HY USMLE Review Part I PDF

MEHLMANMEDICAL HY USMLE REVIEW PART I  MEHLMANMEDICAL.COM YouTube @mehlmanmedical Instagram @mehlman_medical MEHLMANMEDICAL.COM 2  MEHLMANMEDICAL.COM HY USMLE Review – Part I Travel +...

MEHLMANMEDICAL HY USMLE REVIEW PART I  MEHLMANMEDICAL.COM YouTube @mehlmanmedical Instagram @mehlman_medical MEHLMANMEDICAL.COM 2  MEHLMANMEDICAL.COM HY USMLE Review – Part I Travel + self-limiting watery or brown/green diarrhea à Traveler diarrhea = ETEC HL or HS toxin Bloody diarrhea + poultry consumption à Campylobacter jejuni or Salmonella spp. Abx (clindamycin, beta-lactam, cephalosporin) + diarrhea à C. difficile Dx of C. diff à stool AB toxin test, not stool culture Fever of 104 + abdo distension in C diff à toxic megacolon à laparotomy Tx of C. diff à vancomycin, not metronidazole (updated guidelines as of Feb 2018) Bloody diarrhea + travel à Entamoeba histolytica Tx of E. histolytica à metronidazole + iodoquinol; can give paromomycin Close quarters or military barracks or cruise ship + watery diarrhea à Norwalk virus Child 10 mm with inspiration) à cardiac tamponade or severe asthma Beck triad à hypotension + muffled heart sounds + JVD à pericardial tamponade MEHLMANMEDICAL.COM 3  MEHLMANMEDICAL.COM Tx of tamponade à pericardiocentesis or pericardial window Tamponade à do echo before pericardiocentesis if both listed (even though sounds wrong, on 2CK NBME) Community-acquired pneumonia (CPP) + bilateral CXR infiltrates à Mycoplasma CPP + lobar pattern (right-lower lobe consolidation + dullness to percussion) à Strep pneumo CPP + lobar pattern, but they say “interstitial” in the vignette description à Mycoplasma, not S. pneumo Empiric Tx for CPP à azithromycin Tx for CPP is pt on Abx past three months à fluoroquinolone over azithro Pneumonia in CF patient 10 years à Pseudomonas exceeds S. aureus. Pneumonia after influenza infection à USMLE wants S. aureus Pneumonia + rabbits à F. tularensis Pneumonia + cattle à Coxiella (Q fever) Pneumonia + birds à Chlamydia psittaci Leg swelling + pain + shortness of breath à Pulmonary embolism caused by DVT Tx of PE à Heparin before spiral CT Tx of PE in pregnant woman à V/Q scan, not CT Tx of PE in someone already on warfarin à spiral CT to confirm, then IVC filter Acid-base disturbance in PE à resp. alkalosis (low CO2, high pH, low O2, normal bicarb [too acute to change]) Acid-base disturbance in asthma à resp. alkalosis (low CO2, high pH, low O2, normal bicarb [too acute to change]) Acid-base disturbance in aspirin toxicity first 20 mins à resp. alkalosis (low CO2, high pH, normal O2, normal bicarb [too acute to change]) Acid-base disturbance in aspirin toxicity after 20 mins à mixed metabolic acidosis-respiratory alkalosis (low CO2, low pH, normal O2, low bicarb) Tx for aspirin toxicity à bicarb (increased excretion through urinary alkalinization) Tx for TCA toxicity à sodium bicarb à dissociates drug from myocardial sodium channels Normal calcium à 8.4-10.2 mEq/L Tx of hypercalcemia à 10.2-12 à normal saline (0.9% NaCl) MEHLMANMEDICAL.COM 4  MEHLMANMEDICAL.COM Tx of hypercalcemia à 12-14 à normal saline (0.9% NaCl) only if asymptomatic; add bisphosphonate (e.g., pamidronate) if symptomatic Tx of hypercalcemia à 14+ à normal saline (0.9% NaCl) + bisphosphonate High calcium + polyuria à nephrogenic diabetes insipidus (weird, but on NBME) High calcium + confusion à delirium caused by high calcium Low calcium or potassium not responsive to supplementation à cause is low Mg Low calcium or potassium in alcoholic à hypomagnesemia is cause Ataxia, confusion, ophthalmoplegia à Wernicke encephalopathy (B1 deficiency) Retrograde amnesia + confabulation in alcoholic à Korsakoff psychosis Wernicke-Korsakoff syndrome à mammillary bodies Hx of many pregnancies + downward movement of vesicourethral junction à stress incontinence Tx of stress incontinence à pelvic floor exercises (Kegel); if insufficient à mid-urethral sling