Manual Internato com prescrições

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SUMÁRIO 
1. FICHA ANAMNESE ------------------------------------------------------ 3 
2. FICHA EXAME FÍSICO ------------------------------------------------- 4 
3. EVOLUÇÃO --------------------------------------------------------------- 5 
4. SÍNDROME CORONARIANA SEM ST ------------------------------ 6 
5. SÍNDROME CORONARIAN COM ST ------------------------------- 10 
6. CANDIDÍASE -------------------------------------------------------------- 14 
7. AVEH ---------------------------------------------------------------------- 16 
8. AVEI ------------------------------------------------------------------------ 19 
9. DM + INSULINOTERAPIA -------------------------------------------- 21 
10. ANAFILAXIA ------------------------------------------------------------- 25 
11. COLESCISTITE AGUDA ------------------------------------------------ 27 
12. CRISE CONVULSIVA --------------------------------------------------- 31 
13. DIABETES ---------------------------------------------------------------- 37 
14. EDEMA AGUDO DE PULMÃO HIPERTENSIVO ---------------- 41 
15 EDEMA AGUDO DE PULMÃO NÃO HIPERTENSIVO --------- 43 
16. ESCABIOSE ----------------------------------------------------- 46 
17. TRANSFUSÃO MACIÇA DE SANGUE ------------------ 49 
18. HIPERTENSÃO ---------------------------------------------- 52 
19.HEMORRAGIA DIGESTIVA ALTA NÃO VARICOSA ---56 
20. HEMORRAGIA DIGESTIVA ALTA VARUCOSA ------ 59 
21. INTUBAÇÃO --------------------------------------------------- 63 
22. ITU COMPLICADA ------------------------------------------ 62 
23. ITU NÃO COMPLICADA ----------------------------------- 71 
24. RINOSSINUSITE AGUDA ---------------------------------- 74 
25. CELULITE E ERISIPELA NA PED ---------------------- 78 
26. OSTEOMIELITE NA PED ---------------------------------- 83 
27. TRAUMA ------------------------------------------------------- 84
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Ficha Modelo Anamnese 
 
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Ficha Modelo Exame Físico 
 
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Evolução Diária + pós-cirúrgico 
 
 
 
 
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Síndrome Coronariana Aguda sem Supra de ST 
 
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Síndrome Coronariana Aguda com Supra de ST 
 
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Candidíase 
 
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AVE Hemorrágico 
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AVE Isquêmico 
 
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DM + Insulinoterapira 
 
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Anafilaxia 
 
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Colescistite Aguda 
 
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Crise Convulsiva
 
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Diabetes 
 
 
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Edema Agudo de Pulmão Hipertensivo 
 
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Edema Agudo De Pulmão Não Hipertensivo 
 
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Escabiose 
 
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Transfusão Maciça De Sangue 
 
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Hipertensão Arterial 
 
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Hemorragia Digestiva Alta Não Varicosa 
 
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Hemorragia Digestiva Alta Varicosa 
 
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Intubação Orotraqueal
 
 
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ITU Complicada 
 
 
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ITU NÃO COMPLICADA 
 
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Rinossinusite Aguda 
 
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Pediatria 
Celulite e Erisipela Não Complicadas
TRATAMENTO FARMACOLÓGICO 
1.ANTIBIOTICOTERAPIA EMPÍRICA. 
 Cefalexina: 25-100 mg/kg/dia VO de 6/6 
horas, por 7-14 dias. Dose máxima: 2000 
mg/dia ou 500 mg/dose; 
OU 
 Sulfametoxazol + trimetoprim : 8-12 
mg/kg/dia de Trimetoprim VO de 12/12 
horas, por 7-14 dias. Dose máxima: 160 
mg/dose de Trimetoprim. 
2. PROFILAXIA E SINTOMÁTICOS 
 Dipirona: 15-25 mg/kg/dose VO de 6/6 
horas se febre ou dor; 
OU 
 Paracetamol: 10-15 mg/kg/dose VO de 
6/6 horas se febre ou dor. 
 
