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ANATOMY; MUSCLES THAT MOVE THE LOWER ARM & HANDS by Professor Fink

This is Part 3 of 5 Video Lectures on the Skeletal Muscle Groups of the Human Body by Professor Fink. In this Video Lecture, Professor Fink first describes t...  
YouTube
almost 6 years ago
Preview
1
12

ANATOMY; MUSCLES OF THE SHOULDER & UPPER ARM by Professor Fink

This is Part 3 of 5 Video Lectures on the Skeletal Muscle Groups of the Human Body by Professor Fink. In this Video Lecture, Professor Fink describes the Mus...  
YouTube
almost 6 years ago
Preview
9
541

An easy way to remember arm muscles PART 1

Dr Preddy teaching anatomy at Touro University Nevada  
YouTube
almost 6 years ago
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6
664

An easy way to remember arm muscles PART 2

Dr Preddy teaching anatomy at Touro University Nevada  
YouTube
almost 6 years ago
Preview
4
96

Muscles of the upper arm and shoulder blade - Human Anatomy | Kenhub

Find more videos at: https://www.kenhub.com Subscribe to our YouTube channel: http://bit.ly/VOEG2I This is an Anatomy video tutorial covering the muscles of ...  
YouTube
over 5 years ago
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3
110

Anatomical dissection #22: Shoulder & arm muscles.

Disección anatómica # 22: Los músculos del hombro y del brazo.  
YouTube
over 5 years ago
Www.bmj
1
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The FAST tool is effective but not for posterior fossa stroke

Hankey and Blacker’s article provides a practical approach to the diagnosis and management of stroke.1 However, an important issue is the failure of the FAST (face, arm, speech, and time) tool to detect posterior fossa strokes in some patients, who might then not be triaged …  
bmj.com
over 5 years ago
Www.bmj
1
3

Authors’ reply to Huwez

We thank Huwez for highlighting the deficiencies of the FAST (Face, Arm, Speech, and Time) tool, which records the presence of acute facial paresis, arm drift, and abnormal speech, in diagnosing …  
bmj.com
over 5 years ago
Www.bmj
1
18

Focal neurological deficits after trauma

A 38 year old woman developed headache (without neck pain) and weakness of her left upper and lower limbs after a concussive head trauma with scalp lacerations in a motor vehicle crash. On examination (more than 4.5 hours after the trauma), she was conscious, alert, and in cardiac sinus rhythm. There was no carotid bruit. She scored 7 points on the National Institute of Health stroke scale (maximum possible score 42). Positive neurological findings included mild blunting of the left nasolabial fold; left hemiparesis, with extensor muscles being weaker (3/5) than flexors in the left upper limb (4+/5), flexors being weaker (4 to 4+/5) than extensors in the left lower limb (4+ to 5/5), and distal more than proximal weakness in the left arm and leg. She also had brisk deep tendon reflexes in the limbs on the left side; a left extensor plantar response; left hemianopia; and left hemisensory (including the face) hypoaesthesia for pain, cold, and touch. Eyelid ptosis or paresis of extraocular movements were not present, and pupillary size and light reaction were normal.  
bmj.com
over 5 years ago
Www.bmj
1
40

A sinister cause of shoulder pain, with numbness and weakness in the ipsilateral hand

A 41 year old patient with insulin dependent diabetes presented with a one month history of progressively worsening pain, numbness, and weakness of his right shoulder and arm. His history included peripheral vascular disease, chronic renal failure, and chronic pancreatitis. He was also a smoker with a 60 pack year history.  
bmj.com
over 5 years ago
Www.bmj
1
12

Surgery is no better than a simple sling for displaced fracture of upper arm, study finds

Displaced fractures in the upper arm near the shoulder can be treated just as effectively with sling immobilisation as with surgical treatment, a randomised clinical trial published in JAMA has found.1  
bmj.com
over 5 years ago
11
0
23

What's the effect of taking blood pressure on both arms at once?

In hospital today, while I was taking a patient's blood pressure, another student asked if she could take her pressure on the other arm to practice. The patient didn't mind, but I thought it might be dangerous. Is this dangerous? What would happen if we pumped the cuff on both arms at the same time? Also, would this give an incorrect reading?  
Mohammed Pervez
almost 8 years ago
13
0
75

Voluntary vs Automatic responses in the Somatic Nervous System.

