50860516 cerebral-infarction-case

Homework Help

https://www.homeworkping.com/

Math homework help


Research Paper help


Algebra Help


Calculus Help


Accounting help


Paper Help


Writing Help


Online Tutor


Online Tutoring

https://www.homeworkping.com/ 1


http://www.homeworkping.com/



















GENERAL INFORMATION

I. BIOGRAPHIC DATA

Case no: 89292Name: Mrs. MSLMAddress: B1 L59 D Ph 2, Meywood Subd. Meyc. BulacanSex: Female Age: 67 years oldBirthday: January 26, 1943Birthplace: Lingayen Pangasinan Marital Status: MarriedReligion: ChristianNationality: FilipinoHusband: PIMChildren: RM

II. PRESENTING PROBLEM

Chief Complaint: Date Admitted: January 17, 2011 Time: 8:10 pmAttending Physician: Dra. CDRCollaborative Management: Dra. SMRDepartment: Medical-San JoseAdmitting Diagnosis: T/C CVA HCVDAdmitting Vital Signs: BP: 150/80 mmHg RR: 20 cpm

CR: 78 bpm T: 36˚CDate Handled: January 17 & 19, 2011Date Discharge: January 22, 2011 Time: 6:40 pmFinal Diagnosis: Cerebral Infarction, Left frontoparietal, DM type 2

DM type 2 Hyperrcholesterolemis, HPN stage 2 DM Nephropathy

III. HISTORY OF PRESENT ILLNESSThree days prior to admission, relative of Mrs. MSLM noticed that she had

difficulty finishing a sentence.

IV. PAST HEALTH HISTORY

Childhood Illness: Childhood Immunization: Allergies:

2

Accidents and Injuries: Hospitalization for Illness:

V. FAMILY HISTORY OF ILLNESS

Disease Paternal Maternal

1. Hypertension2. Diabetes mellitus3. Cancer4. Heart Disease5. Obesity6. Hepatitis7. Kidney Disease8. Chronic Lung

Disease9. Other Disease

VI. LIFESTYLE

Diet: Personal Habit: Rest and Sleep pattern: Recreation and Activities:

VII. SOCIAL DATA

Family Relationship: Educational Attainment: Primary:

Secondary: Tertiary:

Occupational History:Economic Status: Patterns of Health Care:

3

Related Literatures

Definition

A stroke is an interruption of the blood supply to any part of the brain. A stroke is sometimes called a "brain attack."

Alternative Names

Cerebrovascular disease; CVA; Cerebral infarction; Cerebral hemorrhage; Ischemic stroke; Stroke - ischemic; Cerebrovascular accident; Stroke - hemorrhagic

Causes, Incidence, And Risk Factors

A stroke happens when blood flow to a part of the brain is interrupted because a blood vessel in the brain is blocked or bursts open.

If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage.

There are two major types of stroke: ischemic stroke and hemorrhagic stroke.

ISCHEMIC STROKE

Ischemic stroke occurs when a blood vessel that supplies blood to the brain is blocked by a blood clot. This may happen in two ways:

A clot may form in an artery that is already very narrow. This is called a thrombus. If it completely blocks the artery, it is called a thrombotic stroke.

A clot may break off from another place in the blood vessels of the brain, or some other part of the body, and travel up to the brain to block a smaller artery. This is called an embolism. It causes an embolic stroke.

Ischemic strokes may result from clogged arteries, a condition called atherosclerosis. This may affect the arteries within the brain or the arteries in the neck that carry blood to the brain. Fat, cholesterol, and other substances collect on the wall of the arteries, forming a sticky substance called plaque. Over time, the plaque builds up. This often makes it hard for blood to flow properly, which can cause the blood to clot.

Ischemic strokes may also be caused by blood clots that form in the heart or other parts of the body. These clots travel through the blood and can get stuck in the small arteries of the brain. This is known as a cerebral embolism.

