exploratory laparotomy appendectomy

3/2/2010 4 Class 1: CLEAN ... Ruptured appendectomy Appendectomy with pus /abscess I&D of perirectal abscess Compound, open fracture Perforated bowel Perforated gastric ulcer. Exploratory laparotomy is done while you are under general anesthesia. • Exploratory laparotomy • Laparoscopy without use of uterine manipulator • Skin (mastectomy, lesions, lipoma, cosmetic) • Neck dissection ... • Appendectomy for inflamed appendicitis • Bile spillage during cholecystectomy • Diverticulitis • Gross spillage or … This medical image is titled 'Exploratory Laparotomy with Lysis of Adhesions' Exhibit number: '09158_01X'. a. 6:30-37, 1998. In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated ex-lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. Laparotomy is done mostly under general anesthesia, except in special circumstances like caesarian section. Cholecystectomy with Cholangiogram. 0000006168 00000 n Small Animal Laparoscopy and Thoracoscopy provides a comprehensive reference to laparoscopy and thoracoscopy, with step-by-step guidance for surgical techniques ranging from basic to advanced. • Acts as both a quick reference to specific ... There are many indications for performing an exploratory laparotomy. %PDF-1.3 %���� Inflammation without symptoms, which is seen in up to 35% of incidentally removed appendixes,26 may also be erroneously diagnosed at laparotomy as appendicitis. Found inside – Page 386Exploratory Laparotomy Laparotomy , Repair of Organs . Ankle . ... Exploratory Incision , Drainage Perineal Region , Incision for Drainage Shoulder . ... I.aparotomy for Drainage Appendectomy , Drainage . Purulent . Laparotomy ... 0000021414 00000 n What can I expect after surgery? Laparoscopic Appendectomy (appendix removal): Discharge instructions This handout explains how to care for yourself when you get home. Transcystic Common Bile Duct Exploration. The patient underwent general anesthesia, and an Exploratory laparotomy revealed a moderate amount of free turbid fluid and a pedunculated MD with a large base, inflamed and perforated in its body, situated on the antimesenteric border at 40 cm proximal to the ileocecal valve . In other cases, a second operation is required. endstream endobj 21 0 obj [ /Indexed 19 0 R 254 40 0 R ] endobj 22 0 obj 433 endobj 23 0 obj << /Filter /FlateDecode /Length 22 0 R >> stream trailer << /Size 51 /Info 4 0 R /Root 7 0 R /Prev 81430 /ID[<301c528ec56b892c18d644bce7e6e67c>] >> startxref 0 %%EOF 7 0 obj << /Type /Catalog /Pages 3 0 R /Metadata 5 0 R /PageLabels 2 0 R >> endobj 49 0 obj << /S 36 /L 143 /Filter /FlateDecode /Length 50 0 R >> stream 44950 Appendectomy 44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as ... 49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) 49002 Reopening of recent laparotomy The pathogenesis and possible significance of this lesion are discussed. A laparotomy is normally used when a laparoscopy cannot be done effectively. By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. During the Open Appendectomy the surgeon uses a #15 to cut free the base of the Appendix. Procedure in Detail: With the patient supine and under endotracheal anesthesia, the entire abdomen and lower chest was prepped with pHisoHex and saline and draped with sterile sheets in the usual manner. Get the Laparoscopic Appendectomy Consent Form you require. Mucocele of the appendix is uncommon and caused by a variety of pathologies. However, routine incidental appendectomy cannot be justified in patients greater than age 50. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. Nursing Problems Nursing Care/Interventions Rationale Expected Outcomes Evaluation 1) Acute pain related to tissue damage secondary to surgical You perform an appendectomy for suspected endometriosis of the appendix. Found inside – Page 165Exploratory laparotomy - appendectomy performed . No gall stones in gall bladder ; stomach explored ( no evidence of ulcers ) ; appendix bound to lateral wall . Spinal anesthesia was used . Immediate postoperative reaction was good . Results. Before the surgery begins, an IV (intravenous) line is put into a vein in your arm or hand. (exploratory laparotomy) and CPT code 44150 (total abdominal colectomy) for the same operation because the surgical field is included in the code