Hyperactive detrusor or detrusor instability à urge incontinence Need to run to bathroom when sticking key in a door à urge incontinence Incontinence in multiple sclerosis patient or perimenopausal à urge incontinence Tx of urge incontinence à oxybutynin (muscarinic cholinergic antagonist) or mirabegron (beta-3 agonist) Incontinence + high post-void volume (usually 3-400 in question; normal is 20 à prerenal (hypovolemia) à heart failure BUN/Cr 30k) Dry cough in winter à cough-variant asthma (1/3 of asthmatics only have cough) Young African American woman + dry cough + normal CXR à asthma (activation of mast cells), not sarcoidosis Young African American woman + dry cough + nodularity on CXR à sarcoidosis (noncaseating granulomas) Electrolyte disturbance in sarcoid à hypercalcemia à LOW PTH + high calcium Hypercalcemia in sarcoid, why? à epithelioid (activated) macrophages produce 1-alpha hydroxylase, thereby activating vitamin D3 Increased calcium in sarcoid à means decreased calcium in feces (bc D3 increased small bowel absorption) Tx for sarcoid à steroids Outpatient Tx of asthma à SABA, then low-dose ICS, then maximize dose of ICS, then LABA, then use any number of drugs (e.g., mast cell stabilizers, anti-leukotriene, etc.), then oral steroids last resort Kid with asthma on SABA inhaler + not effective + next best step? à ICS (fluticasone) Kid with asthma on SABA inhaler + most effective way to decrease recurrence? à oral steroids (not next best step, but certainly most effective) 40s male + hematuria + hemoptysis à Goodpasture syndrome Antibodies in Goodpasture à Anti-GBM (anti-collagen IV) Dx of Goodpasture à antibodies first, but confirmatory is renal biopsy showing linear immunofluorescence Hematuria + hemoptysis + “head-itis” (mastoiditis, sinusitis, otitis, nasal septal perforation) à Wegener New name for Wegener à granulomatosis with polyangiitis Dx of Wegener à c-ANCA (anti-PR3; anti-proteinase 3) Asthma + eosinophilia à Churg-Strauss MEHLMANMEDICAL.COM 11  MEHLMANMEDICAL.COM New name for CS à eosinophilic granulomatosis with polyangiitis Dx of CS à p-ANCA (anti-MPO; anti-myeloperoxidase) Hematuria in isolation + p-ANCA in serum à microscopic polyangiitis (MP) Severe renal disease in Wegener or Goodpasture or MP à rapidly progressive glomerulonephritis (crescentic) High ALP + high direct bilirubin + high amylase or lipase à gallstone pancreatitis = choledocholithiasis High ALP + high direct bilirubin + high amylase or lipase + remote Hx of cholecystectomy à sphincter of Oddi dysfunction (can’t be a stone cuz the gallbladder was removed ages ago) High ALP + high direct bilirubin + normal amylase or lipase in someone with recent cholecystectomy à choledocholithiasis (retained stone in cystic duct that descended, but not distal to pancreatic duct entry point) Dx and Tx of choledocholithiasis à ERCP High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy à pancreatic cancer Dx of pancreatic cancer à CT abdo with contrast High ALP + high direct bilirubin + normal amylase or lipase in someone with remote cholecystectomy + CT is negative à cholangiocarcinoma High ALP + high direct bilirubin + normal amylase or lipase + diffuse pruritis + high cholesterol à primary biliary cirrhosis (PBC) High ALP + high direct bilirubin + normal amylase or lipase + autoimmune disease (in pt or family) à PBC Dx of PBC à anti-mitochondrial Abx next best step; liver biopsy is confirmatory Recent cholecystectomy + fever + abdo pain à post-op bile leak High ALP + high direct bilirubin + normal amylase or lipase + CT shows cystic lesion in bile duct à choledochal cyst à do simple excision of cyst (cholangiocarcinoma not cystic + CT can be negative) Imaging to view liver or pancreas à CT with contrast Imaging to view gallbladder à Ultrasound Imaging to view gallbladder in suspected cholecystitis only if USS negative à HIDA scan Imaging to view bile ducts à ERCP or MRCP (choose ERCP > MRCP if both