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📚 ICMHE Exam Study Guide: Ethical Issues in Child, Reproductive & Mental Health

Based on your professor's slides - written in simple, easy-to-remember language.

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PART 1: ETHICAL ISSUES IN CHILD HEALTH

What is Ethics in Child Health?

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1. Consent, Assent & Autonomy (Most Likely 5-mark Topic)

• Consent = formal legal permission (given by parents/guardians for children)
• Assent = the child's own agreement/permission (not legally binding, but ethically important)

• Parents/guardians give consent for children.
• But we must also RESPECT what the child wants - this is called assent.
• Use child-friendly language. Let the child ask questions. Respect if they say NO.

NHRC National Ethical Guidelines for Health Research 2022 - minimum age for consent in research = 18 years

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2. Beneficence & Non-maleficence

• Always aim to do what is BEST for the child (beneficence).
• Avoid causing harm (non-maleficence).
• Example: Vaccination, nutrition = beneficence.
• Balance benefits vs. risks. If treatment causes more suffering than benefit, reconsider.

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3. Justice (Equity & Fairness)

• Fair access to healthcare regardless of geography, money, gender, caste.
• Children in remote/rural areas must also have access.
• Prioritize scarce resources in a fair, transparent way.
• Example: In a vaccine shortage, you cannot give preference to the leader's relatives - must vaccinate fairly.

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4. Best Interest Standard

• Decisions by parents/doctors should be guided by what is best for the child.
• Not just physical health - also consider emotional, psychological, and quality of life.
• When child cannot decide, parents + doctors choose what benefits child most.

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5. Confidentiality & Privacy in Children

• Keep child's health information private (especially mental health, sexual health).
• For adolescents - respect their privacy but clarify the limits.

1. Child abuse, neglect, or sexual violence (must report to protect child)
2. Child is at risk of self-harm or suicide
3. Child has a notifiable infectious disease
4. Required by law

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PART 2: ETHICAL ISSUES IN REPRODUCTIVE HEALTH

What is Reproductive Health?

• Bodily autonomy - people have the right to decide about their own bodies.
• Situations involve conflicting rights (e.g., mother's rights vs. fetus's rights).
• Cultural beliefs influence practices.
• Laws evolve but ethics provides consistent guidance.

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1. Abortion Ethics

• Most controversial topic in reproductive ethics.
• Core conflict: Bodily autonomy (woman's right to choose) vs. Right to life (fetus).

• Nepal legalized abortion in 2002.
• Affirmed as a fundamental right in the 2018 Safe Motherhood and Reproductive Health Rights Act.
• Free abortion services at public hospitals since 2017.

• Cultural stigma (especially in rural/conservative areas).
• Many abortions still done unsafely by uncertified providers.
• Sex-selective abortion - still practiced but is illegal and unethical.
• Accessibility gaps create inequality.

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2. Assisted Reproductive Technology (ART) & IVF

• IVF is done in Nepal but there are no comprehensive laws to regulate it.
• Without regulation: risk of abuse, exploitation, unsafe procedures, no accountability.
• High cost = inequality.
• Privacy issue: No clear guidelines for donor anonymity, record keeping.
• Mismanagement can cause social stigma and psychological harm.

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3. Contraception

• Needed to avoid unwanted pregnancy and reduce maternal mortality.
• Autonomy is affected by myths, cultural beliefs, and misconceptions.
• Lack of counselling about benefits and side effects = low use.
• Access and equity also affect its use.
• Confidentiality is a major concern for adolescents.

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PART 3: ETHICAL ISSUES IN MENTAL HEALTH

Overview

• Mental health = emotional, psychological, and social well-being.
• Mental illness can impair decision-making capacity.
• In Nepal: mental health is under-served, under-recognized, with cultural barriers.

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1. Autonomy & Decision-Making Capacity

• Mental illness can reduce a person's capacity to decide.
• Tension between: Paternalism (doctor/family deciding for patient) vs. Patient's autonomy (respecting patient's choice).
• Always assess capacity first.
• Involve patients in decisions as much as possible.
• If capacity is impaired, involve guardians + also seek patient assent.
• Involuntary admission is an ethical challenge, especially where legal oversight is weak.

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2. Confidentiality in Mental Health

• Diagnosis and treatment info must be handled with care.
• Breach can cause social harm, stigma, and discrimination.