for the total abdominal colectomy. View Chapter 2 Coding Practice PCS HIT220.docx from CODING AND HIT at Montgomery County Community College. Following the patient's discharge from the hospital, the patient was readmitted to Lake Hospital by Dr. Morris for a urinary tract infection, whereupon a fluid collection in the patient's upper abdomen was discovered and drained. A laparotomy is a surgical incision (cut) into the abdominal cavity. Exploratory laparoscopy, also termed diagnostic laparoscopy, is a minimally invasive method for the diagnosis of intra-abdominal diseases by direct inspection of intra-abdominal organs. Examples includes: biopsy, exploratory laparotomy (explorelap) Ablative/Curative. Diagnostic laparoscopy was first introduced in 1901, when kelling, performed a peritoneoscopy in a dog and was called “Celioscopy”. It may be performed for a variety of reasons, including infection, pain, obstruction or tumors. D. It is not necessary to worry about complications of immobility on … 0000004455 00000 n A exploratory laparotomy was carried out and 200 ml of bloody ascitic fluid was drained. Pancreatectomy. Intraabdominal scar tissue may contribute to recurrent episodes of bowel obstruction, chronic abdominal pain, or both. According to a multicenter study - carried out by E Barrow et al in UK, peritonitis was also the most common cause for Exploratory laparotomy – Description of the Procedure. Peritonitis (197, 57.6%) was the most common indication for laparotomy in the non-trauma patients. Found inside – Page 398... appendectomy and vesico - fixation Double salpingo - oophorectomy , appendectomy and repair of gut . Double oophorectomy Dilatation of rectal stricture Excision of fistula in ano . Exploratory laparotomy Exploratory laparotomy and ... Please discuss this with your doctor. Surgery: A Case Based Clinical Review provides the reader with a comprehensive understanding of surgical diseases in one easy to use reference that combines multiple teaching formats. The book begins using a case based approach. Progression of mass was observed, vitals recorded 0000001333 00000 n They have done appendectomies and the pathology report has come back with "no pathological diagnosis". Laparotomy is the opening of the abdominal cavity to get at the organ which needs the surgical procedure. Endosalpingiosis within the muscularis propria of the distal vermiform appendix was discovered in an appendectomy specimen removed during exploratory laparotomy for inflammatory tubal disease. Since most mucinous tumors of the ovary are large, most surgeons will perform an exploratory laparotomy with removal of the involved adnexa. It may not display this or other websites correctly. Form A-45075-SS RC(8/04) HOSPITAL CONFINEMENT SICKNESS INDEMNITY LIMITED BENEFIT POLICY SURGICAL BENEFIT AFLAC will pay benefits according to the Schedule of Operations when a covered person has a surgical operation performed for a covered sickness in a hospital or ambulatory surgical center. The organs will be examined for disease. A laparotomy is a surgical procedure through an opening (that is larger than that used for laparoscopy) into the abdomen. It would not be coded in addition to the appendectomy. Welcome to the ClinicalKey Store: The one tool you need to make informed, confident clinical decisions. Laparoscopic Appendectomy with Stapler. If other diagnostic tools such as ultrasound can’t diagnose the problem, your veterinarian may recommend performing an exploratory laparotomy to look for the cause. laparoscopic appendectomy recovery time (keyhole surgery): If you had laparoscopic surgery, you will likely return to a normal routine and back to work within 1 to 3 weeks after the surgery. open appendectomy recovery time (appendix removal): If you had an open surgery, it may take longer to recover – about 2 to 4 weeks after the surgery. This book focuses on the diagnostic impact of CT scans in severe abdominal trauma and in non-traumatic acute abdomen, the two clinical entities that constitute the main reasons for referrals for this imaging technique from the intensive ... He also has a history of coronary artery disease and is post Many studies supported this evidence (12, 13). H��TMo�0��W�(�&ɖ,À ۥ��|kwpl%��X��˿E�i� �@�@���'77ٗ&+Uq�T��H.,���OM& Simple appendectomy was found to be sufficient