診斷學全套課件

Bloodgasanalysisandacid-basicdisorder

BloodGasAnalysisArterialbloodSealevel(101.3kPa,760mmHg)QuietAnti-coagulatebloodInspireair(WhetherO2supply)ClinicalSignificanceToevaluaterespiratoryfailuretypeⅠortypeⅡToevaluateacid-basicdisorderHowtoevaluaterespiratoryfailure?PaO2:

Arterialbloodoxygenicpartialpressure.Normal:95-100mmHg(12.6-13.3kPa)Estimateformulaofage:PaO2=100mmHg-(age×0.33)±5mmHgHypoxiaMild:80-60mmHgMediate:60-40mmHgSevere:<40mmHgRespiratoryFailurePaO2<60mmHgrespiratoryfailureNotice:sealevel,quiet,inspireairruleoffothercauses(heartdisease)

ClassificationofRespiratoryFailurePaCO2:ThecarbondioxidepartialpressureofarterialbloodNormal:35-45mmHg(4.7-6.0kPa)mean:40mmHgClassificationofRespiratoryFailure

TypeⅠTypeⅡPaO2(mmHg)<60<60PaCO2(mmHg)≤50>50OtherParametersSaO2:SaturationofarterialbloodoxygenNormal:0.95-0.98Significance:aparametertoevaluatehypoxia,butnotsensitiveODC(Dissociationcurveofoxygenatedhemoglobin):“S”shapeSaO2%PO2OxygendissociationcurvePH2,3DPG

temperatureCO2ODCtorightdeviationOxygenatedhemoglobinreleaseoxygentotissue,preventhypoxiaofthetissue.Butabsorbedoxygenofhemoglobinisdecreasedfromthealveoli.Bohreffect:movementofODCplaceisinducedbyPH.PA-aO2:Differenceofalveoli-arterialbloodoxygenicpartialpressure.

Normal:15-20mmHg(<30mmHgintheold)Significance:asensitiveparameteringasexchangePvO2:Oxygenicpartialpressureofmixedvenousblood.Normal:35-45mmHgmean:40mmHgSignificance:Pa-vO2istoreflectthetissueabsorbingoxygen.CaO2:

Thecontentoftheoxygenofthearterialblood.Normal:19-21mmol/LSignificance:acomprehensiveparametertoevaluatearterialoxygen.Parametersinacid-basicdisorderevaluationPH:negativelogarithmofHydrogenionconcentration.Normal:7.35-7.45mean:7.4PH=Pka+log〔HCO3-〕0.03PaCO2＝6.1+log201HCO3-(bicarbonate):

SB(standardbicarbonate)AB(actualbicarbonate)SB:thecontentsofHCO3-ofserumofarterialbloodin38℃,PaCO240mmHg,SaO2100%.Normal:22-27mmol/Lmean:24mmol/LAB:ThecontentsofHCO3-inactualcondition.Innormalperson:AB=SBABandSBareparameterstoreflectmetabolism,regulatedbykidney.DifferenceofAB-SBcanreflecttherespiratoryaffectiononserumHCO3-.

Respiratoryacidosis:AB>SBRespiratoryalkalosis:AB<SBMetabolicacidosis:AB＝SB<NormalMetabolicalkalosis:AB=SB>NormalBufferbases（BB)：

isthetotalofbuffernegativeionofblood.BB:HCO3-

hemoglobinplasmaproteinsHPO42-(phosphate)Normal:45-55mmol/Lmean:50mmol/LSignificance:Metabolicacidosis:BBMetabolicalkalosis:BBBasesexcess（BE):

theacidorbasesusedtoregulatebloodPH7.4.(in38℃，PaCO240mmHg,SaO2100%)Normal:0±2.3mmol/LSignificance:addacid:BE(+),BBaddbase:BE(-),BBTotalplasmaCO2(T-CO2)：

totalcontentoftheCO2.Normal:HCO3->95%Aniongap(AG):

thedifferenceofundeterminedanionandundeterminedcationinserum.AG=Na+－(Cl-+HCO3-)Normal:8-16mmol/LSignificance:AGacidosis:ketoacidosis,kidneyfailureAGnormalacidosis:Cl,diarrhea,fixedaciddecreasetoevaluatemixacid-basicdisorderRegulationofAcid-basicBalanceChemicalbufferDielectricchangesofincellsandexcellsH+---K+,HCO3-