1. Risk of suicide or serious self-harm
2. Risk of violence to others
3. Required by law

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3. Stigma & Discrimination

• People with mental illness face blame, shame, social exclusion, or self-stigma.
• This prevents them from seeking help.
• Solution: Psychoeducation for families + culturally appropriate communication.

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4. Access & Equity

• Rural-urban divide, cost barriers leave many untreated.
• Support community-based mental health programs.

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5. Research Ethics in Mental Health

• People with mental illness are a vulnerable population.
• Requires: proper consent, minimizing harm, fair participant selection.

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6. Legal & Ethical Protections (Nepal)

• Nepal's National Mental Health Survey (2019-20): awareness is rising but legal protections are weak.
• Mental health professionals (psychologists, counsellors) are not well regulated.
• Very few specialists; minimal beds per population; rural areas lack services.
• Nepal's Constitution: right to dignified life and mental well-being.
• Involuntary treatment must be least restrictive and a measure of last resort.

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CASE SCENARIO ANSWERS (Quick Reference)

Case: 17-year-old girl seeking emergency contraception (confidentiality vs. culture)

• Problem: Premarital sex is culturally stigmatized. If parents find out, she may face violence.
• Best practice:
  1. Provide confidential counselling.
  2. Explain legal/ethical limits of confidentiality.
  3. Only break confidentiality if there is a risk of abuse.

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Case: 16-year-old wants HIV test without informing parents

• Consider adolescent's right to confidentiality.
• Assess risk and capacity.
• Generally, for serious health decisions involving an adolescent's wellbeing, can proceed with proper counselling while respecting privacy.

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Case: Vaccines running out, leader wants his relatives prioritized

• Principle of Justice - must distribute fairly.
• Cannot give preference based on social status or relationships.
• Use fair, transparent criteria (e.g., most vulnerable first).

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Case: 5-year-old with severe pneumonia, father refuses antibiotics

• Best Interest Standard applies - child's welfare overrides parent's refusal.
• Doctor must act in the child's best interest.
• Educate the father about risks of refusing treatment.
• If necessary, involve authorities to protect the child.

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Case: Married woman at 13 weeks seeks abortion, facility refuses

• Principles at stake: Autonomy, Justice, Beneficence, Non-maleficence.
• Facility refusal is NOT ethically justified - law allows abortion up to 18 weeks in certain cases.
• Refusal violates justice (she is legally eligible) and non-maleficence (increases health risks).
• Provider must either provide care OR refer to a facility that can.

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Case: 25-year-old man admitted involuntarily, refuses medication

• Involuntary admission may be ethically justified if he poses a risk to himself AND lacks decision-making capacity.
• Balance beneficence (medication helps) with autonomy (he refuses).
• Consider least restrictive option first.
• Family can act as surrogate decision-makers but patient's rights must be respected.
• Nepal's mental health laws are still evolving - use international human rights standards.

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Case: 17-year-old boy wants to die, asks you not to tell family

• Break confidentiality - suicidal risk is an exception.
• Ethical response: Involve family/guardian and mental health professional.
• Patient safety comes first.

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Case: Woman with schizophrenia refuses medication, family insists

• Assess her decision-making capacity using Appelbaum's 4 steps.
• If she has capacity: her choice must be respected (autonomy).
• If she lacks capacity: family can be surrogate decision-makers but must act in her best interest.
• Use least restrictive treatment approach.

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TAKE-HOME MESSAGE (Memorize for Exam!)

1. Ethics is central to clinical medicine - not optional.
2. Applying ethics considers: age, capacity, law, culture, and communication.
3. Each scenario may involve conflict of principles - requires discussion and documentation.
4. Always prioritize patient welfare, autonomy, and justice in all clinical scenarios.