treatment for such cases [10, 11]. Exploratory laparotomy with a lower midline incision was performed under general anesthesia. Further studies are needed to assess the feasibility of the laparoscopic approach in diagnosis and treatment of such conditions . The exploratory laparotomy is designated as a separate procedure and an integral component of the appendectomy. It would not be coded in addition to the appendectomy. The procedure begins with diagnostics laparoscopy and continues with appendectomy if appropriate. Appendectomy has long been the standard treatment for appendicitis, even though successful use of antibiotic therapy as an alternative was reported more than 60 years ago. The patient was treated with exploratory laparotomy, appendectomy, tube drainage, and prescribing antibiotic treatment. Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. I feel that is wrong. 0000004494 00000 n To relieve symptoms without curing the disease. Diet after Laparotomy. Exploratory laparotomy with a lower midline incision was performed under general anesthesia. Medicaid is refusing to pay for these procedures saying that the above diagnoses do not meet medical necessity. The exploratory laparotomy is designated as a separate procedure and an integral component of the appendectomy. An appendectomy, also termed appendicectomy, is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. INDICATIONS: This is a 73-year-old gentleman who presented to the hospital with a markedly distended abdomen and three-day history of severe abdominal pain, nausea and vomiting. These kind of surgeries are performed to remove a diseased part or organ. This new manual draws together material from these three publications into a single volume which includes new and updated material, as well as material from Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and ... An exploratory laparotomy is surgery to look for causes of pain, infection, disease, or scar tissue inside your abdomen. Answer (1 of 3): Short answer is no. Found inside – Page 130Sometimes, a physician will document that an exploratory laparotomy was performed along with an appendectomy for acute appendicitis. It is not necessary to code the exploratory laparotomy. Usually, some component of exploration occurs ... An exploratory laparotomy may help your healthcare provider diagnose a medical problem. H�b``�f``5e```4Lf�8�� kB1�(?cs De and K. De Krishna, Stump appendicitis, Journal of the Exploratory laparoscopy also allows tissue biopsy, culture acquisition, and a variety of therapeutic interventions. The office manager argues that 789.03 is a payable diagnosis for the laparotomy and therefore since Medicaid won't pay for the appendectomy with that diagnosis we should be using the laparotomy code. Found inside – Page 55Laparotomy . Appendectomy . Laparotomy . Exploratory . Laparotomy . Exploratory Gastrostomy Laparotomy . Exploratory Gastrostomy Laparotomy . Gastrostomy . Laparotomy . Gastroenterostomy Laparotomy . Gastroenterostomy Laparotomy . Such exploratory laparotomy may be avoided by diagnostic laparoscopy. If the problem is something that can be repaired or removed, it will be done at this time. 0000004834 00000 n Methods: We conducted a 3 round international expert Delphi exercise between April and June 2019 using … • Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. First Page) Name: _Lataya Raggi_ … fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis Facility Only : $1,186 Inpatient only, not reimbursed for hospital outpatient or ASC 43333 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis 0000001554 00000 n The observed incidence of non-perforating appendicitis will therefore be influenced by a willingness to perform exploratory laparotomy in cases of suspected appendicitis. In these cases should we be coding appendectomies or exploratory laparotomies? Pt. 0000004855 00000 n Prices start at $295 and printing/shipping costs are additional. 0000055066 00000 n Adrenalectomy. 0000010058 00000 n Form A-45075-SS RC(8/04) HOSPITAL CONFINEMENT SICKNESS INDEMNITY LIMITED BENEFIT POLICY SURGICAL BENEFIT AFLAC will pay benefits according to the Schedule of Operations when a covered person has a surgical operation performed for a covered sickness in a hospital or ambulatory surgical center. Look in the CPT Index for Appendectomy/Appendix Excision for codes choices 44950, 44955, 44960. 