downs + pneum
TRANSCRIPT
![Page 1: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/1.jpg)
GENERAL CLINICS case 4
![Page 2: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/2.jpg)
HISTORY
SHILPA.G.KAMATH080201360
![Page 3: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/3.jpg)
Personal Data
• Patient name- Shreya
• Age- 1 year 4 months
• Date of birth- 29/03/2011
• Address- Bantwala
• Informant- Mother – 7th std (reliable)
• Date of admission- 2/8/2012
![Page 4: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/4.jpg)
Presenting complaints
• Cough with expectoration – 6 days
• Breathlessness – 6 days
![Page 5: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/5.jpg)
History of presenting illness
• Cough – associated with expectoration
Onset- insiduous
Gradually progressive
Present throughout the day
No aggravating factors
Relieved on medication
![Page 6: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/6.jpg)
• Expectoration
Scanty, white, mucoid, non foul smelling, not blood stained
![Page 7: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/7.jpg)
• Breathlessness
Associated with cough and expectoration
Associated with occasional wheeze
Worsens on lying down, at night
Relieved when mother holds baby upright
![Page 8: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/8.jpg)
• Came to GWH on 30th July with above complaints
• Nebulization done
• Symptoms subsided
• Patient discharged the same day
• Symptoms recurred 3 days later, admitted.
![Page 9: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/9.jpg)
Past history
• Has had similar episodes in the past since the age of 1.5months
• 3 admissions
• Nebulization done each time
![Page 10: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/10.jpg)
Antenatal history
• Age at first pregnancy: 26 years
• Birth order-5
• h/o 3 abortions – 4th, 5th and 6th month of gestation
• Age at 4th pregnancy: 29 years (baby healthy)
• Age at 5th pregnancy : 31 years
![Page 11: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/11.jpg)
• Spontaneous conception• 1st trimester- No history of fever with rash,
exposure to drugs or radiation, increased frequency or burning micturition. IFA tablets taken.
• 2nd trimester- No history suggestive of PIH/ GDM. T.T injections taken
• 3rd trimester- No history suggestive of PIH/GDM
• 4 USG done. Anomaly detected at 8th month POG (Down’s syndrome)
![Page 12: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/12.jpg)
Natal and postnatal history
LSCS at 9th month
Cried immediately after birth
Birth weight – 2.8kg
Breast feeding initiated after 2 hrs
NICU admission- 4days – phototherapy
Passed urine and meconium
![Page 13: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/13.jpg)
At 1.5 months age:• Diagnosed to have Down’s syndrome• Child being taken for physiotherapy twice
a week since the age of 1.5 months• h/o recurrent respiratory infections• No h/o constipation / vomiting/ bleeding
gums or from other sites• No h/o impaired vision or hearing• No h/o nasal regurgitation of food/choking
![Page 14: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/14.jpg)
• h/o feeding difficulty since 1.5 months of age
• Inability to feed continuously
• h/o inadequate weight gain
• No history of orthopnoea, cyanosis, syncope or edema
![Page 15: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/15.jpg)
Developmental history
• Social smile - 8 months
• Recognized mother- 9 months
• Stranger anxiety – 1 year
• Head control – 1 year
• Rolling over – 1 year
• Unidextrous grasp – 1 year
• Monosyllables- 14 months
• Bisyllables- 16 months
![Page 16: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/16.jpg)
Immunization history
• Appropriate for age
![Page 17: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/17.jpg)
Diet history
• Exclusively breast fed till 6 months of age
Calories(kcal) Proteins(g)
Breakfast 226 6.4
Lunch 302 7.7
Snacks 290 4.1
Dinner 88 1. 7
Total 791+ 402= 1190 18.5+6.6=25
Expected 1030 22
![Page 18: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/18.jpg)
Family history
• Total family members- 4
• Non consanguineous marriage
• Parents healthy.