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QUICK MEMORY TRICKS

• 4 Principles: "A BNJ" = Autonomy, Beneficence, Non-maleficence, Justice
• Consent ages in Nepal: 7/12/16/18 rule (verbal assent at 7, written assent at 12, self-consent at 16 for NMC, adult at 18)
• Abortion limits: 12 weeks on request / 18 weeks for rape/incest
• Break confidentiality when: Abuse, Self-harm, Suicide, Notifiable disease, Law requires
• Appelbaum's capacity: Understand - Appreciate - Reason - Communicate

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• Cover page with your exam details + a bright orange Memory Tricks banner at the top
• Part 1 - Child Health: Principles table, Consent/Assent age rules (7/12/16/18), NHRC guidelines, confidentiality rules - all in colour-coded tables
• Part 2 - Reproductive Health: Nepal abortion law table (12/18 weeks), ART issues, contraception ethics
• Part 3 - Mental Health: Appelbaum's 4-step capacity assessment table, confidentiality rules, Nepal legal facts
• Case Scenario Answer Key: All case answers organised by topic - ready to reference
• Take-Home Message box at the end

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📚 ICMHE MBBS 2nd Year Exam Study Guide

Components of Respiratory & Abdominal Examinations

Written in simple language - easy to remember for tomorrow's exam!

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THE GOLDEN RULE OF ALL PHYSICAL EXAMINATIONS

I - P - P - A

Inspection → Palpation → Percussion → Auscultation

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PART 1: RESPIRATORY (CHEST) EXAMINATION

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STEP 1: INSPECTION (Just LOOK at the patient)

Patient position:

• Patient sitting upright, chest fully exposed.

What you look for:

• Normally in the midline of the suprasternal notch.
• Deviated trachea = shifted mediastinum (important finding!)

• Are both sides moving equally?
• Reduced movement on one side = disease on that side (pneumonia, effusion, pneumothorax)

• Using neck muscles (sternocleidomastoid), intercostal recession = severe respiratory distress

• Scars (previous surgeries)
• Gynecomastia
• Tobacco stains on fingers/lips/teeth
• Smell: ketones (DKA), foul smell (lung abscess)

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STEP 2: PALPATION (FEEL the chest)

What you check:

• Place finger in suprasternal notch - is trachea central or deviated?
• Deviated TOWARDS lesion = lung collapse, fibrosis
• Deviated AWAY from lesion = pleural effusion, tension pneumothorax

• Place both hands on chest with thumbs meeting at midline.
• Ask patient to breathe in deeply.
• Thumbs should move apart EQUALLY by 2-3 cm.
• Reduced expansion on one side = disease on that side.

• Place the palm/ulnar border of hand on chest.
• Ask patient to say "one, two, three" (or "ninety-nine").
• You feel vibrations through the chest wall.

• Tenderness over ribs/sternum (fractures, costochondritis)
• Subcutaneous emphysema (crackling feel under skin - air leaked into tissue)
• Cervical ribs
• Apical impulse of heart (shifted in cardiac enlargement)

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STEP 3: PERCUSSION (TAP the chest)

Technique:

• Place middle finger (pleximeter) flat on chest wall.
• Strike it firmly with the middle finger of the other hand (plexor).
• Listen to the note produced.

Percussion notes - MEMORIZE THIS TABLE:

Areas to percuss:

• Front: apices, upper zones, mid zones, lower zones
• Back: same zones comparing left and right side always
• Sides: for liver dullness (right) and splenic dullness (left)

Liver and lung boundary:

• Upper border of liver dullness = lower border of right lung
• Percussion from above downward on right side - dullness begins at the 6th rib in mid-clavicular line

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STEP 4: AUSCULTATION (LISTEN with stethoscope)

Technique:

• Use diaphragm of stethoscope for high-pitched sounds (breath sounds, crackles).
• Use bell for low-pitched sounds.
• Patient breathes through open mouth.
• Compare left and right sides symmetrically.

Normal Breath Sounds:

Abnormal Breath Sounds:

Vocal Resonance (Auscultation equivalent of fremitus):

• Ask patient to say "99" while listening with stethoscope.
• Increased = consolidation (sounds louder and clearer)
• Aegophony = voice sounds like a bleating goat - heard at the upper border of pleural effusion
• Whispering pectoriloquy = whispered sounds heard clearly = consolidation

Summary table - Classic Examination Findings:

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PART 2: ABDOMINAL EXAMINATION

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IMPORTANT: Position & Preparation

• Patient lies flat on their back (supine), arms by the sides.
• For inspection: legs extended flat.
• For palpation: hips and knees slightly flexed (relaxes abdominal muscles).
• Expose from nipples to groin (inguinal ligament).
• Examiner stands on the right side of the patient.
• Good lighting is essential.
• Warm your hands before palpating! (cold hands cause muscle guarding)

ALWAYS start with General Examination first:

• Look for: weight loss, dehydration, jaundice, anaemia, pedal oedema
• Hands: signs of liver disease (palmar erythema, Dupuytren's, leukonychia, clubbing)
• Face/eyes: jaundice, anaemia
• Lymph nodes: especially left supraclavicular (Virchow's node = intra-abdominal malignancy)
• Vital signs: pulse, BP, temperature, RR

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STEP 1: INSPECTION (LOOK at the abdomen)

What to look for - remember "6 S's + V + U + P":

• Midline scar = laparotomy
• Right iliac fossa scar = appendicectomy
• Right subcostal (Kocher's) scar = cholecystectomy
• Left iliac fossa scar = sigmoid colectomy

• Normal = flat or slightly rounded
• Distension = the 5 F's (Fat, Fluid/ascites, Flatus, Faeces, Foetus/fetus)
• Scaphoid (sunken) = malnutrition, peritonitis (rigid abdomen)
• Asymmetric = mass/organomegaly on one side

• Jaundice, scratch marks (obstructive jaundice)
• Grey Turner's sign = bruising in the FLANKS = retroperitoneal haemorrhage (severe pancreatitis, ruptured AAA)
• Cullen's sign = bruising around the UMBILICUS = severe pancreatitis, ruptured ectopic pregnancy

• Dilated veins around umbilicus (caput medusae) = portal hypertension
• Blood flowing AWAY from umbilicus = portal obstruction
• Veins on flanks, blood flowing UPWARD = inferior vena cava obstruction

• Normally central.
• Displaced upward = pelvic mass
• Displaced downward = ascites (Tanyol's sign)
• Everted (pointing out) = ascites or large mass
• Inverted = obesity

• Visible peristalsis = intestinal obstruction (in thin patients)
• Visible pulsation = aortic aneurysm

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STEP 2: AUSCULTATION (LISTEN first before touching - unique to abdomen!)

Why auscultate BEFORE palpation?

Bowel sounds:

• Normal = soft gurgling sounds every 5-10 seconds
• Increased (loud, tinkling) = intestinal obstruction (high-pitched, rushing)
• Absent = paralytic ileus, peritonitis (silent abdomen)

Bruits (vascular sounds):

• Aortic bruit (above umbilicus) = aortic aneurysm or stenosis
• Renal bruit (flanks) = renal artery stenosis (cause of secondary hypertension)
• Hepatic bruit = hepatocellular carcinoma, hepatic arteriovenous malformation

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STEP 3: PALPATION (FEEL the abdomen)

Two phases:

• Use flat hand, gentle pressure.
• Watch patient's face for pain.
• Start from the area AWAY from pain (far side first).
• Feel for: guarding (voluntary/involuntary muscle tensing), rigidity, tenderness, superficial masses.

• Firmer pressure.
• Feel for: organs (liver, spleen, kidneys), deep masses.

Key palpation findings:

Liver palpation:

• Start from RIGHT ILIAC FOSSA, move upward.
• Ask patient to breathe in (liver descends during inspiration).
• Normally not palpable (or just palpable at costal margin).
• If enlarged: measure in finger-breadths below costal margin.

Spleen palpation:

• Start from RIGHT ILIAC FOSSA, move toward left upper quadrant.
• Enlarged spleen has a notch on its medial border.
• Normally not palpable (must be 2-3x enlarged to feel it).
• Support left costal margin with left hand, palpate from right with right hand.

Kidneys:

• Bimanual palpation (ballot the kidney between two hands).
• Right kidney occasionally palpable in thin people.
• Enlarged kidney = hydronephrosis, polycystic kidney, tumour.

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STEP 4: PERCUSSION (TAP the abdomen)

What you assess:

• Tympanitic (drum-like) = gas in bowel (normal for most of abdomen)
• Dull = solid organ (liver, spleen) or mass or fluid

• Upper border of liver = where lung resonance changes to liver dullness (normally ~5th rib in mid-clavicular line)
• Lower border = where liver dullness changes back to bowel tympany
• Normal liver span = 10-12 cm in mid-clavicular line

• Percuss in the LEFT upper quadrant near 10th rib (posterior to midaxillary line)
• Dullness here = enlarged spleen

• Percuss from umbilicus toward flank - note where it becomes dull.
• Keep finger at that point and ask patient to roll toward you.
• If dullness SHIFTS (moves) = ascites present (fluid moves with gravity).