0000004785 00000 n Found inside – Page 263Peritoneum , exploratory laparotomy . Peritoneum , postoperative repair . ... Appendicitis , acute : Adhesions broken up .. Appendectomy ( died : 1 abscess , liver ; 1 abscess , lung ; 1 lung embolism ; 5 peritonitis ) . 0000005387 00000 n Found inside – Page 51Peritoneum : Carcinoma , retro - peritoneal , exploratory laparotomy . ... 1 Appendicitis , acute , scarlet fever , appendectomy 1 1 Appendicitis , acute , abscess , appendectomy 1 Appendicitis , acute , gangrenous , appendectomy ... 0000003852 00000 n She alleged that Brecher had failed to recognize that the hospital had mixed up Hill’s CT scan with that of another patient, which resulted in an unnecessary exploratory laparotomy and a needless appendectomy, constituting negligence that was a breach of the standard of care, amounting to medical malpractice. The abdominal contents are checks for An exploratory laparotomy is an open surgery usually performed by a general or trauma surgeon in a hospital under general anesthesia. For 66 years, Surgery has published practical, authoritative information about procedures, clinical advances, and major trends shaping general surgery.Each issue features original scientific contributions and clinical reports. Palliative. We had 9 cases, three males and sex females, … 0000008653 00000 n Operative management can be achieved either via open laparotomy or laparoscopy (B). HTP/EHT/CPR 6.1 LAPAROTOMY Laparotomy is used to expose the abdominal organs so as to institute definitive diagnosis and treatment of abdominal trauma and acute abdominal conditions At the district hospital, nonspecialistpractitioners with specific training can capably perform laparotomyand, on occasion, will perform laparotomyon complex cases In most cases, the recovery time for appendectomy surgery is relatively short. You will be normally allowed to leave the hospital after 1 to two days after the surgery. To get back to work and normal activities, you may need 2 to 4 weeks depending on the conditions. Major abdominal operations result in random and unpredictable scar tissue formation. Sarpy County OB/GYN, P.C. Found inside – Page 161Exploratory laparotomy , appendectomy , plastic reduction . EMIL C. ROBITSHEK , M.D. operations on both ovaries . 13. Exploratory laparotomy . 14 14. Appendectomy , repair of abdominal wound , and ANÆSTHESIA separation of adhesions . Nonetheless, it is a valuable procedure for acute abdominal conditions. 0000004080 00000 n Vinay Chandrasekhara, Mouen Khashab, B. Joseph Elmunzer, and V. Raman Muthusamy, ensures that you stay current with the latest technology and techniques in GI endoscopy. This video demonstrates how to perform an appendectomy for patients with an acute appendicitis. If your healthcare provider finds a problem during exploratory laparotomy, he may fix it. appendicitis diagnosis. Exploratory laparoscopy, also termed diagnostic laparoscopy, is a minimally invasive method for the diagnosis of intra-abdominal diseases by direct inspection of intra-abdominal organs. Exploratory laparoscopy also allows tissue biopsy, culture acquisition, and a variety of therapeutic interventions. Found inside – Page 5851 Fecal fistula following an 3 2 1 Laparotomy and partial appendectomy . dissection of tract 1 Exploratory la parotomy .. 1 Laparotomy and freeing of Adhesions after appendicitis . 4 adhesions . 3 Appendicostomy 1 Dysentery , ambic . 0000003451 00000 n 0000002237 00000 n 6 0 obj << /Linearized 1 /O 8 /H [ 1333 242 ] /L 81676 /E 79784 /N 1 /T 81439 >> endobj xref 6 45 0000000016 00000 n During the exploratory laparotomy, Dr. Laparotomy . Appendectomy (open surgery) for acute appendicitis. Patients should be NPO for 8 hours before surgery. An issue has come up in our office where several of our surgeons have had patients with right lower quadrant pain, an elevated white cell count, guarding, and rebounding. You perform an exploratory laparotomy, TAH-BSO, omentectomy, limited para-aortic lymphadenectomy. Pre-op Nursing responsibilities of exploratory laparotomy appendectomy? Customize the template with exclusive fillable areas. is stable, NPO, and in pain. Exploratory Laparotomy Mastectomy Vascular Bypass Abdominal Aortic Aneurysm Non-penetrating blunt trauma Thyroidectomy. G����N�Zz She says it is virtually the same thing except the physician took out the appendix while he was in there. https://www.winchesterhospital.org/health-library/article?id=100983 Appendix was inflamed. 