SULAIMI SADIRAN

8/9/2019 SULAIMI SADIRAN

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CASE PRESENTATION

µPULMONARY

HYPERTENSION ¶

MATRIX NO. : 0154

GROUP : 3 (2/2009)



LEARNING OBJECTIVES

1. State the Meaning or Definition of Pulmonary Hypertension.

2. State the Etiology of Pulmonary Hypertension.

3. Explain the Pathophysiology of Pulmonary Hypertension.

4. State the Clinical Manifestation of Pulmonary Hypertension.5. List down the Complication of Pulmonary Hypertension.

6. Explain the Management for patient with Pulmonary Hypertension.

7. Carry out the care for patient with Pulmonary Hypertension usingnursing process.

8. Appreciate the Health Education given for the patient in home care planning.



NURSING ASSESSMENT



NURSING ASSESSMENT

Name : Mr S

Sex : Male

MRN Number : 287828

Age : 41 years old

IC No. :681028-01-5703

Address :Tiang 6, belakang taman suraya, jalan kukup, 8200 Pontian Johor

Tel. No. : 013-7557575

Marital Status : Married with 4 children

Occupation : Factory worker(lorry driver)

Race : Malay

Religion : Islam

Language spoken : Malay, English Ward : 6th floor(premier)

Room No. : 621B

Consultant : Dr. Y

Date and Time of admission : 10th May 2010 @ 1915 hours



NURSING ASSESSMENT

Reason of admission : c/o cough with blood x2/52

Medical history : Nil

Surgical history : Nil

Family history : Nil

Current Medication : Nil

Allergics : Nil Diagnosis : Pulmonary Hypertension

Date of discharge : 12 May 2010 @ 1030 hours

Date of follow up :

26 May 2010 @ 1130 hours at Dr. Y clinic



NURSING ASSESSMENT

During the admission time in the ward, his vital sign has been taken

and the result is as follow :

Temperature : 35.70 C

Pulse : 82 beats/min

Respiration : 18 breaths/min

Blood Pressure : 146 / 101 mmHg

Weight : 79 kg

Height : 166 cm



PHYSICAL EXAMINATION




Inspection Of The Head :

Hair : Mr S hair is curly; black in color. Its structure is fine and soft. Eyes : Mr S eyes is quite normal. His eyes is free from pale or jaundice

(yellow)

Ears : Mr S hearing is normal. He can hear without any complication andhe can hear clearly.

Mouth : Mr S mouth is moisture, there is no oral mucosa presence, nolesions at tongue. Gums and teeth are normal.

Neck : Mr S neck is normal, there is no swelling or surgical scars.

Face : Mr S face is round in shape, there is no presence of edema or scarsat his face.

Inspection Of The Body :

Chest : Mr S chest is normal, he can breath well without anycomplication. There is no edema or swelling.

Axilla: Mr S axilla is normal. There is no presence of lymph nodes, noinfection of fungal.

Abdomen : Mr S abdomen is normal, there is no surgical scars,tenderness or mass.




Inspection Of The Upper Limbs : Nails : Mr S nails are clean, no clubbing spoon shape. I pintch at his

nails to check his blood circulation and its normal.

Fingers : Mr S fingers is normal and adequate. Movement of the fingersalso normal.

Skin : Mr S has a good condition of skin, no rashes or sign of dehydration. No presence of lesion or scars.

Inspection Of Groin And Genitalia :

Actually for this part of examination, Mr S is refused, he don¶t want toexpose it. But he told me that he always take good care of his groin andgenitalia. He saids that there is no infection of fungal, no discharge or swelling.

Inspection Of The Lower Limbs :

All is normal, in correct allignment, good movement and bloodcirculation and there is no varicose vein.

Inspection Of Spine :

Mr S spine is normal, no tenderness, mass, backache or pressure sore.

There is no hordosis ( an abnormal forward curve of the lumbar spine ).



ACTIVITY OF DAILY LIVING




Breathing :Mr S can breath normally without any complication. His depthrespiration is normal. His rhythm of respiration is regular andnormal and the character of his breathing is normal and no moresound is out from her breathing.

Cough :

When Mr S is admitted he is having a coughing with blood.

Smoke :

Mr S is a smoker.

