GIM Flashcards
1
Q
Plan-Do-Study-Act
A
quality improvement: plan intervention, apply on limited small scale, analyze, broader scale
2
Q
Floaters, squiggly lines, flashes of light, sudden peripheral vision defect, progressive curtain
A
Retinal detachment
tx: surgery
3
Q
Painless loss of vision
A
central retinal artery occlusion
elderly people
pale fundus with cherry red fovea
4
Q
abrupt monocular vision loss, cloudy vision
A
central retinal vein occlusion
congested tortuous veins
retinal hemorrhage, cotton wool spots
5
Q
post op vte prophylaxis in high risk patients (previous vte, ortho surgery, cancer)
A
28 days of lovenox if abdominal surgery
35 days of warfarin/aspirin for ortho surgeries
only use compression devices in patients with low risk / high risk of bleeding (antiplatelet therapy)
6
Q
tenderness to palpation of acromioclavicular joint (superior shoulder) and pain with adduction and abduction above 120
A
acromioclavicular joint degeneration
tx: NSAIDs, activity modification
bilateral-rheumatoid arthritis
7
Q
pain between 60 and 120 degrees of abduction, limited rotation, pain with full flexion, pain with Hawkins sign
pain with active shoulder abduction, painful arc, not passive motion
A
rotator cuff tendinitis
tx : steroid injection
supraspinatus tendinitis-conservative therapy
8
Q
adhesive capsulitis
A
thickening of capsule around glenohumeral joint
gradual pain
avoid lying on affected side
no active/passive ROM
9
Q
Rotator cuff tear
A
supraspinatus weakness, external rotation weakness, impingement, positive drop arm test (can’t slowly and steadily lower arm), can’t abduct above 60 degrees
get MRI
10
Q
vaginal atrophy treatment
A
mild to moderate: lubricants and moisturizers
severe: vaginal estradiol tablets/ring
11
Q
Bacterial vaginosis
A
vaginal discharge, increased ph, clue cells, positive whiff test
tx: metronidazole
12
Q
thick, white potassium hydroxide positive vaginal discharge
A
yeast
tx: vaginal clotrimazole
13
Q
Dependent bilateral symmetric lower extremity edema only (worsening with day)
A
Venous stasis
Tx: weight reduction, sodium restriction, leg elevation, compression stockings
no testing
*different from drug induced lower extremity edema-CCBs
14
Q
palpitations then syncope
A
Arrhythmogenic syncope
episodal
15
Q
Sensorineural hearing loss
A
Weber-heard better on unaffected side
Rinne-heard better through air than on mastoid
If no Meniere (hearing loss, vertigo, tinnitus) Get MRI to r/o meningioma, neuroma
If sudden-give steroids
16
Q
Uncontrolled pain in cancer
A
Long acting morphine (30-50% of 24 hr dose) plus PO for breakthrough
17
Q
Suspected BPH
A
r/o UTI, get U/A
18
Q
Stage III ulcer
Stage IV ulcer
A
subq tissue-debridement
bone, tendons, muscle-debridement
Refractory-surgery
19
Q
Pancytopenia (macrocytic anemia) low rec count
A
Vitamin B12 deficiency
20
Q
Dizziness
A
Vertigo-spinning, peripheral (bppv, vestibular neuronitis, Meniere disease, aminoglycosides, herpes zoster, diagnosed with Dix-hallpike, vestibular suppressant trial) vs. central (other neuro symptoms, prolonged vertical nystagmus-get MRA)
Presyncope
Dysequilibrium
21
Q
Cough, sore throat, coryza, rhinorrhea, nasal congestion, myalgia, fatigue, afebrile, conjunctival injection, nasal drainage, lungs clear
A
Rhinosinusitis (cold)
tx: chlorpheniramine (antihisUntamine), no abx
If > 10 days and bacterial is suspected-amoxicillin clavulanate
22
Q
Unilateral conjunctivitis
Recurrent, seasonal, conjunctival edema, cobblestoning under eyelid
A
Viral
Allergic conjunctivitis
*no topical steroids
23
Q
Pulsatile tinnitus
A
Listen
stenosis, AV malformation, glomus tumor
bruit-Doppler/MRA
24
Q
Preop testing
A
Only test what you suspect is abnormal
25
Dyspnea in hospice patients with cardiopulm disease
morphine
26
Anterior nosebleeds
| Posterior
Hold pressure for 15 to 30 mins
| ENT
27
OCD treatment
SSRI + therapy (CBT)
