approach to. contents clinical evaluation history examination lab evaluation management
TRANSCRIPT
![Page 1: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/1.jpg)
Approach to
![Page 2: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/2.jpg)
Contents
Clinical Evaluation History
Examination
Lab Evaluation
Management
![Page 3: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/3.jpg)
Basics
Wakefulness depends on the integrity of both cerebral hemi- spheres and the ascending reticular activating formation of the brain stem.
![Page 4: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/4.jpg)
Cont..
The management of an unconscious patient is never an easy task in clinical practice
The duty of physician is Arrive at diagnosis Predict the eventual outcome
![Page 5: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/5.jpg)
![Page 6: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/6.jpg)
History
![Page 7: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/7.jpg)
i) Onset of coma (abrupt, gradual)
ii) Recent complaints ( headache, depression, focal weakness,
vertigo )
iii) Recent injury
iv) Previous medical illness ( diabetes,uraemia, heart disease )
v) Access to drugs ( sedatives,psychotropic drugs )
![Page 8: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/8.jpg)
Examination
![Page 9: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/9.jpg)
General physical Examination
i) Vital signs
ii) Evidence of trauma
iii) Evidence of acute or chronic system illness
iv) Evidence of drug ingestion ( needle marks alcohol breath )
v) Nuchal rigidity (examine with care)
![Page 10: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/10.jpg)
Neurological Examination
![Page 11: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/11.jpg)
State of consciousness Obtundation; responds-to verbal
stimuli although slow and inappropriate. Stupor; the subject can be aroused
only by vigorous and repeated noxious stimuli.
Coma; unarousable and unresponsive.
![Page 12: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/12.jpg)
Respiratory pattern a ) Hyperventilation - midbrain and upper pons lesion metabolic diseases e.g. hepatic coma, diabetes and generalised
raised intracranial pressure in its early stages.
( b ) Hypoventilation - medullary, upper cervical spinal lesion Drug overdose and later stages of cerebral herniation.
( e ) Cheyne-Stoke respiration – usually diencephalic lesion central transtentorial herniation and obstructive hydrocephalus.
( d ) Ataxic respiration (completely irregular breathing) brain-stem dysfunction of a diffuse nature
![Page 13: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/13.jpg)
Pupillary size and reaction
Medium to dilated symmetrical pupils fixed to light structural disease of the brain stem.
Small symmetrical pupils reactive to light metabolic diseases and drug overdose.
Unequal pupil fixed to light intracranial mass lesion producing 3rd nerve palsy e.g
in unilateral uncal herniation.
![Page 14: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/14.jpg)
Eye movements
Vestibulo-ocular reflexes – douching of one ear with cold water produces ipsi-lateral deviation of both eyes with a contralateral quick phase nystagmus lasting for 1—2 minutes. Use of hot water produces the opposite effect i.e. contralateral deviation with ipsilateral quick phase nystagmus. Bilateral douching with cold water gives rise to downward deviation with upward nystagmus and with hot water the opposite response. Absence or abnormal response indicates brain-stem dysfunction.
Oculo-cephalic reflexes (Doll's eye movement ) - Normal response consist of deviation of both eyes to the opposite direction of head rotation. Again absence or abnormal response indicates brain-stem dysfunction.
![Page 15: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/15.jpg)
Motor Responses
This is elicited by applying peripheral noxious stimuli e.g. pinching of limbs rubbing the sternum to elicit pain.
( a ) Appropriate response – brushing away the source of stimulus.
{ b ) Inappropriate response - decerebrate or decorticate rigidity. Motor response is also of localising value. Paralysed limb will show no response and presence of hemiplegia can therefore be evident. Decerebrate rigidity indicates brain-stem damage and if bilateral is usually associated with a very poor prognosis. Complete flaccidity with no response to noxious stimuli is often indicative of severe central nervous system depression due to drug overdose.
