About userAction 4lastPage <> "About" userAction userAction About About lastPage This is the ToolBook version of the Windows application originally developed by Andrew Booth and Jonathan Danks. You can distribute the unmodified book freely and modify it to your own requirements. However, we ask the following: 1 - By all means give yourself credit for your work, but please leave this page unaltered in your book and provide a route to it. 2 - It is important that teaching material of this kind is disseminated as widely as possible, so please ensure that your material is also freely available. 3 - We would like to set up a library of Case Notes, so when you have finished and tested your case(s), please would you send a copy (with any accompanying material) to: Dr A.G.Booth, Department of Biochemistry & Molecular Biology, University of Leeds, Leeds LS2 9JT, UK 44 532-333142 fax 333167 email bmb6agb@uk.ac.leeds.gpssssssssssssssssssssssss About Case Notes userAction 4MB_OK,MB_ICONEXCLAMATION 4score, ,examination,diagnosed 4BloodTest1,BloodTest2,BloodTest3,BloodTest4,BloodTest5,BloodTest6,BloodTest7 MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ Iblood have been done -- no need dialog box - just -- Script Tests -- The code placed here so that _can be edited. -- Its are attached B"Dialog" -- on "Blood_tests". However, its destroyed each re-authored, so xused. -- Initialise controls, disable those already Disabling a Hdirectly altering estyle dlgBox property names These were editor. init dlgInit -- initialise Ibecause they -- might come ctesting authoring version FALSE setValue( , button1, , button2, , button3, , button4, , button5, , button6, , button7, DisableControl( Bloodtest7 wait dismissed retValue -- If Bhas pressed -- find out qstate update fill card appropriately. -- We must a linefeed Author Reader getValue( -- glucose + 10 -- lactate + 10 -- salicylate -- urate } + 10 -- cholesterol Bloodtest5 -- triglycerides -- free fatty acids userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox Dialog dlgInit setValue setValue setValue setValue setValue setValue setValue Dialog dlgBox DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl Bloodtest7 DisableControl Dialog dlgBox Dialog dlgBox dialog getValue getValue Author Reader getValue Author Reader getValue Author Reader getValue Author Reader getValue Bloodtest5 Author Reader getValue Author Reader getValue Bloodtest7 Author Reader Blood tests... Blood_tests retValue button7 button6 button5 button4 button3 button2 button1 BloodTest1 BloodTest2 BloodTest3 BloodTest4 BloodTest5 BloodTest6 BloodTest7 score history examination diagnosed MB_OK MB_ICONEXCLAMATION userAction 4lastPage 4examination, diagnosed,BiopsyTest1,BiopsyTest2 4MB_OK,MB_ICONEXCLAMATION,MB_YESNO,MB_DEFBUTTON2,MB_ICONQUESTION,IDNO MessageBox( "Diagnosis should xdepend" & "solely on guesswork intuition." & "Try examining the patient.", \ "A moment please.",\ -- has a definitive biopsy been done yet? FALSE "You still xhave enough" & "information aa diagnosis." & Iwill be penalised heavily "you aa wrong "Do want d?", \ -- remember where we are so that we can come userAction userAction Diagnosis should not depend solely on guesswork or intuition. Try examining the patient. A moment please. MessageBox You still do not have enough information to make a diagnosis. You will be penalised heavily if you make a wrong diagnosis. Do you want to continue? A moment please. MessageBox Diagnosis Diagnosis MB_OK MB_ICONEXCLAMATION MB_YESNO MB_DEFBUTTON2 MB_ICONQUESTION examination diagnosed BiopsyTest1 BiopsyTest2 lastPage Diagnosis Dismiss Diagnoses B"OK" buttonDoubleClick buttonDoubleClick buttonUp Juvenile-onset diabetes mellitus von Gierke's disease Glycogen storage disease type 1b Pompe's disease Galactosaemia Hereditary fructose intolerance Maple syrup urine disease Lesch-Nyhan syndrome Tay-Sachs' disease Booth-Danks syndrome &Info --find out which diagnosis selected the list box temp selectedTextLines "Diagnoses" "Diagnosis" & "Info" B"Dismiss" buttonUp buttonUp Diagnoses Diagnosis Dismiss Dismiss Cancel 4lastPage B"Dismiss" "Info" buttonUp buttonUp Dismiss lastPage Cancel :PHYSSIZE Tay-Sachs' disease This usually presents at 4-6 months of age with progressive neurological symptoms. Delay in psychomotor development, irritability, spasticity, weakness and muscle wasting lead to loss of vision, deafness and decerebrate rigidity. Death occurs usually by three years. It is inherited as an autosomal recessive character and is 100 times commoner in Ashkenazi Jews than in the general population. Due to a deficiency of beta-N-acetyl hexosaminidase. erance test is unnecessary. utropaenia.s inevitable. "Info" buttonUp buttonUp Diagnosis1 Juvenile-onset diabetes mellitus This presents over a period of a few weeks with thirst, polyuria and rapid weight loss. There is glycosuria and progressive hyperglycaemia and ketoacidosis. Untreated the condition will rapidly progress with metabolic acidosis, hyperventilation, vomiting, abdominal pain and dehydration leading to circulatory collapse, coma and death. In such cases, diagnosis is made on the basis of unequivocal hyperglycaemia and ketoacidosis. The glucose tolerance test is unnecessary. Diagnosis2 von Gierke's disease This is glycogen storage disease type 1a. It is characterized by an absence of glucose 6-phosphatase in biopsies of liver, intestine or in platelets. There is hepatomegaly, hyperuricaemia, hypoglycaemia and hyperlipidaemia, but no aminoaciduria or ketosis. The glucose tolerance test shows an abnormal rise in blood glucose concentration with hypoglycaemia at the beginnining and end. There is an abnormal response to glucagon with an increase in blood lactate but not glucose. Diagnosis3 Glycogen storage disease type 1b This is clinically very similar to von Gierke's disease (q.v.). Glucose 6-phosphatase is present at normal levels of activity, but it shows abnormal latency, i.e. full activity is only seen after disrupting membrane structures with freezing and thawing or by treatment with detergent. The defect is in the glucose 6-phosphate translocase T1, which transports glucose 6-phosphate from the cytoplasm into the lumen of the endoplasmic reticulum. These patients often have a neutropaenia..... Diagnosis9 Diagnosis10 Diagnosis4 Pompe's disease This is due to an absence of the lysosomal enzyme alpha-1,4-glucosidase which can be demonstrated in cultured fibroblasts. It presents in the first few months of life, with marked hypotonia and cardiomegaly, hepatomegaly not becoming marked until the inevitable heart failure becomes severe. There is accumulation of glycogen, an abnormal response to glucagon but no hypoglycaemia. As yet there is no effective treatment and death is inevitable, usually within the first twelve months.ia..... Diagnosis5 Galactosaemia This is due to a deficiency of galactose 1-phosphate uridyl transferase which can be detected in cultured fibroblasts. Normal at birth, symtoms start to appear as early as the second week with weight loss, jaundice, vomiting and hepatomegaly. After a few weeks cataracts develop. Unless the condition is quickly recognised death is inevitable and unless treatment (the substitution of a galactose (milk) free diet) is started in the first week of life a degree of mental subnormality appears inevitable.. Diagnosis6 Hereditary fructose intolerance This is due to a deficiency of fructaldolase B and can be demonstrated in liver and intestine biopsy samples. Symptoms of sweating, vomiting and trembling are precipitated by feeding sucrose. There is hypoglycaemia, fructosaemia, fructosuria, hyperuricaemia and aminoaciduria. If the condition is not recognised and exposure to fructose continues, then jaundice, hepatomegaly, oedema, ascites, haemorrhage and eventually death will follow. Many of the liver function tests are abnormal.ears inevitable.......... Diagnosis7 Maple syrup urine disease This is due to a deficiency of branched chain alpha-ketoacid decarboxylase. There is hypertonicity alternating with flaccidity, opisthotonus and nystagmus, convulsions and often mental retardation. There are branched chain amino acids and keto acids in the urine.minoaciduria. If the condition is not recognised and exposure to fructose continues, then jaundice, hepatomegaly, oedema, ascites, haemorrhage and eventually death will follow. Many of the liver function tests are abnormal.ormal.ears inevitable.......... Diagnosis8 Lesch-Nyhan syndrome This presents in affected males (it is an X-linked disorder) with delayed motor development in the first few months leading to choreoathetosis, spasticity and a bizarre urge to self-mutilation such as biting off finger tips. Due to a deficiency of hypoxanthine-guanine-phosphoribosyl transferase (HGPRT), the striking biochemical feature is a gross hyperuricaemia. The diagnosis may be confirmed by demonstrating the enzyme deficiency in cell extracts. e liver function tests are abnormal.ormal.ears inevitable.......... Tay-Sachs' disease This usually presents at 4-6 months of age with progressive neurological symptoms. Delay in psychomotor development, irritability, spasticity, weakness and muscle wasting lead to loss of vision, deafness and decerebrate rigidity. Death occurs usually by three years. It is inherited as an autosomal recessive character and is 100 times commoner in Ashkenazi Jews than in the general population. Due to a deficiency of beta-N-acetyl hexosaminidase. liver function tests are abnormal.ormal.ears inevitable.......... Booth-Danks