SLE

MARCH 2008
2008 !"# $% &'() *+# ,-
.
.
. /0 12 3 4 5 16 789 :; : hepatocellulat hepatoma metastesis :6- <+ =,8 "
78>(
you have to fin out ho! must "no! 1? @ A(+ 12 B3 CD4 3
2 12 3 E F G,H : pa#alysis E?% GI>( $% J*( $5 @ KL K5 " @? K;M% :;"4
K;M% A,N D neu#o 'O(" @ 4 F
conve#sion iso#e#
P Q E % ,) R /) P S6) @ 0')" i$s GD G;M% B+ T9 0')" @ G,N R) K*6M U V>(
%ast#oente#olo%y <+ W;(( X-Y Z S[ \\
] E Q !* K'" K;MI " 1 .0F00 S[? " 0'"6 U ..F.Z ')" G^ !* K'_ ,5Y <+ W;(
" @? A, X[? 60 complicate patient ``
Z 'Q :5 :, U" 0'* H _6* $3,* a4 G_ '6 X')" C% a GM Ib <+ W;( \\ S8 K) @?- 64 $8
'6 c* 4 B> 1 hematoma ``
All featu#es of tonsilla# a$scess e&cept '
deviation of uvula to affected side:
cent#al a#te#y em$olism all t#ue e&cept '
causes painful visin loss
#etinal etachment painless !ith $lu##e vision
fi#st EC( si%n of acute pe#ica#itis '
ST elevation
q waves
porlonged PR interval
)n initial evaluation couples fo# infe#tility'
temperature chart :
semen analysis more than50 % live , motile, morphology ,,,,,,,,,,, count more than 0 million
refer to reproductive clinic!!!"

E#ethema noosum ' #est felt than see , T$ ,%$&
painful red nodules treated #y 'S(%&s

initial )n& in small $o!el o$st#uction '
)rect* +,R) $)ST - . supine a#dominal /0 ray

chil !ith ec*ema fla#e up he is on ste#oi an havin% itchin% istu#$ his sleepin%
my ans!e# to %ive antihistamine o# ste#oi c#eam ++
- -= --
if angioedema 000 epinephrine
(ol stana# ima%in% in acute pance#iatitis '
- 1T scan , if less than 23h no value , d4 on clinical and al#s
p#e%nant lay 28 !"s !ith chlamya infection '
a5ithromycin not pregnant
erythromycin in pregnant #est 6 treat partners if amo4 *#est-
do4cyline not pregnant
common cause of male infe#tility' The most common cause is a low sperm count
primary hypogonadism, most common cause is 7linefeter syndrome 2844y
secondary hypogonadism
e9aculation o#struction
!!! -~ '~
The most common con%enital cause is :linefelter syndrome
,8yea#s ol $oy !ith $ac" pain investi%ation to o e&cept '
1$1 "
)SR
/ 0ray
#one scan
if lytic lesion , #one scan is #est
i#on eficiency aneamia '
serum iron
ferritin * difference #;t chronic anemia 0
T%$1
#one marrow * #est if not there ferritin -
Hypothy#oiisim '
free T2
TS<
T2
in !hich %#oup you !ill o lo!e# enoscopy fo# patients !ith i#on eficiency aneamia in !ith no $eni%n
cause'
male all age group
children
permanupausal women & male more than 59 y
women = ,1P
- '==
chil !ith piece of %lass- $eans - $atte#y eep in ea# canal !hat to o'
no irrigation ,,,,,, , best pick with forceps

sie effects of Levoopa '
dys7inesia
speech
fatal hepatic to4icity!!"
> (#normal thin7ing: holding false #eliefs that cannot #e changed #y fact
> (gitation
> (n4iety
> 1lenching or grinding of teeth
> 1lumsiness or unsteadiness
> 1onfusion
> &ifficulty swallowing
> &i55iness
> )4cessive watering of mouth
> ?alse sense of well #eing
> ?eeling faint
> @eneral feeling of discomfort or illness
> <allucinations *seeing, hearing, or feeling things that are not there-
> <and tremor, increased
> 'ausea or vomiting
> 'um#ness
,. patient !hile he playin% foot $all the#e is one come / pop his "nee f#om the late#al sie -come to the
hospital -
0hat is the most p#o$a$ly cut in1u#y occu#+
0medial collateral ligament
valgus force applied to a fle4ed 7nee may cause a tear of the medial meniscus! ( varus force on a fle4ed 7nee
with the femur e4ternally rotated may lead to a lateral meniscus lesion! (ccording to Ric7lin, the medial meniscus
is attached more firmly than the relatively mo#ile lateral meniscus, and this may result in a greater incidence of
medial meniscus in9ury!
