Calculating Risk Types of risk factors CVD – causes/risk factors CVD – treatments
Risk factors for ↓ PLT
-
Upload
pandora-hood -
Category
Documents
-
view
28 -
download
0
description
Transcript of Risk factors for ↓ PLT
![Page 1: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/1.jpg)
Risk factors for ↓ PLT Idiopathic Thrombocytopenic purpura (ITP):
bleeding disorder, immune system destroys PLTs Thrombotic Thrombocytopenic disorder (TTP):
blood disorder causing blood clots to form in small blood vessels around body→ ↓ PLT
Hypercoagualtion disorder (DIC, Thrombosis) Hypocoagulation disorder (Liver Dz, Vitamin K
deficiency) Chemotherapy—nadir day+7-14 recovery within 2-
6 weeks Radiation tx Medications( ASA, digoxin, furosemide, phenytoin,
quinidine, sulfonamide, tetracycline)
![Page 2: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/2.jpg)
Mgmt Thrombocytopenia
PLT transfusions PLT<10,000 Colony stimulating factors, eg IL 11
(Neumega) Steroids Progesterone ↓ menstrual bleeding
![Page 3: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/3.jpg)
Nursing interventions
Avoid tight BP cuffs when PLT<20,000 Avoid invasive procedures Avoid sharp objects/no barefoot Apply firm pressure to venipuncture sites
for 5 minutes Treat nose bleeds with high fowler’s
position-icepack Prevent constipation Encourage soft toothbrushes
![Page 4: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/4.jpg)
Why do we evaluate WBC?
To assess body's response to significant bacterial insult, such as appendicitis, Pelvic inflammatory disease, pneumonia, pyelonephritis, and SEPSIS
![Page 5: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/5.jpg)
WHITE BLOOD CELLSWHITE BLOOD CELLS
Segmented Segmented Neutrophil (60%)Neutrophil (60%)
Lymphocytes(30%)Lymphocytes(30%) Monocytes(6%)Monocytes(6%) Eosinophils(3%)Eosinophils(3%) Basophils(1%)Basophils(1%)
![Page 6: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/6.jpg)
SEGMENTED SEGMENTED NEUTROPHILNEUTROPHIL
11STST line of defense line of defense Normal 50-70%Normal 50-70% Survive 1-2 DAYSSurvive 1-2 DAYS
![Page 7: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/7.jpg)
LYMPHOCYTESLYMPHOCYTES
2 Types by 2 Types by appearance: Large appearance: Large granular and smallgranular and small
Large granular are Large granular are NK cellsNK cells
Small are T & B cell Small are T & B cell T cell mediated T cell mediated
immunityimmunity B cell humoral B cell humoral
immunityimmunity
![Page 8: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/8.jpg)
MONOCYTEMONOCYTE
5-10 % Circulating 5-10 % Circulating WBCsWBCs
When stimulated When stimulated become become Macrophages and Macrophages and dentritic cells in dentritic cells in the tissuethe tissue
Clean up the Clean up the debrisdebris
![Page 9: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/9.jpg)
EOSINOPHILEOSINOPHIL
1-5% Circulating 1-5% Circulating WBCSWBCS
Involved in Involved in parasitic infectionsparasitic infections
Involved with Involved with mechanism mechanism associated with associated with allergy and asthmaallergy and asthma
↑↑In case of w.w.w.In case of w.w.w.
![Page 10: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/10.jpg)
BASOPHILBASOPHIL
< 1% circulating < 1% circulating WBCSWBCS
Involved with Involved with allergic and allergic and inflammatory inflammatory responseresponse
Release histamines Release histamines and cytokinesand cytokines
![Page 11: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/11.jpg)
Hematological Symptoms
![Page 12: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/12.jpg)
Hematological Symptoms
Neutropenia—defined as ANC<1000/mm3
Anemia--↓RBC & Hgb Thrombocytopenia—low PLT <100,000 Leukopenia—decrease in WBC, below
the lower limit Pancytopenia-an abnormal deficiency
in all blood cells, RBC, WBC, & PLT; usually associated with bone marrow tumor or with aplastic anemia)
![Page 13: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/13.jpg)
Risk factors for febrile neutropenia
Previous Hx Chemo/Type of chemo/prior radiation Tx
Age>65/ female gender Poor nutritional status Advanced cancer and bone marrow
involvement ↑LDH, ↓Hgb Leukemia/lymphoma/lung cancer Open wounds DM COPD
![Page 14: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/14.jpg)
Prevention of Neutropenia
Growth stimulating factors activate production of bone marrow cells. It can be given prophylactically or therapeutically
BMT give GCSF on day+4 of stem cell SCT
GCSF-/filgrastim 5mcg/kg Pegfilgrastim--Neulasta 6mcg/kg
![Page 15: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/15.jpg)
Neutropenic Precautions
Limit exposure of pts to infections Hand washing ↓spread Avoid crowds Avoid fresh fruits
/vegetables/flowers Avoid caring for animals esp.