28
Tingling first, second and third digits, pain in thenar eminence, pain with palmar flexion at wrist with elbow extended, pain with percussion over median nerve, intact strength
Dx: Carpal tunnel syndrome
Tx: wrist splinting and avoidance of repetitive wrist emotions
*no steroids if acute, weakness or sensory loss
Drugs/surgery only if refractive, sensory/motor loss, moderate-severe findings on electrodiagnostic studies
29
Recurrent syncope without heart disease
Tilt table test-neurocardiogenic vs orthostatic vs psych
30
Hypertension tx in diabetic with proteinuria
ARB
31
Hypertension in preg tx
| Diabetes in preg tx
Labetalol, methyldopa (if htn before 20 weeks, it's chronic htn)
Insulin preferred, metformin acceptable
*ACEI, statin, ARBs contraindicated* *Aspirin may interfere with implantation*
32
Urge incontinence tx
Tolterodine
33
Mild cognitive impairment
one or two domains (such as memory)
MMSE score of 24-25
<24-dementia
34
Start palliative care early
Along with even life prolonging therapy
35
Acute cervical radiculopathy without trauma/weakness/ myelopathy
Conservative-analgesics, avoidance of provocation
36
PPI trial for chronic cough secondary to GERD
3 months
37
Drugs that cause low testosterone
Opioids, steroids, hormones
| Check morning level of testosterone
38
hypertriglyceridemia (>500) treatment
fenofibrate
Nicotinic acid (increases HDL, decreases LDL also) but increases gout
Omega 3 fatty acids-third line
*colesevelam for decreasing LDL*
39
Pain in superior and posterior testicle, high fevers, leukocytosis, dysuria, urgency, frequency
Epididymitis
gonorrhea, chlamydia
*pain with direct palpation of the testicle, enlargement-orchitis*
40
pelvic pain, UTI symptoms, tender prostate
acute prostatitis
41
xerophthalmia (dry eyes), xerostomia (dry mouth) + anti Ro SSA, anti La SSB, abnormal Schimer (tears)
polyarthritis, vasculitis, peripheral neuropathy, interstitial nephritis
Primary Sjogren syndrome
* just dry eyes-meibomianitis*
* secondary sjogren syndrome to RA/lupus*
42
Palpable breast mass
Evaluate even if unlikely to be cancer
in young woman: u/s-cyst (aspirate, cytology if bloody/recurrent), solid (biopsy)
If biopsy is benign-still follow up
43
Prevention of periop pulm complications
Pre and post op incentive spirometry
44
>40 years with hematochezia
| hemorrhoids
```
colonoscopy
conservative treatment (no banding, etc.) unless refractory
```
45
prostate cancer screening
talk with patient, patient decides
46
obesity treatment
diet
47
Lower LDL with
| Athesclerosis-goal LDL <100
Statin
lower drug-drug interactions with pravastatin (renally cleared)
*do not combine atorvastatin, lovastatin, simvastatin with diltiazem*/ *rosuvastatin with warfarin*
48
Excessive menstrual bleeding treatment
Moderate-medroxyprogesterone acetate for 21 days
Monophasic OCP 4x daily for 5 to 7 days, then qd
Orthostatic/dizzy-IV estrogen
49
Anterior knee pain worsened by sitting or stairs, pressure to patella with knee in extension and moving patella medially and laterally
palletofemoral pain syndrome-no testing
| *anterior knee pain+swelling+erythema-prepatellar bursitis due to recurrent trauma-aspirate fluid-no imaging needed*
50
pain in anteromedial proximal tibia, swelling
pes anserine bursitis
51
chronic dizziness in elderly
multifactorial, disequilibrium
PT for gait training
*vestibular rehab is for BPPV*
52
>60 yrs, menopausal vasomotor symptoms (hot flashes)
venlafaxine, paroxetine
* if using estrogen, add progesterone to prevent cancer*-still get clots
* if no uterus-estrogen only*
* systemic therapy reasonable in healthy <60yo, time since menopause <10 years
53
DEXA
>65 yo / >9.3% risk of fracture (FRAX)
54
Lipid screening
40-75 years q 5 years
| 10 year cardiovascular event risk of >10% + dyslipidemia/diabetes/htn/smoking-statin
55
Glucose screening
40-70 years who are obese or overweight q 3 years