syndrome This is characterized by rectopthmus and a general photophobia in the presence of computer monitors. There is an irrational fear of rodents, most noticably mice. There is often a neurosis connected with particularly obscure metabolic diseases. Carbohydrate metabolism is normal, the glucose tolerance test etc. etc. ...how are you feeling now?r in Ashkenazi Jews than in the general population. Due to a deficiency of b-N-acetyl hexosaminidase. liver function tests are abnormal.ormal.ears inevitable.......... userAction 4MB_OK,MB_ICONEXCLAMATION 4score, ,examination,diagnosed 4HETest1,HETest2,HETest3,HETest4,HETest5,HETest6 4HETest7,HETest8,HETest9,HETest10,HETest11,HETest12 4HormoneDone MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ Ihormones enzymes have been done -- no need dialog box - just TRUE HETest13 "HormonesEnzymes" -- Script -- The code placed here so that can be edited. -- Its are attached B"Dialog" -- on However, its destroyed each re-authored, so xused. -- Initialise controls, disable those already Disabling a Hdirectly altering estyle dlgBox property names These were editor. init dlgInit FALSE setValue( , button1, , button2, , button3, , button4, , button5, , button6, , button7, , button8, , button9, , button10, , button11, , button12, DisableControl( wait dismissed retValue -- If Bhas pressed -- find out qstate update fill card appropriately. -- We must a linefeed Author Reader getValue( -- cortisol FirstHDone -- no -- ACTH -- no -- insulin -- glucagon + 10 -- growth -- no -- free thyroxine index -- no -- total -- no -- TSH -- no -- acid phosphatase -- no -- amylase -- no -- creatine kinase -- no -- lactate dehydrogenase -- no - see #4" & "Blood_tests" userAction FirstHDone s#userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox HormonesEnzymes Dialog dlgInit setValue setValue setValue setValue setValue setValue setValue setValue setValue setValue setValue setValue Dialog dlgBox DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl DisableControl Dialog dlgBox Dialog dlgBox dialog getValue getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader getValue FirstHDone Author Reader Hormones & Enzymes... HormonesEnzymes retValue button12 button11 button10 button9 button8 button7 button6 button5 button4 button3 button2 button1 HETest13 HormoneDone HETest7 HETest8 HETest9 HETest10 HETest11 HETest12 HETest1 HETest2 HETest3 HETest4 HETest5 HETest6 score history examination diagnosed MB_OK MB_ICONEXCLAMATION FirstHDone Hormones & Enzymes - see card #4 Reader Blood_tests HormoneDone Biopsy Liver Biopsy: Microscopy: The liver cells are packed with a granular material that stains strongly with periodic acid/Schiff's reagent. Biochemistry: Very low levels of glucose 6-phosphatase. Intestinal Mucosa Biopsy: Microscopy: Nothing abnormal detected. Biochemistry: Very low levels of glucose 6-phosphatase. Culture of Skin Fibroblasts: Microscopy: Nothing abnormal detected. Biochemistry: Nothing abnormal detected. Sternal Puncture: Microscopy: Nothing abnormal detected. Biochemistry: Nothing abnormal detected. Biopsy Results Dialog --Move linkDLL statement handler "tbkdlg.dll" dialog( setValue( getValue( init dlgInit ,"","") function retValue dlgBox ", "") buttonUp buttonUp tbkdlg.dll dialog setValue getValue dlgInit dlgBox dialog retValue dlgInit ,g38, button button1,b5,FALSE button button2,b6,FALSE button button3,b7,FALSE button button4,b8,FALSE button OK,b29,TRUE button Cancel,b30,FALSE dlgBox 524480,7,30,20,172,90,,,Biopsies,8,Helv,,3.85,3.49,108.27,67.57,38,1342177287,128,,0,button1,12.91,12.76,87.70,10.46,5,1342177289,128,&Liver,0,button2,12.91,26.83,91.50,10.46,6,1342177289,128,&Intestinal mucosa,0,button3,12.91,40.90,89.60,10.46,7,1342177289,128,Skin &fibroblasts,0,button4,12.91,54.97,89.60,10.46,8,1342177289,128,&Sternal puncture,0,OK,119.31,18.79,50.90,12.31,29,1342242817,128,OK,0,Cancel,119.31,42.91,50.90,12.31,30,1342242816,128,Cancel,0 ctrlID Dialog Examination_done userAction 4score, ,examination,diagnosed 4MB_YESNO,MB_ICONQUESTION,IDYES MessageBox( "Before doing z" & "wouldn't be a good idea" & take the patient's "A moment please",\ -- penalise ignoring advice! "Details_hidden" "Author" "Reader" e"Examination" "Examination_done" userAction keyChar userAction Before doing any examination, wouldn't it be a good idea to take the patient's history? A moment please MessageBox Details_hidden Author Reader Examination Examination_done MB_YESNO MB_ICONQUESTION IDYES score history examination diagnosed keyChar Details buttonUp Details buttonUp Details_hidden Some tests will provide additional material such as graphs etc. In this case, the extra material will be attached to the back of the card with a paper clip. To see it, press the space bar or move the mouse pointer over the clip or the visible part of the attached material and press the left button. Try it now. Then go to the next card (left button - remember?) Details_hidden "Details" buttonup buttonup Details Little_Clip Details "Details" buttonUp buttonUp Details Big_Clip To put the attached material back behind the card, simply press the space bar again or move the mouse pointer over the paper clip and click the left button. Try it now. Author Reader getValue Author Reader getValue Author Reader getValue Author Reader getValue Author Reader getValue Author Reader Author Reader Author Reader getValue Author Reader Urinalysis.... Urinalysis retValue button10 button9 button8 button7 button6 button5 button4 button3 button2 button1 UTest7 UTest8 UTest9 UTest10 UTest1 UTest2 UTest3 UTest4 UTest5 UTest6 score history examination diagnosed MB_OK MB_ICONEXCLAMATION .{ {.s .k S/c /[ 30S E 4u< Biopsy userAction 4score,TotalPossible,pack, ,examination, diagnosed 4BiopsyTest1,BiopsyTest2,BiopsyTest3,BiopsyTest4 4ProvocativeTests,BiopsyTests 4MB_OK,MB_YESNO,MB_ICONEXCLAMATION,MB_ICONQUESTION 4MB_ICONHAND,MB_DEFBUTTON2,IDNO MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ -- don't allow biopsies be done Zenough other have been !(uses function declared ReadyForNastyTests() "These may prove valuable," & "but they j potentially" & "dangerous. unfair try these 4you exhausted "sources information.", \ .", \ , simply unlikely happen since -- too many provocative will kill TRUE < 2) "Are sure that there anything" & gain subjecting a small child" & procedure?", \ .", \ -- Script dialog box. -- The code placed , can be edited. -- Its are attached B"Dialog" -- on However, its destroyed each re-authored, so xused. -- Initialise controls, disable those already Disabling a Hdirectly altering estyle dlgBox property names were editor. init dlgInit FALSE setValue( V, button1, n, button2, , button3, , button4, DisableControl( wait dismissed retValue Bhas pressed, values -- buttons act accordingly getValue( w,OK) -- introduce a conscience! > 0 really going another biopsy?", \ .", \ complications! = 2) "Your had a haemorrhage." & now under Do you" & "want d?", \ .", \ = 3) massive" & , went shock" & died. Not only "lost your " & "also %points.", \ .", \ up results student gets credit liver intestinal allowed wrong immediately E o convince he/she dealing infant rather than a lab + 50 -- deduct unnecessary suffering! - 50 - 50 five lines on card J"Author" J"Reader" mucose + 50 - 50 - 50 three -- skin fibroblasts -- no , so - 50 - 50 -- sternal puncture -- no , so - 50 - 50 e"Biopsies" userAction &userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox ReadyForNastyTests These tests may prove valuable, but they are potentially dangerous. It is unfair to the patient to try these tests before you have exhausted other sources of information. A moment please. MessageBox Biopsy Are you sure that there is anything to gain in subjecting a small child to this procedure? A moment please. MessageBox Dialog dlgInit setValue setValue setValue setValue Dialog dlgBox DisableControl DisableControl DisableControl DisableControl Dialog dlgBox Dialog dlgBox dialog getValue Are you really going to subject this small child to another biopsy? A moment please. MessageBox Your patient has had a haemorrhage. It is now under control. Do you want to continue? A moment please. MessageBox Your patient had a massive haemorrhage, went into shock and died. Not only have you lost your patient, you have also lost all of your points. A moment please. MessageBox getValue Author Reader Author Reader Author Reader Author Reader Author Reader getValue Author Reader Author Reader Author Reader getValue Author Reader Author Reader Author Reader getValue Author Reader Biopsies Biopsy retValue button4 button3 button2 button1 MB_ICONHAND MB_DEFBUTTON2 MB_OK MB_YESNO MB_ICONEXCLAMATION MB_ICONQUESTION ProvocativeTests BiopsyTests BiopsyTest1 BiopsyTest2 BiopsyTest3 BiopsyTest4 score TotalPossible history examination diagnosed 4lastPage, diagnosed, score, TotalPossible 4MB_OK, MB_ICONQUESTION 4UTest1,UTest3,UTest10,UandE, LFT, BloodTest1,BloodTest4 4BiopsyTest1,BiopsyTest2, ProvTest5 -- find out which diagnosis has been selected choice selectedTextLines "Diagnoses" -- juvenile-onset diabetes -- must have looked )urine glucose, ketones -- urea electrolytes FALSE MessageBox( "You xdone enough" & "tests distinguish "several other possible diagnoses.", \ "Juvenile- Diabetes", \ - 20 - 20 setScore "This cannot be correct ." & "The patient acidosis," & "but no ketosis glycosuria." & st 100 points.", \ - 100 - 100 --von Gierke's disease appropriate biopsy may be a reasonable ," & "glycogen storage type 1B.", \ "Von - 20 - 20 "Yes, well gain 100 + 100 "Diagnosed1" -- GSD 1B ," & e.", \ "Glycogen Storage Disease Type 1B", \ - 20 - 20 ." & samples w" & "levels 6-phosphatase." & lose 100 - 100 - 100 -- Pompe's )blood - 20 - 20 ." & clearly hypoglycaemic" & no cardiac abnormalities." & st 100 - 100 - 100 -- Galactosaemia Zliver function jaundiced?" & "Try .", \ - 20 - 20 ." & "There there "be cataracts since optic" & "fundi could be examined." & st 100 - 100 - 100 -- Fructose intolerance fructose infusion "Did child adverse" & "reaction ?", \ Intolerance", \ - 20 - 20 urate, chromatography aminoaciduria?" & .", \ - 20 - 20 ." & "Although hypoglycaemia "hyperuricaemia, no" & ." & st 100 - 100 - 100 -- Maple syrup -- Must acids "Is evidence "nor ?", \ Syrup Urine u ", \ - 20 - 20 ." & no sign ." & st 100 - 100 - 100 -- Lesch-Nyhan syndrome -- need "Is a gross ?", \ Syndrome", \ - 20 - 20 ." & "While %marked %that found e. Other "indicate much more likely st 100 - 100 - 100 -- Tay-Sachs ." & does clinical" & "presentation ." & st 100 - 100 - 100 -- Booth-Danks sysWIndowHandle, \ be joking - we were!" & st 100 - 100 - 100 buttonUp S6buttonUp Diagnoses You have not done enough tests to distinguish it from several other possible diagnoses. Juvenile-onset Diabetes MessageBox tsetScore This cannot be the correct diagnosis. The patient has an acidosis, but no ketosis or glycosuria. You have lost 100 points. Juvenile-onset Diabetes MessageBox tsetScore This may be a reasonable diagnosis, but you have not done enough tests to distinguish it from glycogen storage disease type 1B. Von Gierke's disease MessageBox tsetScore Yes, well done. You gain 100 points. Von Gierke's disease MessageBox tsetScore Diagnosed1 This may be a reasonable diagnosis, but you have not done enough tests to distinguish it from von Gierke's disease. Glycogen Storage Disease Type 1B MessageBox tsetScore This cannot be the correct diagnosis. The biopsy samples do not show normal levels of glucose 6-phosphatase. You lose 100 points. Glycogen Storage Disease Type 1B MessageBox tsetScore You have not done enough tests to distinguish it from several other possible diagnoses. Pompe's Disease MessageBox tsetScore This cannot be the correct diagnosis. The patient is clearly hypoglycaemic and has no cardiac abnormalities. You have lost 100 points. Pompe's Disease MessageBox tsetScore This may be a reasonable diagnosis but is the patient jaundiced? Try the liver function tests. Galactosaemia MessageBox tsetScore This cannot be the correct diagnosis. There is no jaundice and there cannot be any cataracts since the optic fundi could be examined. You have lost 100 points. Galactosaemia MessageBox tsetScore Did the child have an adverse reaction to the fructose infusion test? Fructose Intolerance MessageBox tsetScore This may be a reasonable diagnosis but is there an aminoaciduria? Try chromatography of the urine. Fructose Intolerance MessageBox tsetScore This cannot be the correct diagnosis. Although there is hypoglycaemia and hyperuricaemia, the patient has no aminoaciduria. You have lost 100 points. Fructose Intolerance MessageBox tsetScore Is there any evidence of aminoaciduria nor ketones in the urine? Maple Syrup Urine Disease MessageBox tsetScore This cannot be the correct diagnosis. There is no sign of aminoaciduria or ketones in the urine. You have lost 100 points. Maple Syrup Urine Disease MessageBox tsetScore Is there any evidence of a gross hyperuricaemia? Lesch-Nyhan Syndrome MessageBox tsetScore This cannot be the correct diagnosis. While the patient has a hyperuricaemia, it is not as marked as that found in the Lesch-Nyhan syndrome. Other tests indicate much more likely diagnoses. You have lost 100 points. Lesch-Nyhan Syndrome MessageBox tsetScore This cannot be the correct diagnosis. The patient does not have the clinical presentation of Tay-Sachs disease. Other tests indicate much more likely diagnoses. You have lost 100 points. Tay-Sachs' Disease MessageBox tsetScore You must be joking - we were! You have lost 100 points. Booth-Danks Syndrome MessageBox tsetScore choice BiopsyTest1 BiopsyTest2 ProvTest5 UTest1 UTest3 UTest10 UandE BloodTest1 BloodTest4 MB_OK MB_ICONQUESTION lastPage diagnosed score TotalPossible userAction 4score,TotalPossible,lumbar, ,examination,diagnosed 4MB_OK,MB_ICONEXCLAMATION,MB_YESNO,MB_ICONQUESTION,MB_DEFBUTTON2,IDNO MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ "Are you sure that there anything" & gain subjecting a small child" & procedure?",\ e"LumbarPuncture" -- decrease H20 because unnecessary unpleasant - 20 - 20 "Author" "Reader" userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox Are you sure that there is anything to gain in subjecting a small child to this procedure? A moment please MessageBox LumbarPuncture Author Reader Lumbar MB_OK MB_ICONEXCLAMATION MB_YESNO MB_ICONQUESTION MB_DEFBUTTON2 score TotalPossible lumbar history examination diagnosed 4MB_OK,MB_OKCANCEL,MB_YESNO,MB_YESNOCANCEL 4MB_ICONHAND,MB_ICONQUESTION,MB_ICONEXCLAMATION,MB_ICONASTERISK 4MB_DEFBUTTON1,MB_DEFBUTTON2,MB_DEFBUTTON3 4IDOK,IDCANCEL,IDYES,IDNO 4pack, diagnosed,ScoreMessage, lastPage 4firstTime, lastTime -- ToolBook's produces dialog boxes that -- cannot contain icons titles unlike the Windows -- MessageBox. We will use $latter rather than up constants (our version windows.h!) -- link required DLL's linkDLL "commdlg.dll" -- no need declare functions -- since be handled HFILEDLG. \filedlg. CommDlgOpenFile( CommDlgSaveFile( -- speed things up a little xkeeping a record -- don't allow screen updates chas been changed asure there Reader menuSetup runtime sysRuntime --handler up menus 4MF_ENABLED, MF_DISABLED, MF_GRAYED, MF_BYPOSITION cwe alter RXXSNOCANCEL leaveBook lastTime menuSetup Object Window &File &Open... Save &as... E&xit &Patient &New Patient... Patient History && &Examination &Initial Presentation History & Examination Initial Presentation &History History & Examination &Examination History & Examination &Tests &Blood Tests... Tests &Urea && Electrolytes Tests &Liver Function Tests Tests &Horm Tests Lumbar &Puncture Tests Pro&vocative Tests... Tests B&iopsies... Tests &Diagnosis The &problem is... Diagnosis &Help &Hint &Score Score &About Case Notes... GetMenu EnableMenuItem GetMenu EnableMenuItem GetMenu EnableMenuItem GetMenu EnableMenuItem &Command MF_ENABLED MF_DISABLED MF_GRAYED MF_BYPOSITION NewPatient AdmitNewPatient :PHYSSIZE Teaching and Learning Technology Programme produced by the :PHYSSIZE I'm very worried about this behaviour goats and other large blind, but no he took no notice one thousand Jamaican dollars Costa Rica and Nicaragua Patient Button Button Button Receive Notes NewPatient buttonUp buttonUp NewPatient buttonUp buttonUp buttonUp buttonUp e"&Hormones && Enzymes..." e"Hae&matology" e"&Radiology" e"Uri&nalysis..." e"E&CG" e"E&EG" e"Lumbar &Puncture" e"Pro&vocative ..." e"B&iopsies..." c"&Diagnosis" e"The &problem ..." e"&Hint" e"&About Case Notes..." -- now routines Llevel menuHandle , 0, /, 2, I, 3, e, 4, allows us access -- but running under e"&Command" -- these handlers cope fmessages generated NewPatient AdmitNewPatient "Admission" AboutCaseNotes userAction eBook enterBook menuSetup NewPatient leaveBook AboutCaseNotes enterBook commdlg.dll filedlg.dll CommDlgOpenFile CommDlgSaveFile GetMenu EnableMenuItem MessageBox Reader menuSetup reader author firstTime lastTime diagnosed ScoreMessage lastPage IDCANCEL IDYES MF_GRAYED MF_ENABLED MF_DISABLED MF_BYPOSITION MB_DEFBUTTON1 MB_DEFBUTTON2 MB_DEFBUTTON3 MB_ICONHAND MB_ICONQUESTION MB_ICONEXCLAMATION MB_ICONASTERISK MB_OK MB_OKCANCEL MB_YESNO MB_YESNOCANCEL leaveBook lastTime menuSetup Object Window &File &Open... Save &as... E&xit &Patient &New Patient... Patient History && &Examination &Initial Presentation History & Examination Initial Presentation &History History & Examination &Examination History & Examination &Tests &Blood Tests... Tests &Urea && Electrolytes Tests &Liver Function Tests Tests &Hormones && Enzymes... Tests Hae&matology Tests &Radiology Tests Uri&nalysis... Tests Tests Tests Lumbar &Puncture Tests Pro&vocative Tests... Tests About userAction 4lastPage <> "About" userAction userAction About About lastPage This is the ToolBook version of the Windows application originally developed by Andrew Booth and Jonathan Danks. You can distribute the unmodified material freely and modify it to your own requirements. However, we ask the following: 1 - By all means give yourself credit for your work in your books but please leave this page unaltered in this book 2 - It is important that teaching material of this kind is disseminated as widely as possible, so please ensure that your material is also freely available. 3 - We would like to set up a library of Case Notes, so when you have finished and tested your case(s), please would you send a copy (with any accompanying material) to: Dr A.G.Booth, BioNet teaching and Learning Technology Programme Department of Biochemistry & Molecular Biology, University of Leeds, Leeds LS2 9JT, UK tel. 44 532-333142 fax 333167 Internet bmb6agb@gps.leeds.ac.uk buttonUp These simulations are designed primarily as aids for teaching preclinical science. They are not intended to be used to teach diagnostic skills or clinical management. The author(s) have tried to provide a variety of presentations using data that are as realistic as possible. Nonetheless, all of the data are synthetic and any similarity in name, presentation or detail to any actual case or patient is coincidental and unintentional. The BioNet Teaching and Learning Technology Programme accepts no responsibility for material reauthored from this original package. of large quantities of glycogen. 