cleaning excretes Avoid gardening
![Page 16: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/16.jpg)
Infections
Mechanical barriers—skin, mucous membranes
Chemical barriers-pH of tissues Inflammatory and immune responses
![Page 17: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/17.jpg)
Risks of Infections
High risk Intermediate risk Low risk
![Page 18: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/18.jpg)
High Risk for infection Allogeneic BMT Acute Leukemia's GVHD tx ↑dose steroids Neutropenic lasting >10 days Break in skin/mucosal barrier Prolonged ABX or steroid use Poor nutrition Invasive procedure Poor personal hygiene
![Page 19: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/19.jpg)
Intermediate Risks for infections
Autologous BMT Lymphoma/MM/CLL Neutropenic anticipated to last >7-
10 days
![Page 20: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/20.jpg)
Low Risk for infections
Standard Chemotherapy Neutropenia <7 days
![Page 21: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/21.jpg)
PT AND PTTPT AND PTT
PT (PROTIME) Test the extrinsic PT (PROTIME) Test the extrinsic pathwaypathway
PTT Tests the intrinsic pathwayPTT Tests the intrinsic pathway COUMADIN (WARFARIN) Affects the COUMADIN (WARFARIN) Affects the
Vitamin K factors (II,VII,IX,X ) of which Vitamin K factors (II,VII,IX,X ) of which factor VII is the most labilefactor VII is the most labile
Hemophilia is a factor VIII deficiencyHemophilia is a factor VIII deficiency INR: Method for standardizing Protimes. INR: Method for standardizing Protimes.
It is a ration of tested results : controlIt is a ration of tested results : control
![Page 22: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/22.jpg)
COAGULATION COAGULATION PRODUCTSPRODUCTS
Fresh Frozen PlasmaFresh Frozen Plasma Cryoprecipitate: Factor VIII, Cryoprecipitate: Factor VIII,
FibrinogenFibrinogen Activated Products: Factor IXActivated Products: Factor IX
![Page 23: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/23.jpg)
Chemistry TestsChemistry Tests
Liver Function StudiesLiver Function Studies Renal FunctionRenal Function Electrolytes—Na, K, Ca, Mg, Po4, Electrolytes—Na, K, Ca, Mg, Po4,
Co2Co2
![Page 24: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/24.jpg)
LIVER FUNCTIONLIVER FUNCTION
Hepatocelluar Enzymes: Hepatocelluar Enzymes: AST AST (ASPARTATE AMINOTRANSFERASE) (ASPARTATE AMINOTRANSFERASE)
ALTALT (ALANINE AMINOTRANSFERASE) (ALANINE AMINOTRANSFERASE)
SGGT (very specific) SGGT (very specific) LDH (Lactate Dehydrogenase)LDH (Lactate Dehydrogenase)
![Page 25: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/25.jpg)
LIVER FUNCTIONLIVER FUNCTION
ALKALINE PHOSPHATASE-AP not specific to ALKALINE PHOSPHATASE-AP not specific to liverliver
AP= LARGE COMPONENT IN BONE AP= LARGE COMPONENT IN BONE
BILIRUBIN -2 TYPESBILIRUBIN -2 TYPES DIRECT OR CONGUGATED AND DIRECT OR CONGUGATED AND
INDIRECT OR INDIRECT OR UNCONGUGATED.UNCONGUGATED.
AP / BILIRUBIN the first enzymes AP / BILIRUBIN the first enzymes to rise with liver GVHDto rise with liver GVHD
INDIRECT BILIRUBIN associated INDIRECT BILIRUBIN associated with hemolysiswith hemolysis
![Page 26: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/26.jpg)
LDH Nearly every type of cancer, as well as many
other diseases, can cause LDH levels to be ↑, cannot be used to dx a particular type of cancer.
LDH levels can be used to monitor treatment of some cancers, including testicular cancer, Ewing's sarcoma, non-Hodgkin's lymphoma, and some types of leukemia
Elevated LDH levels can be caused by a number of noncancerous conditions, including heart failure, hypothyroidism, anemia, and lung or liver disease.