• Place one hand flat on one flank.
• Tap the other flank sharply.
• If a ripple/thrill is felt = large amount of ascites.
• (Ask someone to press the midline to block transmission through fat)

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ADDITIONAL ABDOMINAL EXAMINATIONS

Always remember to also examine:

1. Hernial orifices - inguinal (most common), femoral, umbilical
2. Genitalia - scrotal swellings, hydrocele
3. Inguinal lymph nodes
4. Per Rectal (PR) examination - for rectal masses, prostate, blood in stool
5. Gynaecological examination if needed

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QUICK COMPARISON: What's Different About Abdominal Exam

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MEMORY TRICKS 🧠

• Respiratory exam order: "I Prefer Proper Auscultation" = Inspection, Palpation, Percussion, Auscultation
• Abdominal exam order: "I Always Palpate Patients" = Inspection, Auscultation, Palpation, Percussion
• 5 F's of abdominal distension: Fat, Fluid, Flatus, Faeces, Foetus
• Trachea in effusion: Pushed AWAY (fluid pushes); in collapse: pulled TOWARDS (lung collapses and pulls)
• Consolidation: ALL findings INCREASED (fremitus, resonance, breath sounds dull but bronchial)
• Effusion: ALL findings ABSENT/DECREASED (stony dull + absent sounds)
• Grey Turner = flanks bruising; Cullen's = umbilicus bruising (both = severe pancreatitis)
• Shifting dullness tests for ascites
• Murphy's sign = cholecystitis
• McBurney's point = appendicitis

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5-MARK QUESTION CHECKLIST

1. Brief intro - sequence of examination (IPPA)
2. Patient position - sitting / supine
3. Each step with 2-3 key points each (Inspection, Palpation, Percussion, Auscultation)
4. One clinical correlation per step (e.g., "increased fremitus = consolidation")
5. Summary table if possible or additional examinations (PR exam, hernial orifices)

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• Golden Rule banner (IPPA vs IAPP order)
• Step 1 Inspection: chest shapes table + breathing patterns table
• Step 2 Palpation: trachea, chest expansion, vocal fremitus table
• Step 3 Percussion: all 5 percussion notes with causes
• Step 4 Auscultation: normal sounds + added sounds table
• Master comparison table - all 6 conditions (consolidation, effusion, pneumothorax, collapse, COPD) side by side

• IAPP order reminder (auscultate before palpation)
• Step 1 Inspection: scar locations, 5 F's, Grey Turner's vs Cullen's sign
• Step 2 Auscultation: bowel sounds + bruits
• Step 3 Palpation: Murphy's sign, McBurney's point, liver/spleen/kidney technique
• Step 4 Percussion: liver size, splenic dullness, shifting dullness for ascites
• Memory tricks box + 5-mark answer template

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📚 ICMHE MBBS 2nd Year Exam Study Guide

Medical Malpractice

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WHAT IS MEDICAL MALPRACTICE?

• Their professional skills
• Their ability to do their job
• Their relationships with patients

1. Medical Negligence
2. Professional Misconduct

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PART 1: MEDICAL NEGLIGENCE

Simple Definition:

A doctor fails to do their job properly and because of that, the patient gets harmed or dies.

Full Definition (write this in exam):

Failure to exercise or execute reasonable care and skill of an ordinary prudent medical practitioner in the circumstances; a breach of duty to act with care; resulting in bodily injury or death of patient.

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ACTS OF NEGLIGENCE — 2 Types

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THE 4 D's — CRITERIA FOR MEDICAL NEGLIGENCE

All 4 Ds must be present to prove medical negligence.

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EXAMPLES OF NEGLIGENCE BY SPECIALTY

• Inadequate medical records
• Failure to get informed consent
• Wrong diagnosis

• Not referring patient to specialist when needed
• Toxic drug reactions (wrong dose)

• Leaving instruments, swabs, or towels inside the operation site
• Operating on the wrong patient or wrong side of the body

• Unwanted pregnancy after failed tubal ligation
• Performing abortion without proper indication

• Over-tight plaster cast causing nerve damage
• Missing a diagnosis of intracranial hemorrhage

• Neurological damage from spinal/epidural injection
• Incorrect or excessive anesthetic agents

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TYPES OF MEDICAL NEGLIGENCE

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PART 2: DEFENSES AGAINST MEDICAL NEGLIGENCE

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PART 3: IMPORTANT LEGAL DOCTRINES

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1. DOCTRINE OF RES IPSA LOQUITUR

• The error is SO OBVIOUS that the patient does NOT need to prove negligence.
• The doctor must prove their innocence (burden shifts to doctor).
• Applies to both civil AND criminal negligence.