0000008632 00000 n An exploratory laparotomy is often an emergency procedure for patients with acute abdominal pain from disease or injury to the abdomen. Found inside – Page 32For example , for laparotomy with appendectomy , one would code only the appendectomy because the laparotomy is an integral ... Procedure : Exploratory laparotomy with percutaneous needle liver biopsy 54.11 Exploratory laparotomy 50.11 ... a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. In many cases, the problem – once identified – can be fixed during the laparotomy. Complete the empty fields; involved parties names, places of residence and phone numbers etc. Often times, if you are being asked to sign for informed consent for the exploratory laparotomy there may often be another procedure listed, like 'exploratory laparotomy with possible appendectomy.' involved exploratory laparotomy with adhesiolysis with appendectomy or appendectomy with drainage or right hemicolectomy with iliocolic anastomosis. ?ËRyü(õaëøiklnÉ:øˆøWÌ,S5¯d!G?ϋµ9g)ãc\žeêÊþu-nç֎Ü4üër)Å)MÁåjhúÁa+˜©+û¿Ù™ŽqOLáÔÌäL]ÿ0²ZQYÙ!fËgNŒÍUc4–K¦2i­% ªîLMâkl5¦såŇxsì ð/#~ÅÇ. Found inside – Page 591 Appendectomy , closure Appendicitis , ulcer . of perforation . perforated , duodenal i Appendectomy , ventral Appendicitis , retroverfixation 1 Appendectomy , exploratory laparotomy .. Appendicitis , chronic .. 3 3 . Enterostomy . Purchase the right to use this exhibit in litigation: placement. The most frequently used treatment is exploratory laparotomy to complete the previous appendectomy; however, there are 5 reported cases of stump appendicitis, where surgical resolution was performed through laparoscopic surgery, of 36 cases described in the literature, 4 required hemicolectomy, due to perforation with involvement of the cecum. Outcomes: The patients were discharged with complete recovery. In therapeutic laparotomy, a cause has been identified (e.g. Found inside – Page 603Leg Toes Appendectomy Appendectomy , double oophorectomy . Capulotomy . ... Esophegotomy Exploratory incision .. Exploratory laparotomy Exploratory laparotomy and enterorrhaphy Extraction of lens Excision : Bone .. Cyst .. Fistula . The doctor will make one long incision in the skin on your abdomen. For a better experience, please enable JavaScript in your browser before proceeding. Code 44960 is Appendectomy; for This is done only in medical emergencies or when other diagnostic tests can’t explain symptoms. 0000007846 00000 n 3/2/2010 7 Included here is a discussion of the pathophysiological aspects and risks of laparoscopic staging (such as trocar metastases) on the basis of international experience. In this instance, a major break in sterile technique has occurred and the circulating nurse would need to change the initial wound classification of clean/class I to contaminated/ class III. Found inside – Page 598In these atypical cases , due to its localization , it may be confused with the pain of appendicitis , gall - bladder ... reason for failure lies in the small abdominal incision which means appendectomy , not exploratory laparotomy . Dial discovered a retrocecal appendix and performed an appendectomy. JavaScript is disabled. Pt. A laparotomy is a surgical incision (cut) into the abdominal cavity. • An exploratory laparotomy is a surgery where the surgeon will look inside your abdomen at the organs and other body structures. Exploratory laparotomy is most commonly performed for trauma, [...] severe abdominal pain of unknown cause, intestinal obstruction, inflammatory diseases like appendicitis and diverticulitis, and cancer of any of the abdominal organs. An exploratory laparotomy may help your healthcare provider diagnose a medical problem. 