Celulite e Erisipela com Indicação de Internação Hospitalar 
Dieta e Hidratação 
1. Dieta oral própria para idade. 
Antibioticoterapia Empírica 
Esquema A: Celulites com exsudatos 
purulentos/ refratariedade/ sinais de 
doenças sistêmica/infecções recorrentes 
com condições predisponentes/infecção 
prévia por MRSA: Escolha uma das 
opções: 
 Clindamicina: 20-40 mg/kg/dia EV de 
6/6 ou de 8/8 horas por 7-14 dias. Dose 
máxima: 2.700 mg/dia; 
 Sulfametoxazol + trimetoprim: 8-12 
mg/kg/dia de Trimetoprim EV de 12/12 
horas, por 7-14 dias. Dose máxima: 160 
mg de TMP; 
 Linezolida: 10 mg/kg/dia EV de 8/8 
horas, por 7-14 dias. Dose máxima: 600 
mg/dose; 
 Vancomicina: 40-60 mg/kg/dia EV de 6/6 
horas, dose ajustada conforme nível 
sérico, por 7-14 dias. Dose máxima: 4.000 
mg/dia. 
Esquema B: Celulite em 
neonatos: Escolha uma das opções: 
 Cefotaxima: 50-150 mg/kg/dose EV de 
8/8 horas, por 7-14 dias; 
 Até 1 semana de vida: 50-100 
mg/kg/dia EV de 12/12 horas; 
 De 1-4 semanas de vida: 75-100 
mg/kg/dia EV de 8/8 horas; 
 Gentamicina: 4 mg/kg/dose EV de 24/24 
horas + Vancomicina 40-60 mg/kg/dia 
EV de 6/6horas, por 7-14 dias. 
Profiláticos e Sintomáticos 
1. Analgésico e antitérmico: Se presença 
de dor ou febre. Escolha uma das opções: 
 Dipirona: 15-25 mg/kg/dose EV. 
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2. Antiemético: Se presença de náuseas 
e/ou vômitos. Escolha uma das opções: 
 Ondansetrona: 0,15 mg/kg/dose EV. 
ETIOLOGIA 
 CELULITE: Estreptococos beta-
hemolíticos; Staphylococcus aureus; 
bacilos anaeróbicos gram-negativos; 
 ERISIPELA: Estreptococos beta-
hemolíticos. 
ANAMNESE 
Lesões cutâneas decorrentes de trauma 
(picadas de insetos, abrasões, feridas 
penetrantes, uso de drogas injetáveis), 
inflamação (eczemas ou radioterapia), 
infecções cutâneas prévias 
(impetigo, tinea pedis), varicela ou edema 
devido à insuficiência venosa. 
EXAME FÍSiCO 
CELULITE: Lesões cutâneas eritematosas, 
quentes e com formação de edema, com 
pouca delimitação da lesão. Pacientes 
com quadro de início mais indolente, com 
sintomas localizados que se desenvolvem 
ao longo de alguns dias. Pode haver 
drenagem de material purulento. 
ERISIPELA: Lesões cutâneas 
eritematosas, quentes, elevadas e com 
formação de edema (aspecto de "casca 
de laranja"), com clara demarcação 
entre tecido sadio e acometido . 
Pacientes com início abrupto de quadro 
cutâneo e sintomas sistêmicos (febre e 
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INDICAÇÃO DE INTERNAÇÃO 
- Quadros moderados a graves: grande 
extensão 
- Rápida progressão do eritema 
- Imunodeficiência 
- Persistência ou progressão do quadro 
mesmo após antibioticoterapia oral por 
48-72h 
- Sintomas sistêmicos: febre e calafrios 
- Paciente toxêmicos 
ABORDAGEM TERAPêuTiCA 
Medidas gerais: 
 Elevar a área acometida para redução 
do edema; 
 Hidratação da pele edemaciada para 
evitar fissuras; 
 Tratamento das condições 
predisponentes: tinea pedis, insuficiência 
venosa crônica; 
 Realizar demarcação inicial do eritema 
para avaliar evolução. 
Celulites com exsudatos purulentos ou 
refratariedade ou sinais de doenças 
sistêmica ou infecções recorrentes com 
condições predisponentes ou infecção 
prévia por MRSA: tratamento com 
antibióticos com cobertura para S. 
aureus resistente à Meticilina. Opções 
sugeridas: 
 Clindamicina (20-40 mg/kg/dia EV 
divididos de 6/6 ou 8/8 horas); 
 Sulfametoxazol + trimetoprim (8-12 
mg/kg/dia de Trimetoprim EV divididos 
de 12/12 horas); 
 Linezolida (10 mg/kg/dia EV divididos de 
8/8 horas, máximo 600 mg/dose); 
 Vancomicina (40-60 mg/kg/dia EV 
divididos de 6/6 horas) quando os outros 
antibióticos não apresentam efeito. 
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Celulites sem exsudatos 
purulentos: Devem ser tratadas com 
terapia empírica para estreptococos beta-
hemolíticos e S. aureus sensível à 
Meticilina. 
 Cefalexina (25-100 mg/kg/dia VO 
divididos de 6/6 horas); 
 Sulfametoxazol + trimetoprim (8-12 
mg/kg/dia de Trimetoprim VO divididos 
de 12/12 horas). 
CELULITE EM NEONATOS: Realizar 
antibioticoterapia parenteral para 
estreptococos beta-hemolíticos, 
estreptococos do grupo B e S. 
aureus MRSA. 
 
