Transcript Palpation - abdominal organs

The Physical Examination of
Abdomen
Liaoning Medical University
Affiliated First Hospital
He Xin
1
一、Abdominal landmarks
and regions
2
Abdominal landmarks and regions
Abdominal landmarks
xiphoid process
lower margin of costal
arch
iliac antero-superior
spina
umbilicus
symphysis pubis
abdominal middle line
3
Abdominal landmarks and regions
SUPERFICIAL ANATOMY
Xiphoid
Costal
margins
Ventral
median
line
Rectus muscle
umbilicus
Anterior superior
iliac spine
pubes
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Inguinal
ligament
Abdominal landmarks and regions
Abdominal regions
four quadrants system
5
nine regions system
Abdominal landmarks and regions
Four quadrants system
Right upper quadrant
liver
gallbladder
pylorus
duodenum
pancreas(head)
right kidney
hepatic flexure of colon
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Abdominal landmarks and regions
Right lower quadrant
cecum
appendix
ascending colon
small intestine
right ovary and
tube
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Abdominal landmarks and regions
Left upper quadrant
liver (left lobe )
spleen
stomach
pancreas
(body tail)
left kidney
splenic flexure of colon
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Abdominal landmarks and regions
Left lower quadrant
sigmoid colon
descending colon
small intestine
left ovary and tube
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Abdominal landmarks and regions
Nine regions system
the abdomen is divided into nine regions
by four intersecting lines, two horizontal
lines—costal arch line and iliac spina line,
two vertical lines extending vertically
across the middle point from iliac anterosuperior spina to abdominal middle line.
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Abdominal landmarks and regions
Regions
right & left
hypochondrial
right & left lumbar
right & left iliac
epigastric
umbilical
hypogastric
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Abdominal landmarks and regions
Right hypochondrial
liver gallbladder
right kidney
hepatic flexure of colon
right lumber
ascending colon
right kidney
right iliac
cecum appendix
right ovary and tube
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jejunum
Abdominal landmarks and regions
Epigastric
liver (left lobe) pylorus
duodenum
omentum
transverse colon
the head and body of pancreas
umbilical
duodenum jejunum ileum
mesentery abdominal aorta
lymph node omentum
hypogastric
bladder womb ureter
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Abdominal landmarks and regions
Left hypochondrial
spleen stomach
splenic flexure of colon
pancreas (tail part )
left kidney
left lumber
descending colon
jejunum ileum
left iliac
sigmoid colon
left ovary and tube
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二、Inspection
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Inspection
The contents of inspection
1. abdominal contour
2. respiratory movement
3. abdominal veins
4. gastral/intestinal pattern and peristalsis
5. abdominal skin
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Inspection- abdominal contour
1、Abdominal contour
Abdomen flat
in healthy person abdomen is usually
flat from xiphoid to symphysis pubis , we
call abdominal flat or even abdomen. the
umbilicus is located in the abdominal
center. depending on the nutritional
status, the abdominal contour may be
lightly protuberant or scaphoid.
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Inspection- abdominal contour
Abdominal bulge
generalized abdominal bulge is usually
caused by ascites
When the patient is in supine position,
the flanks of patient is bulging, the
shape of abdomen is like frog we call
frog belly
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Inspection- abdominal contour
some causes for ascites:
heart failure
cirrhosis of liver
nephrotic syndrome
TB peritonitis (apical belly)
how to measure abdominal
circumference? with a belt ruler go
around abdomen through umbilicus to
see how long it is (cm)
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Inspection- abdominal contour
the other causes of abdominal bulge:
include the distention of the bowel
with trapped gas, such as intestinal
obstruction, massive tumor, such
as ovariogenic cystoma, factitious
abdominal fullness with air,
pregnancy, obesity
20
Inspection-abdominal contour
both the patients with massive ascites
and obesity have
abdominal distention, how do we
distinguish from each other, you
can observe the appearance of the
umbilicus, umbilicus is usually
deeply inverted in obesity and
everted in long—standing ascites
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Inspection-abdominal contour
located abdominal fullness
upper abdominal fullness may
result from a mass in the upper
abdominal structures, such as liver
pancreas, stomach or transverse
colon. similarly fullness in the lower
abdomen may result from bladder
distention, pregnancy or masses
from the ovaries, uterus or colon
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Inspection- abdominal contour
the mass or tumor may be on the
abdominal wall or in the abdominal
cavity, how to differentiate, you can
ask patient to make abdominal
muscles contract, if the tumor is
more distinct the tumor is on the
abdominal wall, if the tumor is not
distinct the tumor is in the
abdomen
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Inspection- abdominal contour
Abdominal retraction
anterior abdominal wall is much lower
than the level from xiphoid to symphysis
pubis
generalized abdominal retraction ：
we called scaphoid abdomen, mainly
seen in sever malnutritional status,
marasmus, cachexia, acute diffusive
peritonitis due to muscle rigidity
located retraction:
mainly seen in scar after operation
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Inspection- Respiratory movement
2. Respiratory movement
the manner of breathing: in men
and children, manner of breathing is
abdominal respiration. But in
women the manner of breathing is
thoracic respiration. In some
diseases such as perforation
because acute peritonitis., the
respiratory movement is limited or
disappear.