2. 2o# this case the t#eatment is'
(0 conservative
ACL' Results f#om a noncontact t!istin% mechanism- fo#ce hype#e&tension- o# impact to an
e&tene "nee - 3 ante#io# #a!e# an Lachman tests. Rule out a meniscal o# MCL in1u#y.
4CL' Results f#om fo#ce hype#e&tension - 3 poste#io# #a!e# test .
Meniscal tea#s ' Result f#om an acute t!istin% in1u#y - Clic"in% o# loc"in% may $e p#esent - E&am
sho!s 1oint line tene#ness an a 3 McMu##ay5s test.
6. 70 o# 77 8.9 patient p#esent !ith unilate#al shoule#- uppe# / lo!e# limp pain !ith mo#nin%
stiffness of mo#e intensity afte# !a"e up -the#e is mil feve# / the patient is ep#esse '
:ia%nosis'
(0R!(
$0 Polymyalgia rheumatic )SR!
;. Male patient "no!n case of :M )) come !ith H$ A,C ' 8< -he is ta"in% metfo#min /
%li$enclami- to #e%ulate the $loo su%a# nee '
(0 !!!!!!!!!!!!insulin
$0!!!!!!!!!!!!insulin
10 metformin . acar#ose !
7. case scena#io patient p#esent !ith constipation ......:& ' hypothy#oiism
=o confi#m that the patient has hypothy#oiism'
(0T2
$0TS<
10free T2
>. Case scena#io ?patient p#esent !ith symptoms of hype#thy#oiism- tene# nec" s!ellin% '
:ia%nosis'
su#acute thyroiditis - t#ate !ith @SA): A@: S=ER9):
A. mothe# $#in% he# $a$y to you !hen she complain of iape# #ash - she !ent to iffe#ent #u%
$efo#e she come to you - she use 6 iffe#ent co#ticoste#oi #u% p#esc#i$e $y iffe#ent
physician- ..........
the #ash is !ell ema#cate / scaly '
:ia%nosis'
(0se#orrheic dermatitis
$0contact dermatitis include la#i wheras candida not
10"
A. =he t#eatment'
++avoi alle#%en an ste#oi fo# contact e#
8. female patient man%e# since sho#t time - $ecome ep#esse - she sai she canBt mana%e the
conflicts that happen in the !o#" $et!een the employees.
:ia%nosis'
(0&epression!
$0@enerali5ed an4iety disorder!
10(d9ustment &isorders
C. Case scena#io ?female patient p#esent !ith e&cessive fea# in he# chil#en ....... ...D my opinion it is a
case %ene#ali*e an&iety iso#e#.
=#eatment'
+
,0. 4atient $efo#e menst#uation $y 2.6 ays p#esent !ith ep#esse moo that isappea# $y 2.6 ay
afte# the $e%innin% of menst#uation...
:ia%nosis'
(0Premenstrual dysphoric disorder if sever symptoms *or premenstrual syndrome "-!
,,. 2emale patient $#east feein% p#esent !ith mastitis in uppe# oute# Eua#ant'
=#eatment'
(0stope #reast feeding . evacuate the mil7 #y the #reast pump!
$0 @ive!!!!!anti#iotic to the mother . anti#iotic to the #a#y!
c0 anti#iotics with continue #reast feeding
,2. case scena#io - $a$y p#esent !ith unilate#al efo#mity in the foot appea# !hen it is $ecome the
!ei%ht $ea#in% is in the othe# foot $ut !hen it is the !ei%ht $ea#in% the efo#mity isappea# -the
patient has efect in o#sifle&ion of that foot .......) thin" they a#e ta"in% a$out ? clu$ foot D
t#eatment '
(0orthopedic correction !!!"
$0shoe!!!!
10surgery !!!!
T)A is caused #y genetic factors such as )dwards syndrom ,8 ch#omosome
serial casting, or splints called 7nee an7le foot orthoses *:(?,- first if no respons , surgery!
