Eye Ear Nose Throat Upper Respiratory tract Infection

1. Eye Ear Nose Throat & Upper Respiratory tract Infection Jittipon Tantivit BCPS Faculty of Pharmaceutical Science Khon Kaen University

2. Outline Eye Glaucoma Conjunctivitis Ear Otitis media Vertigo Nose Sinusitis Throat Pharyngitis

5. ????????????? ??????????? ????? ???????-????? ???????????? ???????????????? ????????????????????? ???? ??????????,????????????,?????????????? ??????????? ???????????????? ???? ??????????? ??????????? ????? ???????????/????????????? ???????

6. ????????? ???? ?????? ???????????? ????? ???????? ????? ???????? ?????????????????? ????????????????? ????????? ?????????? ?????????????????????? 72 ?????????????????????????? ?????? ??????????? ????????? ????? ???????? ????????? ??????????????? ?????????? ?????????????????????????

7. Glaucoma

8. Glaucoma Intra ocular pressure ??????? ???????????????????????????????????? ???????????????

9. Physiology Epithelium of Ciliary body produce aquaous humor Flow to Posterior chamber and Anterior chamber Flow out of the eye by Trabecular meshwork Flow into Schlemm’s canal

12. Classification of Glaucoma Primary Glaucoma Subacute close angle glaucoma Acute close angle glaucoma Chronic close angle glaucoma Chronic open angle glaucoma Secondary Glaucoma Congenital Glaucoma

13. Symptom Close angle glaucoma ???????????????????? (???????????????????????????????????????????????????????????????????) ?????????????????????????????????? ????? Open angle glaucoma ??????????????? ????????????????????????? ?????????????????????????

16. Cause of Glaucoma Genetic Age Trauma Disease Drug

17. Drug induce Glaucoma

18. Treatment Non pharmacologic(Surgery,Laser) Pharmacologic Decrease aquaous humor production Increase outflow of aquaous humor

19. Drug for Open angle Glaucoma Beta blockers Alpha-2 selective Adrenergic Agonists Carbonic Anhydrase Inhibitor Prostaglandin analogs Miotics Mydriatics

22. Pilocarpine(+/-Timolol) plus Acetazolamide plus Mannitol Drug for Close angle Glaucoma

23. Beta blockers Timolol(Glauco oph,NS),Betaxolol(Betoptic S,Beta1),Carteolol(Arteoptic,NS+ISA), Levobunolol(Betagan,NS) Decrease aquaous humor production S/E:Stinging,Dry eye,Blurred vision,Corneal anesthesia,Blepharitis,BP&HR drop,Bronchospasm,CNS effects Precaution Pulmonary diseases Bradycardia,Heart block,CHF DM

24. Alpha-2 selective Adrenergic Agonists Brimonidine(Alphagan) Decrease aquaous humor production Increase aquaous humor outflow by uveoscleral route Allergy(lid edema,eye discomfort,Itching) S/E:Dizziness,Fatigue,Somnolence,Dry mouth Precaution:CVD,Renal compromise DI:Antihypertensive drugs,MAOIs,TCAs

25. Carbonic Anhydrase Inhibitor Acetazolamide(Diamox) :Systemic Brinzolamide(Azopt) :Topical Dorzolamide(Trusopt):Topical Decrease aquaous humor production S/E(topical):Burning,Stinging,Ocular discomfort,Blurred vision S/E(systemic)Anorexia,N/V,Hypokalemia, Acidosis,Fatigue,Taste alteration Precaution:Sulfa Allergy,Respiratory acidosis,Renal calculi,E’Lyte imbalance

26. Prostaglandin analogs Latanoprost(Xalatan),Travoprost(Travatan), Bimatoprost(Lumigan) Increase aquaous humor outflow by uveoscleral route Give OD S/E:Alter iris pigmentation,Uveitis Precaution:Ocular inflammatory conditions

27. Miotics Pilocarpine(Isopto Carpine), Carbachol(Miostat) Open&Close angle glaucoma Increase aquaous humor outflow by Trabecular meshwork Frequent dosing requirement S/E:Decrease night vision,Visual field constriction,Eyelid twiching,Conjunctival irritation,Headache,Diarrhea,Abdominal pain,Cholinergic effect