 Cefotaxima (50-150 mg/kg/dia EV 
divididos de 8/8 horas — dose 
dependente da idade pós natal); 
 Gentamicina (4 mg/kg/dose EV 
24/24 horas) associada a 
Vancomicina (40-60 mg/kg/dia EV 
divididos de 6/6 horas). 
ERISIPELAS 
 Ceftriaxona (100 mg/kg/dia EV divididos 
de 12/12 horas ou dose única diária); 
 Cefazolina (50-100 mg/kg/dia EV 
divididos de 8/8 horas). 
Tratamento oral: 
 Amoxicilina (50 mg/kg/dia VO 
divididos de 8/8 horas); 
 Cefalexina (25-10 mg/kg/dia VO 
divididos de 6/6 horas); 
 Clindamicina (20-40 mg/kg/dia VO 
divididos a cada 6 ou 8 horas); 
 Duração do tratamento: 5 dias (casos 
leves e com resposta clínica à 
antibioticoterapia) podendo chegar a 14 
dias em casos graves e/ou de difícil 
resposta clínica. 
Transição para antibioticoterapia 
oral: Pode-se trocar o esquema para oral 
nos casos de pacientes com celulites não 
complicadas que estão afebris e com 
melhora dos sintomas. 
Drenagem cirúrgica: Resposta ruim ao 
tratamento antibiótico, evidências de 
abscesso, falha de resposta precoce ao 
antibiótico. 
 
PROFiLAXiA 
Celulite de repetição com fatores 
predisponentes que não podem ser 
aliviados: Infecções por estreptococos 
beta-hemolíticos: penicilina benzatina a 
cada 28 dias nas seguintes doses: 
 ≤ 20 kg = 600.000 unidades; 
 > 20 kg: 1.200.000 unidades 
intramuscular. 
Na suspeita de infecções de repetição 
por S. aureus : 
- Pode ser tentado um ciclo de 
descolonização com mupirocina em 
regiões de dobras, principalmente nasal, 
axilas e perianal, 8/8 horas, por 7 dias. 
ANOTAÇÕES: 
 
 
 
 
 
 
 
 
 
 
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Osteomielite Aguda 
Inflamação do osso e da medula óssea 
ETIOLOGIA 
 MAIS COMUM: 
1. Staphylococcus aureus 
2.Streptococcus pneumoniae 
3. Streptococcus pyogenes. 
 RN: 
1. bactérias gram (-) 
2. estreptococos do grupo B 
 APÓS FERIMENTO EM PÉS 
1. Pseudomonas aeruginosa 
 ANEMIA FALCIFORME 
1. Salmonella 
EXAMES 
 Hemograma 
 Hemocultura 
 Cultura óssea e de líquido articular 
 PCR e VHS 
 RX 
 USG 
 Cintilografia 
 TC 
 RNM 
ABORDAGEM TERAPêuTiCA 
ANTIBIOTICOTERAPIA 
 INICIAL: 
- Internação hospitalar 
- ATB EV por no mínimo 21-28 dias 
- Sintomático + suporte 
 ABORDAGEM CIRURGICA- Quando pus franco é obtido após aspiração subperiosteal 
ou metafisária, ou há suspeita com base nos achados de RM, um procedimento de 
drenagem cirúrgica geralmente é indicado. 
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PRESCRIÇÃO GERAL 
1. Dieta oral livre, conforme aceitação, se paciente lúcido e orientado: 
 Variações de dieta de acordo com comorbidades; 
 Se paciente instável, optar por dieta zero e aporte calórico basal (~ 100 g de 
glicose). 
2. Ringer lactato ~ 20 mL/kg/EV ou SF 0,9 % entre 20-30 mL/kg/dia EV, com 
variação de volume de acordo com a necessidade . 
3. Antibioticoterapia Empírica 
Esquema: Tratamento empírico com associação: 
 1. Glicopeptídeo, Daptomicina ou Linezolida, por 6-12 semanas. 
 + 
 2. Cefalosporina de 3ª/4ª geração, Carbapenema, quinolona ou Aztreonam, por 6-12 
semanas. 
 
