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Payment for the surgical procedure includes postoperative care of the patient during these periods. You can also use modifier -24 with the General Ophthalmological Service codes 92002-92014 for eye evaluations, even though these codes are located in the Medicine section. Ophthalmologists report new and established medical examinations using 92002-92014. C O D I N G S H O T Modifier -24 requests payment for an unassociated E/M within a global period. The diagnosis code would indicate that the reason for the service was unrelated to the surgical procedure. For example, a male patient is within the 10-day global period for an incision and drainage of a skin abscess. The postoperative visit is reported with 99024 (no charge code), and the evaluation of the mole is reported with 9921X-24 to indicate a medically necessary E/M service unrelated to the incision and drainage of the skin abscess. The diagnosis code reported with the E/M service for the mole would indicate the medical necessity of the service, such as D23. Modifier -57 would be added to an E/M code when the service resulted in a decision for surgery on the day before or the day of a procedure with a global surgical package of 90 days. To assign modifier -25 correctly, there must be a medical necessity to provide a separate, additional E/M service on the same day a procedure was performed or another service was provided. If you do not add modifier -25 to the additional E/M code for service on the day of a procedure, the thirdparty payer would disallow the charge because it would be thought to be the evaluation/management portion of the procedure. By adding modifier -25, you are stating that the service was separate from the procedure or original service. In addition, the physician provided a separate discharge service (not related to the dialysis). You would report the dialysis service (procedure) and also report the inpatient service (discharge), adding the modifier -25 to the discharge service. The modifier can also be assigned when additional E/M services are provided on the same day to the same patient. For example, if a patient came into the office for a visit early in the day and then later in the day returned for a separate unrelated E/M service. You report both services using E/M codes and add modifier -25 to the second E/M code. If the services were for the same related condition as seen in the earlier service, documentation for both services would be considered to assign only one E/M code for that day. A patient presents for repair of a laceration (12042, intermediate laceration repair) and the questions asked by the physician were related only to the laceration repair. In this case, the E/M service is included in the laceration repair service and not reported separately. However, if the physician documented the patient had elevated blood pressure and a history of hypertension and the physician evaluated and treated the hypertensive condition, modifier -25 would be added to the E/M code. The laceration repair would have a trauma diagnosis for open wound, and as such, the diagnosis code would support the medical necessity for the laceration repair. In this example, both the E/M service (with -25) and the laceration repair are reported with diagnosis codes that indicate the medical necessity of both services. An example of the technical component is an independent radiology facility that takes the x-rays (technical component) and sends them to a private radiologist who reads the x-rays and writes a report of the findings (professional component). The physician component of the xray for the radiologist would be reported with 73000-26. After considerable time and effort, which extended the surgery by 60 minutes, the hemorrhage was controlled. Modifier: 6 A 60-year-old female patient is referred to a radiology laboratory by her general physician. The laboratory takes the x-rays requested and sends them on to a radiologist to interpret and to develop the written report that is sent to the general physician. If you were coding for the radiologist, what modifier would you add to indicate the service provided by the radiologistfi Modifier: (Answers are located in Appendix B) -32, mandated services Modifier -32 indicates a service that is required by some third-party entity. This modifier is not used to report a second opinion requested by a patient, a family member, or another physician. For example, the police require a suspected rape or abuse victim to have certain tests. The third-party payer usually waives the deductible and copayment for the patient and usually pays 100% of these mandated services. There are times, although they occur infrequently, when a physician acts as both the anesthesiologist and the surgeon. For example, a closed reduction of a mandibular fracture performed in the office under intravenous sedation/general anesthesia would be reported with 21451 for the procedure and 21451-47 as a separate line item for the anesthesia/sedation. C M S R U L E S Medicare does not reimburse the surgeon for anesthesia service when he/she is the performing surgeon. If the third-party payer allowed payment for modifier -47, payment would be made based on the time spent administering the anesthetic. The surgeon acting as an anesthesiologist would report modifier -47 with the surgery code. Modifier -47 is added only to surgery codes and is never added to anesthesia codes. For example, an arthroplasty (total knee replacement, 27447 and 27447-50) for both left and right knees at the same operative session would be reported using the modifier -50. Another example in which the same services may be performed on two sides would be a bilateral breast procedure. It is very important to determine how the third-party payer wants bilateral procedures submitted on the claim form, on a single line or multiple lines. One payer may require two codes to be displayed for the bilateral procedure (such as 27447 and 27447-50) for which they would reimburse 100% for the first code and 50% for the second code. Another payer may require that bilateral procedures be reported with only one code (27447-50) and would reimburse 150% based on that one code with modifier -50 representing two services. C M S R U L E S Medicare does not accept two line items to describe a bilateral procedure. Medicare rules direct the coder to use one line with modifier -50 and 1 unit of service. Be sure to find out whether your third-party payer wants the surgical code to be used once with the modifier (code plus modifier -50) or used twice (code alone and code plus modifier -50) or whether the procedure should be listed twice. Code 92020 (gonioscopy) is also a bilateral procedure and use of modifier -50 would be inappropriate. Assign modifier -51 when multiple procedures, other than the E/M services, are performed on the same day or at the same session by the same provider. When reporting multiple surgeries, the primary procedure (the procedure with the highest relative value unit) should be listed first on the claim. The service is reported with 11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter over 4.