28. Mydriatics Epinephrine,Dipivefrin Increase aquaous humor outflow by Trabecular meshwork and uveoscleral route S/E:Tearing,Burning,Ocular discomfort,Allergic blepharoconjunctivitis,Stenosis of the nasolacrimal duct,Blurred vision,Deposition of pigment in conjunctiva&cornea,Headache,Increase BP,HR,Tremor May precipitate acute CAG in Pt with narrow anterior chamber Precaution:CVD,Celebrovascular disease,Aphakia,DM,Hyperthyroid

30. Conjunctivitis

31. Bacteria Virus Allergy Conjunctivitis

34. Allergic Conjunctivitis No pain , vision changes Marked pruritus Bilateral watery eyes Treatment :antihistamine or steroid drops

35. Herpes Conjunctivitis

36. Comparison

38. Cataract  Lens opacity Blurred vision ,progressive over months or years No pain or redness Treatment :surgery Prednisolone 15mg/day for 1 year

40. Macular degeneration Age-related Painless loss of visual acuity No Tx , but patient often retains adequate peripheral vision Non Pharmacologic therapy VitC 500mg+ VitE 400 U+ Vit A 25,000U(Beta-Carotene 15 mg) +Copper 2 mg Pharmacologic therapy Pegaptanib, Bevacizumab, Ranibizumab Verteporfin Triamcinolone

43. ???????? ??????? ????????????? ????????????????????? ??????????????????? ????????????? ????????????????????????????????? ??????????????????????? ????????????????????????????????? ?????? ????????????????????????1-2 ???? ???????????????????? ???????? ?????????????????????? ???????

44. ????????(???) ?????????? 1 ??? ????????????????????? 1-5 ???? ?????????????????? 2 ???? ?????????????????? 5-10 ???? ??????????????????????? ????????? ??? ?????????????????? ??????????????????????????????????? ??????????????? 1 ????? ??????????????????????? ???????????????????? ?????????????? ??? contact lens ???????

45. ???????? ??????? ??????? ?????????? ?????????????????? ?????????????????????????????????????????????????????? ??????????????????????? 1 ??.????????????????????? ????????????? ???????? ?????? ????????????? ????? ??????????????????????????????? ????????????????????? 10 ????

46. The Ear

47. ????????????? ????? ???????????????????????????? ?????????????? ??????????????????????????????????????????? ????????????????????????? ???????? ?????????????? ?????????????? ?????????? ??????????????????????????????????????? ??????????????????????????? ???????????????????????????????? ???????????????????????????????????? ?????

48. ????????????? ?????? ????????? ????????????????????? ????? ????????????????? ???????????????????????????? ???????????????????????? ??????????????????????????????????????????????????????????????? ?????????????????? ???????????????????????????????????????????? ?????????????????????????????????

49. ????????????? ?????????????????? ???????????????????????????????????? ??????????????????? ?????????????????????????????????? ???????????????????(?????,??????,??????) ???????????

50. ???????? ??????? ???????????????????????? ?????????????????????????? 2-3???? ???????????????????????????????????? ???????????? ???????????????????????? ????????????????????????? 3-5 ???? ???????????????????????????? ?????????????? ??????????????? ?????

51. OTITIS EXTERNA Presents with otalgia Pruritus Purulent discharge h/o recent water exposure or mechanical trauma Examination reveals : erythema and edema of the ear canal and pulling on pinna or pushing on tragus cause pain

52. Pseudomonas is usual cause Treatment: Protection of the ear from additional moisture Otic drops containing a mixture of aminoglycoside antibiotic and anti-inflammatory corticosteroid( eg. Neomycin sulfate , polymyxin B , and hydrocortisone OTITIS EXTERNA

53. Otitis Media

57. ????????????????????????????????? Acute OM < 3 ??????? Subacute OM 3 ???????- 3 ????? Chronic OM > 3 ????? Recurrent >3 ?????????? 6 ????????? >4?????????? 1 ??

59. ATB for OM DRSP risk ??? ?????? ATB ?????? 3 ?????????????? ???????????? 2 ?? ??????????????????????????DRSP risk ??? ?????? ATB ?????? 3 ?????????????? ???????????? 2 ?? ??????????????????????????