56
Pre op cardiothoracic surgery
Spirometry for everyone
57
Lateral epicondylitis
repetitive wrist motion, pain over lateral elbow, pain with resisted wrist extension
tx: avoidance of pain inducing activities
refractory-surgery
clinical diagnosis
58
Quality improvement-Eliminating waste
-quality control of particular step
Root cause analysis results
Lean model-system inefficiencies
DMAIC (six sigma)-perfection
fishbone/ishikawa diagram
* spaghetti diagram-workflow*
* pareto chart-improvement initiatives*
* control chart-effect of intervention*
59
Primary dysmenorrhea tx
NSAIDs/ COX 2 inhibitors
| combined estrogen progestin pill
60
PMS/PMDD treatment
SSRI
61
Severe menstrual bleeding treatment
tranexamic acid
62
Most important measure to prevent pressure ulcers
Advanced static mattresses or overlays
63
Age to stop breast cancer screening
| breast MRI+mammography
```
75 yo (consider if life expectancy >10 years)
lifetime risk> 20%
```
64
Anorexia vs bulimia vs binge eating disorder
BMI <18.5 vs normal/overweight BMI vs. no compensatory behaviors
65
Aural fullness, hearing loss, fluid behind tympanic membrane, post URI or allergies
+evidence of infection
Otitis media with effusion
self-resolves in 12 weeks, refractory-miringotomy with tympanostomy tubes
acute otitis media-amoxicillin
otitis externa (external ear canal inflammation)-neomycin, polymyxin B, hydrocortisone
66
Postherpetic neuralgia tx
Lidocaine patch
Localized therapies such as lidocaine, capsaicin cream, preferable for neuropathies
Systemic neuropathic pain-gabapentin
67
eye pain, redness, photophobia, circumferential redness around the border of the sclera and cornea, pupillary miosis, flare cells in anterior chamber
uveitis
inflamed iris, body and choroid
*may be associated with ankylosing spondylitis*
68
redness, irritation, tearing in eyes, no pain
| bilateral redness across entire sclera
episcleritis
| scleritis
69
Drugs for weight
BMI>/30, 27 with comorbidities
Orlistat
Lorcaserin-appetite suppressant-do not use in increased serotonin pts
phentermine-topiramate: CI in glaucoma
70
medically unexplained symptoms treatment
cognitive behavioral therapy, regularly scheduled visits
71
Palpable breast mass with negative mammography (postmenopausal)
still biopsy
72
Disequilibrium
unsteadiness with walking/standing
multifactorial including sensory (visual, auditory) deficits
physical therapy
*CT not adequate for cerebellum-MRI instead*
73
postop anemia + cardiovascular disease
observe
| transfuse only if symptomatic or hgb <7
74
delivering bad news
SPIKES-setting, perception, invitation, knowledge, empathy, strategize
Be blunt
75
Former smoker screening
55-80 years with >/30 pack year smoking history
quit in the last 15 years
low dose CT
reasonable life expectancy, willing to undergo surgery
76
AAA screening
once by u/s in men 65-75 yo who have smoked 100 cigs/ first degree relative who required repair
77
Cauda equina syndrome
Acute low back pain, radiculopathy, saddle anesthesia, urinary retention, areflexia, decreased anal tone
compression and ischemia of nerve roots
imaging and surgery
78
Erectile dysfunction treatment
Lifestyle modification, then PDE 5 inhibitors
79
Statin guidelines regarding clinical ASCVD (PAD, MI, Stroke, angina)
High intensity statin therapy regardless of LDL level unless >75 yo, CKD or use of interacting drug such as diltiazem-then moderate intensity
80
Give niacin when
severe triglyceridemia, no response/tolerance to statin
81
Cohort study outcome measure
Similar patients exposed to different risks or exposures
Relative risk
>1-more likely with exposure
82
Case control study outcome measure
patients with disease vs. patients without a disease, retrospective
odds ratio
83
Sacroiliitis
stepping off a curb, leg length discrepancies, pregnancy, scoliosis, lumbar fixation