Opções de glicopeptídeos, Daptomicina, Linezolida (I): 
 Vancomicina: 15-20 mg/kg/dose (não exceder 2 g por dose) EV a cada 8/8 a 12/12 
horas para cobertura empírica de MRSA; 
 Teicoplanina : (6-12 mg/kg) 400 mg EV de 12/12 horas, por 3 doses (dose de ataque). 
Seguido de 400 mg EV/IM de 24/24 horas (dose de manutenção); 
 Daptomicina : 6-10 mg/kg EV de 24/24 horas; 
 Linezolida: 600 mg VO/EV de 12/12 horas. 
Opções de cefalosporinas de 3 ª/4a geração, Carbapenema, quinolona, Aztreonam 
(II): 
 Ceftazidima : 2 g EV de 8/8 horas; 
 Ceftriaxona: 2 g EV de 24/24 horas; 
 Cefepima: 2 g EV de 8/8 horas; 
 Meropeném: 1 a 2 g EV de 8/8 horas; 
 Imipeném: 500 mg EV de 6/6 horas ou 1 g EV de 8/8 horas; 
 Ciprofloxacino: 400 mg EV ou 500 mg VO de 12/12 horas; 
 Levofloxacino: 500-750 mg EV ou 500 mg VO de 24/24 horas; 
 Aztreonam: 1-2 g EV de 8/8 a 12/12 horas. 
Tratamento Adjuvante 
1. Água boricada (2-3 g/100 mL) 2-3% por 10 minutos, 2-3x/dia, com gaze ou algodão; 
2. Permanganato de potássio: (1:20.000) no banho, 2x/dia; 
83 
 