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Inspection- Abdominal veins
3. Abdominal veins
in healthy person abdominal vein
can not be seen or can be seen a
little in thin person, but not dilated,
in patient with obstruction of the
portal venous system or in the vena
cava,You may find distended vains.
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Inspection- Abdominal veins
when you find distended veins on the
abdomen you should ascertain the
direction of flow. the normal
direction of flow is away from the
umbilicus , that is the upper
abdominal veins carry blood up
ward to the superior vena cava.
And the lower abdominal veins flow
downward to the inferior vena cava.
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Inspection- Abdominal veins
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Inspection- Abdominal veins
how to ascertain the
direction of blood flow
you can choice a segment
of vein, then the vein is
emptied between two
fingers to a distance
of a few centimeters,
then allows blood to
refill the vein from
one direction by removing
one compressing finger
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Inspection- Gastric or intestinal pattern and peristalsis
4. Gastric or intestinal pattern and peristalsis
in healthy person peristalsis is not visible,
but in patient with pyloric or intestinal
obstruction you can see peristalsis,
in pyloric obstruction on epigastrium
the peristalsis is from left costal margin
to right, in intestinal obstruction you can
see peristalsis around umbilicus the
direction of peristalsis is irregular.
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Inspection- The skin of abdomen
5. The skin of abdomen
skin eruption
in some diseases especially
infectious disease such as typhoid
fever you can find roseolas on the
skin of abdomen
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Inspection- The skin of abdomen
Pigment
in normal condition, the pigment of
abdomen is more decreased than
exposed part of skin, in patient with
chronic adrenocortical hypofunction
also called addison’ s disease,
hyperpigmentation can be found at
the belt line.
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Inspection- The skin of abdomen
There are two special sings of
discoloration on the abdominal skin,
One is Cullen’s sign: a bluish
discoloration around the umbilicus,
another is Grey-Turner’s sign: a
bluish discoloration of the flanks.
these two signs may occur as the
result of hemoperitoneum such as
hemorrhagic pancreatitis
broken of ectopic pregnancy.
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Inspection- The skin of abdomen
Striae
silver striae distribute on the lower
quadrants of abdomen or iliac
regions, it is seen after a large gain
of weight or after pregnancy. bluish
striae (purple) distribute on lower
quadrants of abdomen upper legs
or hips this is found in
hypercortisolism.
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Inspection- The skin of abdomen
Scar
when you find a operation scar on
the patient abdomen, you should
ask some question about the scar,
when and why the patient got the
scar, the history of operation may
be helpful to diagnosis of the
disease
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Inspection- The skin of abdomen
Hernia
umbilical hernia may be seen in
belly or patient with a massive
ascites
incisional hernia operation scar
femoral hernia mainly seen in
female
inguinal hernia mainly seen in male
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Inspection- The skin of
abdomen
Hair distribution
in female the pubic hair is roughly
triangular with the base above the
symphysis. where as in male it is in
the shape of a diamond often with
hair continuing to the umbilicus,
the distribution and quantity of hair
maybe changed by chronic liver
disease and endocrine
abnormalities
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Inspection- The skin of abdomen
Epigastric pulsation
may be seen in the following condition:
Thin person
Right ventricular hypertrophy COPD
Abdominal aneurysm
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三、Palpation
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Palpation- The principle of palpation
The principle of palpation
Following inspection, the examiner should
perform auscultation of the abdomen.