positive FABER test, pain in posterior hip
rest, NSAID, PT
84
Hip joint OA
Pain radiates to groin, limited ROM
85
Piriformis syndrome
Trochanteric bursitis
Trapped sciatic-pain, tingling and numbness down leg
Lateral hip pain
86
Direct to consumer DNA testing positive results only
Without family history or symptoms, don't test
87
Insulin in perioperative period
Stress-hyperglycemia
Give long acting (glargine, detemir), hold short acting as there will be no PO esp for short procedures
*iv insulin for cardiac surgery*
88
bipolar tx-depressive phase
manic phase
maintenance phase
quetiapine (hypersomnolence, weight gain, tardive dyskinesia, hyperglycemia), olanzapine-fluoxetine
lithium, antipsychotics, antiepileptics
lamotrigine
89
Obstructive sleep apnea post op management
nonsupine positioning, continuous pulse ox, be careful about opioids/sedatives
If hypoxic/apneic-CPAP
90
Chronic fatigue syndrome (systemic exertion intolerance) tx
CBT, graded exercise program
91
OCP in migraine patient
No estrogen
| minimize bleeding by not using progestin only methods
92
Screening test bias-aggressive disease in non screened cohort vs less aggressive in screened cohort
Length time bias
93
Stress dosing of steroids
<10mg prednisone-not needed, take usual dose on morning of surgery
>10-IV hydrocortisone q8h for 48 hours post op
94
Automatic statin
40-75 yo, >/7.5% 10 yr ASCVD risk
clinical ASCVD (MI, stroke, angina, PAD, TIA, revascularization)
>/21 yo w/ LDL >/190
DM 40-75 yo, LDL 70-189
95
boggy testicle, lower urinary tract symptoms, superolateral tenderness relieved by elevation
epididymitis
96
stress incontinence treatment
| overactive bladder
pelvic floor muscle training, weight loss
| oxybutynin
97
drugs which affect statin metabolism
CCBs, fibrates, protease inhibitors, amiodarone. macrolides
98
fall prevention vitamin D
| mineralocorticoid supplement
neuromuscular benefits
| orthostasis
99
depression vs anticipatory grief
guilt, hopelessness, helplessness, worthlessness vs none
100
Hypogonadism
test AM testosterone twice
Primary vs secondary-get LH and FSH levels
Secondary (if low)-brain MRI
101
Sharp pain in foot with first few steps
Posterior burning heel pain, stiffness and tenderness after rapid increase in exercise, improves with rest
pain in middle of heel, barefoot on hard surfaces
Midfoot pain with radiation into medial arch, extensive exercise
Plantar fasciitis
pain with palpation of medial calcaneal tubercle and passive dorsiflexion of toes
Achilles tendinopathy
heel pad syndrome
Stress fracture of tarsal navicular bone
102
colon cancer screening
```
50 to 75yo
annual gFOBT or FIT (preferred)
flex sig q5years
ct colonography q5years
flex sig q10years+annual gFOBT
colonoscopy q 10 years
```
103
Image neck pain if
trauma/compression fracture/weakness/neuro/infection/cancer (point tenderness to palpation)
104
Anovulatory bleeding
in premenopausal woman
Confirm menopause with
Unpredictable
endometrial biopsy
if<35 yo with no risk factors-hormonal therapy
FSH (if amenorrheic for 12 months)
*postmenopausal bleeding-transvag u/s*
105
Blepharitis
Orbital cellulitis
Endophthalmitis
Preseptal cellulitis vs orbital
eyelid/lash
EOM, recent sinus/dental infection, get CT brain
vision changes
no proptosis/pain with eye movement
106
cardiac risk factors+good functional capacity preop
just get an EKG
107
```
AR
ARR
NNT
RR
RRR
```
patients with event/total number of patients
difference between two groups
1/ARR
experimental event rate/control event rate
1-RR
108
bupropion positive profile
no weight gain, minimal sexual side effects,effective
109
If good sleep hygiene doesn't work
try sleep restriction, then drugs
110
For reducing ASCVD risk/controlling cholesterol, combined therapy (statin+something else) is unnecessary unless
no response/tolerance to statins
111
centor criteria
fever, no cough, anterior cervical LAD, tonsillar exudate