![Page 16: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/16.jpg)
Laboratory Evaluation
![Page 17: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/17.jpg)
Supratentorial lesions
Skull radiograph Computerised tomographic scan
CTscan) Carotid angiography EEG ( electroencephalogram )
![Page 18: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/18.jpg)
Infratentorial lesions
Skull radiograph CT scan Vertebral angiography EEG Ventriculography
![Page 19: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/19.jpg)
Diffuse neuronal lesions Examination of CSF ( cerebro spinal fluid ) Serum glucose, calcium, Na, K, magnesium Blood gases and PH Liver and renal functions Drug levels
![Page 20: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/20.jpg)
Management
![Page 21: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/21.jpg)
Initial Management
Airway Breathing Circulation Deformity Exposure
![Page 22: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/22.jpg)
Definitive Management In general, management of the comatose patient
depends on the cause. However, while the patient is undergoing evaluation, it is essential to :
pressure area care care of the mouth, eyes and skin physiotherapy to protect muscles and joints risks of deep vein thrombosis risks of stress ulceration of the stomach nutrition and fluid balance urinary catheterization monitoring of the CVS infection control maintenance of adequate oxygenation, with the
assistance of artificial ventilation
![Page 23: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/23.jpg)
You are in emergency department when an unconscious patient land in emergency with B.P 90/50 pulse 92/min and attendants tell u that the patient suddenly fell unconscious, how will you approach ?
![Page 24: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/24.jpg)
APPROACH
ABC
Immediate management
Examination
History
Investigations
![Page 25: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/25.jpg)
ABC
ABC
A –Open theairway
B –breathing C –circulation
![Page 26: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/26.jpg)
Immediate management
Maintain i.v line, oxygen inhalation
Blood sample for RBS
Control seizures
Consider i.v glucose, thiamine, naloxone, flumazenil
![Page 27: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/27.jpg)
Examination
Examination
•Vitals•Skin petechial rash
•Injection marks
•Neurological assessment•Neck rigidity•Fundoscopy
•Brainstem reflexes
•Detailed medical examination
![Page 28: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/28.jpg)
CONTD.
Vitals1.Pulse
tachycardia Hypovolemia/haemorrhage hyperthermia Intoxication
bradycardia Raised intracranial pressure Heart blocks
![Page 29: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/29.jpg)
CONTD.
2.Temperature increased Sepsis Meningitis ,encephalitis Malaria ,Pontine haemorrhage
Decreased Hypoglycemia Hypothermia (less than 31 C) Myxedema Alcohol, barbiturate ,sedative or
phenothiazine intoxication.
![Page 30: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/30.jpg)
CONTD.
3.Blood pressureincreased
Hypertensive encephalopathy Cerebral haemorrhage Raised intracranial pressure
Decreased Hypovolemia /hgr Myocardial infarction Intoxication/poisoning Profound hypothyroidism, Addisonian
crisis
![Page 31: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/31.jpg)
CONTD.
4.Respiratory rateIncreased(tachypnae)
Pneumonia Acidosis (DKA, renal failure) Pulmonary embolism Respiratory failure
Decreased Intoxication/poisoning
![Page 32: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/32.jpg)
CONTD.
Skin petechial rash Meningococcal meningitis
Endocarditis
Sepsis,thrombotic thrombocytopenic purpura
Rickettsial infectionRMS (rocky mountain spotted fever)
![Page 33: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/33.jpg)
CONTD.
Multiple injection marks Drug addiction
Acute endocarditis
Hepatitis B /C with encephalopathy
HIV
![Page 34: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/34.jpg)
CONTD.
Neurological assessment;
General posture
Level of conciousness
![Page 35: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/35.jpg)
CONTD.
Posture; Lack of movements on one side
Intermittent twitching
Multifocal myoclonus
DECORTICATION
DECEREBRATION
![Page 36: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/36.jpg)
CONTD.
Level of conciousness Glasgow coma scale (GCS)Best motor response Best verbal responseEye opening GCS score 3 –severe injury less than or equal to 8 –
moderate injury 9 to 12 – minor injury
![Page 37: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/37.jpg)
CONTD.
An abbreviated coma scale is used in the assessment of critically ill patient (primary servey)
AVPUA –alertV – respond to voice stimulusP – respond to painU - unresponsive
![Page 38: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/38.jpg)
Brainstem reflexes
Pupillary responses to light
Spontaneous and elicited eye movements
Corneal responses
Respiratory movements
![Page 39: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/39.jpg)
CONTD.Ocular movements
Conjugate deviation of eyes to a side – ipsilateral hemisphere frontal leison or contralateral pontine leison. Rarely eyes may turn paradoxically away from the side of deep hemisphere leison (WRONG-WAY EYES)
Downward conjugate deviation of eyes – mesencephalic leison.
![Page 40: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/40.jpg)
CONTD.
Eyes turn down and inward in – thalamic hgr and upper midbrain leison.
Ocular bobbing – is diagnostic of pontine hgr.
Ocular dipping - indicates diffuse cortical anoxic damage.
Dysconjugate ocular deviation – brainstem leison.
![Page 41: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/41.jpg)
CONTD.