3. Neomicina + bacitracina pomada: (20 g/frasco) aplicar sobre a área de 1-3x/dia; 
4. Mupirocina pomada : (15 g/frasco) aplicar sobre a área 3x/dia; 
5. Ácido fusídico 2%: (10 g/frasco), aplicar sobre a área de 2-3x/dia. 
Profiláticos e Sintomáticos 
1. Analgésico e antitérmico: Se presença de dor ou febre ≥ 37,8°C. Escolha uma das 
opções: 
 Dipirona sódica : (500 mg/mL) 1-2 g EV até de 4/4 horas (dose máxima: 5 g em 24 
horas); 
 Dipirona sódica gotas: (500 mg/mL) 20-40 gotas VO até de 4/4 horas; 
 Dipirona sódica : 500-1.000 mg VO até de 4/4 horas; 
 Paracetamol gotas: (200 mg/mL) 35-55 gotas VO até de 6/6 horas; 
 Paracetamol: 500-750 mg VO até de 6/6 horas. 
2. Antiemético: Se presença de náuseas e/ou vômitos. Escolha uma das opções: 
 Metoclopramida: ( 10 mg/2 mL) 10 mg EV, diluídos em água destilada, até de 8/8 horas; 
 Metoclopramida: (4 mg/mL) 50 gotasVO de 8/8 horas; 
 Metoclopramida: 10 mg VO de 8/8 horas; 
 Bromoprida: (10 mg/2 mL) 10 mg EV de 8/8 horas; 
 Bromoprida: (4 mg/mL) 1-3 gotas/kg VO de 8/8 horas. 
3. Proteção gástrica: Escolha uma das opções: 
 Omeprazol (40 mg/10 mL) 20-40 mg VO/EV de 24/24 horas, pela manhã; 
 Pantoprazol sódico 20-40 mg VO de 24/24 horas, em jejum; 
 Pantoprazol sódico (40 mg/10 mL) 40 mg EV de 24/24 horas. 
Cuidados 
1. Glicemia capilar de 2/2 horas. Em seguida, usar intervalos maiores ou mesmo avaliar 
necessidade de novas mensurações. 
2. Glicose hipertônica 25% 50 mL VO/SNE/EV em caso de HGT < 60 mg/dL. 
3. Avaliar necessidade de uso de cateter vesical de demora e medição de diurese (alvo: 
> 1 mL/kg/hora). 
4. Repouso no leito. Se for indicado, com o membro elevado. 
5. Compressa de gelo sobre o local, por 15 minutos, 3-6x/dia. 
6. Acesso venoso periférico salinizado. 
7. Sinais vitais 4/4 horas. 
7RESUMO CIRURGIA GERAL | 1. Trauma atendimento inicial Capítulo 1
Conceitos básicos
 Doença que mais mata jovens no mundo e a 
melhor medida para evitar mortes é a prevenção 
primária. Doença hiperaguda e com necessidade de 
tratamento imediato que não suporte anamnese e 
exame físico detalhados.
 Lesão externa que causa desequilíbrio na 
homeostase do paciente, geradora de mortalidade 
e morbidade, mais prevalente em países em 
desenvolvimento.
Mortalidade trimodal
 O trauma tem 3 picos principais de morte: morte 
imediata (1° pico); morte precoce (2° pico); morte 
tardia (3° pico). Para prevenir essas mortes temos as 
melhores formas de tratamento, respectivamente: 
prevenção primária, atendimento inicial e cuidados 
hospitalares. A maior parte dos óbitos acontecem 
no primeiro pico.
 As aulas de trauma abrangem o 2° pico de morte da 
doença, a chamada Golden hour.
Abordagem
 A abordagem envolve o tratamento conforme 
achados, priorizando o que mais mata. O 
diagnóstico definitivo não é importante 
inicialmente. Para agilizar o atendimento é 
necessária a padronização do atendimento e das 
equipes.
ABCDE
 O ATLS prioriza o atendimento de acordo com o 
que mais mata, na ordem do ABCDE.
o A  Airway  Via aérea e imobilização de 
coluna
o B  Breathing  Respiração e ventilação
o C  Circulation  Circulação
o D  Disability  Afecções neurológicas
o E  Exposure  Exposição e ambiente
 Diretrizes novas estão colocando uma letra 
X antes do ABCDE, que significa parar 
lesões exsanguinantes, isso porque sangra-
mentos exsanguinantes matam mais que a 
letra A.
 Medidas para padronização da atividade da equipe 
podem ser elencadas tanto para o atendimento pré-
hospitalar quanto para o atendimento hospitalar.
o Pré-hospitalar
 Preparação, planejamento
 Segurança da cena
 Parar sangramento, garantir via aérea segura
 Realizar transporte rápido e com segurança
 Comunicação entre equipes
o Hospitalar
 Sala e equipe preparadas
 Avaliação rápida e tratamento simultâneos
 Monitorização
 ABCDE
 Reavaliar constantemente
 Já programar transferência a depender do 
local
 Ao socorrista chegar no atendimento hospitalar ele 
deve passar as informações de maneira ordenada, 
com a ajuda de um mnemônico MIST.
o M  Mecanismo
o I  Injúrias
o S  Sinais vitais
o T  Tratamento
 Depois do MIST o hospitalar deve seguir com o 
ABCDE.
A - Airway
 Garantir via aérea e imobilização da coluna através 
do colar cervical e headblock. Ofertar 15L com 
máscara reinalante para todo mundo, independente 
de saturação.
 Se a via aérea não estiver pérvia devemos garantir via 