listed) Teenage girl with Hx of cutaneous candida infections since childhood à chronic mucocutaneous candidiasis MCC à answer = T cell dysfunction = impaired cell-mediated immunity on the USMLE Bacterial + fungal + protozoal + viral infections since birth à SCID MEHLMANMEDICAL.COM 12  MEHLMANMEDICAL.COM Bacterial infections since age 6 months à Bruton Bacterial infections only since birth à Bruton (rare as hell to say from birth, but it’s on new 2CK NBME) SCID XR variant à common gamma-chain mutation (IL-2 receptor deficiency) SCID AR variant à adenosine deaminase deficiency Bruton mechanism à tyrosine kinase mutation Hyper IgM syndrome à deficiency of CD40 ligand on T cell (can’t activate CD40 on B cell to induce isotype class switching) Greasy, scaly scalp + itchy + papules + adult à seborrheic dermatitis Tx for SD à azole or selenium shampoo Tx for tinea capitis à oral griseofulvin for patient only How to decrease risk of tinea capitis à avoidance of sharing of hats Tx of onychomycosis (nailbed fungus) à oral terbinafine Tx of tinea pedis à topical terbinafine or topical azole Tx of tinea corporis (ring worm) à topical azole (clotrimazole or miconazole) Tx of cutaneous candida à oral azole Tx of oropharyngeal candida à nystatin mouthwash Tx of esophageal candidiasis à oral azole, not nystatin mouthwash Tx of vaginal candidiasis à topical nystatin before trying oral azole Odynophagia (painful swallowing) in immunocompromised pt à esophageal candidiasis till proven otherwise CNS fungal infection or fungemia (rigors/chills) à amphotericin B Cryptococcal meningitis à amphotericin B + flucytosine, then do fluconazole taper Simple fungal pneumonia à fluconazole Sporothrix schenckii (rose thorn + finger papule) à itraconazole Hypopigmentation on upper back / trunk à tinea versicolor (Malassezia furfur) Tx of tinea versicolor à topical selenium Most common cause of impetigo à S. aureus now exceeds S. pyogenes Tx of impetigo à topical mupirocin Beefy red, well-demarcated skin plaque à erysipelas Most common cause of erysipelas à Group A Strep (S. pyogenes) >>> S. aureus MEHLMANMEDICAL.COM 13  MEHLMANMEDICAL.COM More diffuse pink skin lesion + tenderness + fever à cellulitis Most common cause of cellulitis à S. aureus exceeds S. pyogenes Tx of erysipelas + cellulitis à oral dicloxacillin or oral cephalexin Wide-complex tachyardia à ventricular tachycardia (VT) Narrow-complex tachy à SVT Tx for SVT à vagal/carotid massage first; if doesn’t work, then adenosine Tx of VT à anti-arrhythmics, e.g., amiodarone Tx of SVT or VT in setting of coma / unconsciousness à direct-current countershock Tx of first-degree heartblock or second-degree Mobitz I (Wenckebach) à observe Tx of second-degree Mobitz II or third-degree heartblock à pacemaker First-degree heartblock à PR-interval >200 milliseconds Mobitz I à gradually prolonging PR-interval before a QRS drops Mobitz II à no gradual prolongation of PR-interval; QRS randomly drops Third-degree à HR super slow at 30-40; no relation between p-waves and QRS complexes Infective causes of third-degree à Lyme disease, congenital lupus, diphtheria Give killed IM influenza vaccine when? à Every year in fall/winter only; start from 6 months of age Killed IM Influenza vaccine safe in pregnancy? à Yes, give anytime to pregnant women Live-attenuated intranasal influenza vaccine guidelines? à Only give age 2-49 to non-pregnant, non- immunocompromised persons Vaccines at age 2, 4, 6 months: HepB, Polio Salk, Pneumo PCV13, DPT, HiB, rotavirus (also give HepB at birth) HPV vaccine when à age 9-45 Mom’s HepB status unknownà give neonate HepB vaccine; only give immunoglobulin if mom comes back + MMR à first dose at 12-15 months; second dose age 4-6 years Varicella à one dose between 12-18 months Age 65 or older à give Pneumo PCV13 followed by PPSV23 6-12 months later Asplenia or sickle cell à PCV13 + PPSV23 + HiB + Meningococcal Circular lesion in pancreas