4-group a strep-treat
2-3-test
1-dont test/treat
112
Tdap vaccine during pregnancy
between 27 and 36 weeks during each pregnancy
113
otosclerosis
presbycusis
conductive hearing loss, side on Weber-tx; amplification/surgical stapedectomy
sensorineural hearing loss, symmetric
114
Do not use anticholinergics in elderly
ex. loratidine, oxybutynin
115
scheduled opioids should also be on
if laxatives fail
scheduled senna or bisacodyl +miralax/sorbitol/lactulose
methylnaltrexone
116
Specialized rehab hospital
have to tolerate 3 hours, 5 days a week
117
Dry age-related macular degeneration (loss of central vision, drusen deposits, atrophy of retinal pigment epithelium) treatment
Wet AMD
treatment
high dose antioxidants, zinc
neovascularization in subretina
VEGF inhibitors
118
Tarsal tunnel syndrome
painful squeeze/ cross-legged test
compression of posterior tibial nerve, pain and paresthesia in medial ankle
high ankle sprain
119
Continuous high pitched tinnitus
Rinne test
Weber-louder in affected ear
louder in normal ear
sensorineural hearing loss
should be heard better through air-otherwise conductive hearing loss
conductive hearing loss
sensorineural hearing loss
120
bilateral and painless gradual peripheral vision loss
treatment
primary open angle glaucoma
increased cup to disk ratio, vertical extension of central cup, disc hemorrhages, increased IOP
beta blockers, prostaglandins, laser therapy, surgery
121
alcohol withdrawal in patient with liver disease
do not use long acting benzos (chlordiazepozide)
| use short term (lorazepam)
122
Back pain with no neuro/systemic findings
acute (<4 weeks), subacute (4-12 weeks), chronic (more)
activity, heat, NSAIDs within 6 weeks
spinal manipulation/massage therapy if unresolving
123
Metformin side effect
lactic acidosis
124
Knee meniscal tear
weight bearing, locking/catching sensation
| abnormal Thessaly and medial-lateral grind test
125
Acute sinusitis
| Bacterial if
usually viral, symptomatic treatment
persistent and severe, high fever, failure to improve after 10 days-amoxicillin clavulanate, doxy
*no imaging needed*
126
syncope with prodrome of warmth, nausea and lightheadedness
syncope triggered by standing, high risk setting, no organic heart disease
```
neurally mediated (vasovagal) syncope
get orthostatics and EKG
*EKG in all syncope cases*
```
tilt-table testing
MRI if seizure-like or neuro symptoms
127
Elective noncardiac surgery with recent coronary stent
Delay surgery at least 6 months (drug eluting stent), 30 days (bare metal)
if surgery is needed-continue antiplatelet therapy
128
Panic disorder must have fear of another attack. Tx
| Buspirone
SSRI +therapy
| generalized anxiety tx
129
Pre OCP use testing
Pregnancy test if more than 1 week since last menstrual period
Blood pressure
130
Full thickness rotator cuff tear
cant abduct above 90 degrees, surgery
131
Olanzapine
Antipsychotic, may be used in combination therapy (+ fluoxetine) for depression, not alone
* aripiprazole, quetiapine+ any antidepressant*
* refractory depression-switch drugs after 6 weeks*
132
Palpate pulse in 65yo/older to find
afib
133
trichomonas
copious malodorous frothy yellow discharge w/ itching, burning, bleeding
metronidazole
test for other STDs and treat partner
134
Metabolic syndrome (waist circ, triglyceride of 150, hdl <40, htn, diabetes) + 10 year risk of ASCVD>10%
aspirin
135
Teratogenic drugs
statins, ACEIs, ARBs
136
Lifestyle intervention for weight loss
Drugs BMI
Surgery BMI
behavioral therapy, diet changes, exercise
>/30 or >/27 with comorbidities
>/40 or >/35 with comorbidities
137
Somatic symptom disorder
conversion disorder
illness anxiety disorder
at least one symptom interfering with life, excessive behavior, at least 6 months
abnormal sensation/motor function
general health, minimal to no symptoms
138
CBT useful in chronic systemic pain.