This question is about the somatic nervous system (SNS). I read that this the SNS part of the peripheral nervous system (PNS) and that it controls skeletal muscle. It is therefore thought to be voluntary. In contrast, the autonomic nervous system controls smooth muscle, under involuntary control. What I'm wondering is if reflex arcs (or reflexes) are controlled by the autonomic nervous system, why is it making use of skeletal muscle? Take the example of the reaction of moving your hand away when it is placed on something hot. These motor commands come from the autonomic nervous system but control the arm muscles that are normally controlled consciously. In other words things normally controlled voluntarily. The response was activated by the ANS, and was therefore automatic, but the muscles supplied by these motor commands were skeletal muscles? Can someone explain this (contradition) or perhaps correct my wrong thinking?  
Alex Catley
almost 8 years ago
Foo20151013 2023 1i9rgu8?1444773940
3
220

The elephant in the room: Is everything you see on an x-ray relevant?

Recent 'tongue in cheek' research which has been reported in a Washington Post blog recently has caused a lot of questions to be raised concerning inattention blindness, which could cause concern unless you understand the underlying psychology. Here's a CT scan: During psychology lectures at Med School, you may have encountered the basketball bouncing students in front of a bank of elevators where you were asked to count the number of passes the basketball made from the player wearing the white T shirt, while a gorilla ran between the students. (Even if you did watch it before, you can re-watch the video on the Washington Post blog). The recent study asked radiologists to identify and count how many nodules are present in the lungs on a regular CT thorax. If you look at the image you may see a gorilla waving his arms about. As a radiologist, I see the anatomy in the background, the chambers of the heart and mediastinum, but nothing there out of the ordinary. As radiologists, we are looking for pathology, but also report pathological findings that are unexpected. The clinical history of a patient is very important for us in interpretation of imaging examinations, as we need to answer the question you are asking, but have to be careful we do not miss anything else of serious import. As we do not see any other pathology, we would not expect to find a gorilla in the chest, so our brains can pass over distracting findings. The other psychological issue is the satisfaction of search, where we can see the expected pathology, but may miss the other cancer if we do not carefully and systematically look through the images. So the main thing to learn from this is that your training should always keep you alert, not just to expected happening, but to not discount the unexpected, then many lives will be saved as a result of your attention to detail.  
Chris Flowers
over 7 years ago
Foo20151013 2023 1mijl9t?1444773950
6
201

You'll never walk alone - medical student/intercalator musings...

I'm not sure why I like to quote lines from films on this blog. I mean, I really haven't seen enough of them to make myself out to be some sort of hotshot film geek. I'm hoping this is the last (probably inappropriate) quote I use for a while, so here goes... 'Give me a word, any word, and I show you that the root of that word is Greek.' Courtesy of Gus Portokalos, the funniest character in the My Big Fat Greek Wedding. Sometimes I feel like medics tend to do that, we have a habit of making absolutely any conversation about Medicine. It seems to give us a bit of a bad rep, but surely it's understandable? I mean, it's what we do. It's what we've 'always wanted to do' i.e. since leaving the womb*. It's what we're always going to do. Right? Even so, it's surely human nature to relate everyday conversation to something you think that you know a lot about. Let's take a look at real-life example, cue the Blue Peter quip 'here's one I made earlier': I know nothing about football. Well, I know a bit more than some and a lot less than your average football fan so I guess I know VERY little about football. I do, however, know a thing or two about Hillsborough Stadium in Sheffield. Why, you ask? Well, the Hillsborough Disaster in 1985 saw the deaths of 96 Liverpool fans during an FA cup semi-final. A pivotal case emerged from this disaster which affected medical decision-making at the end of life, that of Anthony Bland. Bland was left brain damaged and in a 'persistent vegetative state' (a disorder of consciousness) after the disaster. In 1993, he finally won his battle to have the treatment that was keeping him alive withdrawn. This was a landmark case in both medical ethics and law. Don't say you heard it hear first, look it up: it's relevant. It would be dishonest to say, 'Give me a word, any word, and I'll show you that it's somehow linked to Medicine. But just ask me what I know about football, just once and I might just surprise you. *After writing this entry, I realised that it might be unfair to presume that there isn't at least one person who knew that they wanted to be a doctor just seconds after taking their first gasp of air and crying their eyes out in the midwife's arms. My sincere apologies if this applies to you. (To have a look at more of my entries, visit: http://contemplationsofamedic.blogspot.co.uk/)  
Chantal Cox-George
over 7 years ago
Foo20151013 2023 7owyf5?1444773963
3
152