4

Certain drugs and medical conditions can make your blood more likely to clot and raise your risk for ischemic stroke. A common cause of ischemic stroke in people under age 40 is carotid dissection, or a tear in the lining of the carotid artery. The tear lets blood flow between the layers of the carotid artery. This causes narrowing of the carotid artery that is not due to plaque buildup.

Some ischemic strokes start out without any bleeding, and then bleeding into the damaged area occurs.

HEMORRHAGIC STROKE

Hemorrhagic stroke occurs when a blood vessel in part of the brain becomes weak and bursts open, causing blood to leak into the brain. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood that occurs after the blood vessel ruptures damages brain cells.

STROKE RISKS

High blood pressure is the number one risk factor for strokes. The following also increase your risk for stroke:

Atrial fibrillation Diabetes Family history of stroke Heart disease High cholesterol Increasing age

Certain medications make blood clots more likely, and therefore increase your chances for a stroke. Birth control pills can increase the chances of having blood clots, especially in woman who smoke and who are older than 35.

Men have more strokes than women. However, women have a higher risk of stroke during pregnancy and in the weeks immediately after pregnancy.

The following can increase the risk of bleeding into the brain, which makes you more likely to have a stroke:

Alcohol use Bleeding disorders Cocaine use Head injury

5

Symptoms

The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke.

Symptoms usually develop suddenly and without warning, or they may occur on and off for the first day or two. Symptoms are usually most severe when the stroke first happens, but they may slowly get worse.

A headache may occur, especially if the stroke is caused by bleeding in the brain. The headache:

Starts suddenly and may be severe Occurs when lying flat Wakes you up from sleep Gets worse when you change positions or when you bend, strain, or cough

Other symptoms depend on the severity of the stroke and what part of the brain is affected. Symptoms may include:

Change in alertness (including sleepiness, unconsciousness, and coma) Changes in hearing Changes in taste Clumsiness Confusion or loss of memory Difficulty swallowing Difficulty writing or reading Dizziness or abnormal sensation of movement (vertigo) Lack of control over the bladder or bowels Loss of balance Loss of coordination Muscle weakness in the face, arm, or leg (usually just on one side) Numbness or tingling on one side of the body Personality, mood, or emotional changes Problems with eyesight, including decreased vision, double vision, or total loss of vision Sensation changes that affect touch and the ability to feel pain, pressure, different

temperatures, or other stimuli Trouble speaking or understanding others who are speaking Trouble walking

Signs And Tests

A complete physical and neurological exam should be performed. Your doctor will:

6

Check for problems with vision, movement, sensation, reflexes, understanding, and speaking. Your doctor and nurses will repeat this exam over time to see if your stroke is getting worse or is improving.

Listen for an abnormal sound, called a "bruit," when using a stethoscope to listen to the carotid arteries in the neck. A bruit is caused by turbulent blood flow.

Check and assess your blood pressure, which may be high.

Tests can help your doctor determine the type, location, and cause of the stroke and rule out other disorders that may be responsible for the symptoms.

A CT scan of the brain is often done soon after symptoms of a stroke begin. An MRI scan of the brain may be done instead or afterwards.

Magnetic resonance angiography (MRA) or CT angiography may be done to check for abnormal blood vessels in the brain that may have caused the stroke.

Echocardiogram may be done if the stroke could have been caused by a blood clot from the heart.

Carotid duplex (a type of ultrasound exam) can show if narrowing of the neck arteries (carotid stenosis) led to the stroke.

An angiogram of the head can reveal which blood vessel is blocked or bleeding, and help your doctor decide if the artery can be reopened using a thin tube.

Laboratory tests will include a complete blood count (CBC), bleeding time, and blood clotting tests (prothrombin time or partial thromboplastin time). They will also check your blood cholesterol and sugar.

Electrocardiogram (ECG) and heart rhythm monitoring can help determine if an irregular heartbeat (such as atrial fibrillation) caused the stroke.

A spinal tap (cerebrospinal fluid exam) may also be done.