| Lidocaine patch for
localized pain
139
reduce fall risk in cognitively impaired with no reversible risk factors
continue current cure
140
Live flu vaccine vs inactivated
| Recombinant flu vaccine
49 yo and immunocompetent w/ no egg allergies
| only in severe (anaphylaxis) egg allergy
141
Most effective smoking cessation therapy
combination nicotine replacement (rapid onset-gum+ extended release-patch> varenicline> bupropion/single agent nicotine
142
Central vertigo imaging
MRI, not CT cos CT can't properly image posterior fossa
| *carotid artery distribution would be monocular vision loss+ hemisensory/hemimotor+ apraxia+speech*
143
Breast cancer screening in patient with high breast density
Digital screening mammography
144
Urinary incontinence+ dementia
prompted voiding
145
Unstageable pressure ulcer
base covered by slough/eschar
| debridement (surgical or wet-to-dry dressings)
146
drugs that cause extrapyramidal symptoms
1st gen antipsychotics-chlorpromazine, haloperidol, thioridazine
use 2nd gen-clozapine
147
Acute severe pain at end of life
Opioids, no morphine in kidney failure
148
Interrupted vaccine series
Resume, do not restart
149
Noninfectious olecranon bursitis tx
physical protection+NSAID, if refractory-steroids
| *if suspected to be infectious or crystalline-aspirate*
150
HIV testing
15-65 yo, just once
* lipid levels 40-75 yo every 5 years*
* blood glucose 40-70 years+overweight q 3 years*
151
Cancer patients with cachexia
appetite stimulants/ TPN do not improve M&M or quality of life
152
Central pain syndrome
nociceptive pain
dysregulation of sensory pathways, constant with bursts, exacerbated by movement, emotions, etc.
Fibromyalgia, post stroke pain, post spinal cord injury pain
dull, aching, throbbing, localized, caused by tissue injury
153
pneumococcal vaccination in asplenia
PCV13 (prevnar), then PPSV 23 in 8 weeks
* PPSV 23 again five years after first dose, if 19-64.
* again at 65
154
Preop echo
if more than a year or change in clinical status
155
Cyclic mastalgia
support bra, education, reassurance
156
Suspected arrhythmogenic syncope (no prodrome) with risk factors
Recurrent syncope
inpatient cardiac monitoring
loop recorder
157
Acute nonspecific low back pain with negative exam
no imaging
| image if no improvement after 4-6 weeks
158
BPH treatment
Get urinalysis-treat UTI if present
| AUASI score: 1-7 (mild-observe), 8-19 (moderate-tamsulosin), 20-35/ 40ml prostate (severe-finasteride)
159
Chronic neurogenic pain (may be due to space narrowing around nerve, OA ) treatment
gabapentin, TCAs
| *no epidural steroids*
160
vestibular neuronitis vs. labyrynthitis
no hearing loss
161
bilateral severe boring radiating ocular pain, worse at night and with movement, redness, photophobia, tearing
blotchy redness
painless redness, irritation, tearing
scleritis
*underlying systemic disease*
refer to ophtho
subconjunctival hemorrhage
episcleritis
162
bilateral severe boring radiating ocular pain, worse at night and with movement, redness, photophobia, tearing
blotchy redness
painless redness, irritation, tearing
scleritis
*underlying systemic disease*
refer to ophtho
subconjunctival hemorrhage
episcleritis
163
tamsulosin+ PDE-5inhibitor
profound hypotension
| *cardiac stress test before viagra*
164
Recurrent (>/4 times a year) vulvovaginal candida treatment
extended course antifungal
165
hypertrophic cardiomyopathy murmur
systolic crescendo-decrescendo @ left lower sternal border
| increases with valsalva, decreases with increased preload (leg elevation)/afterload (handgrip)
166
surveillance of long term opioid therapy for noncancer pain
assess risk, baseline and periodic urine drug tests (doesn't have to be at every visit), signed agreement, prescription drug monitoring program
167
Hyperlipidemia w/o ASCVD, diabetes, LDL>190, risk >7.5%
lifestyle modification
168
Asymptomatic cerumen impaction
observe
| if symptomatic-ceruminolysis, irrigation, manual removal
169
Upper airway cough syndrome
due to allergic rhinitis, >8 weeks
excess mucus, postnasal drip
tx: intranasal glucocorticoid
170
Upper airway cough syndrome
due to allergic rhinitis, >8 weeks
excess mucus, postnasal drip
tx: intranasal glucocorticoid
171
Pre-invasive procedure anticoagulation in patient on chronic warfarin w/ low risk of clot
intermediate/high risk
stop 5 days before, no bridging, continue aspirin
lovenox