2 - Apart from hydrolysis to glucose, what are the other metabolic fates of glucose 6-phosphate? 3 - Explain why each of the provocative tests gave abnormal results. see over... Further comments Diagnosed4 4 - The active site of glucose 6-phosphatase is located on the non-cytoplasmic side of the endoplasmic reticulum membrane. How does glucose 6-phosphate reach the active site from the cytoplasm and how are the products returned. 5 - What would be the consequence of the failure of any of the components of the system that you describe in answer to 4? Further comments HormonesEnzymes Cortisol (08.00-10.00am) 1000 nmol/L (normal 110 - 1076) ACTH (08.00-10.00am) 60 ng/L (normal < 80) Insulin 4.3 mU/L (normal 4 - 30) Glucagon 35 pmol/L (normal < 50) Growth Hormone 1 g/L (normal < 2) Free Thyroxine Index 3.2 (normal 1.3 - 5.1) Total Thyroxine (T4) 115 nmol/L (normal 90 - 195) TSH 4.0 mU/L (normal < 4.5) Acid Phosphatase 7 IU/L (normal 6.2 - 10.6) Amylase 154 IU/L (normal 98 - 405) Creatine Kinase 35 IU/L (normal 4 - 60) Lactate Dehydrogenase 225 IU/L (normal 120 - 280) Chemical Pathology 444 Dialog --Move linkDLL statement handler "tbkdlg.dll" dialog( setValue( getValue( init dlgInit ,"","") function retValue dlgBox ", "") buttonUp buttonUp tbkdlg.dll dialog setValue getValue dlgInit dlgBox dialog retValue dlgInit ,g38, button button1,b5,FALSE button button2,b6,FALSE button button3,b7,FALSE button button4,b8,FALSE button button5,b9,FALSE button button6,b10,FALSE button button7,b11,FALSE button button8,b12,FALSE button button9,b13,FALSE button button10,b21,FALSE button button11,b22,FALSE button button12,b23,FALSE button OK,b29,TRUE button Cancel,b30,FALSE dlgBox 524480,15,30,20,171,202,,,Hormones and Enzymes,8,Helv,,3.54,4.92,108.30,180.92,38,1342177287,128,,0,button1,13.07,15.30,87.73,10.46,5,1342177289,128,&Cortisol,0,button2,13.07,29.37,91.47,10.46,6,1342177289,128,&ACTH,0,button3,13.07,43.45,89.60,10.46,7,1342177289,128,&Insulin,0,button4,13.07,57.52,89.60,10.46,8,1342177289,128,&Glucagon,0,button5,13.07,71.59,89.60,10.46,9,1342177289,128,Gr&owth hormone,0,button6,13.07,85.66,91.47,10.46,10,1342177289,128,&Free Thyroxine Index,0,button7,12.91,99.04,93.33,10.46,11,1342177289,128,&Total Thyroxine (T4),0,button8,12.91,113.11,91.47,10.46,12,1342177289,128,T&SH,0,button9,13.07,127.88,93.33,10.46,13,1342177289,128,Acid &Phosphatase,0,button10,13.07,141.95,91.47,10.46,21,1342177289,128,A&mylase,0,button11,13.07,156.02,91.47,10.46,22,1342177289,128,C&reatine Kinase,0,button12,13.07,170.09,97.07,10.46,23,1342177289,128,&Lactate dehydrogenase,0,OK,117.60,57.52,50.86,12.31,29,1342242817,128,OK,0,Cancel,117.60,85.66,50.86,12.31,30,1342242816,128,Cancel,0 ctrlID Dialog LiverFunction userAction 4score,LFT, ,examination,diagnosed 4MB_OK,MB_ICONEXCLAMATION MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ e"LiverFunctionTests" -- no -- because irrelevant diagnosis -- but you want give a here e.g. + 10 "Author" "Reader" - see card #3" & "Blood_tests" userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox LiverFunctionTests Author Reader Liver Function Tests - see card #3 Reader Blood_tests LiverFunction MB_OK MB_ICONEXCLAMATION score history examination diagnosed Liver Function Tests: Alkaline phosphatase (total) 112 IU/L (normal 71 - 212) GOT (AST) 12 IU/L (normal 6 - 17) Total bilirubin 9 mol/L (normal 2 - 14) Total protein 65 g/L (normal 56 - 72) Albumin 39 g/L (normal 33 - 44) Globulins 25 g/L (normal 23 - 28) Calcium 2.50 mmol/L (normal 2.25 - 2.60) Standard calcium 2.35 mmol/L (normal 2.13 - 2.43) Phosphorus 1.72 mmol/L (normal 1.2 - 2.1)) Chemical Pathology 3 userAction "Admission" handler gives the hints according -- which test needs be done -- you will work out your own algorithm - remember declare _used! giveHint 4diagnosed,History,Examination 4BloodTest1,BloodTest2,BloodTest4,BloodTest7 4UTest1,UTest3,UTest10,UandE 4ProvTest1,ProvTest2,ProvTest3,ProvTest4,ProvTest5 4BiopsyTest1,BiopsyTest2 4MB_OK,score,TotalPossible -- already MessageBox( "Why 4MB_OK,MB_OKCANCEL,MB_YESNO,MB_YESNOCANCEL 4MB_ICONHAND,MB_ICONQUESTION,MB_ICONEXCLAMATION,MB_ICONASTERISK 4MB_DEFBUTTON1,MB_DEFBUTTON2,MB_DEFBUTTON3 4IDOK,IDCANCEL,IDYES,IDNO -- ToolBook's produces dialog boxes that -- cannot contain icons titles unlike the Windows -- MessageBox. We will use $latter rather than up constants (our version windows.h!) -- link required DLL's linkDLL "commdlg.dll" -- no need declare functions -- since be handled HFILEDLG. \filedlg. CommDlgOpenFile( CommDlgSaveFile( -- speed things up a little xkeeping a record -- don't allow screen updates chas been changed menuSetup runtime sysRuntime 4lastTime keyDownArrow \ --handler up menus cwe alter c"Edit" c"Text" c"Page" c"Help" c"Object" c"Draw" up a minimal be added patient a separator e"E&xit" c"&Patient" e"&New ..." \ -- these handlers cope fmessages generated NewPatient Zfilename,filter, Files (*.CBK)|*.cbk|" -- call COMMDLG. routine via requested full path AboutCaseNotes userAction enterBook keyDown menuSetup leaveBook NewPatient AboutCaseNotes enterBook commdlg.dll filedlg.dll CommDlgOpenFile CommDlgSaveFile MessageBox menuSetup reader author IDCANCEL IDYES MB_DEFBUTTON1 MB_DEFBUTTON2 MB_DEFBUTTON3 MB_ICONHAND MB_ICONQUESTION MB_ICONEXCLAMATION MB_ICONASTERISK MB_OK MB_OKCANCEL MB_YESNO MB_YESNOCANCEL leaveBook lastTime keyDown menuSetup Object Window &File E&xit &Patient &New Patient... Patient NewPatient Patient Files (*.CBK)|*.cbk| New Patient CommDlgOpenFile filename filter title AboutCaseNotes userAction About CommDlgOpenFile filename filter title AboutCaseNotes userAction About :PHYSSIZE Time for a diagnosis! MessageBox MB_OK score TotalPossible BiopsyTest1 BiopsyTest2 ProvTest1 ProvTest2 ProvTest3 ProvTest4 ProvTest5 UTest1 UTest3 UTest10 UandE BloodTest1 BloodTest2 BloodTest4 BloodTest7 diagnosed History Examination AdmitNewPatient Patient Files (*.CBK)|*.cbk| New Patient CommDlgOpenFile leaveBook filename filter title Haematology Haematology Haemoglobin 11g/dL (normal 10.0 - 12.5) Packed cell volume 0.35 (normal 0.33 - 0.38) 9 White cell count 14 x 10 /L (normal 6 - 15) Neutrophils 36% (normal 30 - 50) Mean cell volume 87fL (normal 80 - 96) Mean corpuscular haemoglobin concentration 33% (normal 32 - 36) HbF 4.8% (normal 5%) 9 Platelet count 320 x 10 /L (normal 150 - 400) Bleeding time 12 min (normal < 7) userAction 4score,haematology, ,examination,diagnosed 4MB_OK,MB_ICONEXCLAMATION MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ e"Haematology" -- increase Honly 5 because bleeding abnormal "Author" "Reader" userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox Haematology Author Reader Haematology MB_OK MB_ICONEXCLAMATION score haematology history examination diagnosed userAction 4score,TotalPossible,EEG, ,examination,diagnosed 4MB_OK,MB_ICONEXCLAMATION,MB_YESNO,MB_ICONQUESTION,MB_DEFBUTTON2,IDNO MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ "Are you sure that there anything" & gain subjecting a small child" & procedure?",\ -- decrease H10 because unnecessary - 10 "Author" "Reader" "EEG" userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox Are you sure that there is anything to gain in subjecting a small child to this procedure? A moment please MessageBox Author Reader MB_OK MB_ICONEXCLAMATION MB_YESNO MB_ICONQUESTION MB_DEFBUTTON2 score TotalPossible history examination diagnosed Haematology userAction 4score,TotalPossible,pack, ,examination, diagnosed 4ProvTest1,ProvTest2,ProvTest3,ProvTest4,ProvTest5 4ProvocativeTests,BiopsyTests 4MB_OK,MB_YESNO,MB_ICONEXCLAMATION,MB_ICONQUESTION 4MB_ICONHAND,MB_DEFBUTTON2,IDNO MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ -- don't allow provocative Zenough other have been done (uses function declared ReadyForNastyTests() "These may prove valuable," & "but they involve fasting." & "In your potentially dangerous." & unfair try these 4" & exhausted "sources information.", \ .", \ , simply unlikely happen since -- too many will kill TRUE < 2) "Are you sure that there anything" & gain subjecting a small child" & procedure?", \ .", \ away graphs ) > 0 ' paper clip "Details" -- Script dialog box. -- The code placed . can be edited. -- Its are attached B"Dialog" -- on However, its destroyed each re-authored, so xused. -- Initialise controls, disable those already Disabling a Hdirectly altering estyle dlgBox property names were editor. init dlgInit FALSE setValue( a, button1, y, button2, , button3, , button4, , button5, DisableControl( wait dismissed retValue Bhas pressed, values -- buttons act accordingly getValue( w,OK) -- introduce complications! = 2) "Your had" & "another convulsion." & want d?", \ .", \ = 3) died. 9 " & "lost points.", \ .", \ up results -- glucose tolerance + 20 three lines on card J"Author" J"Reader" ) > 0 ,lactate," & "Details_hidden" -- glycerol challenge + 20 ) > 0 "glycerol_glucose,glycerol_lactate," & -- glucagon + 20 ) > 0 ," & -- galactose infusion + 20 ) > 0 ," & -- fructose + 20 ) > 0 ," & userAction !(userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox ReadyForNastyTests These tests may prove valuable, but they involve fasting. In your patient's case this is potentially dangerous. It is unfair to the patient to try these tests before you have exhausted other sources of information. A moment please. MessageBox Provocative Are you sure that there is anything to gain in subjecting a small child to this procedure? A moment please. MessageBox Details Provocative Provocative Dialog dlgInit setValue setValue setValue setValue setValue Dialog dlgBox DisableControl DisableControl DisableControl DisableControl DisableControl Dialog dlgBox Dialog dlgBox dialog getValue Your patient has had another convulsion. Do you want to continue? A moment please. MessageBox Your patient has had another convulsion and has died. You have lost all of your points. A moment please. MessageBox getValue Author Reader Author Reader Author Reader glucose,lactate, glucose,lactate Details_hidden Provocative getValue Author Reader Author Reader glycerol_glucose,glycerol_lactate, glycerol_glucose,glycerol_lactate Details_hidden Provocative getValue Author Reader glucagon, glucagon Details_hidden Provocative getValue Author Reader galactose, galactose Details_hidden Provocative getValue Author Reader fructose, fructose Details_hidden Provocative ProvocativeTests Provocative retValue button5 button4 button3 button2 button1 MB_ICONHAND MB_DEFBUTTON2 MB_OK MB_YESNO MB_ICONEXCLAMATION MB_ICONQUESTION ProvocativeTests BiopsyTests ProvTest1 ProvTest2 ProvTest3 ProvTest4 ProvTest5 score TotalPossible history examination diagnosed Radiology Diagnosed4 Provocative -p0<1 Glucose tolerance: hypoglycaemia at beginning and end with glucose concentration rising to abnormally high level. Marked decrease in blood lactate. Glycerol challenge: no change in blood glucose concentration, increase in blood lactate concentration. Glucagon challenge: decrease in blood glucose concentration. Galactose infusion: decrease in blood glucose concentration. Fructose infusion: decrease in blood glucose concentration.. Details_hidden 4pack the graph large clip "Details" O) > 1 "see_over" buttonUp buttonUp Details see_over Little_Clip lactate 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, glucose (1.75 g/kg body weight) was given orally at time zero. glucose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, glucose (1.75 g/kg body weight) was given orally at time zero. fructose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, fructose (0.5 g/kg body weight) was infused intravenouslyzero.. galactose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, galactose (1g/kg body weight) was infused intravenouslylyzero.. glucagon 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp T!,!Q! Peter W. Patient: After fasting, glucagon (0.5 mg) was administered intramuscularly at time zero. glycerol_glucose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After a short fast glycerol was given orally at time zero. uslyyyyyyyylyzero.. glycerol_lactate 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After a short fast glycerol was given orally at time zero. uslyyyyyyyylyzero.. Details 4pack "see_over" buttonUp buttonUp see_over see_over see over... After fasting, fructose (0.5 g/kg body weight) was infused intravenouslyzero.. galactose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, galactose (1g/kg body weight) was infused intravenouslylyzero.. glucagon 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. Patient: After fasting, glucagon (0.5 mg) was administered intramuscularly at time zero. glycerol_glucose 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp Peter W. v'N's' Patient: After a short fast glycerol was given orally at time zero. uslyyyyyyyylyzero.. glycerol_lactate 4pack tgraph there buttonUp rightButtonUp buttonUp rightButtonUp r,J,o, Peter W. Patient: After a short fast glycerol was given orally at time zero. uslyyyyyyyylyzero.. Details 4pack "see_over" buttonUp buttonUp see_over see_over see over... n123} Dialog --Move linkDLL statement handler "tbkdlg.dll" dialog( setValue( getValue( init dlgInit ,"","") function retValue dlgBox ", "") buttonUp buttonUp tbkdlg.dll dialog setValue getValue dlgInit dlgBox dialog retValue 3B3dlgInit ,g38, button button1,b5,FALSE button button2,b6,FALSE button button3,b7,FALSE button button4,b8,FALSE button button5,b9,FALSE button OK,b29,TRUE button Cancel,b30,FALSE 4dlgBox 524480,8,30,20,171,102,,,Provocative Tests,8,Helv,,3.85,3.98,108.27,82.09,38,1342177287,128,,0,button1,12.88,13.25,87.73,10.46,5,1342177289,128,&Glucose tolerance,0,button2,12.88,27.32,91.50,10.46,6,1342177289,128,Gl&ycerol challenge,0,button3,12.88,41.39,89.60,10.46,7,1342177289,128,Gl&ucagon challenge,0,button4,12.88,55.47,89.60,10.46,8,1342177289,128,Ga&lactose infusion,0,button5,12.88,69.54,89.60,10.46,9,1342177289,128,&Fructose infusion,0,OK,119.47,19.73,50.90,12.31,29,1342242817,128,OK,0,Cancel,119.47,53.91,50.90,12.31,30,1342242816,128,Cancel,0 F6ctrlID Dialog Lumbar Diagnosis urier System Times New Roman Courier New Case Notes Times New Roman Script Arial urier New Arial Arial Wingdings --Script Handlers leaveBook enterBook menuSetup author enterBook menuSetup leaveBook menuSetup Object Window &File &Patient History && &Examination &Tests &Diagnosis &Help &Command author Plain :IMAGELIST Cards 4diagnosed,lastPage uttonUp rightButtonUp buttonUp rightButtonUp buttonUp diagnosed lastPage Author uttonUp rightButtonUp buttonUp rightButtonUp buttonUp About This is the ToolBook version of the Windows application originally developed by Andrew Booth and Jonathan Danks. You can distribute the unmodified material freely and modify it to your own requirements. However, we ask the following: 1 - By all means give yourself credit for your work in your books but please leave this page unaltered in this book. 2 - It is important that teaching material of this kind is disseminated as widely as possible, so please ensure that your material is also freely available. 3 - We would like to set up a freely-accessible library of Case Notes, so when you have finished and tested your case(s), please send a copy (with any accompanying material) to: Dr A.G.Booth, BioNet Teaching and Learning Technology Programme, Department of Biochemistry & Molecular Biology, University of Leeds, Leeds LS2 9JT, United Kingdom tel. 44 532-333142 fax 333167 Internet bmb6agb@gps.leeds.ac.ukkkkkkkk gnosis About diagnosed lastPage You must pretend that you are a doctor receiving a patient referred to you by a colleague. Your task is simply to find out what is wrong with the patient. You should proceed in a sound clinical manner - take the patient's history, carry out an examination, do routine tests and then, if necessary do more involved tests. You start with 100 points and while you gain points for carrying out relevant tests, you will lose them for carrying out irrelevant ones, particularly if they are dangerous or unpleasant. Your diagnosis should be based on fact, not intuition. Diagnosed4 Admission Diagnosis About diagnosed lastPage 4MB_OK,MB_OKCANCEL,MB_YESNO,MB_YESNOCANCEL 4MB_ICONHAND,MB_ICONQUESTION,MB_ICONEXCLAMATION,MB_ICONASTERISK 4MB_DEFBUTTON1,MB_DEFBUTTON2,MB_DEFBUTTON3 4IDOK,IDCANCEL,IDYES,IDNO -- ToolBook's produces dialog boxes that -- cannot contain icons titles unlike the Windows -- MessageBox. We will use $latter rather than up constants (our version windows.h!) -- link required DLL's linkDLL "commdlg.dll" -- no need declare functions -- since be handled HFILEDLG. \filedlg. CommDlgOpenFile( CommDlgSaveFile( -- speed things up a little xkeeping a record -- don't allow screen updates chas been changed menuSetup runtime sysRuntime 4lastTime keyDownArrow \ --handler up menus cwe alter c"Edit" c"Text" c"Page" c"Help" c"Object" c"Draw" up a minimal be added patient a separator e"E&xit" c"&Patient" e"&New ..." \ allows us access -- but running under e"&Command" -- these handlers cope fmessages generated NewPatient Zfilename,filter, * Files (*.CBK)|*.cbk|" -- call COMMDLG. routine via requested full path AboutCaseNotes userAction enterBook keyDown menuSetup leaveBook NewPatient AboutCaseNotes enterBook commdlg.dll filedlg.dll CommDlgOpenFile CommDlgSaveFile MessageBox menuSetup reader author buttonUp buttonUp buttonUp buttonUp buttonUp buttonUp buttonUp buttonUp buttonUp rightButtonUp buttonUp rightButtonUp userAction About on. He was conscious on arrival and has been fed. I feel that he should be admitted for observation and investigation.Q 4diagnosed, lastPage "Admission" "Biopsy" "Diagnosed4" "Diagnosis" "About" "Diagnosed1" uttonUp rightButtonUp buttonUp rightButtonUp Admission Biopsy Diagnosed4 Diagnosis About diagnosed About diagnosed lastPage Plain History_done userAction 4score, ,diagnosed e"History" "Author" "Reader" "History_done" userAction userAction History Author Reader History_done score history diagnosed The child was a full term normal delivery to a healthy twenty six year old woman. This was her third pregnancy and there were no complications. The two previous pregnancies were also normal but the first child died at three weeks following a convulsion. The other child is a normal, healthy three year old. Neither parent has any history of ill health or convulsion in childhood and there is no relevant family history. In the first few weeks, his mother noticed that he became pale, sweaty and irritable before feeds, particularly if the feed was delayed. As time went on, these symptoms led her to give him frequent feeds and it was to this that she attributed his rather fat appearance and round face. Today the feed was delayed and he had a generalized convulsion lasting several minutes. UreaElectrolytes -- link the required DLL's linkDLL "commdlg.dll" -- no need declare functions -- since will be handled HFILEDLG. ^filedlg. CommDlgOpenFile( CommDlgSaveFile( -- speed things up a little xkeeping a record -- don't allow screen updates chas been changed menuSetup