60. Duration Assess at 48-72 hrs 10 days vs 5-7 days Age>6 yrs Age 2-6 yrs Age<2 yrs

62. ??????????????????????????? ?????????????????????????????????? ????????????????????? ADR ????????????????? (Paracetamol,Ibuprofen)

63. Vertigo

64. Vertigo A false sensation of movement associated with difficulty in balance or gait The perceived motion is rotary, spinning, whirling Feel as the environment is moving

65. The Inner Ear

66. Vestibular Labyrinth Pathophysiology Complex interaction of visual, vestibular and proprioceptive inputs that the CNS integrates as motion and spatial orientation 3 semicircular canals rotational movement cupula 2 otolithic organs utricle & saccule linear acceleration Macula

67. ??????????????????????????????? ????????????? ?????????? ?????????????? ?????????????? ???????? ??????? 4 ??????? ??????????????? ???????????????????? ??????????????????? ????????????? ???? ???????? ??????? (?????????) ???????????????????? ???? ??? ?????? ??????????????????? ???????????? ????????? ????????? ?????????? ?????? ????????????????????

68. Medical Treatment Symptomatic Specific therapy Vestibular rehabilitation

69. Drug use in vertigo Vestibular suppresants - inh. vestibular signals to brain stem autonomic centre - inh. Neurotransmitters ( vestibular signal) Antihistamine, anticholinergic, antidopamine

70. Mechanism involved in Vertigo

71. Mechanism involved in Emesis

72. Symptomatic Pharmacotherapy Predominant targeted vestibular neurotransmitters: Cholinergic Histaminergic GABA neurotransmitters - negative inhibition Vomiting center transmitters: Dopaminergic (D2) Histaminergic (H1) Serotonergic Multiple classes of drugs effective

73. Symptomatic Pharmacotherapy Some drugs of the antihistamine class are useful for symptomatic control of vertigo Have anti-motion sickness properties in large part due to inhibition of vestibular system H1 histaminergic neurotransmitters Examples include dimenhydrinate (Dramamine) and promethazine (Phenergan) Also suppress the vomiting center

74. Anticholinergics Reduce firing rate of vestibular neurons Muscarinic cholinergic stimulation of the vestibular neuron inhibit by atropine Scopolamine(Hyoscine), Atropine

75. Phenothiazine D2 antagonist at CTZ, weak antihistaminic, anticholinergic, alpha blocker-reduce firing rate of vestibular neurons and vomiting center via CTZ Chlorpromazine(Lagactil): 25mg q 4-6 h Prochloperazine(Stemetil):5-10 mg po tid Butyrophenone Haloperidol(Haldol):1-2mg po q 4-6 hr More EPS Antidopaminergics

76. Tranquilizers Vestibular suppression through RF system Crossed vestibular&cerebello-vestibular inhibitory transmission GABA agonist Phenobarbital,Clonazepam Diazepam 5-10 mg po q 4-6hr

77. Histamine H1-vasodilator,flushing H2-proton in stomach H3-presynaptic

78. Antihistamines Promethazine(Phenergan): 25-50 mg q4-6 h Dimenhydrinate(Dramamine): 50 mg 1-2tab tid-qid

79. Histamine analogue Potent H3 autoreceptor antagonist on histaminergic neuron: release of histamine Weak H1&H2 agonist, Ca antagonist Control release of histamine at nerve terminal Cochlear & labyrinthine vasodilator Cholinergic system involved Betahistine mesylate(Merislon):6-12mg tid Betahistine dihydrochloride(Serc):8-16mg 1-2tab tid,24mg 1tab bid

80. Calcium Antagonists Class IV blocker, non specific slow CCB in myocardium but specific in brain tissue Reduce excitatory neurotransmitter, Ca influx Antihistamine, anticholinergic, antidopaminergic EPS Cinnarizine(Stugeron): 25mg po q8 h Flunarizine(Sibelium): 5-10mg po od

81. Miscellaneous Vasodilator Almitrine/Raubasine(Duxaril) 1tab od-bid Ergoline derivatives:Nicergoline(Sermion) 10mg tid or 30mg bid, Dihydroergocristine(Hydergine) 3-6mg/day

82. Medical treatment ??????????????????? ?????????????????? ????????????????? ????????????????????????????? ????????????????????? ?????? 2-3 ??????????