aérea segura. caso chegue intubado, checar o tubo. Se 
não chegar intubado, tentar conversar com o doente.
RESUMO CIRURGIA GERAL #01
1. TRAUMA ATENDIMENTO INICIAL
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Capítulo 1 RESUMO CIRURGIA GERAL | 1. Trauma atendimento inicial8
B - Breathing
 Garantir oxigenação dos tecidos, avaliar caixa 
torácica, ausculta pulmonar e se identificar 
problema causando insuficiência respiratória 
tratar imediatamente, seja drenagem de tórax ou 
indicação cirúrgica.
C - Circulation
 Diagnosticar possíveis locais de sangramento e 
parar o sangramento. Repor perdas: 1L de ringer 
lactato aquecido para todos (independente de 
sangramento) e se precisar de mais é recomendado 
dar sangue.
 Pegar 2 acessos venosos periféricos calibrosos 
periféricos e coletar exames e tipagem sanguínea.
D – Disability
 Avaliar escala de coma de Gasglow, fazer 
diagnóstico diferencial para uso de drogas.
 Se suspeita de TCE ou TRM  TC de crânio 
+ transferência/avaliação da neurocirurgia. 
Sempre prevenir lesão secundária (hipoxemia e 
hipovolemia).
E – Exposure
 Tirar toda a roupa do doente e movimentar em 
bloco para observar o dorso.
 Controlar a temperatura do ambiente e do doente.
 Só para lembrar:
o Encontrou o problema  Tratou
 Refazer o ABCDE até paciente estabilizar.
o Terminou a avaliação primária  paciente 
estável  avaliação secundária e transferência 
para tratamento definitivo.
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9RESUMO CIRURGIA GERAL | 2. Trauma vias aéreas Capítulo 1
 Medidas temporárias ou preparatórias.
o Oxigenação + Imobilização;
o Equipamentos não definitivos: cânula de 
Guedel, máscara laríngea;
 No trauma sempre considere ser uma via aérea 
difícil, então na sua sala de trauma sempre tenha 
uma caixa de via aérea difícil preparada.
Via aérea difícil
 A primeira e melhor medida será a intubação 
orotraqueal assistida por drogas.
 Conseguiu intubar? Checa o tubo – padrão ouro é a 
capnografia, se tiver.
 Se não conseguir intubar, o que fazer?
o Chamar alguém mais experiente;
o Utilizar materiais de via aérea difícil (Bougie);
o Após a 3ª tentativa falha está indicada a via 
aérea cirúrgica.
 3 tentativas de alguém experiente e com 
material de via aérea difícil.
Intubação orotraqueal assistida por drogas
 Pré-medicação(não é obrigatório, mas é legal fazer):
o Lidocaína  pouco usado, bom em crianças;
o Atropina  pouco usado, evita bradicardia;
o Fentanil  O mais usado, analgésico bom;
 Indução:
o Midazolam  hipotensor e meia-vida longa.
o Propofol  hipotensor
o Cetamina  não causa hipotensão e tem 
efeito analgésico e amnésico
o Etomidato  menor efeito hipotensor, não 
pode ser usado contínuo
 Bloqueador neuromuscular:
o Succinilcolina  não usar em suspeita de 
rabdomiólise e hipercalemia
o Rocurônio  escolha quando contraindicação 
a succinilcolina
Conceitos
 Via aérea definitiva = tubo na traqueia, com cuff 
insuflado abaixo das cordas vocais, conectado a um 
sistema de ventilação e fixado.
o Seja tubo orotraqueal, nasotraqueal ou via aérea 
cirúrgica.
 Falta de oxigenação dos tecidos é a causa mais 
rápida de morte no doente traumatizado.
 Paciente está falando? Conversando? A via aérea 
está pérvia, pula para o B.
 Se não conversa ou não respira  Manobras para 
desobstruir a via aérea (Chin Lift e Jaw-thrust), 
sempre mantendo o colar e o Headblock.
o Via aérea desobstruiu com manobras?
 Sim  Prosseguir para próximo passo do 
ABCDE
 Não  Via aérea definitiva
Via aérea pérvia, mas não ventila  BCD
 Se trauma cranioencefálico ou torácico grave  Via 
aérea definitiva
 Se hipóxia e RNC por choque hemodinâmico  
Via aérea definitiva
o Sempre manter a imobilização cervical.
Indicações de via aérea definitiva
 Indicações:
o A: Obstrução de via aérea; trauma 
maxilofacial; queimadura de face; sangramento 
de via aérea e tubo digestivo incoercível; lesões 
inalatórias.
o B: apnéia; insuficiência respiratória.
o C: hipoperfusão causando rebaixamento e 
agitação;
o D: Inconsciência; Gasglow <8.
 Sempre manter a imobilização, se for realizar 
via aérea cirúrgica pedir ajuda para manter a 
imobilização.
RESUMO CIRURGIA GERAL #01
2. TRAUMA VIAS AÉREAS
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Capítulo 1 RESUMO CIRURGIA GERAL | 2. Trauma vias aéreas10
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