untime version sysRuntime 4lastTime keyDownArrow \ --handler up menus cwe alter ToolBook's c"Edit" c"Text" c"Page" c"Help" c"Object" c"Draw" c"Window" up a minimal added patient a separator e"E&xit" c"&Patient" e"&New ..." \ -- these handlers cope fmessages generated NewPatient Zfilename,filter,title Files (*.CBK)|*.cbk|" -- call COMMDLG. routine via ested full path eBook enterBook keyDown menuSetup leaveBook NewPatient enterBook commdlg.dll filedlg.dll CommDlgOpenFile CommDlgSaveFile menuSetup reader author leaveBook lastTime keyDown menuSetup Object Window &File E&xit &Patient &New Patient... Patient NewPatient Patient Files (*.CBK)|*.cbk| New Patient CommDlgOpenFile filename filter title Examination_details :PHYSSIZE Note the chubby face and distended abdomen Patient: Peter W. Big_Clip Details_hidden "Details" buttonup buttonup Details Little_Clip Admission Diagnosed3 History_done About Examination_done Diagnosed2 Examination_done userAction 4score, ,examination,diagnosed 4MB_YESNO,MB_ICONQUESTION,IDYES MessageBox( "Before doing z" & "wouldn't be a good idea" & take the patient's "A moment please",\ -- penalise ignoring advice! "Details_hidden" "Author" "Reader" e"Examination" "Examination_done" userAction keyChar userAction Before doing any examination, wouldn't it be a good idea to take the patient's history? A moment please MessageBox Details_hidden Author Reader Examination Examination_done MB_YESNO MB_ICONQUESTION IDYES score history examination diagnosed keyChar Details buttonUp Details buttonUp Details_hidden Some tests will provide additional material such as graphs etc. In this case, the extra material will be attached to the back of the card with a paper clip. To see it, press the space bar or move the mouse pointer over the clip or the visible part of the attached material and press the left button. Try it now. Then go to the next card (left button - remember?) Details_hidden "Details" buttonup buttonup Details Little_Clip buttonUp Details Big_Clip "Details_hidden" buttonUp buttonUp Details_hidden Details There may be more than one sheet attached to the card. If so, then the words 'see over...' will be at the bottom of the sheet and you can use the direction keys or the mouse buttons to examine the other sheets. To put the attached material back behind the card, simply press the space bar again or move the mouse pointer over the paper clip and click the left button. Try it now. UreaElectrolytes Your case notes are entered on a card like this one. At first, most of the cards will be empty but as you do tests the results will be entered on the appropriate card. You can move to the next card by pressing the down arrow, right arrow or Page Up keys or by moving the mouse pointer over the card and clicking the left button. Pressing right button or using the up arrow, left arrow or Page Down keys will take you to the previous card. Try it now. set sysC Examination_done "Details" "Details_hidden" keyChar keyChar Details buttonUp Details buttonUp Details_hidden > j Some tests will provide additional material such as graphs etc. In this case, the extra material will be attached to the back of the card with a paper clip. To see it, press the space bar or move the mouse pointer over the clip or the visible part of the attached material and press the left button. Try it now. Then go to the next card (left button - remember?) Details_hidden "Details" buttonup buttonup Details Little_Clip Details "Details_hidden" buttonUp buttonUp Details_hidden Big_Clip There may be more than one sheet attached to the card. If so, then the words 'see over...' will be at the bottom of the sheet and you can use the direction keys or the mouse buttons to examine the other sheets. To put the attached material back behind the card, simply press the space bar again or move the mouse pointer over the paper clip and click the left button. Try it now. You can get 'Info' on the possible diagnoses, but you should not commit yourself until you have done enough tests. Hints are available at a cost of 10 points each. The Help menu contains a glossary of the terminology used and you can use it without cost. You are expected to have a reasonable grasp of the scientific principles involved and so no help is provided with these. Advice will occasionally be given, free of charge, and you may fail to gain points if you do not follow it. However, do not rely on it always being correct! Remember that while you must gain as much information as possible, you must not harm the patient in doing so. BlackChan BioNet "System (kf Gj rine p&H,0 ,buttoo "Helv "Helv "Helv "Helv "Helv "Helv "Helv "Helv bloods "Helv (mM) "Helv hours "Helv patien "Helv normal "Helv Glucos e toleranc e test4 &>o(&> "Helv "Helv glucos F>#H> #f O( "Helv "Helv "Helv "Helv "Helv "Helv "Helv "Helv "Helv "Helv blood "Helv lactat "Helv (mM)S "Helv hoursA "Helv patien "Helv normal "Helv Glucos e toleranc e test "Helv bloodZ "Helv (mM)R "Helv patien "Helv normal "Helv glucos "Helv minute "Helv "Helv "Helv "Helv "Helv "Helv "Helv infusi "Helv Fructo se infusio n test@ "Helv bloodZ "Helv (mM)R "Helv patien "Helv normal "Helv glucos "Helv minute "Helv Galact ose infusi on testI@ "Helv "Helv "Helv "Helv "Helv "Helv "Helv infusi "Helv "Helv "Helv "Helv bloodC "Helv (mM)E "Helv hours "Helv patien "Helv normal "Helv glucos "Helv Glucag on challen ge test "Helv "Helv "Helv "Helv GDHf/ "Helv GDHf/ "Helv GDHf/ "Helv "Helv "Helv blood "Helv (mM) "Helv hours "Helv patien "Helv normal "Helv G0Hf/ glucos "Helv Glycer ol challen ge test "Helv "Helv BMP/ "Helv "Helv "Helv "Helv "Helv "Helv blood "Helv (mM) "Helv hours "Helv patien "Helv normal "Helv lactat "Helv Glycer ol challen ge test "Helv "Helv 4MB_OK,MB_OKCANCEL,MB_YESNO,MB_YESNOCANCEL 4MB_ICONHAND,MB_ICONQUESTION,MB_ICONEXCLAMATION,MB_ICONASTERISK 4MB_DEFBUTTON1,MB_DEFBUTTON2,MB_DEFBUTTON3 4IDOK,IDCANCEL,IDYES,IDNO 4pack, diagnosed,ScoreMessage, lastPage 4firstTime, lastTime -- ToolBook's produces dialog boxes that -- cannot contain icons titles unlike the Windows -- MessageBox. We will use $latter rather than up constants (our version windows.h!) -- link required DLL's linkDLL "tbkdlg.dll" setValue( getValue( Wcommdlg. -- no need declare functions filedlg. CommDlgOpenFile( CommDlgSaveFile( -- speed things up a little xkeeping a record -- don't allow screen updates chas been changed asure there Reader menuSetup runtime sysRuntime --handler up menus cwe alter c"Edit" c"Text" c"Help" c"Object" c"Draw" section customise your ..." %..." a separator e"E&xit" c"&Patient" e"&New ..." \ c"History && &Examination" e"&Initial Presentation" \ -- initial presentation always c"&Tests" e"&Blood ..." e"&Urea && Electrolytes" e"&Liver Function e"&Hormones && Enzymes..." e"Hae&matology" e"&Radiology" e"Uri&nalysis..." e"E&CG" e"E&EG" e"Lumbar &Puncture" e"Pro&vocative ..." e"B&iopsies..." c"&Diagnosis" e"The &problem ..." e"&Hint" e"&Glossary..." e"&About Case Notes..." allows us access -- but running under e"&Command" -- these handlers cope fmessages generated NewPatient AdmitNewPatient "Admission" AboutCaseNotes userAction eBook enterBook menuSetup NewPatient leaveBook AboutCaseNotes enterBook tbkdlg.dll dialog setValue getValue commdlg.dll filedlg.dll CommDlgOpenFile CommDlgSaveFile MessageBox Reader menuSetup reader author firstTime lastTime diagnosed ScoreMessage lastPage IDCANCEL IDYES MB_DEFBUTTON1 MB_DEFBUTTON2 MB_DEFBUTTON3 MB_ICONHAND MB_ICONQUESTION MB_ICONEXCLAMATION MB_ICONASTERISK MB_OK MB_OKCANCEL MB_YESNO MB_YESNOCANCEL leaveBook lastTime menuSetup Object Window &File &Open... Save &as... E&xit &Patient &New Patient... Patient History && &Examination &Initial Presentation History & Examination Initial Presentation &History History & Examination &Examination History & Examination &Tests &Blood Tests... Tests &Urea && Electrolytes Tests &Liver Function Tests Tests &Hormones && Enzymes... Tests Hae&matology Tests &Radiology Tests Uri&nalysis... Tests Tests Tests Lumbar &Puncture Tests Pro&vocative Tests... Tests B&iopsies... Tests &Diagnosis The &problem is... Diagnosis &Help &Hint &Score &Glossary... &About Case Notes... &Command firstTime NewPatient AdmitNewPatient Admission AboutCaseNotes userAction About olinergic nerves B:3:F:1 :will block the effects of isoprenaline B:4:T:1 :is used in the treatment of hypertension B:5:F:1 :acts through an effect on the central nervous system :Guanethidine is an adrenergic neurone blocker and is used as an :antihypertensive. Nasal stuffyness and postural hypotension are side :effects. It inhibits release of NA from peripheral noradrenergic nerves and :therefore reduced total peripheral resistance thus reducing blood pressure. :Reflex control of blood pressure is therefore also affected - hence the :postural (hypostatic) hypotension. E:----------------------------------------------------------------------------- G: 1 2 3 :Propranolol B:N:5 B:1:T:1 :has antidysrhythmic properties B:2:F:1 :is selective for beta(1) receptors B:3:T:1 :may be undesirable in patients with asthma B:4:T:1 :can be used in the treatment of angina B:5:T:1 :may produce a fall in blood pressure :Nonselective beta1 and 2 blockade may cause bronchoconstriction by removing :the bronchodilator effect of circulating ADR (beta). Angina is prevented by :reduction of exercise induced tachycardia (reduced heart work). :It is very effective as an antihypertensive and relatively free from :unpleasant side effects. E:----------------------------------------------------------------------------- G: 1 2 3 :Mepyramine and