![Page 27: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/27.jpg)
RENALRENAL
BUN BUN (BLOOD UREA NITROGEN)(BLOOD UREA NITROGEN) Elevated with:Elevated with: Kidney Kidney dysfunction, Dehydration, excess protein in dysfunction, Dehydration, excess protein in blood such as TPN, High protein diet, GI blood such as TPN, High protein diet, GI bleedingbleeding
Creatinine: Creatinine: chemical waste is generated chemical waste is generated from muscle metabolism. Creatinine is from muscle metabolism. Creatinine is produced from creatine, a molecule of major produced from creatine, a molecule of major importance for energy production in importance for energy production in muscles. Creatinine is transported through muscles. Creatinine is transported through the bloodstream to the kidneys. The kidneys the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose filter out most of the creatinine and dispose of it in the urine.of it in the urine.
![Page 28: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/28.jpg)
CREATININE CREATININE CONT.CONT.
The ratio of BUN : creatinine determines The ratio of BUN : creatinine determines renal dysfunction VS pre-renal dysfunction renal dysfunction VS pre-renal dysfunction such as dehydrationsuch as dehydration. .
CALCULATED CREAT. CLEARANCE:CALCULATED CREAT. CLEARANCE:
in ml/min---CRCL=(140-AGE) x ideal B.W./Scr. in ml/min---CRCL=(140-AGE) x ideal B.W./Scr. x 72 (x 0.85 for females)x 72 (x 0.85 for females)
![Page 29: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/29.jpg)
ELECTROLYTESELECTROLYTES
SODIUMSODIUM POTASSIUMPOTASSIUM CALCIUMCALCIUM PHOSPHORUSPHOSPHORUS MAGNESIUMMAGNESIUM CO2CO2
![Page 30: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/30.jpg)
SODIUM/POTASSIUMSODIUM/POTASSIUM
SODIUM SODIUM /POTASSIUM /POTASSIUM MEMBRANE MEMBRANE PUMPPUMP
![Page 31: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/31.jpg)
CALCIUM/PHOSPHORUSCALCIUM/PHOSPHORUS
DIRECT DIRECT INTERACTIONINTERACTION
IF GIVEN IF GIVEN CONCOMBINETLYCONCOMBINETLY:: NaPO4 + NaPO4 + CaCO3 =CaCO3 =
![Page 32: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/32.jpg)
CALCIUMCALCIUM
Calcium in plasma is bound to Albumin. Calcium in plasma is bound to Albumin. If Albumin is low, you get a falsely low If Albumin is low, you get a falsely low serum calcium. serum calcium.
2 ways to get a more accurate Calcium: 2 ways to get a more accurate Calcium:
IONIZED CALCIUMIONIZED CALCIUM CORRECTED CALCIUMCORRECTED CALCIUM
CORRECTED Calcium: CORRECTED Calcium: [(4.0 – serum alb) x 0.8 ] + s Ca [(4.0 – serum alb) x 0.8 ] + s Ca = corrected Ca= corrected Ca
![Page 33: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/33.jpg)
MAGNESIUM
Very important for Cardiac, Nervous Very important for Cardiac, Nervous and GI systems.and GI systems.
Interacts with calcium and Interacts with calcium and Potassium.Potassium.
Difficult to get a Normal serum level Difficult to get a Normal serum level of Potassium if Mg is low.of Potassium if Mg is low.