Treatment

A stroke is a medical emergency. Immediate treatment can save lives and reduce disability. Call 911 or your local emergency number or seek immediate medical care at the first signs of a stroke.

It is very important for people who are having stroke symptoms to get to a hospital as quickly as possible. If the stroke is caused by a blood clot, a clot-busting drug may be given to dissolve the clot.

Most of the time, patients must reach a hospital within 3 hours after symptoms begin. Some people may be able to receive these drugs for up to 4 - 5 hours after symptoms begin.

Treatment depends on the severity and cause of the stroke. A hospital stay is required for most strokes.

TREATMENT IN THE HOSPITAL

7

Clot-busting drugs (thrombolytic therapy) may be used if the stroke is caused by a blood clot. Such medicine breaks up blood clots and helps restore blood flow to the damaged area. However, not everyone can receive this type of medicine.

For these drugs to work, a person must be seen and treatment must begin within 3 hours of when the symptoms first started. A CT scan must be done to see whether the stroke is from a clot or from bleeding.

If the stroke is caused by bleeding rather than clotting, clot-busting drugs (thrombolytics) can cause more bleeding.

Other treatments depend on the cause of the stroke:

Blood thinners such as heparin or warfarin (Coumadin) may be used to treat strokes due to blood clots. Aspirin or clopidogrel (Plavix) may also be used.

Other medications may be needed to control other symptoms, including high blood pressure. Painkillers may be given to control severe headache.

In some situations, a special stroke team and skilled radiologists may be able to use angiography to highlight the clogged blood vessel and open it up.

For hemorrhagic stroke, surgery is often required to remove blood from around the brain and to repair damaged blood vessels.

Surgery on the carotid artery may be needed.

Nutrients and fluids may be necessary, especially if the person has swallowing difficulties . These may be given through a vein (intravenously) or a feeding tube in the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

Physical therapy, occupational therapy, speech therapy, and swallowing therapy will all begin in the hospital.

LONG-TERM TREATMENT

The goal of treatment after a stroke is to help the patient recover as much function as possible and prevent future strokes.

The recovery time and need for long-term treatment differs from person to person. Problems moving, thinking, and talking often improve in the weeks to months after a stroke. A number of people who have had a stroke will still continue to improve in the months or years after the stroke.

Bladder and bowel problems Living at home rather than a nursing facility Muscle and nerve problems Speech problems Stroke rehabilitation

8

Swallowing and eating problems Thinking and memory problems

Expectations (Prognosis)

The outlook depends on the type of stroke, how much brain tissue is damaged, what body functions have been affected, and how quickly treatment is received. Recovery may occur completely, or there may be some permanent loss of function.

Over half of the people who have a stroke are able to function independently at home.

If treatment with clot-busting drugs is successful, the symptoms of a stroke may completely go away. However, patients do not often arrive at the hospital soon enough to receive these drugs, or there are complicating medical conditions that prevent their use.

People who have an ischemic stroke (stroke due to a blood clot) have a better chance of surviving than those who have a hemorrhagic stroke (stroke due bleeding in the brain).

The risk for a second stroke is highest over the first few weeks or a month after the first stroke and then begins to lessen.

Complications

Breathing food into the airway (aspiration) Decreased life span Difficulty communicating Fractures Malnutrition Muscle spasticity Permanent loss of brain functions Permanent loss of movement or sensation in one or more parts of the body Problems due to loss of mobility, including joint contractures and pressure sores Reduced ability to function or care for self Reduced social interactions Side effects of medications

Calling Your Health Care Provider

Stroke is a medical emergency that requires immediate treatment. Call your local emergency number (such as 911) if someone has symptoms of a stroke.

Prevention

To help prevent a stroke:

9

Avoid fatty foods. Follow a healthy, low-fat diet. Do not drink more than 1 to 2 alcoholic drinks a day. Exercise regularly: 30 minutes a day if you are not overweight; 60 - 90 minutes a day if

you are overweight. Get your blood pressure checked every 1 - 2 years, especially if high blood pressure runs

in your family. Have your cholesterol checked. If you are at high risk for stroke, your LDL "bad"

cholesterol should be lower than 100 mg/dL. Your doctor may recommend that you try to reduce your LDL cholesterol to 70 mg/dL.