• No history of TB/ congenital defects/ allergy in the family
![Page 19: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/19.jpg)
![Page 20: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/20.jpg)
Summary
• 16 months old baby , a known case of Down’s syndrome, came to RAPCC with cough and expectoration and breathlessness 6 days prior to admission. Patient has history of recurrent respiratory tract infections, feeding difficulty since 1.5 months , was diagnosed to have a cardiac anomaly at 1.5months of age.She has global developmental delay. She is immunized up to date and no calorie deficit
![Page 21: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/21.jpg)
EXAMINATIONTamanna ahemad
080201372
![Page 22: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/22.jpg)
VITALS
• Pulse rate-104 beats per min (normal)
• Respiratory rate-36 per min (tachypnea)
• Afebrile during examination
![Page 23: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/23.jpg)
ANTHROPOMETRY
• Weight for age
• Less than 3rd percentile
• Grade 1 PEM (IAP)
• undernutrition (wellcome trust)
![Page 24: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/24.jpg)
• Length
• Less than 3rd percentile
• Grade III stunting (waterlow classification)
• Weight for height
• No wasting (waterlow classification)
![Page 25: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/25.jpg)
• Head circumference• Microcephaly (less than 3rd percentile)• Brachycephaly is present
• Mid arm circumference-14 cm(normal)
• Chest circumference is greater than head circumference
![Page 26: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/26.jpg)
Head to toe examination
• Sparse thin shiny hair
• Flat occiput
• Ant fontanelle-1*1cm
• Depressed nasal bridge
• Hypertelorism
• Epicanthic fold present
![Page 27: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/27.jpg)
• Up-slanting of eyes
• Low set ears
• Mouth kept open with protruding tongue
• Short neck
• Short broad hands
• Hypotonia,hyperflexible limbs
• Kennedy crease
![Page 28: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/28.jpg)
Developmental assesment
• Gross motor-sits without support (8 months)
• DQ-50• Fine motor-radial grasp present (8 months)• DQ-50• Social-stranger anxiety (6 months) DQ-38 • Language-bisyllables (9 months) DQ-56
![Page 29: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/29.jpg)
SYSTEMIC EXAMINATION
![Page 30: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/30.jpg)
RESPIRATORY SYSTEM
• Respiratory rate-36/min• On Inspection,abdominothoracic
respiration,movements bilaterally symmetrical• On Palpation,trachea is central,inspectory
findings confirmed• On percussion,resonant note heard in all
areas• On auscultation,breath sounds of equal
intensity bilaterally,vesicular,crepitations heard bilaterally
![Page 31: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/31.jpg)
• Cardiovascular system• S1 S2 heard,no murmurs
• CNS• Hypotonia,power cannot be
assessed,reflexes are normal
• P/A• Soft nontender,no organomegaly
![Page 32: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/32.jpg)
Summary
• Tachypnea
• Grade 1 PEM
• Grade III Stunting
• Microcephaly,brachycephaly
• Mongoloid facies
• Developmental delay
• Bilateral crepitations
![Page 33: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/33.jpg)
DIFFERENTIAL DIAGNOSIS
- Naseeba(080201378)
![Page 34: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/34.jpg)
ON HISTORY
• COUGH WITH EXPECTORATION
• BREATHLESNESS• WHEEZING• FEEDING DIFFICULTY• DEVELOPMENTAL
DELAY
ON EXAMINATION
• MONGOLOID FACIES • HYPOTONIA• B/L CREPITITIONS• DEVELOPMENTAL
DELAY
![Page 35: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/35.jpg)
CHARACTERISTIC FACIAL FEATURES
SUGGESTIVE OF
DOWN SYNDROME
![Page 36: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/36.jpg)
RESPIRATORY
COUGH WITH EXPECTORATION• PNEUMONIA• TB• FB
WHEEZE• WALRI• BRONCHIOLITIS• FB
![Page 37: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/37.jpg)
BREATHLESSNESS
• PNEUMONIA
• BRONCHIOLITIS
• BA
• FB
![Page 38: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/38.jpg)
CARDIAC
• CHD
• PULMONARY EDEMA
![Page 39: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/39.jpg)
HYPOTONIA
• DOWN SYN
• HYPOTHYROIDISM
• MYOPATHIES
![Page 40: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/40.jpg)
INVESTIGATIONS
- Aiswarya . S (080201390)
![Page 41: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/41.jpg)
INVESTIGATIONS FOR DOWN S SYNDROME
• Karyotyping.• To diagnose complications-• Complete blood count.• Peripheral smear• Radiological findings• X ray spine• X ray chest.• X ray bones.• X ray pelvis.