,6. case scena#io ? ....patient p#esent plante# fascitisD
=#eatment' $est !ith @SA): =HE@ )@F S=ER9): - H9= GA=H
(01orticosteroid in9ection!
$0silicon!!!
,;. 4atient p#esent !ith #etinal a#te#y occlusion- !hich is !#on%'
(0 Painful loss of vision!
$00 Painless loss of vision!
,7. 4atient p#esent !ith co#neal a$#asion'
=#eatment'
(01over the eye with a dressing!
$0(nti#iotic ointment put it in the home without covering the eye"
,>. 4atient p#esent !ith epista&is'
=he $est mana%ement'
0 the patient leaning forward ,ma7e pressure in the lower side of the nose !
,A. 4atient p#esent !ith unilate#al nasal ischa#%e - foul smellin% in the nose . Most p#o$a$ly ia%nosis'
0 (denoid
0 ?oreign #ody
The presence of unilateral foul smelling nasal discharge is always an indication of foreign #ody in the nose
. ,8 months $a$y p#esent that he only sayin% mama $a$a !hich is a$no#mal fo# his a%e - no othe#
symptoms o# si%n a$no#mal - fi#st thin% to $e asses '
0 0hearing assessment !
0 0developmental assessment !
,C. Case scena#io -chil p#esent !ith #hino##hea / so#e th#oat fo# 7 ays p#esent !ith mile ea#
pe#fusion- e&amination of the ea# ' no #eness in the ea#
the cause of pe#fusion '
0 otitis media #ecause no pain !
0 Bpper respiratory infection!
20 Case scena#io ?patient "no!n case of co#ona#y a#te#y isease- p#esent !ith a symptoms of it- to
ia%nose that patient has M) o# not- $y first )1@ and 1(R&%(1 )'CD+)
(0 )4ercise stress test !
$0 1oronary angiography
10 )4ercise!!!!
2,. 4atient p#esent !ith acute p#eca#itis - )n EC( !e see EHCE4= '
. S.= se%ment elevation.
0q waves
0prolonged PR interval . t !ave inve#sion st elevation
22.case scena#io ?patient p#esent !ith ca#oti a#te#y o$st#uction $y 80<- t#eatment $y
0 carotid endarterectomy!
0 !!!!!!!!surgical #ypass
%f more than 80 % go to surgery
26. 4atient p#esent !ith %ene#ali*e sei*u#es not "no!n case $efo#e of any siu*e# - no pe#vious
histo#y li"e that '
=he most impo#tant thin% to o no! is'
0 ))@! (fter that
0 Ea#oratory test !in )R
%f sei5ures are new0onset or if e4amination results are a#normal for the first time, neuroimaging is
required!
))@ is less li7ely to detect a#normalities if sei5ures are infrequent!
)lectroencephalograms are an important tool in determining prognosis for future sei5ures and should #e
strongly considered for all children with a first sei5ure
the ))@ will #e normal in 50% of patients following a first sei5ure
2;. Case scena#io patient p#esent !ith ca#pal tunnel syn#ome-
=#eatment'
0corticosteroid in9ection
Splint the wrist in a neutral position at night and during the day if possi#le!
(dminister 'S(%&s!
1onservative treatment can include corticosteroid in9ection of the carpal
canal! 0 1TS
'!$ they didnFt mention a surgery in the +1G
27.case scena#io ?..... patient p#esent !ith SLED
=he least #u% has sie effect'
0 methotre4ate
0 name of other chemotherapy
2>. case scena#io ? ....patient p#esent !ith p#ostatitis - $y cultu#e %#am ne%ative #oe D
t#eatment '
0 Trimethoprim and Sulfametho4a5ole or flurqunilones
0 ampicillin if suspected sepsis with gentamicin
0 gentamicin if suspected sepsis with ampicillin
2A. case scena#io ? patient p#esent !ith IR=)- afte# , !ee" the patient p#esent to have hematu#ia
-eema ....
most p#o$a$ly ia%nosis'
0 %g( nephropathy
0 post streptococcus @'
Postinfectious glomerulonephritis : ,liguria, edema, hypertension,tea0 or cola0coloredurine! 0 H wee7s ttt supprtive
%g( nephropathy : hematuria , 'ormal 1I , ttt @lucocorticoids
28. the most impo#tant ia%nostic test fo# that is '
. +icroscopic R$1
0+acroscopic R$1!