Eating / Drinking :

When Mr S is admitted at the hospital, I see that he is not havingany problems to eat but he verbalized that he cannot eat the diet atthe hospital, he loss appetite. At home, he eat all foods witout anygood diet, he likes to eat curry, all the kind of foods. Aboutdrinking, he drink a lot of water daily.




Bowel elimination :

Mr S past motion daily everyday.

Bladder elimination :

Mr S past urine every 3 ± 4 hours per day. And he don¶t have any problems to passing his urine and he don¶t get up at night to pasturine.

Sleeping :

Mr S said to me, he hasn¶t any problem in sleeping.

Mobility :

Mr S is independent. He able to move without any assisstant.

Personal Hygiene :

Mr S personel hygiene is maintain. He said to me that he alwayshave his shower twice a day.




Safe Environment :

Mr S safe environment is safety, he just need a siderails to prevent hisfrom accident and drop to the floor .

Communication :

Mr S can speak in English and Malay language clearly and he can

understand properly.

Spiritual :

Hospital is allowed his to bring any prayers for his safety frommosque or surau.

Hobby :Mr S likes to reading when he in free time. He likes to read newspaper and books.



ANATOMY AND PHYSIOLOGY



ANATOMY AND PHYSIOLOGYHeart

The heart is roughly cone-shape hollow muscular porgan. It is about10cm long and is about the size of owners fist. It weight about 225g inwomen is heavier in men about 310g.

Position Of The Heart

The heart lies in the thoracic cavity in the media sternum between thelungs. It lies obliquely, a little more to the left than the right, and presentsa base above, and an apex below. The apex is about 9 cm to the left of the midline at the level of the 5th intercoastals spaces, a little below thenipple and slightly nearer the midline. The base extends to the level of the 2nd rib.

Structure Of The Heart

A double-layered membrane called the pericardium surrounds like a sac.The outer layer of the pericardium surrounds the roots of the heartsmajor blood vessels and is attached by ligaments to spinal column,diaphragm and other part of body. The inner layer of the percardium isattached to the heart muscle.




The heart has 4 chambers. The upper chambers are called the left andright atria, and the lowers chambers are called the left and rightventricles. A wall of muscle called the septum separates the left and theright atria and the left and the right ventricles. The left ventricles is thelargest and the strongest chamber in the heart. The left ventricles

chambers walls are only about a half-inch thick, but they have enoughforce to push blood through the aortic valve and into the body.

Function Of The Heart

The role of the heart is to deliver the oxygen in order to live andfunction. The role of heart is to deliver the oxygen-rich blood to everycell in the blood. The arteries are the passageways through which the blood is delivered. The largest artery is the aorta, which branches of the

heart and then divides into many smaller arteries. The veins carrydeoxygenated blood back to the lung to pick up more oxygen, and then back to the heart once again. Blood flows continuously through thecirculatory system, and the heart muscle is the pump which it all possible.







L O O L O O D T H O G H T H H A T

UNOXYGENATED BLOOD

S I

P

P

L

OXYGENATED BLOOD

P

L

L

L

A

A

* D







Blood Vessels

Arteries And Arterioles

Transport blood away from the heart. Consist more elastic tissue andless smooth muscle. It also has thicker walls and enables them towithstand the blood pressure.

Veins And Venules :

Return blood at lower pressure to the heart. The walls are thinner because less muscle and elastic tissue.

Structure Of Blood Vessels Walls

The blood vessels walls consist of three layers :

Tunica Intema

Inner most layer.

EndotheliumI ± Simple squamous

Some larger vessels have subendothelium

I ± Loose connective tissue.

II ± Basement membrane.




Tunica Media

Middle layer. Circulatory arranged smooth muscle.

Chemical and nervous control of degree of contraction.

I ± Sympathetic nervous system.

Change in diameter

I ± Vasoconstiction

II ± Vasodilation

Tunica Adventitia

Made of collagen fibers

Function : protection, reinforcement, anchor to surrounding tissue.

Accessory tissue : nerve fibers, lymphatic vessels, elastic network, tiny blood vessels within layer ± vasa vasorum.

Arterial Systems

Classification based on size and function.Elastic ( conducting ) arteries

Characteristics :

I ± Thick ± walled

II ± Near heart

III ± Largest diameter

IV ± More elastic




V ± Large lumen

Properties :

I ± Dampen BP changes associated with heart contraction.

II ± Passive accomodation results in smooth flow of blood.