1. Injury would NOT occur without negligence
2. The doctor had CONTROL over the cause
3. The patient did NOT contribute to the injury

• Wrong site surgery
• Leaving instruments inside the operation site
• Loss of hand due to prolonged splinting
• Prescribing overdose causing harm

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2. CALCULATED RISK DOCTRINE

• Injury may occur EVEN THOUGH the doctor took reasonable care.
• Doctor must show statistics that the risk was unavoidable.
• Important defense for doctors.

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3. DOCTRINE OF COMMON KNOWLEDGE

• The negligence is NOT about specialized medical knowledge.
• It is about something any common person would know is wrong.
• Similar to res ipsa loquitur.
• Patient must prove the act of omission or commission — not standard of care.

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4. DOCTRINE OF AVOIDABLE CONSEQUENCE RULE

• The doctor is NOT responsible for additional harm the patient COULD HAVE AVOIDED.
• This applies to patient's unreasonable conduct AFTER the injury.
• Different from contributory negligence (which happens BEFORE or DURING the wrongful act).

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5. NOVUS ACTUS INTERVENIENS

• A NEW act by someone else breaks the link between the original cause and the outcome.
• Can TRANSFER responsibility from the original incident to the new negligent act.
• Courts rarely accept this plea.
• Negligence must be proven.

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PART 4: PREVENTION OF MEDICAL NEGLIGENCE

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PART 5: PROFESSIONAL MISCONDUCT

Simple Definition:

Any conduct which is disgraceful or dishonorable as judged by a professional man of good reputation and competence. Involves abuse of professional position.

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WHEN DOES PROFESSIONAL MISCONDUCT OCCUR?

1. Unethical practices like advertising or endorsement
2. Not maintaining indoor patient records for 3 years OR refusing to give records within 72 hours of request
3. Not displaying NMC registration number on clinic, prescriptions, and certificates
4. Physician in rural area found absent on 2 or more occasions during inspection
5. Teaching faculty found absent on 2 or more occasions (certified by Principal/Medical Superintendent)
6. Providing falsified or misleading information

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SIGNBOARD RULES (Nepal-specific — can be asked!)

• Size: 18 × 14 inches
• Must write: Name, NMC number, qualification, specialty
• Colors: Blue letters on white background
• CANNOT use the International Red Cross symbol
• CANNOT put signboard on a chemist's/pharmacy's shop

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THINGS A PHYSICIAN MUST NOT DO:

• Use agents/touts to get patients
• Insult or misbehave with fellow doctors
• Commit adultery or misbehave with patients
• Be drunk and disorderly
• Be convicted by court of law
• Do sex determination tests
• Issue false, misleading, or inappropriate certificates
• Supply or sell addiction-forming drugs
• Perform illegal abortion or operation
• Disclose professional secrets
• Publish case reports/photographs of patients without consent
• Advertise (directly or indirectly, with or without photo)

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THE 6 A's — IMPORTANT OFFENCES

Association with unqualified persons Advertising Abortion (criminal) Adultery Addiction Alcohol

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WHAT HAPPENS AFTER PROFESSIONAL MISCONDUCT?

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QUICK MEMORY TRICKS 🧠

• Medical Malpractice = 2 types: Negligence + Misconduct
• 4 D's of negligence: Duty, Dereliction, Damage, Direct causation
• 2 acts: Omission (not doing) + Commission (doing wrongly)
• Res Ipsa Loquitur = "Thing speaks for itself" → Doctor proves innocence
• Avoidable Consequence = Patient worsened their own injury after the fact
• Novus Actus = New act breaks the chain → rarely accepted
• 6 A's of misconduct: Association, Advertising, Abortion, Adultery, Addiction, Alcohol
• Nepal statute of limitations: 6 months to file negligence case
• Registration erasure: 2 years; apply for restoration after 2 years; if rejected, wait 12 months
• Medical records: Keep for 3 years; give within 72 hours of request
• Signboard: 18×14 inches, blue on white

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5-MARK ANSWER TEMPLATES

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