0 R$1 cast!
2C. case scena#io patient "no!n case of hype#choleste#emia -GM) '6,
4#esent !ith investi%ation- sho!in% ? num$e#s D 'hi%h total choleste#ol -hi%h L:L / hi%h =(......
9f these investi%ation !hat is the an%e# one fo# evelopin% co#ona#y a#te#y iseas '
0E&E
Total cholesterol J 00 mg;dE, E&E J KI0 mg;dE, triglycerides J 500 mg;
dE, and <&E L 20 mg;dE are ris7 factors for 1(&
60. Case scena#io patient p#esent !ith acute panc#eatitis -$est ia%nosis $y '
0 +R%
0 1ontrast computed tomography
0 /0ray
6,. Case scena#io patient p#esent !ith 6 ays histo#y of $leein% pe# #ectum - p#esent of pain afte#
efecation - $y e&amination ? mass at 6 oBcloc" D '
=#eatment'
(0Put a sit5 #ath 5 time a day !
$0 'S(%& ointment locally !
10 ligate the mass then remove it !
(cute ?issure
very painful #right red #leeding especially after #owel movement
treatment is conservative: stool softeners, sit5 #aths
62. case scena#io ? female patient p#esent !ith I#tica#ia- the#e is a histo#y of s!ellin% in the lip some times-
ia%nosis '
:ia%nosis'
0 angioedema """"around mouth
66. J a$out peptic ulce# -ho! to "no! if it is ue H.pylo#i o# not .
6;. 3 patient -you# ia%nosis fo# hem is cance# -ho! to $#ea" that $a ne! fo# hem '
0 see the patient how many 7now a#out the disease!
.
67. 77 8.9 male patient p#esent fo# chec" up -physical e&amination is no#mal -la$ investi%ation mic#ocytic
hypoch#omic anemia - H$ 'C
the most li"ely cause to e&clue is
0 lymphoma!
0 gastroenterology malignancy!
.
6>.patient !ho is smo"e# the least isease to occu# in him is '
0Brinary cancer!
0 1olon cancer!
6A. case scena#io patient p#esent !ith acute symptoms of $looy ia##hea ......
:ia%nosis -acute ulce#ative colitis '
the initial t#eatment fo# this patient '
0corticosteroid therapy !
0 methotre4ate!
0 50(minosalicylic acid
68. 4#e%nant !omen p#esent !ith a mass in he# mouth $leein% !hen $#ush he# teeth
$y e&amination mass 6&2 cm- ia%nosis '
0 aphthous ulcer!
0 !!!!!cancer
0 !!!!!granuloma
Pyogenic granuloma during pregnancy, the form considered as a pregnancy tumor #ecause of its emergence in the
mouth area,
Pyogenic granuloma *also 7nown as )ruptive hemangioma,@ranulation tissue0type hemangioma,@ranuloma
gravidarum,Eo#ular capillary hemangioma,Pregnancy tumor,Tumor of pregnancy , ', TTT
6C. case scena#io -patient p#esent !ith intestinal o$st#uction '
)nvesti%ation to $e one'
0 /0ray supine . erect position!
0 c0scan
;0. @eonate $a$y p#esent !ith #ash ove# the face / t#un"/ $luste# fo#mation -
:ia%nosis'
0 )rythema to4icum
.
;,. 2emale patient p#esent !ith itchin% in the va%ina associate !ith the va%inal ischa#%e - 4H ' 7 - no
=#ichomonas infection - pseuohyphae $y cultu#e ia%nosis '
0 physiological discharge !
0 1andida infection !
;2. female patient p#esent !ith thic" va%inal ischa#%e colo#..... . no itchin% -va%inal e&amination $y
speculum no#mal -4H ' ;
:ia%nosis'
0physiological discharge
;6. case scena#io ? patient !ho is "no!n case of hepatitis G -)nvesti%ation sho!s'
hi%h al"aline phosphates / aminot#ansfe#ase
HGs A% ' 3ve
HGs a$ ' .ve
:ia%nosis'
0o#struction of #iliary tract ""
;;.epiemiolo%ical stuy fo# smo"e# sai the#e is ,0-000 smo"e# in the a#ea - at sta#t of the stuy the#e is
2000 - at the en of the stuy the#e is ,000 - the incience of this stuy is '
(0 K0% ,,,, K000 ; K0000
$0 I0%
%ncidence proportion *also 7nown as cumulative incidence- is the num#er of new cases within a specified time period divided #y the si5e
of the population initially at ris7! ?or e4ample, if a population initially contains K,000 non0diseased persons and 3 develop a condition
over two years of o#servation, the incidence proportion is 3 cases per K,000 persons, i!e! !3%!