0000013221 00000 n Appendectomy is a common surgery and many people have had their appendix removed. Exploratory Laparotomy with CTT insertion 04 Jake Rodriguez, 16 years old, male, was diagnosed with Multiple Stabbed Wound, Covid-19 probable. A biopsy can be taken during the procedure. While the gold standard approach to these lesions has historically been exploratory laparotomy and right hemicolectomy, there is increasing experience with a minimally invasive approach and the resection limited to an appendectomy. Exploratory laparotomy. Covering both surgical and anesthetic considerations, Anesthesiologist’s Manual of Surgical Procedures, Sixth Edition, is an essential resource for formulation of an anesthetic plan and perioperative management of patients. Exploratory laparotomy with radical pelvic and abdominal tumor debulking for primary ovarian malignancy including right salpingo-oophorectomy retroperitoneal lymphadenectomy, tumor resection from cul-de-sac Gastrectomy, partial for tumor extension Ileal small bowel resection for obstruction Ascending colectomy for tumor mass Appendectomy, … Exploratory laparotomy. The surgery can be done in adults and children, and may be performed emergently (e.g., for a life-threatening acute abdomen or abdominal trauma) or electively (e.g., to evaluate chronic abdominal pain ). If your healthcare provider finds a problem during exploratory laparotomy, he may fix it. An exploratory laparotomy is surgery to look for causes of pain, infection, disease, or scar tissue inside your abdomen. 0000075256 00000 n 0000079676 00000 n Laparoscopic management is comparatively late. Nursing Problems Nursing Care/Interventions Rationale Expected Outcomes Evaluation 1) Acute pain related to tissue damage secondary to surgical In case you have COVID- 19 symptoms, please get the FREE online COVID Medical Evaluation of your condition. ���S�� ��1��(0*(`���������L/8t&00��ȿa���� .��!qB8C�:FF�@� �= O�� endstream endobj 50 0 obj 130 endobj 8 0 obj << /Type /Page /Parent 3 0 R /Resources 9 0 R /Contents [ 23 0 R 25 0 R 27 0 R 29 0 R 31 0 R 33 0 R 35 0 R 37 0 R ] /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 9 0 obj << /ProcSet [ /PDF /Text /ImageC /ImageI ] /Font << /TT2 15 0 R /TT4 13 0 R /TT6 11 0 R /TT8 12 0 R /TT9 18 0 R >> /XObject << /Im1 47 0 R >> /ExtGState << /GS1 48 0 R >> /ColorSpace << /Cs6 19 0 R /Cs8 21 0 R >> >> endobj 10 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 34 /FontBBox [ -558 -307 2000 1026 ] /FontName /GKNPAP+TimesNewRoman,Bold /ItalicAngle 0 /StemV 133 /FontFile2 42 0 R >> endobj 11 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 95 /Widths [ 250 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 ] /Encoding /WinAnsiEncoding /BaseFont /GKNPAP+TimesNewRoman,Bold /FontDescriptor 10 0 R >> endobj 12 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 121 /Widths [ 278 0 0 0 0 0 0 0 333 333 0 0 278 333 278 278 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 667 667 722 0 0 0 0 722 278 0 0 0 833 0 778 667 0 0 667 611 0 0 0 667 0 0 0 0 0 0 0 0 556 556 500 556 556 278 556 556 222 222 500 222 833 556 556 556 556 333 500 278 556 500 722 500 500 ] /Encoding /WinAnsiEncoding /BaseFont /GKNPCB+Arial /FontDescriptor 17 0 R >> endobj 13 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 121 /Widths [ 278 0 0 0 0 0 0 0 0 0 0 0 0 0 278 278 0 0 0 0 0 0 0 0 0 0 333 0 0 0 0 0 0 722 0 722 722 667 0 0 0 278 0 0 611 0 722 778 667 0 722 667 611 0 0 0 0 0 0 0 0 0 0 0 0 556 611 556 611 556 333 611 611 278 0 556 278 889 611 611 611 611 389 556 333 611 556 0 556 556 ] /Encoding /WinAnsiEncoding /BaseFont /GKNPAN+Arial,Bold /FontDescriptor 16 0 R >> endobj 14 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 34 /FontBBox [ -568 -307 2000 1007 ] /FontName /GKNOPM+TimesNewRoman /ItalicAngle 0 /StemV 0 /FontFile2 39 0 R >> endobj 15 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 32 /Widths [ 250 ] /Encoding /WinAnsiEncoding /BaseFont /GKNOPM+TimesNewRoman /FontDescriptor 14 0 R >> endobj 16 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 718 /Descent -211 /Flags 32 /FontBBox [ -628 -376 2000 1010 ] /FontName /GKNPAN+Arial,Bold /ItalicAngle 0 /StemV 144 /XHeight 515 /FontFile2 41 0 R >> endobj 17 0 obj << /Type /FontDescriptor /Ascent 905 /CapHeight 718 /Descent -211 /Flags 32 /FontBBox [ -665 -325 2000 1006 ] /FontName /GKNPCB+Arial /ItalicAngle 0 /StemV 94 /XHeight 515 /FontFile2 45 0 R >> endobj 18 0 obj << /Type /Font /Subtype /Type0 /BaseFont /GKNPCC+SymbolMT /Encoding /Identity-H /DescendantFonts [ 46 0 R ] /ToUnicode 20 0 R >> endobj 19 0 obj [ /ICCBased 38 0 R ] endobj 20 0 obj << /Filter /FlateDecode /Length 217 >> stream

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