seen in pancreatitis à pseudoabscess à answer = ERCP to drain internally Bullous changes on CXR or expanded lungs / hyperlucency à emphysema Centri-acinar emphysema à smokers MEHLMANMEDICAL.COM 14  MEHLMANMEDICAL.COM Pan-acinar emphysema à alpha-1 anti-trypsin deficiency Young adult + non-smoker + has emphysema + relative died of hepatic cirrhosis à alpha-1 anti-trypsin deficiency CREST syndrome lung pathology? à can cause pulmonary fibrosis à pulmonary hypertension Restrictive lung disease à normal or increased FEV1/FVC Obstructive lung disease à decreased FEV1/FVC Why is FEV1/FVC normal or high in restrictive? à radial traction on outside of airways is sticky (keeps airways from closing) Apex to base lung changes when sitting/standing à both ventilation + perfusion increase apex to base Most common cause of otitis media à Strep pneumo Tx of otitis media à oral amoxicillin only Tx of recurrent OM à amoxicillin/clavulanate When to do tympanostomy tube à three or more OM in 6 months, or 4 or more in a year Most common cause of otitis externa à Pseudomonas Tx of otitis externa à topical ciprofloxacin + hydrocortisone drops Prevention of OE in someone with constant water exposure (e.g., crew team) à alcohol-acetic acid drops Tx of earwax buildup à carbamide peroxide drops Low hematocrit + low MCV + low transferrin + low TIBC + transferrin saturation normal or low à anemia of chronic disease Low hematocrit + low MCV + high transferrin + high TIBC + transferrin saturation super-low à iron deficiency anemia Low hematocrit + low MCV + increased red cell distribution width (RDW) à iron deficiency anemia Low hematocrit + low MCV + low/low-normal RDW à thalassemia Low hematocrit + low MCV + low iron + low ferritin à iron deficiency Low hematocrit + low MCV + normal iron + normal or high ferritin à thalassemia Low hematocrit + low MCV + normal iron + normal ferritin in pregnant woman on iron supplements à thalassemia Microcytic anemia that doesn’t improve with iron supplementation à thalassemia Dx of thalassemia à hemoglobin electrophoresis MEHLMANMEDICAL.COM 15  MEHLMANMEDICAL.COM Low hematocrit + normal MCV + low iron + normal or high ferritin à anemia of chronic disease Tx of anemia of chronic disease if renal failure is cause à answer = EPO Tx of anemia of chronic disease if renal failure not cause (IBD, RA, SLE, etc.) à CANNOT give EPO; Tx underlying condition. High BP + smoker + TIA or stroke or retinal artery occlusion. How to best decrease stroke risk à Answer = lisinopril, not smoking cessation Normotensive old pt + TIA or stroke or retinal artery occlusion à atrial fibrillation Hypertensive pt + stroke à do carotid duplex ultrasound Normotensive pt + stroke à do ECG; if ECG normal à Holter monitor High BMI female + irregular menstrual cycles à anovulation Anovulation + hirsutism à PCOS Anovulation. Cause USMLE wants? à insulin resistance à causes abnormal GnRH pulsation Why hirsutism in anovulation à abnormal GnRH pulsation causes high LH/FSH ratio Why high LH/FSH ratio important in anovulation/PCOS à ovulation stimulated when follicle not ready à no ovulation (anovulation) à follicle retained as cyst What’s LH do? à Stimulates theca interna cells (females) and Leydig cells (males) to make androgens What’s FSH do? à Stimulates granulosa cells (females) and Sertoli cells (males) to make aromatase; also primes follicles Tx for PCOS à if high BMI, weight loss first always on USMLE Tx for PCOS if they ask for meds and/or weight loss already tried à OCPs (if not wanting pregnancy); clomiphene (if wanting pregnancy) PCOS increases risk of what à endometrial cancer (unopposed estrogen) Tx of prostate cancer à flutamide + leuprolide together (if they force a sequence, choose F then L). Tx of acute gout à indomethacin (NSAID) first on USMLE; then steroids, then colchicine Tx of acute gout if indomethacin + steroids not listed à colchicine Tx of acute gout in pt with renal insufficiency