Follow your doctor's treatment recommendations if you have high blood pressure, diabetes, high cholesterol, and heart disease.

Quit smoking.

Aspirin therapy (81 mg a day or 100 mg every other day) is recommended for stroke prevention in all men who have stroke risk factors, and in women under age 65 who are at risk for stroke, as long as the benefits outweigh the risks. It should be considered for women over age 65 only if their blood pressure is controlled and the benefit is greater than the risk of gastrointestinal bleeding and brain hemorrhage. Ask your doctor if aspirin is right for you.

Your doctor may also recommend aspirin therapy or another blood thinner if you have had a transient ischemic attack (TIA) or stroke in the past, or if you currently have:

Congestive heart failure Irregular heartbeat (such as atrial fibrillation) Mechanical heart valve Other risk factors for stroke

A type of surgery called carotid endarterectomy may help prevent new strokes from occurring in persons with large blockages in their neck arteries.

References

Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke. 2009;40:3646-3678. Epub 2009 Sep 24.

Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr: American Heart Association Stroke Council, Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40:2945-2948. Epub 2009 May 28.

10

Cerebral infarction, also known as ischemic stroke, occurs when the blood vessels that supply the brain are disturbed so that blood flow is interrupted. There are two common types of ischemic stroke: atherothrombotic, and embolic, as well as other less common causes. The cause of an ischemic stroke cannot be determined in approximately 40% of cases.

Infarction is a medical term which describes the necrosis that occurs when blood supply to tissues is interrupted. Blood supply can be interrupted in a number of ways, such as blockage of a supplying artery, mechanical compression of an artery by a tumor or hernia, or rupture of an artery due to trauma.

Cerebral infarction occurs when the blood supply to the brain is interrupted. Within minutes, a series of reactions known as the ischemic cascade begins, and can continue for several hours, and may even last for days. The brain is still vulnerable even when the blood supply is restored, due to the possibility of reperfusion injury.

During the ischemic cascade oxygen deprivation leads to the absence of ATP in the brain’s tissues. ATP proton pumps fail, allowing a massive influx of calcium ions into cells. This results in the generation of reactive oxygen species, free radicals, and other harmful chemicals. Eventually cells begin to die, some via necrosis, which triggers an inflammatory response which can itself cause further damage to brain tissue. The ischemic cascade can occur in any type of tissue, but the brain is considered most vulnerable due to its complete dependence on aerobic metabolism.

Cerebral infarction can occur for several different reasons. The formation of a thrombosis, or blood clot, in an artery or blood vessel that feeds the brain can result in an interrupted blood supply. Embolism, in which a portion of thrombosis breaks off and causes a blockage, is another common cause infarction. Cerebral venous sinus thrombosis, in which blood vessels that drain the brain become blocked, may result in cerebral infarction as blood fails to recirculate in the body.

Symptoms of cerebral infarction are fairly distinctive. Interruption of the blood supply to the brain can cause muscle weakness in the face and other parts of the body, tingling or numbness, inability to speak or understand speech, confusion, and memory disturbances. Diagnosis is usually made on the basis of symptom evaluation and neurological exams, as well as medical imaging tests such as CT or MRI.

Treatment of ischemic stroke may involve breaking down or removing a thrombosis or embolus, and administering medication to prevent further clots. A large portion of brain infarction treatment is supportive in nature, as many people suffer brain tissue damage that requires rehabilitative therapy. Some people find they must relearn how to walk, talk, and carry out other everyday activities, while others may have to adjust to the permanent loss of such abilities.

