
clothing catches on fire, be sure to
stop
them from running and make them
STOP, DROP, and ROLL.
 First-degree:
• Eg., sunburn; heal without
scarring.
Road to Success by: JONAS MARVIN ANAQUE
 Second-degree:
• Blister formation; usually
heal without scarring.
 Third-degree:
• Painless; full thickness burns.
• Scarring is inevitable.
• Keloids and potential for
developing squamous cell
carcinoma.
 P. aeruginosa
• Infection is common in burn
victims.
 .
 Ionizing radiation injury:
• Most sensitive tissues:
lymphoid, bone marrow,
mucosa of GI tract; germinal
tissue.
 Iron-overload disorders:
• Hemochromatosis and
hemosiderosis.
 Give desferal or deferoxamine.
 Acute leukemia:
• Fever, bleeding, fatigue.
• Bone pain, tenderness.
• Anemia, thrombocytopenia.
• Metastatic disease: liver,
CNS, lymph nodes, skin.
 Chronic leukemia:
• Insidious onset.
• Involved: liver, lymph nodes.
• Thrombocytopenia, anemia.
 Chronic lymphocytic leukemia:
 NLE POINTERS
• Over 60 years of age.  Preparedness Disaster &
• "Smudge cells." Management
• Most common leukemia.
• Lymphadenopathy.  Onco-
• Immune hemolytic anemia.
• Neutropenia.  Triage

 Prof Adjustment

 Hodgkin's Lymphoma:  LMR

• EBV association. Leadership Style
• Reed-Sternberg cells;
Research
CD15/CD30 positive; two
mirror image nuclei. Assisting patient in commode
• Reactive cells: eosinophils,  Assisting client under maintatinance
plasma cells, drug for hypertension
• Fever, weight loss, night  S/E of antihypertension
sweats.  Lead Poisoning
• Anemia.  Ampule dosage computation
 IV – priming
• Painless enlargement of
 IVF types
single group of lymph nodes;  Blood expanders – PLRS , crystalloids
cervical, supraclavicular,  Normal assessment of newborn
anterior mediastinal  Delegations
 Autonomy
– INTEGRATED POINTERS  Beneficence
 Misfeasance
 Heat exhaustion and stroke  Malpractice & negligence
 Bed Making
 Massage purposes
 Code of ethics
 LGU – Devolution code – RA 7160-
 DRUG COMPUTATION
Local Government Code  BT
 blood products computation,
 Leptospirosis
 Sputum culture
 Immunization  CVA,
 M.I
 3 vaccine with 3 doses – Dpt , OPV,  CARE WITH THE ELDERLY WITH
Hep. B INCONTINENCE
 CATHERIZATION
 Needs dilluent – bcg and AMV or  DROPLET PRECAUTION
measles  HIV/AIDS
 COLOSTOMY CARE
 6 weeks baby must receive – Penta 1,  RESEARCH
PCV1,OPV1  TRACHEOSTOMY CARE
 NUTRITION -GAVAGE FEEDING
 Therapeutic communications BURNS

Road to Success by: JONAS MARVIN ANAQUE

 NLE POINTERS
 TBSA  AAA - Aneurysm
 IMCI  ANGINA –
 PCA  DM - INSULINS –
 APPLIED RESEARCH  SLE
 DABDA PROCESS  *POSITIONING in bleeding
 NANDA -madami din  Positioning Post op – cataract, and
 POSITIONING THORACENTESIS
mastectomy
 BLOOD PRODUCTS
 *ASPIRIN
 INFECTION CONTROL
 LUNG CANCER
 SHOCK MANAGEMENT
 SMOKING  BRACHYTHERAPY
 AML & ALL  CHEMO AND RADIATION
 THEORISTS  PERIOPERATIVE
 FAMILY PLANNING PROCEDURES AND
 PHARMACOLOGY –
 Z TRACK IRON – 10 mins hold PRINCIPLE
 Leopolds  BUCKS & BRYANTS
 Menstrual cycle phases and hormones  SKELETAL TRACTIONS
 IUD & Hmole  Depression
 •vaccine--is damage by heat –  SLE
 COPD – bronchitis
measles – brown vial
 •pillars of PHC
 Partograph  Therapeutic communications
 NORMAL ASSESSMENT OF  marijuana - -cannabis sativa
 CONFLICT management ,
NEWBORN  PTSD –
 TYPES OF BREASTMILK - colostrum  BULIMIA –
 PID-Pelvic inflammatory disease signs  Suicide precation
and symptoms and predisposing factors  ALZHEIMER'S –
 PARKINSON'S –
(Gonorrhea &clamydia)  ANTI DEPRESSANTS –
 Trichomoniasis  SEIZURE –
 Candidiasis/moniliasis  neurotransmitter –
 HPV - Condylomata  Mydriatics and miotics
 30cm fundic height = 35 weeks AOG  Atropine
 ZIKA