;7. epiemiolo%ical stuy !ant to see the affect of smo"in% in the $#oncho%enic ca#cinoma - they sa! that
is C0< of smo"e# has $#oncho%enic ca#cinoma .
60< of non smo"e# has the isease - the specificity of the isease as a #is" facto# is '
080%
0M0%
;>. female patient complainin% of thi#sty / #in" a lot of !ate# / f#eEuent u#ination -
she has a histo#y of ia%nose as $ipola# since ? 2 !ee" D -sta#t !ith a meication
of lithium-
0 psychogenic polydipsia!
0 central dia#etes insipidus!
nephrogenic dia#etes insipidus !
Eithium0induced nephrogenic &% may #e effectively managed with the administration of amiloride, a potassium0sparing diuretic often
used in con9unction with thia5ide or loop diuretics!
;A. case scena#io female patient p#esent !ith lo!e# a$ominal pain ? o# $ac" painD
2.6 ay $efo#e menst#uation- then 2.6 ay afte# $e%innin% of it '
:ia%nosis'
0primary dysmenorrhea!
0 secondary dysmenorrhea !
;8.el#ly !omen p#esent !ith ia##hea- hi%h feve# / chills- othe# physical e&amination is no#mal incluin%
$ac" pain is no#mal -
:ia%nosis'
(0 Pyelonephritis!
$0 $acterial gastroenteritis!
10 Airal gastroenteritis!
;C. 4atient ta"in% antiep#essant #u%- ?names of a #u% ) cant #emem$e# it $ut !hat ) #emem$e# it a #u%
of hype#tension /.....D
the antiep#essant #u% ma"e #u% #u% inte#action !ith one of the follo!in% #u% '
0 'on of the a#ove!
70. 4atient p#esent !ith seve# $#onchial asthma !hich of the follo!in% #u% - not #ecommene to %ive it '
(0 Sodium gluconate !
$0 1orticosteroid *in9ection or orally" -
10 1orticosteroid ne#uli5er!
7,. $a$y p#esent !ith pain in the ea# -$y e&amination the#e is piece of a %lass eep in his ea# canal - the
mothe# mention a histo#y of a $#o"en %lass in the "itchen $ut she clean that completely .... 0e t#eat that
$y' no i##i%ation
(0 $y applying a stream of solution to syringing the ear!
$0 Remove it #y forceps!
72. Case scena#io.... $a$y ?K2 yea#s a%e D p#esent !ith a histo#y of IR=) .... nasal ischa#%e afte# that
complicate to !hee*in% - / the#e is #ales in the en inspi#ato#y / ea#ly e&pi#ato#y phase -p#olon%e
e&pi#ato#y phase - seve# #espi#ato#y ist#ess -usin% the accesso#y muscle in #espi#ation.
:ia%nosis'
(0Airal pneumonia!
$0$ronchilitis!
10$acterial pneumonia!
76. Mothe# $#in% he# $a$y to you !hen he p#esent !ith hematoma in his nail-
Ho! to mana%e this patient'
(0'o need things . as7 him to go to the home!
$0#ring a sharp metal * - - . press in the middle to evacuate the <ematoma!
10remove the nail!
7;. in the initial evaluation fo# infe#tility'
(0 Temperature chart!
$0 Semen analysis!
10 Refer to reproductive clinic!
&0 Brine analysis to detect the ovulation !
77.sie effect of levoopa '
0 fatal hepatic to4icity !
0 fatal renal to4icity!
0dys7inesia
0speech
7>. patient p#esent to you - !hen you see his case - you iscove# that patient has te#minal sta%e of ch#onic
illness - ho! to mana%e this patient '
0 ma7e him go to the home!
7A. All featu#es of tonsilla# a$scess e&cept '
deviation of uvula to affected side:
78.E#ethema noosum '
painful red nodules treated with 'S(%&s not steroids
7C chil !ith ec*ema fla#e up he is on ste#oi an havin% itchin% istu#$ his sleepin%'
mana%ement '
0 ointment
0 antihistamine""
.