By: Emma Lloyd & Bronwyn Harris

11

http://www.wisegeek.com/what-is-mri.htm

http://www.wisegeek.com/what-is-a-sinus.htm

http://www.wisegeek.com/what-are-embolisms.htm

http://www.wisegeek.com/what-is-calcium.htm

http://www.wisegeek.com/what-is-a-proton.htm

http://www.wisegeek.com/what-is-oxygen.htm

http://www.wisegeek.com/what-is-a-trauma.htm

http://www.wisegeek.com/what-is-a-hernia.htm

http://www.wisegeek.com/what-is-necrosis.htm

http://www.wisegeek.com/how-does-the-brain-work.htm

Cerebral Infarction

A cerebral infarction is the ischemic kind of stroke due to a disturbance in the blood vessels supplying blood to the brain. It can be atherothrombotic or embolic. From stroke caused by cerebral infarction two other kinds of stroke should be distinguished: cerebral hemorrhage and subarachnoid hemorrhage.

There are various classification systems for a cerebral infarction. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain affected, the underlying cause, and the prognosis. The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation).

Symptoms of cerebral infarction are determined by topographical localisation of cerebral lesion. If it is located in primary motor cortex- contralateral hemiparesis occurs, for brainstem localisation typical are brainstem syndromes: Wallenberg's syndrome, Weber's syndrome, Millard-Gubler syndrome, Benedikt syndrome or others.

In last decade, similar to myocadial infarction treatment, thrombolytic drugs were introduced in the therapy of cerebral infarction. The use of intravenous rtPA therapy can be advocated in patients who arrive to stroke unit and can be fully evaluated within 3 h of the onset.

This article is licensed under the Creative Commons Attribution-ShareAlike License. It uses material from the Wikipedia article on "Cerebral Infarction" All material adapted used from Wikipedia is available under the terms of the Creative Commons Attribution-ShareAlike License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.

12

PATHOPHYSIOLOGY

13

DRUG STUDY

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION

INDICATION ADVERSE REACTION

DOSAGE, ROUTE &

FREQUENCY

NURSING CONSIDERATION

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION

INDICATIONS ADVERSE REACTION

DOSAGE, ROUTE &

FREQUENCY


14

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


15

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


. . ,

GENERIC NAME

BRAND NAME

MECHANISM OF ACTION


DOSAGE, ROUTE &

FREQUENCY


.

16

LABORATORY RESULTS

HEMATOLOGY RESULT01-17-118:10 pm

PARAMETER RESULT Normal Value SIGNIFICANCE

Hemoglobin 142 g/L 120-150g/L Normal Hematocrit 0.420 0.38-0.48 Normal RBC Count 4.80 10^12/L 4.2-5.4 Normal RDW-SD 41.80 fl 37-54% Normal RDW-CD 13.40% 11-16% Normal

WBC 8.27 10^12g/L 5-10 x 10/l NormalNeutrophils 0.559 0.45-0.65 Normal

Lymphocytes 0.291 0.25-0.4 Normal Monocyte 0.110 0.02-0.1 Not normal due to

possible infection Eosinophil 0.036 0.020-0.040 NormalBasophil 0.004 0-0.010 Normal

Platelet Count 301 10^12g/L 150-450 x 10/l Normal

MVC 88 fl 80-100 Normal MCH 30 Pg 27-31 Normal

MCHC 33.80 % 31-36% Normal

17

01-17-118:45 pm

Fluid Serum

Test Result Normal RangeCreatinine 2.0 mg/dl 0.7-1.2Sodium 140 mmol/L 137-145Potassium 4.2 mmol/L 3.5-5.1

URINALYSIS

01-18-11Color : YellowAppearance : turbidSpecific gravity: 1.015Reaction : ph 5.0Albumin : positiveSugar : negativeMicroscopic examinationPus cells : 30-35 / hpfRBC : 3-6 /hpfEpithelial cells : rareAmorphous Urates : fewMucus threads : rare

18

01-19-1110:35

Fluid Serum

Test Result Normal RangeCholesterol 261 mg/dl 0-200 mg/dlTriglycerides 298 mg/dl 0-199 mg/dlDirect HDLC 33 mg/dl 40-60ALT 24 U/L 9-52LDL 168 mg/dl gg-178VLDL 60 mg/dl