 CLIENTS WITH DYSPHAGIA  EBOLA and MERS and ZIKA,

 Reynauds , Measles, Cholera
 thromboangitis,
 thyroidectomy,  Blood Transfusion
 Chest physiotherapy
 Hyperkalemia
Newborn Assessment
 Heparin Copar
 GCS BMI computations
 Cushings syndrome, Burns -Rule of 9
 periop.onco –
 CHRONS –
DM, IIP, PTB, HPN,Arthritis,
 M.I – Asthma,Pneumonia

Road to Success by: JONAS MARVIN ANAQUE

 NLE POINTERS
Eye Ear Procedures  Emphysema
InSomnia
Phobia  Grieving process – DABDA
Assault and Battery  Parathyroidism
Beneficence,
Addiction slogan- “Jail the pusher  Hyperthyroidism
save the user “
 Sub Q is it 25-27
Nsg Delegation
Nsg process  Cotton balls in thermometer cleaning
Maslow of hierarchy
Peer problems  Herbal meds – niyog niyogan –
Erick Erickson Theory antihelmithic

 Emphysema
Crude Birth Rate
 Respiratory depression signs and
symptoms
BEMONC
 Positioning of client in bed
 Unang Yakap
 Condom counseling
 ImCI
 HIV
 IV computation
 defamation
 Autonomy
 DM
 Veracity
 IIP
 Code of ethics
 PTB
 Pacemaker
 HPN
 Abdominal aortic aneurism
 Arthritis
 Penylketonuria
 Asthma
 Ebola
 Pneumonia
 Perioperative nursing Eye

 Charting of drug administration  Ear Procedures

 Malnutrition signs and symptoms  InSomnia – provide milk

 Log rolling patient and its procedure  Phobia.

Road to Success by: JONAS MARVIN ANAQUE

 NLE POINTERS
 Abnormal blood bleeding
endometrial cancer
 Oxytocin hormones influences milk
let down reflex
 Libel
 Apnea – respiratory arrest
 Iron
 oxytocin emergency drug for
postpartum bleeding
 position of patient for bedpan
 postpartum mother position for
bleeding
 diagnosed with Diabetes - above 5.5
mmol/mol
 Normal: Below 42 mmol/mo
 Obese- Endomorph body
 For ID injection: needle size is ¼
-1/2 inch26-27 gauge
 Crede’s Prophylaxis – prevents
Gonorrhea and Chlamydia to baby
 little boy brought to health center. He
has a lot of anting-antings -Welcome
the mom & child to health center
 Generic Name of Dilantin? Answer:
Phenytoin
 Snake Bite First Aid: Check the
wound
 Condom catheter How to apply it:
spirally around the shaft of penis
Road to Success by: JONAS MARVIN ANAQUE
 Advantage over Foley Catheter
 source of Mers Cov Camel
 1st vaccine given at birth – Bcg
 Pink eye disease - Viral
conjunctivitis
 Who owns patient chart’? Answer:
hospital.
 Stages of COPAR.
 Stages of Conflict Management
 Rheumatic Fever infected mother –
delivery in semifowlers or sitting
position
 AIDS support group
 Arterial Blood Gases. Metabolic
Acidosis & Alkalosis. Compensated
VS uncompensated.
 Amphetamine/Cocaine overdose
 Seeing things Illusion falsely
 Hearing sounds - hallucination
 A teenage girl was raped. But she
wants to keep it from her parents. –
disclosed the information or divulge
and tell to the parents
 Affordable Rich in calcium –
Anchovies
 ADPIE process
 Tracheostomy care!
 charting,
 SOAPIE.
 NLE POINTERS
 Charting by exception, incident
report

 Heart. Hyperkalemia

 kidney failure – acid base imbalance

 Measles – SQ route (40-50 angle

degree)

 ECTOPIC – palpable adnexal mas

 H- mole – palpable mass are broad

and round

 PRC - The office who has the

custody of records of administrative
cases and investigations
 Note: that PRC fix the time and
place of examination
 Note: DECS or CHED has the power
to close Nursing schools

 Ratings - General average of at least

75%; With a rating of not below 60%
in any subject

 BON powers- to issue and, after due

investigation, suspend or revoke
certificates of registration

 replaces lost certificates of

registration - CBQ

Road to Success by: JONAS MARVIN ANAQUE