>0.p#e%nant lay 28 !"s !ith Chlamyia infection '
0a5ithromycin * single dose -
0erythromycin * this point ,what % remem#er was not present -
0 &o4ycycline
0 points of drug of oinolon group
.
>,. common cause of male infe#tility'
0primary hypogonadisim : 7ilnfelter syndrome NNNNN turner syndrome in female
0secondary hypogonadisim
0e9aculation o#struction
>2.,8yea#s ol $oy !ith $ac" pain investi%ation to o e&cept '
CGC +
)SR
/ 0ray
#one scan
>6. i#on eficiency anemia '
0serum iron
0ferritin
0T%$1
>; .)n !hich %#oup you !ill o lo!e# enoscopy fo# patients !ith i#on eficiency anemia in !ith no $eni%n
cause'
0male all age group
0children
0permanupausal women
0women = ,1P
>7. female patient "no!n to you since 6 yea#s a%o has )GS - she in5t a%#ee !ith you a$out that -you o all
the investi%ation nothin% su%%estive othe# than that - she !ant you to #efe# he# .
at this case -!hat you !ill o
0 !!!!!!!!!!!!!!you will response to her . refer her to the doctor that he is want !
0 !!!!!!!!!!!you will response to her . refer her to the doctor that you are want !
>>. one of you# female patient has complicate case -come to you / %ive him othe# appointment fo# 2LI -
!hen he came he# appointment !as at ,0'00 / in5t inte# to you e&cept at ,,',7 - she !as an%#y $ecause
of that - !hat you !ill o no! '
0 )mpathy with the patient .!!!!!!!!
0empathy with the patient .!!!!!!!!
0 !!!!!!!!!!!!!!!!!!!! told to the patient you have other complicated case must inter #efore you !
>A. 3 female patient p#esent to you complainin% of suen pa#alysis- she has a histo#y that hus$an
anointe he# ?o# happen that in the clinic +D
4hysical e&amination incluin% neu#olo%ical e&amination is no#mal
:ia%nosis'
01onversion disorder
=HERE )S J. AG9I= IR=) CAISE:: G8 RSM
H90 =9 =REA= =HE N@EE )@FIR8 ) =H)@N G8 N@EE GRACE @9= )@FEC=)9@ 92 S=ER9):
()RL 0)=H ,R8 :8SME@9RRHEA A@: I 0)LL ()ME @SA):S
in Euestion A i thin" it !as mension that the#e !as stellate lesion
++
patient came !ith sc#otal s!ellin% !hat invest%ation to o'
B;S
the#e !as a Euestion a$out $a$y !ith melanoma'
wide e4ision and follow up
refer to dermatology
.....
youn% lay !ith pelvic pain an meno##h%ia e&. sh!e ute#ine mass+
&.
uterine fi#roid
adenomyosis
endometriosis
$est in&'
B;S
laproscopy
tennis el$o! t#eatment'
'S(%
'S(%&s = restrict activity ? late#al epiconyle D
44H mana%ement '
o4itocin infusion
mesoprosto
mana%ement of o$esity in + ,0 yea#s $oy'
multifactorial
youn% man !ith plu#isy $est mana%ement'
'S(%s
acetaminophen
cortisone
the#e J a$out patient !ith ia$etes an hype# tension... !hich one of anti hype#tensive maication you
!anna a fi#st
K!(1)
!#0#loc7er
I!ca0channel #loc7er
2!alpha0#lo7er
then if patient stil hype#tensive !hat the ne&t choice.........+
K!#0#lo7er
!thia5ide
I!(R$
2!ca0channel #loc7er
#eccu#ent a$o#tion at ,C !ee" - no#mal fetus ?!ithout any con%enetal anomalieis
0cervical incompetence
va%inal itchin% - !hite ischa#% not offensive
candida
va%inal itchin% - !hite ischa#% O$P offensiveOLG
#acteial vaginosis
4a%et isease '
0 @o#mal ca an po; - hi%h AL4
Gechat isease '
Painful ulcer in mouth and gentialia
Gest p#ophyla&is fo# sic"le cell anemia '
Pencillin
,titis e4terna : ear tragus painful 0000
,tits media if persistent effusion 000 myringotomy
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