This change in the order of examination is
necessary because the auscultatory findings
may be markedly altered by any manipulation
of the abdominal wall. Consequently
percussion and palpation, which may
increase or decrease peristaltic sounds, are
deferred until auscultation has been
completed.
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Palpation- The principle of palpation
For the patient:
--- continue to lie supine with arms relaxed on
the chest or at the sides and thighs and knees
flexed to relax his abdominal muscles
--- may be further relaxed by instructing him
to breathe slowly and deeply
--- according to different parts and organs of
examination, the patient can be in right lateral
decubitus position such as the examination of
spleen, or standing position such as the
examination of kidney
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Palpation- The principle of palpation
For the examiner:
--- the doctor stands at the right side of
patient
--- use the palmar aspect of fingers
examine gently and lightly from superficial
to deep, and from healthy part to lesion
area
--- make certain that his hands are warm
--- assure the patient that he will make an
effort not to cause discomfort and follow
up this assurance
--- tackle with the ticklish patient
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Palpation- The principle of palpation
The sequence of palpation
usually the sequence of palpation is contraclock
direction:
left lower left lumber
left upper epigastric
right upper right lumber
right lower hypogastric
umbilical
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Palpation- The principle of palpation
The palpating methods
---浅部触诊法 （light palpation）
---深部触诊法 （deep palpation）
深部滑行 （deep slipping palpation）
双手触诊法 （bimanual palpation）
深压触诊法 （deep press palpation）
冲击触诊法 （ballottement）
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Palpation- The contents of palpation
The contents of palpation
1.abdominal muscles tensity 2.tenderness and
rebound tenderness
3.abdominal organs
4.abdominal masses
5.fluid thrill
6.succussion splash
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Palpation - abdominal muscles tensity
1.abdominal muscles tensity
In normal persons, abdominal wall is
somewhat tense, but usually soft when
palpated and easily depressed , and is called
abdominal softness
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Palpation - abdominal muscles tensity
1.abdominal muscles tensity
Increased tensity of generalized abdominal
muscles
--- gastrointestinal flatulence
--- board-like abdomen --acute diffuse peritonitis
（ gastrointestinal perforation）
--- dough kneading sensation --TB peritonitis
carcinomatous peritonitis
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Palpation - abdominal muscles tensity
Increased tensity of located abdominal muscles
one organ inflammation
---right upper abdomen
acute cholecystitis: involved
peritoneum
---right lower abdomen
acute appendicitis: involved
peritoneum
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Palpation - abdominal muscles tensity
Decreased tensity of abdominal wall
---decreased
chronic deeline or drainage of large amount of
ascites
---disappeared
abdominal muscles paralysis
myasthenia gravis
spinal cord trauma
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Palpation -.tenderness and rebound tenderness
2.tenderness and rebound tenderness
usually caused by inflammation carcinoma
and TB. The part of tenderness is usually the
location of lesion
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Palpation -.tenderness and rebound tenderness
2.tenderness and rebound tenderness
tenderness in
right upper abdomen: hepatitis cholecystitis
lumber region：
kidney stone
right lower abdomen：appendicitis
epigastric region ： peptic ulcer
umbilical ：
small intestine diseases
ascariasis
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Palpation -.tenderness and rebound tenderness
2.tenderness and rebound tenderness
rebound tenderness
---This is a test for peritoneal irritation. Palpate
deeply and then quickly release pressure. If it
hurts more when you release, the patient has
rebound tenderness
---When inflammation involve parietal
peritoneum such as acute peritonitis, acute
appendicitis. The rebound tenderness is
positive
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Palpation -.tenderness and rebound tenderness
tenderness
points
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
palpating methods
--palpation with one hand
--bimanual palpation
--clasping palpation
--ballottement
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
When you palpate the liver you should pay
special attention to the following items
(1) size
(2) texture
(3) contour margin
(4) tenderness
(5) pulsation
(6) friction sound