Benchmarking Outpatient Referral Rates

Introduction GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients. It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons It's Very Difficult to Normalise Surgeries Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another. There Are Several Reasons For The Referral I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition. We Need To Look At The Bigger Picture The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital. Education, Education, Education When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories: 2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker. 2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc. Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis. Consultant to Consultant Referral. As advised between consultants. Patient Choice. Sometimes the patient just wants to see the hospital doctor. The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below. Reasons For Referrals Firstly a few disclaimers and thoughts. These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures. There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right. The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption. This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further. In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason. So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services. 3 Step Plan As I’m not one to just give problems here are my 3 suggestions to help referrals. To have a more responsive Layered Outpatient Service. Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation. Education, education, education It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first. Diagnose Earlier and Refer Appropriately The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process. Conclusion At the end of the day it's about appropriate referrals always, not just a reduction. Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.  
Raza Toosy
over 7 years ago
Foo20151013 2023 1fq5o2?1444773981
7
17778

The Hypocrite's Oath

A medical student reflects on exams: the pressure to perform, and the temptation to cheat (original post here) New and naive the journey begins, Forsaking folly for study and service, To "make the world a better place", To "alleviate suffering" to "give hope". The public trust, respect, maybe even revere us. They offer us their arms for a third attempt, They bleed and bruise so we can learn, Enduring pain for our practice. They think our vocation "the noblest of professions". Their trust they freely offer, We snatch it, thinking ourselves worthy, Considering ourselves men of noble blood, Trustworthy, moral and virtuous beings. Hours, days, years invested in books, Given in worship to the acquisition of knowledge. On wards we arrive in dress rehearsal, Regurgitating information at the whim of the gods. We desire their glory and brilliance, Panting for success, respect, power, control, Nothing terrifies more than failure, Exams loom incessantly... Offers of assistance entice. Tantalising tip-offs tempt, Some sharpen skills whilst others sully their souls. Time to swear the Hypocrite's Oath.  
David Jones
over 7 years ago
Foo20151013 2023 gc6z71?1444774005
7
222