![Page 34: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/34.jpg)
CO2CO2
Gives a rough idea of pH and buffer Gives a rough idea of pH and buffer system in bloodsystem in blood
Infections typically have low venous Infections typically have low venous CO2CO2
![Page 35: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/35.jpg)
Bone marrow Biopsy-aspirate
Used in Identi. metastatic Dz, esp hematological malignancies
Assess iron stores Assess megaloblastic maturation, in
Vit B12 and folate deficiencies or in MDS
Assess fat atrophy, aplasia or fibrosis
![Page 36: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/36.jpg)
Other tests done in Hem/Onc
Fractionated bilirubin—to differentiate cause of hyperbilirumia
Stool guaiac--? bleeding Coombe’s test—direct/indirect Haptoglobin level—to detect
hemolytic anemia Hgb electropheresis----
![Page 37: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/37.jpg)
MICROBIOLOGYMICROBIOLOGY
BACTERIABACTERIA VIRUSVIRUS FUNGAL/YEASTFUNGAL/YEAST PROTOZOANPROTOZOAN
![Page 38: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/38.jpg)
BACTERIABACTERIA
CATAGORIZED BY SHAPE AND CATAGORIZED BY SHAPE AND STAINING PROPERTIESSTAINING PROPERTIES
GRAM’S STAINGRAM’S STAIN SHAPES ARE COCCI, RODS, AND SHAPES ARE COCCI, RODS, AND
SPIROCHETESSPIROCHETES
![Page 39: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/39.jpg)
BACTERIAL SHAPESBACTERIAL SHAPES
COCCICOCCI RODSRODS SPIROCHETESSPIROCHETES
![Page 40: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/40.jpg)
GRAM’S STAINGRAM’S STAIN INTERACTS WITH THE BACTERIAL INTERACTS WITH THE BACTERIAL
MEMBRANE AND STAINS IT EITHER MEMBRANE AND STAINS IT EITHER BLUE OR REDBLUE OR RED
BLUE IS GM (+)BLUE IS GM (+) RED IS GM (-)RED IS GM (-)
![Page 41: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/41.jpg)
GRAM POSITIVEGRAM POSITIVE
COCCI: 1. STAPHALOCOCCUS COCCI: 1. STAPHALOCOCCUS EITHER COAGULASE (-) OR EITHER COAGULASE (-) OR
(+)(+) COAG NEG=STAPH COAG NEG=STAPH EPID.EPID. COAG POS= STAPH COAG POS= STAPH
AUREUSAUREUS
2. STREP, 2. STREP, ENTEROCOCCUSENTEROCOCCUS
RODS: BACILLUS, LISTERIA, RODS: BACILLUS, LISTERIA, CORYNEBACTERIA CORYNEBACTERIA
DIPTHERIADIPTHERIA
![Page 42: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/42.jpg)
Staph aureusStaph aureus
![Page 43: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/43.jpg)
GRAM NEGATIVEGRAM NEGATIVE
COCCI: NEISSERIA, MORAXELLA, COCCI: NEISSERIA, MORAXELLA, ACINETOBACTERACINETOBACTER
RODS: E.COLI, PSEUDOMONAS, RODS: E.COLI, PSEUDOMONAS, SHIGELLA, SALMONELLA, SHIGELLA, SALMONELLA, KLEBSIELLA, PROTEUS, KLEBSIELLA, PROTEUS, ENTEROBACTER, VIBRIOENTEROBACTER, VIBRIO
![Page 44: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/44.jpg)
Gram Negative rodsGram Negative rods
![Page 45: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/45.jpg)
FUNGUSFUNGUS
MOLDS: MOLDS: ASPERGILLUS , ASPERGILLUS , MUCOR, MUCOR,
YEAST AND YEAST-YEAST AND YEAST-LIKE: CANDIDA, LIKE: CANDIDA, TORULOPSIS, TORULOPSIS, HISTOPLASMOSIS, HISTOPLASMOSIS, CRYPTOCOCCUS, CRYPTOCOCCUS, BLASTO.BLASTO.
![Page 46: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/46.jpg)
FUNGUSFUNGUS
![Page 47: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/47.jpg)
VIRUSVIRUS
CYTOMEGALOVIRUSCYTOMEGALOVIRUS EPSTEIN-BAREPSTEIN-BAR BKBK ADENOVIRUSADENOVIRUS INFLUENZA A & BINFLUENZA A & B PARAINFLUENZAPARAINFLUENZA RSVRSV
![Page 48: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/48.jpg)
PNEUMOCYSTIS PNEUMOCYSTIS CARINIICARINII
PREVIOUSLY PREVIOUSLY CONSIDERED A CONSIDERED A PROTOZOAN BUT PROTOZOAN BUT NOW IN FUNGUS NOW IN FUNGUS CLASSCLASS
![Page 49: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/49.jpg)
References Demetri, G. (2001) Anemia and its functional consequences in
cancer pts, current challenges in management & prospects for improving therapy. British Journal of Cancer,84,31-37
Dessypris, E, Erythropoiesis (1988). Lee G R, Foster J, Lukens J, Wintrobe M M, eds.Wintrobe’s clinical hematolology. Pa: Lippincott Williams & Williams 1998. 169-192.
Ludwig H, & Strasser K.(2001) Symptomatology of anemia. Seminars in oncology, 28, 7-10
Means, R. (1999). The anemias of chronic disorders. Lee GR, Foerster J, Lukens J, Paraskeras F, Greer J P, Rodgers GM, eds. WIntrobe’s Clinical hematolgoy.10th ed, Pa. Lippincott Williams & Wilkin;1999:1011-1021
National Comprehensive Cancer Network (2007). Cancer and treatment related anemias, version 3.2007
![Page 50: Risk factors for ↓ PLT](https://reader038.fdocuments.us/reader038/viewer/2022110101/56812dcf550346895d930fed/html5/thumbnails/50.jpg)
Shortcut to DSC03990.lnk
The End