![Page 42: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/42.jpg)
• AUDIOLOGY
• OPHTHALMOLOGICAL.
• THYOID FUNCTION TESTS.
• ECHO-PDA with Left to Right shunt.
• BLOOD SUGAR.
![Page 43: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/43.jpg)
INVESTIGATIONS
• BIOCHEMISTRY—LFT,RFT,Electrolytes;ABG analysis
• HEMATOLOGY—Hb,Counts,ESR,Plateletes,PeripheralSmear
• RADIOLOGY—ChestX ray.
• MICROBIOLOGY—Blood culture;Stool & Urine examination
• KARYOTYPING
![Page 44: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/44.jpg)
INVESTIGATIONS FOR PNEUMONIA
• Chest radiography
• Total and differential count.
• Haemoglobin count.
• Culture studies
![Page 45: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/45.jpg)
HAEMATOLOGICAL INVESTIGATIONS
HEMOGLOBIN—9gm% COUNTS —
Total count-6500/cc. ESR—27.9 PLATELETS —3,40,000/cc
![Page 46: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/46.jpg)
BIOCHEMICAL INVESTIGATIONS
• ELECTROLYTES
Na+,K+,Cl-,HCO3
‘LIVER FUNCTION’ TESTS
Total and Direct Bilirubin ; ALT
• ARTERIAL BLOOD GAS ANALYSIS
• THYOID FUNCTION TESTS.
![Page 47: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/47.jpg)
Electrolytes.
• Na+=139meq/l((136-149meq/L)• K+=5.2meq/l (3.5-5.3meq/L)• Cl-=99meq/l (98-111meq/L)• Hco3-=27.4meg/l. (22-26mmol/L)
• BLOOD GAS ANALYSIS• PH-7.55 (7.35-7.45) PCO2-17.2mmHg. (35.0-45.0mmHg) PO2-159mm Hg• LIVER FUNCTION TESTS• Total bilurubin-.2 mg/dl (0.2-1.2mg/dL)• Direct bilirubin-.1mg/dl. (upto 0.3mg/dL)• SGOT-33U/L. (15-55U/L)• SGPT-22U/L. ( 5-40 U/L)• ALP-107U/L.
![Page 48: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/48.jpg)
THYROID FUNCTION TESTS
• T3-1o7ng/dl.(70-190ng/dl)
• T4-8.05ng/dl(.8-2.2ng/dL)
• TSH-1.60mIU/L(.7-6.4mIU/L)
• KARYOTYPING• T(21,22)
![Page 49: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/49.jpg)
MICROBIOLOGICAL EXAMINATION
• STOOL EXAMINATION
• Stool pus cells-2-3hpf.• Stool RBC-nil.• Stool fat globules-present.• Stool mucous-nil.• Occult blood-nil.• Ova,cyst-nil.
![Page 50: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/50.jpg)
INVESTIGATIONS
• BIOCHEMISTRY—LFT,RFT,Electrolytes;ABG analysis
• HEMATOLOGY—Hb,Counts,ESR,Plateletes,PeripheralSmear
• RADIOLOGY—ChestX ray.
• MICROBIOLOGY—Blood culture;Stool & Urine examination
• KARYOTYPING
![Page 51: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/51.jpg)
TREATMENT - Prithvishree Ravindra (080201366)
![Page 52: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/52.jpg)
IMNCI guidelines
![Page 53: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/53.jpg)
PNEUMONIA
• Indications for hospitalisation :
• AT time of diagnosis:
Features of hypoxia ( restlessness, anxiety, cyanosis. Inability to sleep, talk, walk, unconsciousness, seizures) ; Reduced urine output/ dehydrated ; Vomiting/ poor oral intake
High risk factors
• DURING TREATMENT
No improvement/ progressive deterioration when on treatment as outpatient
![Page 54: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/54.jpg)
OUTPATIENT MANAGEMENT
• 1 – 5 years age :
• Paediatric Tablet Cotrimoxazole (Sulphamethoxazole 100 mg and trimethoprim 20 mg ) - 3 tablets twice a day
• Reassess after 48 hours
• If improves – continue for 3 more days. No improvement – continue for 48 hours and reassess.