Worst Medical Experience Ever

Worst experience ever? - this is pretty difficult as I've worked in some of the poorest countries in the world and seen some things that should never happen like children dying of dehydration and malaria. But this recent experience was definitely the worst. It was midnight and I was trying to get my 16 month old to sleep having woken up after vomiting in his cot. Despite paracetamol, ibuprofen, stripping to nappy, damp sponging and having the window open he went rigid and started fitting. It only lasted a minute or two yet felt like an eternity as he was unable to breathe and became progressively blue as my mind raced ahead to brain damage or some other horrible sequalae. The fitting stopped and my mind turned to whether I was going to have to start CPR. I lay him on the floor and put my ear to his chest and was glad to hear a strong heartbeat but he was floppy with a compromised airway so I quickly got him in the recovery position. The ambulance arrived in 8 minutes and after some oxygen and some observations he was strapped in and ready to go. He had been unconscious for about 15 minutes but was starting to come round, much to my relief. The ambulance crew were great and their quick response made all the difference but then they took nearly half an hour to get to A&E in the middle of the night because they took the most awkward route imaginable. I don't know if it was a deliberate delaying tactic or just a lack of local knowledge but even without a blue light I could have done it in half the time! Why do ambulances not have GPS - ideally with local traffic info built in? We arrived in A&E and were ushered to a miserable receptionist who took our details and told us to have a seat. I noticed above her head that the wait time was 3.5 hours, though we did see a junior nurse who took his observations again. Not long after the screen changed to a 5 hour wait and a bit later to a 6 hour wait! I am glad to say that by about 3 hours my little man was back to his usual self (as evidenced by his attempts at destroying the department) and so after getting the nurse to repeat his obs (all normal) we decided to take him home, knowing we had a few more hours to wait for the doctor, and that the doctor was now unlikely to do anything as he was now well. I tell the story in such detail in part for catharsis, in part to share my brief insight into being on the other side of the consultation, but also because it illustrated a number of system failures. It was a horrible experience but made a lot worse by those system failures. And I couldn't help but feel even more sorry for those around me who didn't have the medical experience that I had to contextualise it all. Sickness, in ourselves or our loved ones, is bad enough without the system making it worse. I had 3 hours of walking around the department with my son in my arms which gave me plenty of time to observe what was going on around me and consider whether it could be improved. I did of course not have access to all areas and so couldn't see what was happening behind the scenes so things may have been busier than I was aware of. Also it was only one evening so not necessarily representative. There were about 15 children in the department and for the 3 hours we were there only a handful of new patients that arrived so no obvious reason for the increasing delay. As I walked around it was clear to me that at least half of the children didn't need to be there. Some were fast asleep on the benches, arguably suggesting they didn't need emergency treatment. One lad had a minor head injury that just needed a clean and some advice. Whilst I didn't ask anyone what was wrong with people talk and so you hear what some of the problems were. Some were definately far more appropriate for general practice. So how could things have been improved and could technology have helped as well? One thing that struck me is that the 'triage' nurse would have been much better as a senior doctor. Not necessarily a consultant but certainly someone with the experience to make decisions. Had this been the case I think a good number could have been sent home very quickly, maybe with some basic treatment or maybe just with advice. Even if it was more complex it may have been that an urgent outpatient in a few days time would have been a much more satisfactory way of dealing with the problem. Even in our case where immediate discharge wouldn't have been appropriate a senior doctor could have made a quick assessment and said "let's observe him for a couple of hours and then repeat is obs - if he is well, the obs are normal and you are happy then you can go home". This would have made the world of difference to us. So where does the technology come in? I've already mentioned Sat Nav for the ambulance but there are a number of other points where technology could have played a part in improving patient experience. Starting with the ambulance if they had access to real time data on hospital A&E waiting times they may have been able to divert us to a hospital with a much shorter time. This is even more important for adult hospitals were the turnover of patients is much higher. Such information could help staff and patients make more informed decisions. The ambulance took us to hospital which was probably appropriate for us but not for everyone. Unfortunately many of the other services like GP out of hours are not always prepared to accept such patients and again the ambulance crews need to know where is available and what access and waiting times they have. Walk-in patients are often also totally inappropriate and an easy method of redirection would be beneficial for all concerned. But this requires change and may even require such radical ideas as paying for transport to take patients to alternative locations if they are more appropraite. The reasons patient's choose A&E when other services would be far more appropriate are many and complex. It can be about transport and convenience and past experiences and many other things. It is likely that at least some of it is that patients often struggle to get an appointment to see their own GP within a reasonable time frame or just that their impression is that it will be difficult to get an appointment so they don't even try. But imagine a system where the waiting times for appointments for all GPs and out of hours services were readily available to hospitals, ambulances, NHS direct etc. Even better imagine that authorised people could book appointments directly, even when the practice was closed. How many patients would be happy to avoid a long wait in A&E if they had the reassurance of a GP appointment the next day? And the technology already exists to do some of this and it wouldn't be that hard to adapt current technology to provide this functionality. Yet it still doesn't happen. I have my theories as to why but this is enough for one post. In case you were wondering my son appears to have made a full recovery with no obvious ongoing problems. I think I have recovered and then he makes the same breathing noises he made just before the fit and I am transported back to that fateful night. I think it will take time for the feelings to fade.  
Dr Damian Williams
over 7 years ago
Foo20151013 2023 86qh1h?1444774193
7
577