(7) liver thrill
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(1)The size of liver
---in healthy person the liver is not palpable
or palpable within 1 cm below the costal margin 3 cm
below the xiphoid
---hepatomegaly
diffuse hepatitis
fatly liver
early cirrhosis of liver
hepatic engorgement
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(1)The size of liver
---located enlargement of liver
hepatic cyst
hepatic abscess
---shrinking of liver
acute liver necrosis
cirrhosis of liver
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(1)The size of liver
hepatometry
---midclavicular line
how many cm below costal margin
---abdominal middle line
how many cm below xiphoid process
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(2) Texture
the consistency of liver is divided into 3
degrees
---soft slightly tough as like lips
normal liver
---middle hard as tough as apex nasi
acute chronic hepatitis
---hard as as hard as forehead
cirrhosis carcinoma
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(3) Surface and edge
normal liver:
the surface is smooth and margin is regular
irregular nodular dull: cancer
(4) tenderness
normal liver: no tenderness
light: hepatitis
sever: hepatic abscess
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
(5) Pulsation
normal liver: no pulsation
distensible pulsation:
tricuspid valve incompetence
transmitted pulsation:
aneurysm
(6) friction sound of the hepatic area:
perihepatitis
(7) liver thrill: echinococcosis
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
The error of palpation
(1) patient can`t coordinate with doctor
(2) massive liver to palpate over liver
(3) the doctor`s hand presses too heavy
to move liver down
(4) some organs may be misapprehended
the liver such as:
---transverse colon
---lower extreme of right kidney
---tendon of abdominal rectus
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Palpation - abdominal organs
3. Palpation of the abdominal organs
1)palpation of the liver
The positive Hepatojugular reflux sign:
If you press the liver, you will find the
dilated jugular vein becomes more
bulged or distended, as from the
enlargement of liver passive
congestion resulted from
right failure
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Palpation - abdominal organs
3. Palpation of the abdominal organs
2) Palpation of spleen
---the position of the patient
supine
right lateral decubitus
---palpating methods
palpation with single hand
bimanual palpation
ballottement
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Palpation - abdominal organs
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Supine position
bimanual palpation
Palpation - abdominal organs
right lateral decubitus position
bimanual palpation
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Palpation - abdominal organs
A
Splenometry
1line (A-B line)
midclavicular line
2line (A-C line)
the longest line
3 line (D-E line)
D
E
B
C
Splenometry
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Palpation - abdominal organs
3. Palpation of the abdominal organs
2) Palpation of spleen
splenomegaly is classified into three levels
--- slight: ＜2 cm below the costal border
chronic hepatitis, typhoid fever
--- moderate: ＞2 cm below the costal border but above the
umbilical horizontal line
cirrhosis of liver chronic hemolytic jaundice
--- severe : below the umbilical horizontal line or over anterio
midline
chronic granulocytic leukemia,myelofibrosis
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Palpation - abdominal organs
3. Palpation of the abdominal organs
2) Palpation of spleen
Some organs may be misapprehend
the spleen
(1) enlargement of left kidney
lower extreme - dull edge
(2)enlargement of left lobe of
liver no notch
(3)cyst of pancreatic trail no notch
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Palpation - abdominal organs
3. Palpation of the abdominal organs
3)Palpation of the gallbladder
Method
Put right hand below the costal margin
or lower border of liver at midclavicular
line (grossly equal to the lateral border of the
right rectus muscles) and palpate deeply to chec
for tenderness or bulging.
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Palpation - abdominal organs
Murphy’s sign: acute cholecystitis
courvoisier’s sign：pancreatic carcinoma
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Palpation - abdominal organs
3. Palpation of the abdominal organs
4)Palpation of kidney
Method：the examiner puts his left hand below left rib
cage, at the costospinal angle, and lifts up.
Examiner uses his right hand to palpate deeply
from umbilical level in the left midclavicular line,
and moves progressively upward. The lower pole
of the kidney may be felt as a smooth, round, and
deep structure that moves relatively little with
respiration.