Oculocephalic reflex (Doll’s eyes response) – brisk in cortical depression ,lost in brainstem leison.
Oculovestibulo responses –two components
1.Conjugate ocular movement – loss in brainstem damage.
2.Nystagmus – loss in damage to cerebral hemisphere
![Page 42: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/42.jpg)
CONTD.Pupillary changes;
Sr no
pupils causes
1 B/L Pin-point pupils ( less than 1mm)but responsive
Opiates poisoning ,extensive pontine hgr.
2 B/L small pupils but responsive
B/L diencephalon involvement or destructive pontine leison
3 B/L slightly small pupils(1 to 2.5 mm) but responsive
Metabolic encephalopathies ,deep B/L hemisphere leison or thalamic hgr.
4 B/L dilated and fixed Severe midbrain damage, Overdose of atropine,scopolamine,glutethemide.
![Page 43: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/43.jpg)
CONTD.
Sr. no.
Pupil cause
6 U/L small pupil Horner syndrome
5 Ipsilateral dilated pupil with no direct or consensual reflexes
Compression of 3rd cranial nerve e.g, uncal herniation
7 U/L small and irregular pupilunresponsive
Leison in pretectal area of midbrain
![Page 44: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/44.jpg)
CONTD.Respiratory movements
Has less localizing value then other brainstem reflexes.
Cheyen-stokes respiration(classic cyclic form ending with a brief apneic period – B/L hemisphere damage or metabolic depression.
Rapid ,deep breathing (Kussmaul) –in metabolic acidosis and in pontomesencephalic leison.
![Page 45: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/45.jpg)
Neck rigidity;
Meningitis
Subarachnoid haemorrhage
![Page 46: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/46.jpg)
Fundoscopy
Raised intracranial pressure
Hypertensive changes
Subarachnoid haemorrhage
Diabetic retinopathy
![Page 47: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/47.jpg)
![Page 48: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/48.jpg)
History
Onset of the symptoms
Antecedent symptoms
Use of medications
Chronic liver ,kidney ,lung or heart disease
![Page 49: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/49.jpg)
CAUSES OF UNCONCIOUSNESS
Braintumor
epilepsy
infectionsCardiovascular
disease
trauma
metabolicdisturbances
Thiaminedeficiency
Causes of unconciousness
![Page 50: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/50.jpg)
Causes of unconciousness
MetabolicDrugs, poisoning e.g CO ,alcoholHypoglcemia, hyperglycemia (keto
acidoti or HONK)Hypoxia, carbondiaoxide narcosis
(COPD)SepticemiaHypothermiaMyxedema ,addisonian crisisHepatic / uremic encephalopathy
![Page 51: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/51.jpg)
CONTD.
NeurologicalTraumaInfections – meningitis, encephalitis,
malaria, typhoid, rabies, trypanosomiasis.
Tumours – cerebral / meningeal tumorsVascular – subdural / subarachnoid hgr,
stroke, hypertensive encephalopathyEpilepsy – nonconvulsive status /
postictal state
![Page 52: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/52.jpg)
Immediate investigations
RBS
Blood CP and ESR
LFTs
Urea and Creatnine
Blood and urine cultures
![Page 53: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/53.jpg)
Other investigations
CRP
ABGs
Toxic screen , drug levels
Lumbar puncture and CXR
CT scan
![Page 54: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/54.jpg)
Summary
ABC of life support
Oxygen and I.V access
Stabilize cervical spine
![Page 55: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/55.jpg)
CONTD.
Blood glucose
Control seizures
Consider I.V glucose, thiamine, naloxone, flumazenil
![Page 56: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/56.jpg)
CONTD.
Brief examination and obtain history
Investigate
Reassess the situation and plan further
![Page 57: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/57.jpg)
Take home message
Early management
Prompt diagnosis
![Page 58: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/58.jpg)
MCQ
Pupillary changes in opiate poisoning
1.B/L pinpoint
2.U/L pin point
3.B/L dilated
![Page 59: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/59.jpg)
Answer
1. B/L pin point
![Page 60: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/60.jpg)
MCQ
Myxoedema coma seen in
1.Euthyroid state
2.Hyperthyroid state
3. hypothyroid state
![Page 61: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/61.jpg)
Answer
3. hypothyroid state
![Page 62: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/62.jpg)
![Page 63: Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management](https://reader035.vdocuments.us/reader035/viewer/2022062422/56649e7f5503460f94b8374e/html5/thumbnails/63.jpg)
Thank You