Thou shalt not doubt oneself in front of the patient

As part as my paediatrics attachment, I was having peripheral nervous system bed side teaching. We had spoken over the examination and I was first up to practice on 4 year old Jake. One consultant and 3 other medical students looked on as I worked my way through the examination. My general inspection and impression of the child got approving nods from my colleagues. Phew! Next up was actual exam “two people can’t resist…” I recalled in my head. First up, tone. I assessed this correctly and nothing had gone majorly wrong yet. Relief. Power was next. “ok, so put out your arms up like this and resist me…ok, no, not like that..erm..oh god…I don’t know how to explain it”. My colleagues looked on. The consultant chipped in “tell him to touch his shoulders”. It did the trick and I was able to get through the rest of the examination without too many hiccups. When we had finished, in classic med school fashion I had to reflect on what had just happened and then say something I did good and something I could have done better. My good thing was “I got through it..I mean I remembered everything”. My bad thing was “I wasn’t good at explaining power to him”. My feedback wasn’t the same as my bad thing though. My feedback was “be more confident. You did everything correctly and didn't forget anything. I think it’s a girl thing. You doubt yourselves more than the boys”. Next up was a male medical student’s turn. He did the examination just fine but there were things that I could pick out that he could have done better and being totally objective my examination was better. But there was a major difference. His confidence. He seemed like he knew what he was doing and when he went wrong or missed something out, he just added it to the end of his examination. If I were his examiner, I would have found it difficult to fault him. He appeared confident and as a patient that inspires confidence and a happy patient makes for a happy examiner and good marks. After the session, I got to thinking: am I really incompetent or am I just underestimating my own ability which is making me lack confidence? The fact that a paediatric consultant and all my colleagues told me that my examination was fine, good even, answers the first part. I am not incompetent. So I must be underestimating my own ability. And if I am, is that something that is unique to me? Or are other medical students doing that too? And more interestingly to me, is this something that the female medical students are doing more than their male colleagues?  
Salma Aslam
over 6 years ago
Foo20151013 2023 3cqojv?1444774240
3
98

Goodbye fear and ego, hello better patient care

The best doctors in the world still have bad consultation. Sometimes you just start off on the wrong foot. The patient leaving in a floor of tears is usually an indication that this has just occurred. On one of my medical placements I witnessed one such consultation. A young woman in the early stages of her pregnancy had a per vaginal bleed and wanted a scan to see if the pregnancy was still ok. Medically speaking, a scan wasn’t indicated as the pregnancy was too early on to detect any changes. The doctors noted the “agenda” as they later remarked, and was not going to “play the game” and send the young woman for a scan. She was not happy about this. The doctor felt that he couldn’t have done more. Medically there was nothing he could offer to the woman other than advice to go home and wait a little while before repeating a pregnancy test. To me, there was lots that could have been done. This woman was scared and worried and a sympathetic ear and a tissue would have gone some way to making her feel better. The doctor I was with couldn’t see this. They were blind sighted by the repeated requests for a scan and slightly frustrated that the unhelpfulness of this was not being understood. When the young woman began to cry I was waiting for the doctor to hand over a tissue. “Any second now...” I thought, but it never happened. I wanted to give the woman a tissue and put my arm around her but that would have meant physically placing myself between the doctor and the patients and interrupting a consultation I wasn’t really a part of. But the truth is. I was a part of that consultation. I might not have been the doctor in charge but I was another person in that room who could have made that situation easier for that patient and I didn’t. Hours later, on my way home, I was still thinking about this. I felt I had let that woman down. I could see what she needed and I sat there and did nothing. After the consultation I immediately told the doctor what I thought. I felt that the patient had been let down. They took on what I said and mostly agreed with it. All egos were put aside in that frank conversation and the doctor genuinely reflected on how they could have done better in that situation. It wasn’t about me or the doctor. It was about the patient. As a medical student it is easy to feel in the way in the hospital environment or in a busy clinic. When the consultant is running behind, it takes a lot to ask the patients something or butt in and add something you think is relevant that in the end may turn out to be a very trivial thing. But at the end of the day, it is worth it if it means that there is a better out come for the patient because when all is said and done they are the ones we are doing this all for. I regret not handing that patient a tissue and it’s a mistake I hope never to repeat again.  
Salma Aslam
over 6 years ago