Size : 2.5 cm

Muscular arteries ± distributing arteries

Distal to elastic arteries.

Deliver blood to specific organs.

Thick media layer.

I ± More smooth muscle.

Size : 0.3 ± 1.0 cm

Arterioles

Determine flow into capillary beds. Mostly smooth muscle.

Size : 10 um ± 0.3 cm.




Capillaries

Smooth blood vessels.

I ± 8 ± 10 um

Tunica intema only.

Exchange of materials.

Control Of Blood Vessels Diameter.

Vasometer centre in the medulla oblongata supplies nerves to the smoothmuscle fibres, of all blood vessels except capillaries.

These nerves can change the diameter of the lumen of the blood vessels andcontrol the volume of blood they contain.

Small arteries and arterioles respond to nerve stimulation whereas thediameter of large arteries varies according to the amount of blood theycontain due to the quantity of muscle tissues.




Vasodilation and vasoconstriction.

Decreased muscle stimulation ± smooth muscle relax, vessel wallthinned, lumen enlarged ± VASODILATION ± increased blood flow.

Increased nerve stimulation ± increased thickness and contraction ± VASOCONSTRICTION ± decreased blood flow.

Peripheral resistance :

Provided by arterioles to maintain homeostasis of blood pressure. Determined by 3 factors : diameter, length and viscosity of fluid

involved.

Auto regulation.

Accumulation of metabolities in local tissues can influence the degree of dilation of arterioles to ensure adequate blood supply to meet tissueneed.

Example : lactic acid accumulates in muscles after exercise causesvasodilation.



DEFINITION OF PULMONARY HYPERTENSION

The right ventricle pumps blood returning from the body into the

pulmonary arteries to the lungs to receive oxygen. The pressures in the

lung arteries (pulmonary arteries) are normally significantly lower than the

pressures in the systemic circulation. When pressure in the pulmonary

circulation becomes abnormally elevated, it is referred to as pulmonaryhypertension.

(http://www.medicinenet.com/pulmonary_hypertension/article.htm#tocc)



Pulmonary hypertension is defined as the mean pulmonary artery blood

pressure greater than 25 millimeter of mercury (mmHg) measured by right

heart catheterization. The pressures can be much higher than 25 mmHg in

some people. Therefore, the pulmonary hypertension can be labeled as

mild, moderate, or severe based on the pressures.

Mean arterial pressure is two-thirds of the difference between systolic and

diastolic blood pressure (systolic is the upper number and diastolic is the

lower number in measuring blood pressure).



Pulmonary hypertension generally results from constriction, or stiffening,

of the pulmonary arteries that supply blood to the lungs. Consequently, it

becomes more difficult for the heart to pump blood forward through the

lungs. This stress on the heart leads to enlargement of the right heart and

eventually fluid can build up in the liver and other tissues, such as the in

the legs.

In the conventional classification, pulmonary hypertension, is divided

into two main categories:

1) primary pulmonary hypertension (not caused by any other disease or

condition)

2) secondary pulmonary hypertension (caused by another underlying

condition)



Primary pulmonary hypertension has no identifiable underlying cause.

Primary pulmonary hypertension is also referred to as idiopathic

pulmonary hypertension.

Primary pulmonary hypertension is an unusually aggressive and often

fatal form of pulmonary hypertension that commonly affects young people. Whereas it is known that the arterial obstruction is caused by a

building up of the smooth muscle cells that line the arteries, the

underlying cause of the disease has long been a mystery.



ETIOLOGY ± FOR ESSENTIAL PULMONARY

HYPERTENSION

1. HEREDITY

2. SMOKING

3. OBESITY

4. DIABETES

5. DIET

6. STRESS

7. RACE

8. MINERAL INTAKE

9. INSULIN RESISTANCE

10. *UNKNOWN



ETIOLOGY ± FOR SECONDARY HYPERTENSION

1.RENAL DISEASE(renal vascular and parenchymal disease).

Example : glomerulonephritis, pyelonephritis, renal tumors.

2. ENDOCRINE DISORDER

Example : primary aldosteronism, crushing¶s syndrome.

3. COARCTATION OF THE AORTA

4. NEUROGENIC

Example : Brain tumors, Encephalitis.