---Cl-PhysiologyregulationofthelungandkidneyClassificationofAcid-basicDisorderComplementary:PHisnormalDis-complementary:PHisabnormal.PH,PaCO2,HCO3-arethreeimportantparametersinacid-basicdisorderevaluation.ClassificationofAcid-basicDisorder

PHPaCO2HCO3-

Resp.acidosisResp.alkalosisMeta.acidosisMeta.alkalosisClassificationofAcid-basicDisorderMixedacid-basicdisorderComplementaryformulaexample:originaldisorder:chronicrespiratoryacidosis⊿HCO3-=⊿PaCO2×0.35±5.58complementarylimit:45mmol/LClassificationofAcid-basicDisorderRespiratoryacidosiswithmetabolicacidosisRespiratoryacidosiswithmetabolicalkalosisRespiratoryalkalosiswithmetabolicacidosisRespiratoryalkalosiswithmetabolicalkalosisRespiratoryacidosiswithmetabolicacidosisPaCO2:HCO3-:,normal,(slight)AB,SB,BB:,normal,(slight)PH:BE:negativevalue

RespiratoryacidosiswithmetabolicalkalosisPaCO2:AB:PH:,N,29Anatomy3031Inspection1Precardialprojectionandexcavation2Apicalimpulse3Abnormalpulsationsofprecardium321Precardialprojectionandexcavation

1)Precardialprojectioncongenitalheartdisease:tetralogyofFallotValvularheartdisease--MS,PSpericardialeffusion(large,childhood)Inspection33Thesecondrightintercostalspace(2ndICS-RS)aneurysmofaorticarchdilatationofascendingaorta

2)flatchest3)pigeonchest/funnelchest342Apicalimpulse

*Normal:

position—thefifthleftintercostalspace0.5-1.0cmmedialtothemidclavicularline

range—2.0-2.5cmindiameter

Inspection35*Abnormal

1)Location

#diaphragm:“transverseposition”upper,outwardobesity,child,pregnacy;ascites;tumorofabdominalcavity

“verticalposition”(thin,high,emphysema)inferior,inner

3637onesidepleuraleffusionorpneumothorax—tothehealthysideonesideatelectesisorpleuraladhesion—totheaffected

#mediastinum:38

#enlargementoftheheart

rightventriculardilatation–leftorslightlyupperleftventriculardilatation—leftinferiorLV&RVdilatation–leftinferior(bothsidedilatation)

3940#Posture:recumbentposition—upper

leftlateralposition—totheleft2-3cmrightlateralposition—totheright1.0-2.5cm

Dextrocardia:5-ICS—RS41

2)Intensityandextentchanges

Inspection-apicalimpulse-abnormal423)Inwardimpulse:apexexcavationinthesystole

seen:adhensivepericarditis

prominentRVhypertrophyInspection

-apicalimpulse-abnormal43Inspection1)leftthird-forthintercostalspacelateraltothesternum(3,4ICS-LS)

seen:RVhypertrophy

Abnomalpulsationsofpercardium

442)hypoxiphoidprocessseen:

differencedeepinspirationRVhypertrophy↑abdominalaorta(aneurysm)

↓45

3)basalpartoftheheart

2ICS-LS:dilatationofthepulmonaryarteryorpulmonaryhypertensin,occasionallyhealthyyoungman

2ICS-RS:aneurysmofaorticarchordilatationofascendingaorta

46Palpation

1Apicalimpulseandpulsationofprecardium2Thrill3Pericardialfrictionrub47

1Apicalimpulseandpulsationofprecardium

ExactpositionofapexThebeginningofsystoleofventriclefirstsoundHeavingapeximpulse:reliableofLVhypertrophyPalpation48

2Thrill

Oneofcharacteristicsignsoforganicheartdisease.Mechanism:theflowofblood→narrowedorifice→vortices→

vibration→chestwallthrill-highfrequencymurmurs-lowfrequencyMethod:position,phaseofcardiaccycle,clinicalsignificanceseen:CHDorvalvularstenosis,occasionallyinsurficiency

49CHD:congenitalheartdisease501)Precardium-4thICS-LS2)bothphasesofthecardiaccycle3)systolicperiod,sittingerectandleaningforward,theendofexpiration4)mechanism:rubofthevisceralandparietallayersofpleura5)seen:acutepericarditis