practolol are both B:N:5 B:1:F:1 :local anaesthetics B:2:F:1 :selective for beta1 receptors B:3:F:1 :useful in the treatment of congestive heart failure B:4:T:1 :active orally B:5:F:1 :able to reduce the heart rate response to exercise :Practolol=beta1 blocker. Mepyramine=H1 blocker. Practolol is unusual among :beta blockers as membrane stabilisation (local anaesthesia) is minimal. :Histamine receptors (H1) play little if any role in the control of normal :peripheral body functions though they are involved in allergic responses :when large amounts of histamine may be released from histamine stores in :mast cells. E:----------------------------------------------------------------------------- G: 1 2 3 :Both propranolol and lignocaine B:N:5 B:1:T:1 :have local anaesthetic properties B:2:T:1 :have antidysrhythmic properties B:3:T:1 :are absorbed from the GI tract B:4:F:1 :stimulate the CNS B:5:F:1 :have a beta substituted ethylamine sidechain :Propranolol=beta1 & 2 blocker. Lignocaine=local anaesthetic. Propranolol has :membrane stabilisation properties (local anaesthesia) and both drugs are :used clinically for their antidysrhythmic effects. Lignocaine, like all :local anaesthetics, can stimulate the CNS especially in overdose. N:A moment's thought will tell you that both cross the blood-brain barrier :(lignocaine to produce convulsions on overdose for example) and both :penetrate nerve membranes since both have local anaesthetic actions. They :are therefore likely to cross the walls of the gut cells easily and be well :absorbed. Lignocai MPo@? Nizx' *CD7i Z"^yj 3S>I: mn56B }pi%i -sMO)z :DX4n2m ?&tv5M S~.F\ DTK\YN GkoP> >@AxO ) #qH5 mC0\o a+APy v.HQlh EH[H e ~2>7}Pk A B\|Ubb 7.p0O ^=@B( _L|T! ()ukL z^_m@H &wZT+@ K>4)G# iR]l8 =Xx< s?8wu aJ&-1w u*WySb [Omn\tMD Gk"}Y ??P/N /YB$h 78vpX kQ3Vi _h}9h :ymNC ==.TZ \_z{a 6]<3| mcQk;i k5mUw g~7Y= "7z-k 4}\fj 5k;=- aRhs-J6 YHX 6JG=Cz d5$W,; D6@Ql)A US{. 6sv$r//c "}P$U q>0yKy- _]*:M M/-y? %O-!B a8 J(Z @4A(h) ?!oBf CW<`+z /({}#/1!b EofhZ Dv#>[ 7#r(N XN,pZ > <~g, UEFB~ fyxix8 ^ZYY@V G%S,~ J tFg +&qH] + y& 04{;,p _:'p'>] []oU)S T6[7J 3w}(6 C@{U, Mct" <2 x{sze*I\M* Q^YwX^ '205q z81(z(#2>n"#$# =-j>Y J_:{P^ zXK]Y{tg>q oo6nu>}utb v5p`y[ <0+)67`~^ NL/-"c0d+LYR PQXQXI L%cLPF kVIK wz}r+3 ?d`t7AX [vqEh .ZG\DH V\JQDBME4 ?76GETA;: c{ong+e bd}m` jdzbnl(e "]!>!o |ooHss x|f*rl E9Ex` ck&zfqIt ,Y.OF \ $ B;`HB README.DOC}R_o !B: 8 lf5*[ SHAREWAR.DOC WHATSNEW.204 {.9#KM q[`=\C 2Vm,# s+')T^k Eyr1e U*[G} gE4[gj v."r%_6 V204G.NEW DqQYXY RD:~@ u ).N Tc7r ;QZXx ,,gJ[U &TR9< p 1Qv O+WJT UMH>d ]-S%{ u@7Y4 HYo@Y \+es* &{8pF A=8 > @.%GL 9=NU]R ~>dH=j /n0p8 R;=MEz HINTS.TXT 82yppp +l[+! \>(a{ 5X ;) lN\$! n@U)z I!QcQZ |4e-. uF/{zG {_>qr S|*^| =Iu"x EqTf!n QV:&vR 6uqyu t\ ): >slvq wwq|yq i,5{0Tz l #t! yPcw[ i}0^I=O `QXzMS Lz?0p L{odmy =nDv] Zw60" Z_Hw& agtk| LICENSE.DOC 93BIV $TJs0[& Fh4x} wEY~IQ+D wZHC: ORDER.DOC [<0lj \1,xQ Ro +n [\Se#h }}`G9"Z {c55S #^IZ\`N -iFq6R@ %^<#7Z K3<4_ f)hf< ADDENDUM.DOC ,vE*i t|yzs! 2O Lr' gbtr= \Kj@U <7}tR mS&taO dE!Q]F F4q3SK e.or9 z6S1, 2\myH Sr50' RU~~] s~qvr~% ic0 $J k x#G w_fVEUi NGA[6V mh^5=& PSlIn d_AP, LSQUx8 m7z@tM ,![=o .+Z9r >|`@A twH)Io \Pc(z Wv8vk aRPM|rUVMt2 jY(5*c9/ [sYbX !w}Um+GN zau/^ ~~{tzxv ?=zS; cd9) UF,OS 0YxymL Et*Pd 1a{i, 1K!_aO% V\, N umS%&5&M J[ %Z 8<5'j 2F]! L1f7ad 0?C,| "jF:48 79t~CUY3 ]2{') tv^Lg _VI[I mtxmP 5"@T; JrgU1 O:w r H@j4X 9B 4{ MM\a _iYHr N#,z` 1 y (x`Ye* 3)2Q| &#UrM Vx ?=% eZR)a &*Q)3`a 2_'>s F)1_ C][Mo -s%t# l;['[ wM!1.X T2vy0 @V0VT1 > l5j;[ r ^-=)& q Sr@ XERD)NK: 7k_C|b6 -EPD2| ij+Eo c?0y: T^RO* {TfJi 4L'A,U 6v6Y8 :&VP}m6 4]ACO; Igz!E VMA*r` h]}X!O BDc)E 5pF%& LVb@] }l`:,6I MVpaU ~iXs65'Q[. +7RQ\ :4`LC j(;Lb EIc4S ;'/0sJ lR4aV WVr7V 1;Q8x3 |uvi:/ 9ov:o UreaElectrolytes userAction 4score,UandE, ,examination,diagnosed 4MB_OK,MB_ICONEXCLAMATION MessageBox( "Before doing tests" & would be a good idea" & examine the patient.",\ "A moment please",\ e"Urea&Electrolytes" + 10 "Author" "Reader" "Blood v - see card #2" & "Blood_tests" "UreaElectrolytes" userAction userAction Before doing any tests it would be a good idea to examine the patient. A moment please MessageBox Urea&Electrolytes Author Reader Blood Urea & Electrolytes - see card #2 Reader Blood_tests UreaElectrolytes MB_OK MB_ICONEXCLAMATION score UandE history examination diagnosed Your case notes are entered on a card like this one. At first, most of the cards will be empty but as you do tests the results will be entered on the appropriate card. You can move to the next card by pressing the down arrow, right arrow or Page Up keys or by moving the mouse pointer over the card and clicking the left button. Pressing right button or using the up arrow, left arrow or Page Down keys will take you to the previous card. Try it now. Examination_done userAction 4score, ,examination,diagnosed 4MB_YESNO,MB_ICONQUESTION,IDYES MessageBox( "Before doing z" & "wouldn't be a good idea" & take the patient's "A moment please",\ -- penalise ignoring advice! "Details_hidden" "Author" "Reader" e"Examination" "Examination_done" userAction userAction Before doing any examination, wouldn't it be a good idea to take the patient's history? A moment please MessageBox Details_hidden Author Reader Examination Examination_done MB_YESNO MB_ICONQUESTION IDYES score history examination diagnosed & P l Some tests will provide additional material such as graphs etc. In this case, the extra material will be attached to the back of the card with a paper clip. To see it, press the space bar or move the mouse pointer over the clip or the visible part of the attached material and press the left button. Try it now. Then go to the next card (left button - remember?) Details_hidden "Details" buttonup buttonup Details Little_Clip Details "Details" buttonUp buttonUp Details Big_Clip To put the attached material back behind the card, simply press the space bar again or move the mouse pointer over the paper clip and click the left button. Try it now. OK1/0/.01031, )-665247601040..-1048241BNPPQIONHH=CBEHHKP2.+...0./9A<>;<;:@D>ACD?.+++++,+./0269;?@@A=;JP=x HA1.///00011, )-25642640100/.//0015342AQXZWLKKKB@A@GKJLS3/..,.0/1?A<,++**-++-0/169>@@A@JCAaJK KA200/./0011. ),2353465/0/0//,/0014231QWSXXPNMJFD?=EKGFM3.*++,..19<;=@?@>BJBA@A@EEDMmC] vG@2./../1111, ',155556510/0//,01233121S`UUWRLPKIDEBGOKKT4/++*,,048=??@E>CJIA::B-*+**++,./0146:<>@CEGFELag;k p;>0.././0111, ),236:55410001/.4482512;Q]QKKLAKFDEKFPWJQY61+,+0.039ECFGFHMSsK;>KIKCDLVMJV>1,++--05@@FEB::===;B@-*+**++.1155668>BACEBHGKN[fpz` h44/,.././02:+ '+2585575111111/49;<<65QG@H>854:;HLCHJQKOU?4.++..17<>CBA??B@>:C?+**+)*,..029AL^fjmootomfekpuwlt d45../////121- (+046578601010/15;BA>6:K>J>66::=FKOKOPPLMP>2/++-038@@CHB@DA;;DIHF@=7;B?,,,++,./04:ALWfltwz P52/..../0120. ,,268658711041236>BDE;=7::AKRKQR[WPHHJ[VPXE00++-11==BBGA98=5?E:++,++-./5?Xz `520/00.01320, *,355797943351037@?C@=:7?=EI[PMV^ZNKLM\VWOE10,+./2;:6<@1*++.+,/26Fc Z61/02000212/, )+279676621572213?FEC=6:6?HOVQRT_ZMKQ[\UJJF40,+./3>APHJ@::94:?-+++.+,.19Mo L710102021340, '+2577;8811351125>BDF?<<0.++//058D?@5876469*++++,,.2:Qu E700000//034/, )+359897;22341121=ECEB?<9?FHG;=DFHF=<=?:976740,,./159:732:52;3++*++,,05BZ} F610/00.00241- (+35:9:::41141215AEHMA;6;DKONNKQQZdfY`\ee[^fcjWA../346854649:.,*,+*-,08Ii I92/000/01220- )*37:;;:923352225@HJRKHQYaYcYQLQVahf`d[ecUZb]nefH,..056436289,++*++-/1:111212453421 '*/1459::?B?BFAXNKIIKMXQRMY_S\a[]jYPYNSYRZ_]cfU^Z\////246255..++++,-1@Xy y:7./001124333/ ')/128<=@FBFJ=SKQKPJY]WT\]ibegdhk`XRUbXRSOPWU[UVh1...34003/,,+++,-/4Acy g64...//265885/ ')//014321315<@RLRVNS_dWVcjobifeikdWWT\WTTWSZPRM[^3,,,05303/-.++,+-14E^x \61.//.0144212. ()/0034420226=LIWUU[Y_W_chg_^lep^[V\\_^YVYX^VSXZh:-+.021./-.1++++-.6Fh| I52/../0110020, ))//03530224:??KNSNQWXUYZ_hb^cggjgfX]ccc]Y]_cWX]`aE,+.0200..0/++.+-.5Hnww F80/./001//0/0, *+/.011100019:@KGYVQa_VYf^ebZdWe`Z`Y^gj`cY[f_XQYfcI/./01../.0,*+,,+/4Ggms| C90,./.130000,+ -+/0012014228:;JJ\R[]af[e_d\cb]li_`]bb`Va]\g_WMZ^bK,,..1/,--.+,+++++4K`^r @:.....02100..+ *+1112120324:9ALM_MYgi^XfadUeegpni\`b`bUT[Z`WPR[caL+,,./.,+.,++,+++,2@LWt :9//,..//0.0.0+ *+00103211439:?MT`JVdh_VcdbXlfmnffc_\d]`Z`Z_Z]ZZ`dR,,,..,,+0,+++++,,19EZ{ y87..,,,.-,.//~, ++/1000000004>@AU`RTbfaVdkeZaepmjZXdad]Z]TalXUYWhfP-*,0.+++/,,,+,+-,/5E^| j77-,*,//,,./..+ -+01/11000004:?HSWQUha\Wgicaae_mea\X_bXP]bfhaM]YgmP++.00,,,,++++,-,..6H` _:6--+./,-,,./,+ .+110101///.3FS\Ydfm]abbc_`e_mo]ZWT`_]R]X[OPTU`[fQ,+.-+*2+**+--0@_uz~ {z||suwwtqpkrh^`^\WXQQb cFAGGGFD M9<,-,++...,./.-- 2,11121245231--/././/0///.+ 3+/3121111111;@W\XYU^[\\hdZUZX\qhVYS\POQ[ZYTYVV]edL.+,,+.0,*+,**,++..,...,-.--......0../00001478::>@KOMMROV]Z`^o A;6./0.////./0/,+ 6)/141111010097ZRZDK;5KBBWT8SpyrdlS3JiK?F@Do 9:01/..-/.//.0/,, 9-79?>=ABFJQT=IdVNcheX__kkdekdl_baa\VZPXSUPOSVkbfhT*+++,1,,+*++----.01415500/10/61/121>:24442:?EHD=;CZc[gfS?8YPa_j{ 7<10//-,.//.//..+ 7,469;<9:::;B;BZNZfgc[edeca`jge^][a`\SR_SZMSU]gdheU+++*-1***+*,+,,.0167875//.0/108//26@2201487;BJ@>S;9TRdq ;=.....,..,/-/.,- 6,6988<=;:<=>9:=?;?cI?MfUZoigrlstcdfvtqclhmcPJVNRMQXadc_iV.+++/2,+**+***+,.159?>???EDcV7MClbABHZJ1DL`QPX@dqtyo==]p K.--,-1.,.00.// ;.246699;;9fvVAGcVYlmhmpql^giqle`cigYRPQUVPV[_fXTcY+,++/1+*++*+++++-15:@EGDILABebJBXrK@HC82]ijjtqF{{{ @0//22/.///// ;-69:<;<<;=SPBAI_WYlj\hkre[dhm^fdkhgRMMLWTMVVaX3/CT,+/+/-*++++++*+--/39=AA8;EHAjtlI_J[54850TggszrCxxz }{c6`}{ P1120011/10. >-8:9865869A9;?ASRWnh`adnhgfsrfcadlaPSSS`[UUWa`0H;R,+/+//+++*,+++-,02:FOUL876L\mjlIL6X674>4 n654424443. B*245966879DCV:BHT[rr\fkqmqpxxegblk^]QZU_R\TXd\Z\]bEL4 G000100/, A@oy~ :@CRQbaXajrjnmpjf^acdVSLYU]VXVY`W\\^E++.+./++++,++,19F[t CCO[IIn v337221/ MFLSSOJNFKJFCEHRXempgd\gfeNUSVSaUJLS[T\_[B++.