or Hx of renal transplant à steroids Tx of chronic gout (decrease recurrence) à allopurinol or febuxostat (xanthine oxidase inhibitors) Never give which drug to pt with Hx of uric acid stones or over-producer à probenecid (uricosuric) What are rasburicase / pegloticase à urate oxidase analogues à cleave uric acid directly MEHLMANMEDICAL.COM 16  MEHLMANMEDICAL.COM Young kid + self-mutilation + red-orange crystals in diaper à Lesch-Nyhan syndrome (X-linked) Lesch-Nyhan enzyme à HGPRT deficiency Crystal type in pseudogout à calcium pyrophosphate deposition disease Two main causes of pseudogout à primary hyperparathyroidism + hemochromatosis Two ways pseudogout presents à monoarthritis of large joint (i.e., knee) or osteoarthritis-like presentation in someone with primary hyperparathyroidism or hemochromatosis 32M + dark skin on forearms + increased fasting glucose; Dx? à hemochromatosis (bronze diabetes) Same male + painful hands + x-ray shows DIP involvement. Joint pain Dx? à pseudogout Tx of pseudogout à same as gout acutely; Tx underlying condition for chronic Biggest risk factor for osteoarthritis à obesity Tx of osteoarthritis à weight loss; if normal BMI à acetaminophen before NSAIDs Patient with OA taking naproxen (NSAID) + peripheral edema à increased renal retention of sodium Patient taking NSAID + edema; why? à NSAID decreases renal blood flow à PCT increases Na reabsorption to compensate for perceived low volume status à water follow sodium Tx of rheumatoid arthritis à Two-armed: symptom-relief + disease-modifying anti-rheumatic drugs (DMARDs) Symptom-relief for RA à NSAID first, then steroids (these do symptoms only; do not slow disease progression) DMARDs for early RA à always methotrexate first; if insufficient, add another DMARD (sulfasalazine or leflunomide); if insufficient add anti-TNF-alpha agent Methotrexate MOA à dihydrofolate reductase inhibitor Methotrexate side-effects à pulmonary fibrosis + hepatotoxicity + mouth ulcers (neutropenia) Sulfasalazine MOA à metabolized into sulfapyridine + mesalamine in the gut by bacteria Mesalamine is 5-ASA absorbed as the Tx for RA; only NSAID considered to be DMARD Leflunomide MOA à dihydroorotate dehydrogenase inhibitor (pyrimidine synthesis) Most specific Abs in RA à anti-CCP (cyclic citrullinated peptide), not RF (rheumatoid factor) X-ray of hands in RA vs OA à Only OA has DIPs involved; RA is PIPs + MCPs Symmetry in RA vs OA à RA is symmetrical; OA is not Any pt with red, warm, tender knee à joint aspiration (arthrocentesis); septic arthritis till proven otherwise Biggest risk factor for septic arthritis à abnormal joint architecture Pt groups most likely to get SA à prosthetic joints, RA/OA, recent intense exercise/joint trauma; peds (JRA) MEHLMANMEDICAL.COM 17  MEHLMANMEDICAL.COM Pt group most likely to get SA à those with prosthetic joints (can’t be more abnormal than fake joint) Pt with OA or RA has red, warm, tender knee à do arthrocentesis (septic arthritis) 17F had kickboxing tournament last weekend + knee is red, warm, tender à arthrocentesis (SA) Kid + recurrent knee redness, warmth, pain + fever à Juvenile rheumatoid arthritis (JRA; Still disease) Kid + recurrent joint pain +/- high ESR +/- rash à JRA Kid + recurrent joint pain + anemia à JRA (anemia of chronic disease) Kid with suspected JRA has sore knee à must do arthrocentesis to rule out septic arthritis Most common presentation finding in SLE à arthritis (>90%) Woman 20s-40s + arthritis + thrombocytopenia à SLE Woman 20s-40s + arthritis + mouth ulcer + circular skin lesions à SLE Malar rash + low RBCs + low WBCs + low platelets; mechanism for low cell lines? à increased peripheral destruction (antibodies against hematologic cells lines seen in SLE; isolated thrombocytopenia most common) Tx of SLE flare à steroids SLE + red urine; Dx? à lupus nephritis, more specifically, diffuse proliferative glomerulonephritis (DPGN) Histology of DPGN à wire looping