01-17-11Examination: Chest X-ray (PA)

Roentgenological Report

Both lungs fields are clear

Heart is not enlarged

The Aorta is tortous and Sclerotic

Diaphram and sulci are intact

Impression: Atheromatous Aorta

URINALYSIS

01-22-11Color : light yellowAppearance : hazySpecific gravity: 1.010Reaction : ph 7.0Albumin : +2Sugar : +3Microscopic examinationPus cells : 3-5 / hpfRBC : 0-3 /hpfEpithelial cells : rareAmorphous Urates : fewMucus threads : rare

19

01-20-1110:09

Fluid Serum

Test Result Normal RangeSodium 144 mmol/L 137-145Potassium 4.3 mmol/L 3.5-5.1

(Not normal due to impaired insulin secretion)

20

Hgt Monitoring (65-130mg/dl)

Patient Result Date Time

193 mg/dl 1-17-2011 8:15 pm

129 mg/dl 1-18-2011 12 am

155 mg/dl 1-18-2011 6 am

246 mg/dl 1-18-2011 11:30 am

270 mg/dl 1-18-2011 6 pm

98 mg/dl 1-19-2011 6 am

280 mg/dl 1-19-2011 6 pm

109 mg/dl 1-19-2011 11pm

98 mg/dl 1-20-2011 6 am

143 mg/dl 1-20-2011 6 pm

88 mg/dl 1-21-2011 6 am

NURSING CARE PLAN ASSESSMENT NURSING

DIAGNOSISPLANNING IMPLEMENTATIONS RATIONALE EVALUATION

Subjective Cue: ,” as verbalized by the patient.

Objective Cues:

Initial Vital Signs:BP: mmHgCR: bpmRR: cpmT: 37.1°C

Laboratory:

: Within hours of effective nursing interventions such as

Independent:1. Establish rapport.

2. Monitor vital signs.

Dependent: Administer IVF as

ordered

Interdependent: Monitor glucose level

To gain trust and promote security

To obtain baseline data and monitor patient status

To promote proper hydration

After hours of effective nursing intervention the patient

LatestVital Signs BP: mmHgCR: bpmRR: cpmT: °C

Laboratory:

21

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS

PLANNING IMPLEMENTATIONS RATIONALE EVALUATION

Subjective Cue: ,” as verbalized by the patient.

Objective Cues:

Initial Vital Signs:BP: mmHgCR: bpmRR: cpmT: °C

Laboratory:

Within hours of effective nursing interventions the patient’s

Independent:1. Establish rapport

2. Monitor vital signs

Dependent: Administer IVF as

ordered.

Interdependent: Monitor glucose level

To gain trust and promote security

To obtain base line data and monitor patient status

To promote proper hydration

After hours of effective nursing intervention the patient’s

LatestVital Signs BP: mmHgCR: bpmRR: cpmT: °C

Laboratory:

22

DISCHARGE PLANNING

MedicationTake full course of medicines in a right time, dosage and frequency to obtain the best result of the drug effect.

1. Clopidogrel (Platexan) 75 mg tab OD2. Citicholine (Zynapse) 1 gm tab BID3. Atorvastatin 10 mg tab (aramax/ Lipitor) HSOD4. Isophane / Regular Acting Insulin vial 52 U pre breakfast & 26 U pre dinner SQ5. Cefuroxime 500 mg cap BID x 2 more days6. Trimetazidine (Vestar) 35 mg tab BID7. MVT + Amino Acid (Moriaminforte) OD

ExerciseInstruct the client to do exercise as tolerated such as walking and stretching

Therapy

Health Teachings

Out-patient follow-upAdvice the patient to comply at the schedule time of follow up check up.The follow-up check up is on January 29, 2011, 10 am

DietDiabetic Diet

Math homework help


23



Homework Help


Math homework help


Research Paper help


Algebra Help


Calculus Help


Accounting help


Paper Help


Writing Help


Online Tutor


Online Tutoring

24





















25