+..+++++.,.27E^w D36355. ]USPYYTNE@;8<:?O_f[^e\NPMLUUWZNZXSVW_?,+,+./,--...//4=Kh 43253, b[YN?JWaqca]`\=55441448877D[VJBNFHH@ADKQQPV]8+-++..+3,-,./27-6Ehb..6:If3+++/8/,...//02;Gaq yo`Y: <444- SSgh_mladU76J_d]^f[A>YaZIA6>?=31/B;1AS^:-59Gc.*,,0;/.//..//6@Mgs L452, \Zdo^QX\bhVG12J^\QYe8;UX\ZC67:9?=@A9MLL;+35:J,,,*/E./.././08DQ^u j344. v]YaV\M[Z\X]_R>3=U`TkR5EWZmXJ@:C?=ADIMRP9+056B++,++<.-././/07@Ndy CGc9@~ kVQbNXQPQRUbYZnW5=dj_uL5Kfxp\G@EHIVBJHOL7+035E+*2+6H-...../10DThz C247C [RXS\I]VbWUjohrnV1IiPxa7:YrvgVNSKMXQPMVS6+,+0<,+*-+.../0735?Oas T`Sa>SUqofFRdm^T`YE:VcGe<7WtqdTJGN[TZVUR1+.0?:0.,140.///,/./2;K\r{ VWWVIAZh^WlAR\_ZQ\f6Yb>T[6G`ceXQGJNMUUVW./5]o{d/++,**+,+,/.-/3?Um} N<:EHGDE?=?=7563h RV]\^IHVVSVd?ZbeXmjHVgDZm@QSW_SZSQ][aZZX.?m G.*))**,+.,*+-0B\pz oSB86Pxsr|w~ \==9Cl SYYiT^M=ZSOUbF`TFshvZmMexRIG_i_]TTWYd_ZV3_ p>:-**++***,*+-1:N]dgmmruwvurxy}} E5Ailmnhhjpw} U\]i]S_Q@SGBN\f85VV gOS]tm\CTa_[X\XZfkdNS B/-/2*////0038AP_jsyx{| rvxrqrqz~| y8jwRZefg_\dfM>:BOG39;;6EaWh2HUmsmj[NFPTXVX[aa= zR72,)+++//,-/05=N\jnxx qpwqwvvt RXcjdbbcimiab`VPLMR9=V_pnrYV[TSPZYVS\TVz c<>-0*+,.,-++../07@XZ[fihfnrpxns]Sf }igd^UXV[S]Ydd^hoipshgchqov|wlhhhcd 7[gRQ\mbf]cljbX^bhY?A41C`f`UYWPVR]Rf_g^a]O S9LhUDm 5,++++,...5:EY?5:?BE9.JH[\\c mY_\A:;;=2RSY^bH\ccggfOXty}x]QUR[PMU 5HZRR_b]c^bfc[SW^b=14:>a`gpYYba`Q]^enlklaX xHDP:l{ 0..-.,-,,//181101121583P]PZr {~klm]8444:?IFIEKK]ZW]ZYWceptm[WVR[NCD 6\TWTgl^]Yb^bUVV\c;01?>`jsogba]\RLQV`emmQ} zoRM/++*+ C/00-+,,.,..0///////.-,KZUK[jfdaedR225976;==;>BDAAFIFHORW\YZTL\VICBV 8SERUefe_^^g[[PWX[J00@<]ktwogg_][SRVTVAF5:BKSWPIFC/-,--8q \0:0,+,-+.,0/.0.,,.--/2d^[SMPPZ[N723488?>>>?FFFHBEDDDMWYZbfdZ\YLLNK 8EFPQf`ec^dc[^TRQWM725=]txwlbbZbZUVY_U?:;CCF3-hM-/1A/,@LSq k5/,-,,++.../,.+,,..0/8hfa`cfg[:24326;>@CFDFGKFFFIMPZ^``]b]WXUNQRRv 7IMUN\`\UUdg\UMQRVK:2/8Ylxvqic^^bWW\[WA48>KO;Ed?,06D,.UU`a {52+,.+.--/.-00./0/041;d^ihh_<3687;=AMTTYWYTRPSXVVbnkmonfjegcX`bkz 6MIWQPUVRQ`aWROUWPF61/4Lipwsh]Z\\[QXUMA36>LO\]U0-/C5,.PFCSMU 4-+,,,,-...29;;@CBG@CBCqXEIF<:7;?HTafhkbfffZ]bf`hljd_eae]a]L\^h~ 5EQYWR[POSZeX[PQRYR;42/Hnjvm^]X\[QN]RR=33:MLdUH.+.X.+4I8J|p[lTx 74J1.+++,,,+,..//2/45? N:9:2148@RV\[^[c]aXPcdkgnifebf]a\]\ddc 4LJUQP[VTVQ\RSJSQQM=:1.;fsligaX\SJP][R@327CPWP4,,5^./9Y:V [+,+..+,++,.-01146D RC;:4245@QSY[_\]bXX[eooijmkbbb`cf[\d[Wu ;ny_XOX`RTR_LRKVXYQHC6.8Zbl^\^V[KJOT\M:-16ALQF++.CW+./?=^ l^yz| ;.55..+.*++-,-0347:Q W?B;6322;AV`_^]bgfmepqxoksgicjfnXWOMVQ` 4RNVWSX]RQ[]RQQPPZMPL8/7]_l][WUXPOQRTN5.29IIH3*,2YS+++..Tw mf<]{..,++,**+,0467;\ ZBCA7113;AKVd`^V[aliommhhigb_gehd[UU\^^ 4NIRYVOZSUSPJMG[\XQTF41:`ejZUPP\OJNRLH/+0?AF@,,.AV=,+*,,-;`| TuU66.,,+++++-.36>EGj eTOQFCBF]c_akvusq|x{~ wwukof^c^``cy 3JHPRWRVQNWUIETUZXPQB40?]dfYTRSVHGRRK@.+6A@B,+-3VS2++**.*++3A<@WjZO::12,.-++++++,-004<7h _vZP<445?DNS\`p_Zeuktyphpniihhijg\VTY[bn 1BGPNSXSSSVXGDMNXYRLJ20>_biWMVNWRJRQE?..?IJ2*+-<^H,****++,*,+,.--/...,,70.++++,+++/46@?b [~pT>9;6;BTU_gxchly vrnsooqTihfgl`_TV`ad 7YMLKLUOJMSTPKQP[aTXB/1DV`cQOPMVMHGKE5-/=G?/+,1QS=****+*+,+../.,,./00.-,92-+,*-+-/3:JRQKGKS[LCKLUX[RF12LVTWQJFKULKOF9/+4I8...0O[6,**+**)+*++,,/,-/011,////,,.20257>CQW]k }hmaVLMtnU[X dfYcob_nptwuokmljibjnfafinnh 8010, 0B@@LW\cc tafhXUUv[XZ`\inZa^b^`qpqnttlkllhidnkaijrfh 300/- -?B=LVbVKPWMSFHKX[^WK16XVCH;AFMMOAD1.AB2/,+.3S8.*++**+**+**+,-.././1601L10112;PGOX_bhrxvnvqg`_[YVYZfh\Wahrtmnbmqvlnnpmdjckppphnplcan W1/20, /C?5+++0AK5,*++**)*+**++,,//.//3901]2036ABPHZliebrutpuughpqsojgmnfZflsryujgsplnurmdhjmrwrzqjg_el <0020- .D=A6+++*+))****+21,./01013;13R248BADVPisnqsz{xxzqquwvyktsxrlceinq{xwx}vuv}y}}|uxtx l43110. 0C;:CNMINUTPQKJHPD<2H53:9576FDPOUZWVQGGHMH75=349>>P\WM@:72.1oA0H2*,+.++-,+*-+,7+>Y[0010./.82489::=HLS]qkmxvsojuoqinkopkbiocWX`bkxrnhrndfbrwqgmsgf{~tojg]anm 7/..//-+ ,A:862BHEL\]VLEBFKS?2:426:@@\VXE;9400D 1<8++**++*+*+,**+*+.0//0//.-/4255;?BBJJQ[mekrs|xvxwtwohlnffjjVQQRYYmkhdsmfqswwooolbdqttvgh]^go o1/../..+ ,>;6416EHGJUQMTTWLH639126:BAdWGE<68.3qY-E-,*),.++*+**+*++--../.-..-/6455:ACIQValtjnpmosnqssljk`hfcmlZNMQRQedddpkinmotkdkhabsstkhf_[fi Q0.,/..+* +=J@@AEB>BFLNMQQOB@145027;@=QJ@=;;0//3,.2+*****+***+)*+*,-01100341./6246=AJKW]gllekqvph`ejknqh]ciaim`VRPMOcbeeofa][qojkkk^cmvnihf^Wfnw {:10//.,++ +9;54432<>EBGGQIDF624/2577:8G?:=H8,,10,0++*+**,+*+****++-,//0///...27227>BGQWcjpmlplrhcbjibmgckrofrn\STRRPb_cib`UWScilfdi[aipxvkh^Xigk t71/,/--,+ +65310103UXirbWW 5VhE0.,+++*++,**,,.3.0-C0a/.0.,.5028AJES^\\ad^giriidYX\NU\U[STZi]TW]Z]]bY^hgYcRiglbmhfUa_\WP]WMVUW[bm wZ./0///.-,,+.,, +7431213455MA44kFB:SNUabYWy oE.-++**+,+*++-,./N/;9T0/,,+.30038N:FT]X`hfm`m[dd\YTOPYKUMJUddUY]`VXbVQc]]NO[mf]gbVSXUeyqqk`YW][bmo f/-...-//-++,.,, +5632124674eA13a77HRM_ZRWk ~fY3.,+****++***+--.222.,..,..1//12T:DL^\\ZaU_\\a]\\KIPKFPNRZd^UZY\NT[RQWYJJJ[dcW_\LXRSRUX]a`^UZZ_mai Y1-,//.-./-/...,, +;611322485k@42\44JDMVVWi uipi=.*)*++-+*,+*+-/,/......,,4//37a;FMXX[]cQYVZ]YYVJLQIKPLPURYUWXXUV\QPYXHLOP[^_XZMOTONUPMRSVPQSZbY[\|Vl W1.-./..../+..,,,+ ,:622222496b><1X44JGJMTWQWUQMUMGBBEDBEJJXaXQPUnSQMIBLH=GJICGGMOIJQTLKJNKLLJTHTaYTLH {@5/../-./-,--,,-,/.,,,,* -:821111212/.-/00...1007T]u 2,*++*.+,++*,.+**++,+,/+++--.359BCHOPPPQKLQKFEEEEHEIMV`YRQYdUNLHDHF=GIGGKDOMFKRKEBGMMJGFNTltxsqcZ @02.///../-...,,,-..--.+* -:52/1100120./.1././0013<EHGFCKMEQNJIKGNLOJGV^WWUX^WNNKBNF9BECGG?PNAENJA=BGIEBCLby }xxty _11./0/,/,..---,,,,--..+* *44200///100/../././0101./2D ]E:>1h}-,+.,+.+.-.../,+**+,-,1,,,+,-/228>@GKIHJLFOPMROIKOPTNY_b\QXWVKLFFIH9AGDCC=HKG@HB?FNFCGB<Rqyx dQ000..-.//0/../-./0/..,.,+ ,63210///11//./-.-../001.00zH iP8/-+*++*++,--./.*****++.1+,+.,./1257;@@=@GLDA@?=:;>:<;Rr bK5./,/./,.0.../...00..../.+ ,44000///100/..--,..6:12.62wR N332;fw ~wf?+**+**+*+,+-,,++++,,,/,.,-M//12::GP=GAHM=FLMCA<=ECBBFQQZPLPUNC@AILALBEEBB?AGCILGLOFFPNMGA>DF@KBSH>BDEC==<:7;;99n zhRNqK/,/,0/..0.//01.-+.../1-/0.+ *0110///0010/.1/0-../<61/.0a xu/1/399<;94;s xrM/+++**++++++-+**,,.+,0,//1K86109;@;D@=KAB>@BFEITTVTTYIHJJAKMJ??;DQEPBA@;@ACGC@GMA97CPCED?:7=:?==6755; yeI60.,.,,,-/,,..0.+...+.00/,/..,+ )//../6.74525<3374@B?D3./.1<2.,/3ERRA=64.02OulH2++**+**+***+***+++++.,,-.53...0/012567976;;=?CDGOMCGA?CGBANMC86BNA?;:628;B<;54237j p[D4...-.+,.-././//,+,-./1/../..,. )//..,640?1>=;519=<3?=1/.,.-.+//3==>CE:91.0.2O?.+**++****++++**+,+++-,./-.+,,-..0/10466:6?A>=@@FJKECDAADC=FKE:6BL?9;554:;::;31316M |jWB2/./.-,.....-./.,./-1.00/./-.,* )-00..:2/90/762254;/260//-+-.-0@?A=DJKOEFFDHFFGFI=012/.//,,+++*)***+,*)**+,,+++*++,.,,,,-,,,+,./100146::<@@C=92..,,,+++,++*++**+**+++*++++-.++,,...+-.,-,,,,,-./10126699=?9466:?GCGEECFJEFE?E::74941965;53112456u wL:./.,+.,,-,.+,,,,,.-..,-,.../...,, *56574212636746435214311127>38441.,+.,,,,++**++*++++,,.,++++,-,.-.---.,.-,*+,..-,.//1114569@<642496CBABEGFIGDD9A=>94540563544101435qyw ia3,..,.,+,,.,,,-.....,0-,-....-..++ *1213753767877;;6658:8:80///3.3,...++++++*++,,++.,,*++,++++++*,,+++++,,++.++..-+,../003246>>A;74445@;>?@DIHECC::::7533056272100010:;7SZd} fu01/.--.,...-,,,-,-.,,,.-.-.,//.,.+ +000054000000.0/...././//,...,--++,*+,*+*+*+*+,.,++***+***+**)++-+,*++++-+++,.++,.////25575:;9;67944>93001//./001n{|s lYUC>Ph ?/..-+,-....,..-.-.,,.,,--,,..../., *11114420//0//110...///.,++++++*+*+,++++,+++*+++,+,++*)+**+++*+,++++*,,++,+,...--///11468::6;:94410276599>AA=*+2+-+,-+*+*+-+,,-^//+.3/-.30;0H@11347:25258:;<23256279A/8^-6Z.-.,=E++++/,48:p2-,,/.0//2322<32102411///0/421/032116F97:565523\TMTK6//Cz5++*+++,..+/0.10/-.,--,,,+-..+../.-..//.,/,2/0/01...** +33544243<2;]224o4V42/011////.--+2S1\///c3.`0:M-,m0L65~D6n9n591F00011112122699?CEBNObgpwy{z~ W-..,,-.,.//1897754658898375600.0000/./0++,,.03010206544782331112111G44556=6=64352245965202342//.//121,,+++++*,++++++,+++++...,.0/.-.-//.//...//.000.//./.+ -14467242A6 @23b5336 w]2234221142343554575401000101422231260000///.4/-.//107170104223326474522344 :<@BA;87524:;65:=68<3441//..//0/00-+*+++,-.,**+++,++*+,-.,-/--.......-/,....1.///.-/,, -43459532;7ur9>F322A 431145315f34A413242222000011011111B6210.0/,0../.1.071810124321639;7464123c?7@6766954=46844767D;1010000//12016/+,-,,--,)*,+.++*+,-,.,,-,+.-/-,-..0.,,.////.,.//,, ,234594114675UH1113B632123223423215m4>T321322112212201311221|101////-02./-3/071532611603;7?5:9>1/01;:26=745731654746:45691113011.//40.34/-,+,,,++*-+,-,+++,,-+++*-,//....,,.-+.///.////.,. ,3244:514232111011;5230001204213004q4AR2114124231111/0001S^V u;11100.1700.5//21001615;4276K2<330094.2145>45523254166;1338911010/1.2///21.-,--,+++*,,*+*,*,,,++,-*+-/3//-,.+.-,/1./////..., ,1354633212411011540220004322232225m6@R3022l y3114:658762124441311551/./011//14-41///..702.3,../,/----.//.//..0..//.-07821/1212., ,145798555682111321100/0103101232;5a5?I422100/11/0001 f\///03.0/0110/1:///225221263262111514526330011014554::;9:9>;:635124452200/001/./2.02...-,3.-,.,..../..+-.-.///0/,/0//001:120/0103., -2586:764;754021000100/10//011433NqtUm\@43110/32000/.IE0/../0010122113@51/0131210146H443655485500001011216C9566788:687432424:K;2////./.4006,/../..../..../..,....,/0//////.0000323180001// ,26:897:88674330220021000//00011126::;@G1/100/140/..-.B[/0/00////./0/09/./101001.032B1444855624020/0022526;5315:8:7?>4443212103C30100/070.;0.............//--0/00///0/00310/0/0112110001.. /46;979<88986455422111110000100002423130//1////:/.//////000/1/.////0/1<./031/000111150113645521//0/0101:56L955?5A49:=655<2@721052///0/.4//@//.-/,-./...0/0/../.1/00//001R\j00/0112010001/. .58>99;@;<;::5;E86444111110010/10111213/**./.0/4.//0/////0//././1038?1:2:155>828674:001D4>EDBB301/11104;68<:;9@49657965492;<21<401/.1/16.6G:/.-././-..9../,../1401./0106v2y51001012111230/ .37>4;7<0/02B4@97K:81:;?B245E=6:9;6=456665514@52:51B320210//8000.0//....2//./911/01214U1122123454342401 049A;<@=<;=99:;;::7754556544:sB657 92:j24254223543244125433344542?:>65;2167;692124::8:7G966977677:B;;;?;99<:;:7:645869<97B87979657;44442445344454KcR@?86596SV75e8ybC9QD99;<7::87;<756