3Pericardilfrictionrub

51Percussion

Aim:todeterminethesizeandshapeoftheheart.Absolutedullness:containnogas

Relativedullness:realsize52

1murneuverofpercussion

patientinerectposition–thepleximeterisverticalwiththeintercostalspace

patientintherecumbentposition–thepleximeterisparallelwiththeintercostalspace

532order:left—right;upwards;inwardleftmargin:from2-3cmlateraltotheapexbeatuptothe2ndICSrightmargin:oneintercostalspacehigherthantheborderofliverdullnessuptothe2ndICSsize:verticaldistancefrommargintotheanteriormidline

5455Percussion56Percussion57

(2)Theupperborder–thelowerborderoftheanteriorendofthethirdrib↑(3)Thebasalpart—thesecondintercostalspaceupwardleft:aorticnodeandPA(4)Concavepart–betweentheaortaandtheleftventricle

585Changesintheareaofcardiacdullnessanditssignificance

Cardiacfactors:1)LVenlargement:“bootshape”

Seen:aorticvalvulardisease,hypertensionheartdiseasePercussion59

2)RVenlargement:

slightly↑--absolutedullness↑

Prominent↑--relativedullness↑

totheleftsideprominently

Seen:PHD,MS

3)Twoventricle↑:

“generallyenlargedheart”seen:DCM,Kashancardiomyopathy60

4)LAand/orpulmonaryartery:

LA:concavepartdisappear

LA+PA:2,3ICS-LSoutwards“pearshape”

Seen:MS---“mitrialtype”61

5)pericardialeffusion:enlargementofbothsidesoftheborderbody’sposition:

recumbentposition：wideningofbaseofthehearterectposition:“triangularshape”

626)dilatationoftheaorta/ascendingaorticaneurysm:wideningifthedullareaoffirstandsecondintercostalspace(withsystolicpulsation)63Extacardialfactors:

1)largepleuraleffusionsandpneumothorax→tothehealthyside

2)atelectasis/pleuralpachynsis→totheaffected

3)alargeamountofascitesorbigabdominaltumor:

diaphragmelevated→transverseposition→leftsideenlargement64Ausclutation65

1Ausclutatotyvalveareas

1)ausclutatorymitralarea:apicalarea

2)ausclutatorypulmonaryarea:2ICS-LS

3)ausclutatoryaorticarea:2ICS-RS

4)secondausclutatoryaorticarea:3rdICS-LS—Erbarea

5)tricuspidarea:4,5ICS-LS

6667

2Order:

MV---PV---AV1---AV2---TV

3Contents

:

1)rate2)rhythm3)heartsound4)extraheartsound5)murmurs6)pericardialfrictionsound681)heartrate:60~100bpmF＞Mchild(＜3years)＞100bpm

tachycardia:normaladult＞100bpm

child(＜3years)＞150bpm

bradycardia:HR＜60bpm

69Ausclutationheartrate:60-100bmp702)cardiacrhythm:

*sinusarrythmia—affectedbybreath

*prematurebeat:

classification:atrial~ventricular~junctional~frequently:＞6bpmoccasionally:＜6bpmbigeminytrigeminy71

*atrialfibrillation:

absoluteirregularrhythm

S1intensityinequality

Pulsedeficit

seen:MS,CHD,hyperthyroidism,PHD,DCM72Ausclutationatrialfibrillation

73

3)

cardiacsound

74AusclutationcontentcardiacsoundS1：S2：7576

4)Abnormalcardiacsound

*Intensity:positionoftheatrioventricularvalveVentricularcontractilityandoutputValvularintegrityandactivity

77S1:Accentuation:MSHR↑contractility↑fever,anemia,hyperthyroidismcompleteAVB→cannonsound

7879S1attenuation:MIP-RintervalenlongAImyocarditis,myopathy,MI,HF

inequality:af,III°AVB

8081

S2---A2,P2S2↑---pressureandflowofblood↑

A2:hypertensin,arterisclerosis

P2:PHD,CoHD(L--R),LVF

S2↓---pressure↓flow↓Seen:hypotension,AS/AL,PS/PI8283

*Quality

monorhythmpendularrhythm---embryocardia

*Splittingofheartsound

S1splitting:seen—RBBB,rightheartfailure

Ebeteinmalformation,MS

LAmyxoma8485

S2splitting:

(1)physiologicalsplitting:endofinspiration

(2)generalsplitting:mostcommonly

seen:CRBBB,PS,MS,MI,VSD

(3)fixedsplitting:ASD

(4)paradoxicalsplitting(reversedsplitting):pathological

seen:CLBBB,AS,hypertension

8687

5)extracardiacsound

Diastolicperiod

1)galloprhythm:

--protodiastolicgallop:S1+S2+S3thethirdsoundgallop(signoforganicheartdisease)

seen:HF（AMI,severemyocarditis,myopathyetc.）

--latediastolicgallop:atrialgallopS1+S2+S4

seen:HBP,HCM,AS,CHD

--summationgallop:quadruplerhythmseen:HF,cardiomyopathy888990

5)extracardiacsound

Diastolicperiod

2)openingsnap:MS

3)pericardialknock:constrictivepericarditis

4)tumorplop:LAmyxoma9192AusclutationCONTENTTumorplop

93Systolicperiod

(1)earlysystolicejectionsound(click)

pulmonary:pulmonaryhypertension;pulmonaryarterydilatation

PS,ASD,VSD

Aortic:hypertension,aneurysm,AS,AI,aortaconstriction

(2)midandlatesystolicclick:S1----mid＜0.08″late＞0.08″

seen:mitralprolapse

949596iatrogenic

(1)prostheticvalvularsound

(2)pacemaker

97

6)cardiacmurmurs

9899*characterizationofmurmurandausclutatorykeypoints

(1)location:L3,4–VSDL2,3—PDA

(2)transmission:MI---leftaxillaAS---neck

(3)phase:systolicmurmurs

diastolic~

continuous~biphasic~early,mid,late,whole

murmurs

100

(4)quality:blowing—MI

rumbling—MS

sighing--AI

machinery--PDA(5)intensity:Levine6gradeclassification

shape:crescendo---MS

decrescendo---AI

crescendo-decrescendo---AS

continuous---PDA

regular---MI

murmurs

101

(6)

others:bodyposition:MS--leftlateralposition

AI--sittingerectedandforwardMI,TI,PVS--lieonone’back

Lie→stand:HCMbreath:expiration--LVmurmurs

inspiration--RVmurmurs

valsalva--HCMexercise:HR↑--murmurs↑

murmurs

102

clinicalsignificancemurmurs:functionalandorganic

7)pericardialfrictionsound:bothphases,unaffectedbyrespiration.seen:pericarditis,RHD,AMI,renalfailure,SLE103*

clinicalsignificanceofcardiacmurmurs

systolicmurmursMV：functional:exercise,fever,anemia,pregnancy,hyperthyroidismrelative:HBP,CHD,DCM,anemiaorganic：MI(RHD),mitralprolapse

104105*

clinicalsignificanceofcardiacmurmurs

systolicmurmursAorticarea：organic：ASrelative：dilatationofascendingaorta

106107*

clinicalsignificanceofcardiacmurmurssystolicmurmurspulmonary：physiologyrelative：MS、ASDorganic：PSTV：relative：RVenlargedorganic：rare

108*

clinicalsignificanceofcardiacmurmurs

Diastolicmurmurs

MV:organic:RHD(MS)

relative:AI(severe)AustinFlintmurmurAV:AI109110111*

clinicalsignificanceofcardiacmurmursDiastolicmurmursPV:organicmurmurisrarePI(dilatationofpulmonaryartery)MS+P2----GrahamSteellmurmurTV:rare112*

clinicalsignificanceofcardiacmurmurscontinuousmurmursPDAinnocentmurmur113

Vascularexamination

ThesecondclinicalhospitalofCMU114pulse

pulseratepulserhythmtensionsandstateofarterialwallintensitypulsewave115pulsepulserate

AtrialfibrillationandfrequentprematurebeatstrokevolumeperipheralarterynopulsepulseratelessthanHR(pulsedeficit)116pulse

pulserhythm

pulsedeficit；

bigeminalpulse,trigeminalpulse；

droppedpulse117pulsetensionsandstateofarterialwallArterytensiondependingonbloodpressure(mainlySBP).Judgestateofarterywall118pulseintensity