83. ?????????????????????????????? Meniere’s disease Benign paroxysmal positional vertigo (BPPV) Vertibular neuritis

84. Meniere’s disease Peripheral vestibular disorder with intermittent excessive accumulation of endolymphatic fluid Dilation of membrane labyrinth due to excess endolymph Most common in adult (men ages 30-60 yrs)

85. Meniere’s Disease Hallpike and Cairns - 1938 found endolymphatic hydrops by histology Implicated a disturbance of salt and water as pathology Classic triad Episodic vertigo lasting several hours Tinnitus Hearing loss

86. Sign and symptom Tinnitus Vertigo Feeling of fullness or blockage in the ear Hearing loss Attacks from 10 minutes to several hour Occur over a few days or weeks

87. Widely accepted medical treatment Dietary salt restriction(1g/day) Diuretics Thiazide diuretics Decrease Na absorption is distal tubule Side effects - hypokalemia, hypotension, hyperuricemia, hyperlipoproteinemia Combination potassium sparing agents Maxzide, Dyazide Avoids hypokalemia

88. Vasodilators Based on hypothesis - pathogenesis results from ischemia of stria vascularis Rationale - improve metabolic function IV histamine, ISDN, cinnarizine (CA antagonist), betahistine (oral histamine analogue) Benzodiazepines Drug treatment

89. BPPV Inner ear problem that results in short lasting, but severe, room-spinning vertigo. Benign: not a very serious or progressive condition Paroxysmal: sudden and unpredictable in onset Positional: comes with a change in head position Vertigo: causing a sense of dizziness.

90. Symptoms Starts suddenly first noticed in bed, when waking from sleep. Any turn of the head bring on dizziness. Patients often describe the occurrence of vertigo with tilting of the head, looking up or down (top-shelf vertigo) rolling over in bed. nausea and vomiting. There is no new hearing loss or tinnitus.

91. Medications Antiemetic Antihistaminic Anticholinergic

92. BPPV Head movements Looking up Lying down Rolling onto affected ear Result in displacement of “sludge” / otoconia Vertigo lasting a few seconds Treatment approaches Liberatory maneuvers Particle repositioning Habituation exercises

93. Epley maneuver

94. Vestibular Neuritis Sudden onset of peripheral vertigo Usually without hearing loss Period of several hours - severe Lasts a few days, resolves over weeks Inflammation of vestibular nerve - presumably of viral origin Spontaneous, complete symptomatic recovery with supportive treatment Treatment aimed at stopping inflammation

96. EPISTAXIS Bleeding from Kiesselbach’s plexus, a vascular plexus on the anterior nasal septum. Predisposing factors : Nasal trauma (nose picking, foreign bodies, forceful nose blowing) Rhinitis, drying of the nasal mucosa ,deviation of the nasal septum, alcohol , bone spurs, antiplatelet medication.

97. Treatment = direct pressure, topical nasal constriction (phenylephrine 0.125-1% solution), consider anterior nasal packing if unable to stop.

98. Sinusitis

99. Sinusitis Sinus ostial obstruction Mucus accumulation Anaerobic environment Commonly viral Bacterial sinusitis S.Pneumoniae H.Influenzae M.Catarrhalis

100. Onset of disease ????????? 30??? ????????????? 30-90 ??? ???????? 90 ??? ????????? ????????? ????? ??????? ???????? ??????????????????? ?????????????????????????? ??????????????2???? ???????????????????????????????? ??????????? ???????????? ???????????????????? ??????????????? ?????? ??? ????????? ?????? ????? ?????????? ?????????????? ????????????????? ??????????????????? ?????????????? ???????????? ???????? ??????????????????????????????? 3 ????? ?????? ?????? ????????????????? ???????? ?????????????????

101. Symptom of Bacterial Sinusitis Duration 10-14 days without improvement Nasal congestion Purulent rhinorrhea Postnasal drainage Facial pain(especially when unilateral) Headache Symptom worse at night Sinus tenderness on palpation Periorbital edema Olfactory disturbances

102. Treatment of Bacterial Sinusitis Symptom should be present at least 10 days before ATB are considered Earlier ATB may be necessary in patients with worsening or severe symptom 10-14 day course is recommended If symptoms do not improve after 3-5 days of any treatment, an alternative ATB should be considered

104. Adjunctive Therapy Intranasal Glucocorticoids Antihistamine Decongestants Mucolytics Nasal Saline Irrigation

105. Throat

106. Throat Dental Canker sores Herpes simplex Candidiasis Xerostomia Halitosis

107. ???????????????????? ??????????????????????????????? ???????????????????? ?????????????? ???????????????????????? ????????????????????????????????????????????? ?????????????????????????????? ??? ??????? ??????????????????????? ?????????????????????????????? ???????????????????? ????????????????????????????? ????????????????????? ???????????? ???????????? ??????????????? ????????????????? ???????? ???????????????? ??????????????????? ???????????