5. PREGNANCY

6. INCREASE INTRAVASCULAR VOLUME

7. BURNS



PATHOPHYSIOLOGY



CLINICAL MANIFESTATION

1. Morning occipital headache

2. Weak/fatigue

3. Dizziness

4. Nausea and vomiting

5. Palpitation

6. Flushing

7. Hemoptysis(coughing up blood)

8. Shortness of breath



COMPLICATION

1. Hypertensive heart disease

2. Heart attacks

3. Congestive heart failure

4. Blood vessels damage (arterosclerosis)

5. Aortic dissection6. Kidney failure

7. Stroke

8. Brain damage

9. Loss of vision

There is no complications that occurs to Mr S.



MANAGEMENT OF PATIENT WITH

HYPERTENSION



INVESTIGATION

The investigation that done to

Mr S are :

1. Urine FEME

2. Blood Test

3. Chest X-ray

4. CT Scan Angiogram

5. Electrocardiogram(ECG)

6. Echocardiography



INVESTIGATION

PATHOLOGY REPORT

Date :10 May 2010 @1932 hours

examination result unit Reference range

Urine FEME (urinalysis)

Appearance,urine Yellow clear Yellow /pale yellow

Specific gravity,urine 1.005 1.005-1.025

pH,urine 7.0 4.8-7.5

Protein,urine Negative Negative

Glucose,urine Negative Negative

Ketone,urine Negative Negative

Bilirubin screen,urine Negative Negative

Urobilinogen,urine Normal Normal

Nitrite,urine Negative Negative

Leukocytes esterase,urine Negative Negative

Blood,urine Negative Negative



INVESTIGATION

PATHOLOGY REPORT

examination Result unit Reference

range

Microscopic

examination,urine

WBC,urine 3/hpf 0-5

RBC,urine 0/hpf 0-3

Epithelial cell,urine Nil

Cast,urine Nil

Crystal,urine Nil

Bacteria,urine Nil

yeast, cell,urine Nil

Others,urine Nil



INVESTIGATION

PATHOLOGY REPORT

Date :10 May 2010 @ 1802 hours

Full executive screening male(GP61J)

examination Result unit Reference range

H aematology

Haemaglobin 16.3 g/dL 13.0-18.0

Red cell count 5.6 10 12/L 4.5-5.9

Haematocrit (PCV) 48% 41-53

MCV 86 fl 80-96

MCH 29 pg 26-34

MCHC 34 g/dL 31-36

Platelet count 260 10 3/UL 150-450

ESR 5 mm/hr 0-15

White blood cell count 9.9 10 3/UL 4.3-10.5



INVESTIGATION

PATHOLOGY REPORT

examination Result

unit

Reference range

White blood cell differential count

Neutrophil 51.2% 40-75

Lymphocyte 41.0% 20-45

Eosinophil 2.0% 0-6

Monocyte 5.5% 1-11

Basophil 0.3% 0-2



INVESTIGATION

PATHOLOGY REPORT

Peripheral blood film comment:

Red cells show normochomic and normocytic picture.

White cell appear normal.

Platelet are adequate.

~coagulation test~

INR 1.18 0.85-1.35

T he INR (International normalised ratio) is a good indicator of t he

affectiveness and risk of bleeding during warfarin t herapy and is kept

about 2.5,wit h a target range of 2.0-3.0 for most clinical conditions.

~biochemistery~

Diabetes mellitus screen

**glucose 6.7 mmol/L

3.9-6.1



INVESTIGATION

Renal function & bone metabolism screen


**uric acid 499 u mol/L 202-434

Creatinine 70 u mol/L 51-133

Urea 4.4 mmol/L 2.0-6.8

Sodium 139 mmol/L 135-155

Potassium 4.5 mmol/L 3.5-5.5

Chloride 102 mmol/L 95-111

Calcium 2.31 mmol/L 2.20-2.55Phosphate 1.23 mmol/L 0.78-1.50



INVESTIGATION


Lipid profile

**total cholesterol 5.7 mmo/L <5.2

**tryglycerides 2.30 mmo/L <2.28

**HDL cholesterol 1.15 mmo/L >1.42

**LDL cholesterol 3.5 mmo/L <2.6**chol/HDL cholesterol 4.8 mmo/L Up to 4.0

Risk classification of lipid profile of Laboratory Standardization Panel of National

C holesterol Education Program (adult treatment panel III) in United states:

-----------------------------------------------------------------------------------------------------------------------------------------

Risk classificationc holesterol T ryglycerides HDL-c hol

LDL-c hol

Desirable <5.2 <1.71 >1.42

<2.6

Borderline 5.2-6.2 1.71-2.28 1.03-1.42 -



INVESTIGATION

Examination Result unit Reference range

Liver function screen

Total protein 73 g/L 63-83

Albumin 43 g/L 35-50

Globulin 30 g/L 25-40

A/G ratio 1.4 1.0-2.0Total bilirubin 5.3 u mol/L 2.0-28.0

Direct bilirubin 1.6 u mol/L <6.8

Indirect bilirubin 3.7 u mol/L <20.5

SGOT/AST 18 U/L 7-44

SGPT/ALT 18 U/L 7-48

CKMB 19 U/L <25

Lactate dehydrogenase, LDH 403 U/L 211-423

Alkaline phosphate 65 U/L 45-122

**Gamma ±GT 52 U/L 11-50



INVESTIGATION

PATHOLOGY REPORT

Examination result unit reference

range

-serology-

--blood group--

ABO group O

Rheusus group (D) positive

--T hyroid function screen--

Free T4 17.9 p mol/L 9.1-24.4

TSH 1.38 m IU/L 0.30-4.50

--r heumatoid factor screen--

Rheumatoid factor 4.7 10 /mL

<15



INVESTIGATION

PATHOLOGY REPORT

Examination result unit reference

range

--veneral disease screen--

VDRL(RPR) non reactive non reactive

-- AI DS screen--

HIV I/II antigen/antibodies non reactive non

reactive

H .pylory antibody (qualitiative) negative

negative

--hepatitis screen--

*Hep A virus (HAV)IgG non reactive

Interpretation : positive to H ep A virus antibody.

May indicate absence of immunity against H ep A virus. Advice vaccination.



PATHOLOGY REPORT

Examination result unit

reference range

--H ep B screen--

HBs antigen non reactive non reactiveHBs antibody <2.0 mIU/ML

H bsAb interpretation: non reactive ,no protective level of anti H bs

Recommendation :vaccination/booster if H bsAg is non reactive

--cancer marker screen--

Alpha-fetoprotein 1.9 ng/mL<15.0

Prostate specific antigen(PSA) 0.19 ng/mL <4.0

As an acid in t he detection of prostate cancer w hen used in conjection wit h

digital rectum exam( DRE) in men 50 years old or older.

Prostatic biopsy in required for diagnosis of cancer.



INVESTIGATION

RADIOLOGIST REPORT

Service:

Doppler USG lower limbs:

Both femoral, popliteleal and posterior tibial veins and arteries have

normal wavepattern.

These veins are compressible.

Augmentation test was positive for both veins.

No trombus within.

IMP: The deep veins of both lower limbs are patent.



INVESTIGATION

Service:

CT Thorax:

Post contrast contigous 10mm axial images from the apixes of the thorax to the adrenal.

There are scattered ground glass changes in both lungs, predominantly in lateral segment of

the middle lobe,superobasal and medialbasal segments of both lower lobes and

apicoposterior segment of the left upper lobe.

There are no areas of decrease vascularity or eligmia in both lungs fields.

The bronchial walls are not thickened.

No fluid within bonchi.

There are no mediastinal or hilar masses.

There are no pleural abnormalities.

The thoracic aorta and pulmonary vasculature are intact.

There are no intra luminal filling defects to suggest foci of emboli in the main pulmonary

artery and branches.

No aortic dissection or aneurysmal dilatation seen.

The heart size is normal.

The adrenals are not enlarged.

RADIOLOGIST REPORT





MEDICATION

NAME DOSAGE FREQUENCY ROUTE PACKING DATE ON

VERAPAMIL 40 mg BD Oral Tablet 11/5/2010

INDEX 30 mg DAILY Oral Tablet 11/5/2010

PARACETAMOL 50 mg DAILY Oral Tablet 12/5/2010



NURSING CARE PLAN

1. Knowledge deficit related to home care management of

hypertension.



PSH

NURSING CARE PLAN 1

DIAGNOSIS : PULMONARY HYPERTENSION

Name : Mr S

MRN No. : 287828

Age : 41 years

Sex : Male

Dr. Y

S/N Nursing Diagnosis Goal Nursing Action Initiated

By Sign

Evaluation Sign

1. Date /

Time

Data Date/ Time /

Data

10May

2010

@

1910

hours

Knowledge deficitrelated to home care

management of

pulmonary

hypertension.