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Palpation - abdominal organs
bimanual palpation
to palpate right kidney
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Palpation - abdominal organs
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bimanual palpation
to palpate left kidney
Palpation - abdominal organs
3. Palpation of the abdominal organs
4)Palpation of kidney
---normal: not palpable
---palpable:
(1) nephroptosis
＞1\2kindey palpable smooth surface middle hard
tenderness (-)
(2)wandering kidney
(3) enlargement of kidney
hydronephrosis，pyonephrosis， tumor
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Palpation - abdominal organs
Tenderness points
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Palpation - abdominal organs
3. Palpation of the abdominal organs
4)Palpation of kidney
Tenderness points kidney urinary tube point
(1) upper ureter point
(2) middle ureter point
ureteritis，ureterolithiasis
(3) costovertebral
(4) costolumber
pyelonephritis，TB kidney
pyelolithiasis
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Palpation - abdominal organs
Costovertebral point
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Palpation - abdominal organs
Costolumber point
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Palpation - abdominal organs
3. Palpation of the abdominal organs
5)Palpation of bladder
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Palpation - abdominal organs
3. Palpation of the abdominal organs
5)Palpation of bladder
---Normal empty not palpable
---distended
palpable round
fluid-filled smooth
disappear after urination
---seen in
unconsciousness
after anesthesia
retention of urine
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Palpation - abdominal organs
3. Palpation of the abdominal organs
6)Palpation of pancrease
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Palpation - abdominal organs
3. Palpation of the abdominal organs
6)Palpation of pancrease
---Normal: not palpable
---epigastric tenderness:
acute pancreatitis
---pancreatic pseudocys
epigastric cystic mass
under the liver no movement
smooth
no tenderness
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Palpation - masses
4. Palpation of masses
(1)Normal masses of abdomen
--tendon of abdominal rectus
--lumber vertebral body
--sacral promontory
--sigmoid colon
--transverse colon
--cecum
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Palpation - masses
4. Palpation of masses
(2)Abnormal mass of abdomen
when you palpate the mass of abdomen you should
describe the
location
size
contour
texture
tenderness
pulsation
mobility
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Palpation - Fluid wave thrill
5. Fluid wave thrill
Methoid
with the patient in supine position, the examiner’s left
hand is placed on the patient’ s right flank, an assistant
(another person) places one hand on the middle of the
abdomen to prevent the transmission of any wave
through the tissues of the abdominal wall
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Palpation - Fluid wave thrill
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Palpation - Fluid wave thrill
5. Fluid wave thrill
Methoid
The examiners’s right hand then lightly taps the left flank
of the patient, in the presence of a significant amount of
ascites, a wave will be transmitted through the fluid to
the examiner’s left hand as a sharp impulse.
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Palpation - Fluid wave thrill
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Palpation - Succussion splash
6. Succussion splash
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Palpation - Succussion splash
6. Succussion splash
this examining method can check for retention of gastric
fluid. If succussion splash is positive after meal 6-8
hours indicating pyloric obstruction
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四、Percussion
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Percussion- The contents of
percussion
The contents of percussion
1、percussion tone of abdomen
2、Percussion of liver
3、Percussion of spleen
4、traube area
5、Percussion of kidney
6、percussion of bladder
7、Percussion of ascites
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Percussion- percussion tone of abdomen
1、percussion tone of abdomen
---liver spleen
---remains
dullness flatness
→ tympany
→
Percussion can check for the presence of abdominal
distention, tumor, fluid, enlargement of viscera.