109. Principles of Management of Genital Herpes Counseling should include natural history, sexual and perinatal transmission, and methods to reduce transmission Antiviral chemotherapy Partially controls symptoms of herpes Does not eradicate latent virus Does not affect risk, frequency or severity of recurrences after drug is discontinued

110. Antiviral Medications Systemic antiviral chemotherapy includes 3 oral medications: Acyclovir Valacyclovir Famciclovir Topical antiviral treatment is not recommended

111. Management of First Clinical Episode of Genital Herpes Manifestations of first clinical episode may become severe or prolonged Antiviral therapy should be used Dramatic effect, especially if symptoms <7 days and primary infection (no prior HSV-1)

112. CDC-Recommended Regimens for First Clinical Episode Acyclovir 400 mg orally 3 times a day for 7-10 days, or Acyclovir 200 mg orally 5 times a day for 7-10 days, or Famciclovir 250 mg orally 3 times a day for 7-10 days, or Valacyclovir 1 g orally twice a day for 7-10 days

113. Severe Disease IV acyclovir should be provided for patients with severe disease or complications requiring hospitalization CDC-Recommended Regimen: Acyclovir 5-10 mg/kg IV every 8 hours for 2-7 days or until clinical improvement Follow with oral antiviral therapy to complete at least 10 days total therapy

114. Fungal (candida) Dysphagia Sore throat with white ,cheesy patches in oropharynx (oral thrush)seen in AIDS and small children Dx : clinical or endoscopy Tx : nystatin ,clotrimazole

115. Second Line Therapy for Refractory Cases Fluconazole 100 mg po daily for 7–14 days after clinical improvement (preferred) Itraconazole 200 mg po daily for 7– 14 days after clinical improvement Alternative therapies are indicated for patients who fail to respond to the first line topical treatments. A number of treatment options exist for the management of refractory cases of oropharyngeal candidiasis. Fluconazole is the drug of choice. The patient should be prescribed 100mg a day to be taken orally for 7 to 14 days after clinical improvement. Itraconazole can also be used as an alternative to fluconazole, taken 200 mg daily orally and continued for 7 to 14 days after clinical improvement. Alternative therapies are indicated for patients who fail to respond to the first line topical treatments. A number of treatment options exist for the management of refractory cases of oropharyngeal candidiasis. Fluconazole is the drug of choice. The patient should be prescribed 100mg a day to be taken orally for 7 to 14 days after clinical improvement. Itraconazole can also be used as an alternative to fluconazole, taken 200 mg daily orally and continued for 7 to 14 days after clinical improvement.

116. Second Line Therapy for Refractory Cases Topical amphotericin B OR Amphotericin B 0.3 mg/kg per day IV for 7–14 days after clinical improvement Patients who are refractory or cannot take azoles, can also be treated with topical or intravenous amphotericin. Clinicians should check the local pharmacopeia to obtain dosing information, strengths and formulations for locally available topical amphotericin B. Patients who are refractory or cannot take azoles, can also be treated with topical or intravenous amphotericin. Clinicians should check the local pharmacopeia to obtain dosing information, strengths and formulations for locally available topical amphotericin B.

117. Pseudomembranous Candidiasis White/Grey Plaques on the Hard Palate (Pseudomembranous candidiasis) This slide shows a patient with oropharyngeal candidiasis with white/gray plaques on the hard palate known as pseudomembranous candidiasis. This is the most common clinical presentation of oral candidiasis. The white/gray plaques can be easily removed by scraping them off with a tongue depressor. Occasionally, there is an erythematous area and/or bleeding under the area that was previously covered by the white/gray plaque. This slide shows a patient with oropharyngeal candidiasis with white/gray plaques on the hard palate known as pseudomembranous candidiasis. This is the most common clinical presentation of oral candidiasis. The white/gray plaques can be easily removed by scraping them off with a tongue depressor. Occasionally, there is an erythematous area and/or bleeding under the area that was previously covered by the white/gray plaque.

118. Erythematous Candidiasis Erythematous Candidiaisis Affecting the Hard Palate This slide shows erythemathous candidiasis affecting the hard palate. This is a less common presentation of oropharyngeal candidiasis. These lesions have a red appearance and cannot be scraped off. This slide shows erythemathous candidiasis affecting the hard palate. This is a less common presentation of oropharyngeal candidiasis. These lesions have a red appearance and cannot be scraped off.