This is evidenced in

:

yPatient verbalized

that he does notunderstand well

regarding to

pilmonary

hypertension.

Patient willverbalize that he

will better

understanding

about management

of disease after

explanation given

within 2 hours

duringhospitalization.

1. Assess patientunderstanding

about his disease.

® As a baseline

data to plan

nursing

intervention.

(I) During

assessment, Iidentify my

patient knowledge

about management

of diet, exercise,

etc is not clear. STN

SULAIMI

10 May 2010@ 2110

hours.

1. Patient

verbalized

that he

understands

how to

manage hisdisease.

2. Patient

verbalized

that he will

follow the

advice.

STN

SULAIMI



2. Re-explain to

the patient by

using layman

what the doctor

said.

® To ensure thathe understand

about his

condition.

(I)I used µBahasa

Malaysia¶ when

communicate with

my patient.

3. Encourage patient to ask

question about

management of

disease.

® To ensure

patient understand

and clear

explanation given.(I) My patient

asks about diet

and hour to

control tension.

STN

SULAIMI

STN

SULAIMI



4. Advice patient

to take low salt

diet, diabetic diet,

soft diet, take

more vegetables

and fruits.

® Salty food may

increase patient

Blood Pressure

and fat food

increase body

weight.

(I)I advice my

patient to not

taking high

cholesterol.

5. Teach patient to

do an exercise

once a week.

® For better

healthy living.(I)I ask patient to

go for jogging

once a week.

STN

SULAIMI

STN

SULAIMI



6. Ensure patient

to complete his

medications at

home.

® Because at

home there wasno nurse to

remind him to

take his

medications

everyday.

(I)I advice patient

to take his

medications athome & do not

stop without

doctor advice.

7. Advice patient

to come for follow

up as ordered by

doctor.

® To monitor his progress and

condition.

(I)I encourage

patient top come

for his next follow

up because it is

important to see

his progress.

STN

SULAIMI

STN

SULAIMI



8. Ask patient to

change his

lifestyle to reduce

his stress.

® Tension

increase the blood

pressure which

can cause

hypertension.

(I)I advice patient

to take for relax.

9. Explain to the

patient about the

early clinical

manifestation and

the complication.

® To detect any

abnormalities

earlier.

(I)I encourage

patient to see

doctor if hecomplain having

numbers of the

extremities /

severe headache

and giddiness.

STN

SULAIMI

STN

SULAIMI



HEALTH EDUCATION

LIFESTYLE-Encourage patient to do tolerated exercise

such as jogging.I also advice my patient to stop smoking.

MEDICATION-I advice to my patient to take the

medications following right time and dosage.

FOLLOW UP-I advice my patient to come foe follow up

after discharge with doc Y.

DIET-Encourage patient to take well balanced diet and

avoid taking oily foods.



DISCHARGE

During discharge time, his condition of vital sign is stable with :

Temperature :36.80CPulse :70 bpm

Respiration :20 bpm

Blood Pressure :140 / 90 mmHg



FOLLOW UP

During the first follow up, his condition of vital sign is more stable

with :

Temperature :36.5

0

CPulse :80 bpm

Respiration : 21 bpm

Blood Pressure : 130 / 90 mmHg



SUMMARY

During the admission time in the ward, his vital sign has been takenand the result is as follow :

Temperature : 35.70 C

Pulse : 82 beats/min

Respiration : 18 breaths/min

Blood Pressure : 146/ 101 mmHg

Weight : 79 kg

Height : 166 cm

Mr S next appoinment on 23 June 2010 at clinic doctor Y.



REFERENCES





www.yahoo.com/hypertension

http://www.americanheart.org/-- American College of Cardiology

(800-253-4636)

http://www.ash-us.org/ -- American Society of Hypertension

www.nhlbi.nih.gov/hbp -- National Heart, Lung, and Blood Institute http://www.heartinfo.org/ -- Information on the heart

http://www.heartriskevaluations.com/ -- A useful heart risk evaluation

test

http://www.ishib.org/ -- International Society on Hypertension in

Blacks

REFERENCES



THE END,

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