• Explain parents WARNING SIGNS – return immediately
![Page 55: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/55.jpg)
INPATIENT MANAGEMENT
Specific Supportive
Antibiotics Hydration
Nutrition
Oxygen
Antipyretics
Physiotherapy
Asthalin nebulisation if wheeze is present
![Page 56: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/56.jpg)
Antibiotics
• Benzyl penicillin/ ampicillin / 3rd generation cephalosporin +/- aminoglycosides
• Inj. Benzyl penicillin – 5000IU per kg/dose 6th hourly IM• Inj. Ampicillin – 50mg/kg/dose 6th hourly IM• Inj. Gentamicin – 2.5 mg/kg/dose 8th hourly IV
• Continue for 10-14 days
• Assess twice a day – if deterioration :
CXR to look for staphylococcal infection
(pneumatoceles ) – change to cloxacillin
• Atypical pneumonia - macrolides
![Page 57: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/57.jpg)
SUPPORTIVE CARE
• Fever – Paracetamol (10-15 kg/dose ) every 4 to 6 hourly
• Tachypnea, cyanosis, chest indrawing – oxygen by oxygen hood, oxygen mask, nasal catheter, nasopharyngeal catheter
• Not drinking/dehydrated – IV fluids
• Asthalin nebulisation : if wheeze present
![Page 58: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/58.jpg)
Treatment of the index case
• Nebulisation with asthalin
• IV fluids Iso – P
• Inj. Ampicillin IV
• Injection Gentamycin IV
• Syp PCT
![Page 59: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/59.jpg)
DOWN SYNDROME – Health supervision
![Page 60: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/60.jpg)
DOWN SYNDROME – Health supervision
Condition Time to screen Comment
Congenital heart disease
Birth Young adult for acquired valve disease
50% risk for congenital heart disease. Increased risk for pulmonary hypertension
Strabismus, cataracts, nystagmus
Birth or by 6 monthsCheck vision annually
15% - cataracts50% - refractory errors
Hearing impairment or loss
Birth or by 3 months – ABERIf tympanic membrane not visualised- 6 monthly for 3 yearsAnnually therafter
Congenital hearing loss70% risk – serious otitis media
Constipation Birth Hirschsprung disease
![Page 61: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/61.jpg)
DOWN SYNDROME – Health supervision
Condition Time to screen Comment
Celiac disease 2 years/ symptomatic Screen – IgA and tissue transglutamase antibodies
Hematologic disease At birth , adoloscence and when symptoms develop
Neonatal polycythemiaLeukemoid reactionLeukemia
Hypothyroidism Birth, repeat at 6 – 12 months and then annually
1% - congenital5% acquired
Growth and development
At each visitUse Down syndrome growth curves
Discuss school placement optionsProper diet to avoid obesity
![Page 62: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/62.jpg)
For index case
![Page 63: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/63.jpg)
For index case
![Page 64: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/64.jpg)
DOWN SYNDROME – Health supervisionCondition Time to screen Comment
Obstructive sleep apnea Start at 1 year. Then at each visit
Monitor for snoring, restless sleep
Atlantoaxial subluxation/ instability
Each visit – history and physical examRadiographs at 3 -5 years or when planning to participate in contact sports / Transient neurological symptoms
Maybe asymptomatic
Gynaecological care Adoloscent girls Menstruation/ contraception use
Recurrent infections When present Check IgG subclass and IgA levels
Psychiatric, behavioral disorders
Each visit Depression,anxiety, OCD, schizoprenia.Autism , Early onset alzheimers
![Page 65: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/65.jpg)
PDA - left to right shunt
• Catheter based treatment – occlusive devices or coils
• Surgery if :• Large PDA ( larger than size of available devices)
![Page 66: Downs + pneum](https://reader033.vdocuments.mx/reader033/viewer/2022050804/555060beb4c905c0448b5186/html5/thumbnails/66.jpg)