Bowndingpulse

seen:highfever,hyperthyroidism,AIMicrosphygmia

seen:HF,ASandshock119pulsepulsewavenormalpulsewave

composedofupstroke（knockingwave）、peak（tidewave）anddownstroke（dicroticwave）120pulsepulsewavewaterhammerpulseseen:AI,hyperthyroidism,PDA,severeanemiapulsetardusseen:ASdicroticpulseseen:HCMpulsusalternansseen:HBP,AMI,AIparadoxicalpulse

seen:cardiactamponade,constrictivepericarditisPulseless

seen:seriousshock,arteritis

121bloodpressuremethodofmeasurement

directmeasurementmethod

indirectmeasurementmethod122bloodpressurestandard

definitionofBplevelandclassification(olderthan18yearsold)classificationSBP(mmHg)DBP(mmHg)IdealBP12080NormalBP13085HighlimitofBP130-13985-89Grade1（mild）140-15990-99subgroup：

boundlinehypertension140-14990-94Grade2（moderate）160-179100-109Grade3（severe）≥180≥110Simplesystolichypertension14090subgroup：boundlinesystolichypertension140-14990123bloodpressureclinicalsignificanceofBPchanges

hypertension：higherthan140/90mmHgfor3timesnotinthesameday

hypotension：lowerthan90/60-50mmHgShock,,MI,acutecardiactamponadeobviousdifferencebetweenbilateralupperlimbs：morethan10mmHg---arteritis,congenitalarterymalformationdifferencebetweenupperandlowerlimbs：lowerlimbBPis20-40mmHghigherthanupperonenormallypathological:constrictiveaorta,arteritis(chest-abdominalaorta)changeofpulseBP：

40mmHg，widepulseBP---hyperthyroidism,AI30mmHg，narrowpulseBP---AS,pericardialeffusion124bloodpressuredynamicBPmonitoring

AverageBPfor24h

130/80mmHg;brightday135/85mmHg;night:125/75mmHgPeak:6am—10am,4pm—6pm125Vesselmurmurandperipheralvesselsignvenousmurmur

jungularmurmur：iscausedbytherapidflowofjungularveinintoSVC(superiorvenacava)126Vesselmurmurandperipheralvesselsignarterymurmur

ContinuousmurmurinthelaterallobeofthyroidinthepatientwithhyperthyroidismSystolicmurmurintheupperabnormalregionorlumberregioncausedbystenosisofrenalartery.Arterio-venousfistula127peripheralvesselsign

pistolshotsoundSeen:AI,hyperthyroidism,severeanemia

Durozier’smurmurcapillarypulsationVesselmurmurandperipheralvesselsign128Themainsymptomsandsignsofcommondiseasesofcirculatorysystem129

Causes:

RHD:rheumaticheartdisease

CHD:congenitalheartdisease

Otherreasons:senileretrogradeMitrialstenosis130Symptoms:

cough;hemoptysis;

dyspnea:dyspneaonexertion→paroxysmalnocturnaldyspnea→pneumonedema

131Signs:Inspection:

mitrialface

ApeximpulsemaybedisplacedtotheleftPalpation

:diastolicthrillpalpableovertheapicalareaPercussion:

normalheartborders→pearshapeheart

132Auscultation:

1)thefirstsound(S1)↑

2)diastolicmurmur:apicalarea;localized;mildandlatediastolic;crescendo;rumbling;moreclearlywhenthepatientislyingonhisleftside.

3)openingsnapmaybeauscultatory

4)accentuationofsecondpulmonarysound(P2↑),splitting

5)GrahamSteel’smurmur(PVdiastolic)

6)Maybeatrialfibrillation(latestage)

133MitralInsufficiencyRHD/non-RHD

;acute/chronic

Symptoms:

fatigue,palpitations,dyspneaonexertion,Leftheartfailure

134Signs:

Inspection:

apexbeatisdisplaceddownwardsandtothe

left

135Palpitation:

apicalimpulseforceful

HeavingapeximpulseSeveresystolicthrill

Percussion:

theareaofdullnesstoleftanddownwards136Auscultation:

1)S1↓(attenuation)2)murmurs:harsh;

pansystolicmurmur;

blowing;

3/6grade↑

widespread-transmittedtoleftaxilla

leftinfrascapularangle

137AorticStenosis

Causes:

RHD

Congenital

Senileretrograde

Symptoms:

palpitation,dizziness,anginapectoris,syncope,HF-dyspnea

138Signs:Inspection:

apicalimpulseincrease

DisplacedtoleftanddownwardsPalpation:apexbeatiselevatedandforcefulsystolicthrillcanbepalpatedoveraorticauscultatoryvalveareaPulsetardus

139

Percussion:theareaofdullnessisnormalortoleftanddownwardAuscultation:1)murmur:aorticauscultatoryvalveareasystolicmurmurharsh,ejectionsound,3/6grade↑(thrill)transmittedtoneck

2)A2↓,reversedsplitting

3)S4

140AorticInsufficiency

Causes:

RHD

Non-RHD：congenital

prolapse

syphilisaortitis

arteriosclerosis

endocarditis

acute/chronic141

Symptoms:

palpitation,dizziness,LHF

Signs

Inspection:apicalimpulsetoleftanddownwards

Palpation:apeximpulsetoleftanddownwards

Heavingapeximpulse142

Percussion:

theareaofcardiacdullnessisenlargeddownwardsandtotheleft;theconcavepartoftheheartisnotenlarged(bootshape)

143Auscultation:

1)specificmurmur:diastolic;sighing;aorticarea;heardclearlysittingerectandforward2)AustinFlintmurmur:relativeMS(rumblingmid-diastolicmurmur)

144

Peripheralvascularsigns

*headbobbing(Musset’ssign):noddingmotionoftheheadwitheachsystole;

*signsofcapillarypulsation;

*waterhammerpulse;

*pistolshotsounds:esp.Femoralarteries;

*Duroziez’smurmur;

*Visiblepulsationofcarotidarteries

145PericardialeffusionCauses:

infectiveandnon-infectivepericarditisSymptoms:

painoverthepericardialregionDyspnea,cough,fever,lassitude

Shock

146Signs:

Inspection:

diminutioninstrengthoftheapexbeatorabsenceoftheapexbeat;jugularvenousenlargement147

Palpation:

*diminutioninstrengthoftheapexbeatortheapexbeatpalpateduneasily

*paradoxicalpulsemaybepresent148

Percussion

:

enlargementofthecardiacdullnessbilaterally,changedwithposture

149Auscultation:

*pericardialfrictionsound

*HR↑,diminutionofintensityofcardiacsound(S1/S2↓)*pericardialknockmaybeheard

150*Largeeffusion:JugularvaricosityLiverenlargementParadoxicalpulsePulsepressure↓

151

*Kussmaulsign:

deepinspiration–jugularveindistension

*Ewartsign:

leftinfrascapularregion

vocalfremitus↑dullness--percussionbronchovesicularbreathsound--auscultation

152

HeartFailure

Causes:

myopathy;ventricularload↑promotefactorsSymptoms:

1

LHF:

fatigue,cough,frothysputum

dyspnea(onexertion→orthopnea→paroxysmalnocturnal~)2RHF:abdominaldistension,oliguria,nausea,vomiting

153Signs:

1LHF:

*Inspection:

tachypnea,cyanosis,semireclining/sittingposition

Acutepneumoedema:

frothysputum,hyperhidrosis

*Palpation:pulsealternans

*Percussion:

*Auscultation:diastolicgalloprhythm

P2↑

Finerales,rhonchi

WhatisDiagnostics?

Diagnosticsisabridgesubject,thissubjectisinapositionbetween

preclinicalmedicine

andclinicalmedicine.

Thecontentsofdiagnosticsinclude

symptomatology

※inquiry

※physicalexamination

laboratory

electrocardiogram

ultrasonic

Inquiry

historytaking

byquestioningtotakeahistory

★Theimportanceofinquiry

forexample:

pepticulcer

gastriculcer

duodenalulcer

Pepticulcerhasthreeclinicalcharacteristics

chronicityseveralyearsperiodicityspecialseasons

lateautumn

earlyspring

rhythmicityofepigastricpainpainmealreliefduodenalulcermealpainreliefgastriculcer

★Thecontentsofinquiry

1generaldata

﹡2chiefcomplaints

﹡3presentillness

4pastmedicalhistory

5systemsreview

6personalhistory

7maritalhistory

8menstrualhistory

9childbearinghistory

10familyhistory

1GeneralData

NameNativeplace

SexWorkingunit

AgeDateofadmission

RaceDat