119. Pharyngitis

120. Pharyngitis ?????????????????????????????????????? ???????? ???????? ?? ???????? ????? ?????????????? ????? ??????????? ???????????????????? ??????????????(virus) ??????????????? ???????? ?????? ????????? ????? ?????????? ???????????????????? ??????????? ????????????????????? ????????????????? ????? ?????????????????????????????????? ??????????? ?????? ???????????????????????????????????????? ??????????? ??????????????????????????????????????????????????????????????(GABHS)

122. Strep Score for GABHS Pharyngitis

123. Strep Score for GABHS Pharyngitis

124. Complication Rheumatic Fever Acute glomerulonephritis Peritonsillar abscess Bacteremia Toxic shock syndrome

125. Antibiotics Shorten the course of infection 1-2 days Prevent complication and the spread of disease Delay in Tx can be made safely for up to 9 days after symptom onset Line of Therapy 1st Penicillin 2nd Cefdinir,Cefuroxime,Cefproxil,Cefpodoxime 3rd Azithromycin or Clarithromycin

127. Acute Bronchitis Acute URI lasting 1-3 weeks in healthy adult Bronchial and tracheal mucosa thicken Fever, Malaise 3-7 days before develop to cough Sputum production and wheezing 5-6 weeks for resolution Virus, M. Pneumoniae, C. Pneumoniae, Normal flora(SP, HI, MC)

128. Complication: Pneumonia(rare) ATB no recommend(Macrolides, Bactrim) Adjunctive therapy Antitussive Bronchodilator short acting Inhaled corticosteroids Acute Bronchitis

129. Pertussis ???????? 2-6?? ????????????? ??????????????? ???????? Bordetella pertussis ???????? ???????????????? ??? ?????????????? ????????????? 7-14 ??? ???????????? ???????????????????????????????????? ?????????????????????????????????????? ?????????????????????? ????????? ???????? ?????????????????? ??????????????????????????????? ?????????????? ???????? ???????? ????????? ???? 1 ????? ???????????? ??????????? ?????????????????????????????????? 3 ????? ?????????????????????????????????????? 1 ??????????????????????????????????????????????????????? ??? Erythromycin 50 ??/??/??? ??????? 4 ???? ???????????? 14 ????????????? Azithromycin, Clarithromycin, Bactrim ??? ??????????????????????????????? ?????????????? ????????????????????????????????????????????????

130. Diphtheria Corynebacterium diphtheriae ????? toxin ?????????????????????? ??????????????? ?????????? ?????? ?????? ?????????????????? ?????? ????????? ??????????????? ???????? ???????? ???????????(????????????????????????????????????) ???????????(stridor) ????????????? ?????????? ???????? Gray-yellow pseudomenbrane ???????????????? ???????????? ???????? ??????????? ???????????????????? ???????? ?????????? Diptheria antitoxin,PenG 1-1.5????????/??/??? ???? Erythromycin 50 ??/??/??? 2 ??????? ???????????????????????????????(?????????????? 5 ???????????????) ????????????????????? ??????????? 7 ??? ?????? erythromycin ?????????????????????????????? 7 ???

131. Common Cold ?????????? ??????????? ??????? Rhinovirus,Adenovirus,coronavirus,RSV,Parainfluenza,Influenza,Enterovirus ??????,??????,????? ????????? ?????? 1-3 ??? ??????????? ?????????????????? ????????? ?????????? ???????? ??????? ???????? ??? ?????? ?????????????? ??????????????????????????? ???????????????????????????????? 4 ??? ???????????????????????????????? 24 ??.????????????????????? ????????????: ?????? ????? ?????????? ?????? ????????? ????????????? ???????????????? ?????? ????????????? 4 ??? ?????????????????????? 24 ??. ????? ?????? ???????????????????????

132. Influenza ????A ????????????????????? Hemagglutinin ??? Neuraminidase ?????? ?????? ????? ?????????????????????????????????????????? ??????????????? ?????????? ????????????????????????? ?????? ????? ?????????? ??????? ???????? ?????? ?????????? ???? 1- 7 ??? ???????????????????? 1-4 ??????? ???????? ???????????????? ????? ?????? ??????????????? pericarditis myocarditis ??????? ??????????? crepitation rhonchi ???????????: ???? ????? ????????? ???????????? ??????? ?????? ?????? ???????? ????? ???????:??????? 7 ??? ??? ???????????

133. Any Question?