capillary pattern Tx of lupus nephritis à mycophenolate mofetil Tx of discoid lupus à hydroxychloroquine Most specific Abs for SLE à anti-Smith (RNP), not anti-dsDNA Which Abs go up in acute SLE flares à anti-dsDNA (and C3 goes down) Drug-induced lupus Abs à anti-histone Drugs that cause DIL à Mom is HIPP à Minocycline, Hydralazine, INH, Procainamide, Penicillamine Viral infection + all three cell-lines are down à viral-induced aplastic anemia Viral-induced aplastic anemia; next best step in Dx? à bone marrow aspiration Viral-induced aplastic anemia; mechanism? à defective bone marrow production (contrast with SLE) Viral infection + low platelets à ITP (immune thrombocytopenic purpura) Woman 30s-40s with random bruising at different stages of healing à (also ITP; first rule out abuse) Mechanism of ITP à Abs against GpIIb/IIIa on platelets Dx of ITP à answer = low platelet count; don’t choose increased bleeding time ITP Tx à steroids first, then IVIG, then splenectomy MEHLMANMEDICAL.COM 18  MEHLMANMEDICAL.COM ITP episode à next best step in management à steroids ITP episode à most effective way to decrease recurrence à splenectomy (not first-line, but most effective) Family Hx of heme condition treated with splenectomy à hereditary spherocytosis (autosomal dominant) Bleeding time meaning? à platelet problem PT and aPTT meaning? à clotting factor problem Heme findings in ITP à increased BT, normal PT, normal aPTT Heme findings in hemophilia à increased aPTT; bleeding time and PT are normal Cause of hemophilia à X-linked recessive; hemophilia A (factor VIII def); hemophilia B (factor IX def) Tx of hemophilia A à desmopressin for hemophilia A (increases VIII release); then give factor VIII Tx of hemophilia B à give factor IX Classic hemophilia presentation à hemarthrosis in school-age boy; bleeding after circumcision in neonate Inheritance pattern of vWD à AD Heme findings in vWD à bleeding time always high; PT always normal; aPTT elevated half the time What is main function of vWF? à bridges platelet GpIb to underlying collagen (adhesion, not aggregation) What is secondary function of vWF à stabilizes factor VIII in plasma (that’s why aPTT only half time increased) vWD presentation à always one platelet problem + one clotting factor problem Platelet problem? à epistaxis, bruising, petechiae à generally mild and cutaneous Clotting factor problem à menorrhagia, excessive bleeding with tooth extraction, hemarthrosis (but hemarthrosis very very rare in vWD; it is seen in hemophilia) vWD treatment à desmopressin à increases release of vWF Vitamin K deficiency heme parameters? à Increased PT + aPTT; bleeding time normal Cause of vitamin K deficiency in adults à chronic Abx knock out colonic flora Cause of sickle cell à glutamic acid to valine mutation on beta-chain Inheritance of sickle cell à AR Nephrotic syndrome in SS à FSGS Dark urine in SS à renal papillary necrosis HY drugs that cause agranulocytosis à clozapine, ganciclovir, propylthiouracil, methimazole, methotrexate, ticlopidine How will agranulocytosis (neutropenia) present on USMLE? à mouth ulcers + fever MEHLMANMEDICAL.COM 19  MEHLMANMEDICAL.COM Tx for febrile neutropenia / neutropenic fever à immediate broad-spectrum IV Abx Broad-spectrum Abx example? à Pipericillin/tazobactam; cefepime + vancomycin What is ganciclovir used for? à Tx of CMV (DNA polymerase inhibitor) PTU and methimazole are used for what? à Tx of Graves Ticlopidine is what? à ADP2Y12 blocker anti-platelet agent (clopidogrel, prasugrel, ticagrelor also) Strongest indication for anti-coagulation à prosthetic material in heart / prosthetic valve (factoid in isolation) MEHLMANMEDICAL.COM 20  MEHLMANMEDICAL.COM YouTube @mehlmanmedical Instagram @mehlman_medical MEHLMANMEDICAL.COM 21  MEHLMANMEDICAL.COM MEHLMANMEDICAL HY USMLE REVIEW PART I All material is copyrighted and the property of mehlmanmedical. 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