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Percussion- liver
2、Percussion of liver
--upper margin
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Percussion- liver
2、Percussion of liver
--lower margin
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Percussion- liver
2、Percussion of liver
normal liver
upper limit : 5th intercostal space
lower border : costal margin
diameter of dullness : 9-11cm
enlargement of liver dullness
hepatitis, hepatic carcinoma
hepatic cyst, hepatic abscess
hepatic engorgement
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Percussion- liver
2、Percussion of liver
decreased liver dullness
cirrhosis of liver, hepatonecrosis
absence of liver dullness
perforation of hollow viscus
interposition of hepatic flexure of colon
percussive pain of liver
hepatitis
hepatic abscess
percussive pain of gallbladder
cholecystitis
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Percussion- liver
99
Percussion - spleen
3、Percussion of spleen
normal
---left midaxillary line 9th –11th intercostal space
---width 4-7cm
---enlargement of splenic dullness: splenomegaly
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Percussion - traube area
4、traube area
tympanitic area of stomach
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Percussion - kidney bladder
5、Percussion of kidney
percusive pain of kidney
nephritis glomerulonephritis
pyelothiasis perirenal abscess
6、percussion of bladder
distended bladder dullness
disappear after urination
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Percussion - kidney
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Percussion - ascites
7、Percussion of ascites
---shifting dullness >1000ml
---elbow-knee position check for small
amount ascites
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Percussion - ascites
7、Percussion of ascites
differentiate massive ovariocyst from ascites
ovariocyst
dullness locate center abdomen
no shifting dullness
ruler pressing test (＋)
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Percussion - ascites
7、Percussion of ascites
differentiate massive ovariocyst from ascites
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五、Auscultation
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Auscultation - The contents of Auscultation
The contents of Auscultation
1、bowel sound
2、vascular bruit
3、Friction rub
4、Scratch sound
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Auscultation - bowel sound
1、bowel sound
---normal 4-5times /min
---increased >10times
acute intestinitis
---loud high-pitched tinkling quality
intestinal obstruction
---decreased or disappeared
acute peritonitis, intestinal paralysis
electrolyte disorder
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Auscultation - vascular bruit
2、vascular bruit
systolic bruit
---partial occlusion of renal artery above
umbilicus left or right side
---hepatic cancer lesion area
---abdominal aneurysm or partial occlusion
of abdominal aorta
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Auscultation - vascular bruit
2、vascular bruit
vein bruit
---periumbilicus, upper abdomen or over the
liver
---continuous humming sound
---seen in portal hypertension caused by
cirrhosis of liver
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Auscultation - Friction rub
3、Friction rub
over the spleen or over the liver
perisplenitis caused by spleen infarction
perihepatitis
112
Auscultation - Scratch sound
4、Scratch sound
---exploration of hepatic lower edge
auscultary percussion
auscultary scratch
---exploration of small quantity of ascites
about 120 ml
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五、The main symptoms
and signs of abdominal common diseases
114
main symptoms and signs
Gastric and Duodenal Ulcer
In etiology, gastric and duodenal ulcer always have
relation to hydrochloric acid and pepsin, so they are
also called Peptic Ulcer
115
main symptoms and signs
Gastric and Duodenal Ulcer
Symptoms
Chronic pigastric pain is main symptom of
peptic ulcer
The pain has following features
116
main symptoms and signs
Gastric and Duodenal Ulcer
1 Location and Extent
The pain from gastric ulcer is just under xiphoid
or left,
but duodenal ulcer is located in the middle of
epigastrium or right
The extent of the pain is just like a palm size
117
main symptoms and signs
Gastric and Duodenal Ulcer
2 The character of pain
The character of pain is frequently described as
burning, blunt or hunger pain
The pain is continuous, often lasting 1-4h
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main symptoms and signs
Gastric and Duodenal Ulcer
3 Chronicity and Recurrence of peptic ulcer
some patients with peptic ulcer are reported
annual recurrence of pain during particular
seasons, such as spring or autumn, especially
early spring or late autumn
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main symptoms and signs
Gastric and Duodenal Ulcer
4 The rhythmicity of pain
The pain from peptic ulcer has certain relation
to meals
The pain from gastric ulcer often occurs at 0.52h after meals, disppear until next meal.
The rhythmicity of pain is meal-pain-remission
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main symptoms and signs
Gastric and Duodenal Ulcer
The pain from duodenal ulcer often occurs at 2-3h
after meal, until next meal, so the rhythmicity of
pain is
pain-meal-remission, so called hunger pain and
the pain usually occurs at bed time or midnight,
so called nocturnal pain.
121
main symptoms and signs
Gastric and Duodenal Ulcer
Other symptoms
in addition to pain, the patient with peptic ulcer
may have other symptoms such as nausea,
vomiting, heartburn, weight loss and so on.
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main symptoms and signs
Gastric and Duodenal Ulcer
Signs
During remission, on signs can be found, but in
active peptic ulcer, most frequently there is a
epigastric tenderness, the point of tenderness
is just the same as the location of peptic ulcer.
123
main symptoms and signs
Gastric and Duodenal Ulcer
Complications
Bleeding
Perforation
Obstruction
Gastric cancer
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THANKS!
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