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The Consultant found in April 2013 that the crossing over the canal was severely damaged by a recent non-professional dredging in the canal bed. The pump station and an earth road creek over the nameless canal (right) the open drainage system and the collectors are in poor shape today because of the lack of maintenance. The drainage system around the future landfill should be restored to avoid the waterlogging. The high density of ditches surface indicates on low permeability of soil because they provided the only means to lead away the excess waters from the land surface. The low permeability of the soil was also indicated by ponding of water in many spots after rainy periods which were observed by the Consultant during the field works. Therefore the Consultants interviewed the local people whether they have experienced flooding on the Tsetskhlauri Plateau in the past. After prolonged and intensive rainstorms some lowest parts of the Plateau were flooded for a short period. The low risk for floods may be confirmed by the fact that an animal farm with a large number of buildings and facilities would not have been constructed here if inundations occurred in the past. The design of drainage of surface / storm and leachate water collection considered the above mentioned and targeted at fi leakage into the ground water aquifer should be prevented fi emission of untreated leachate water into the surface water should be strictly avoided fi saving as much as possible the hydro-geographic network and natural runoff conditions fi keeping maximum possible distance to the settlements fi minimizing the flood risk fi ensuring favourable collection of leachate and storm waters from the landfill area fi creating good treatment options for the leachate waters. Based on preliminary desk studies and site visits, the following findings have been made: fi the land between village Tsetskhlauri and highway / railway line is state owned (this information was given to the Consultant by Land Cadastre Office). The situation shall be further assessed in the ressttlement action plan to be prepared by the local municipality. It should be noted that according to Georgian legislation, no dwelling houses and agricultural land can be located within the 500 m sanitary protection zone around a landfill. The border of the sanitary protection zone was defined by the aforementioned regulations as 500 m around the landfill. However, in case of the isolated dwelling houses the legal requirement is not so explicit. This may be done on the basis of environmental impact assessment, if it would be possible to demonstrate that the zone of negative landfill impact is less than 500 m. A visit was made to Tsetskhlauri of the social team on the 30th of March 2015 that generally confirms the findings made spring 2014. Interviews were carried out with affected people on the landfill, affected people within/just outside sanitary zone as well as with acting head of the villages in and around Tsetskhlauri. The dirt road leading to the landfill had recently been improved by the Government of Ajara by the time of this visit, this also includes making trenches on both sides of the road. Irrigation channels exist, but these have not been in used for a while and vegetation is covering most. The plot is said to be 10,500 m3 (a bit more than 1 ha) and is registered under the ownership of the head of the family, who is a man (also the one interviewed). His son and daughter in law, as well as two (2) grandchildren live on the same plot but in another house (in total 6 people, 3 female and 3 male). In addition to the registered plot, the family uses another 2 ha, where they grow mainly nuts and potatoes. The plot with the house is registered and is approximately 3 500 m3 and is registered in the name of the mother in law. One (1) ha is being used on the other side of the road as well as another 3,500 m3 located a bit further away. The family consists of 5 people (3 female and 2 male), 2 adults, 1 pensioner and 2 children). Both families confirmed they had been interviewed and some kind of questionnaire had been filled in by the Ministry. It is unclear, but likely, that the families have been promised something in return. Neither family said they had planted crops at the centre of the new landfill territory. The 2012 resettlement survey conducted (please refer to chapter 2) for the Kobuleti bypass road indicated lower annual incomes per households, than indicated here. The villagers had made their own calculations and reached a result of 380 meters to the boarder of the new landfill. Communication on distance and sanitary zone area and what this entail for these people needs to be done. The average size of the four interviewed households were (9+4+6+5)/4= 6 people, with slightly more males than females. Three (3) of these families had some kind of additional income, from jobs or by going to Turkey to work in the tea plats for seasonal work. The 4 interviewed families had plots with houses sized 2900 m2, 2500 m2, 3000 m2 and 3000 m2. The plots were all registered in the name of the head of the family, who were all men. Besides these plots that they all reported to have official papers on, but did not know wher the actual official registration was, also had unregistered land plots were vegetables/potatoes and especially nuts were grown. The incomes on the land only were estimated to be app/annually: 12000, 30000 (had cattle), 15000 and 15000. Average plot size of the interview people in Tsetkhlauri (minus the cattle farmer) was approximately 1 ha of unregistered land (user right). Averaged reported income per ha is estimated to be: 17 400 (leaving out the cattle farmer, as this person had significantly higher annual turnover/ha). The 4 interviewed families did not feel they had been consulted and had not received sufficient information from the government. An inventory had been made by government officials last year, but since then the villagers had not received any new information. One demonstration was made in front of the Kobuleti municipality with approximately 70-80 people. Impact on crops Mitigation measure on social risks include, but is not limited to: information disclosure orally and in writing, ensuring women are present at these meetings and have equal access to information. The visit revealed that findings have been made in Ajara region that dates back 300 000 years. Chance finds have been made mainly in Dmanisi (South-East Georgia), Gonio (Ajara, Khelvachauri region) and Pichvnari (Ajara, Kobuleti region). Both chance finds (reported as accidental finds) and finds from excavations are placed at the museum. Museum guide reported that the public as well as public/private organisations come in with chance finds and that they were paid for the artefacts that they founds. It was also the opinion of the museum staff that people in general had some sort of understanding that finds should be reported to the museum or the department for archaeology at the university. A stage 1 permit is being issued after recommendations by the Ministry of Culture who has made an ocular assessment. Potential impact from construction work cannot be said to be without possibilities to do chance finds. Although museum report that knowledge is high among people in general about the need to preserve artefacts, there is a slight risk that the matter is not dealth with in a proper way during construction works. All subcontracted consultants/companies should, in addition, be informed about chance find procedures and contracts should obligate precaution in relation to cultural heritage. The plan is that an access road will be built from the new highway passing to the landfill. It can be assumed that a temporary road for the construction period should be built or the current provisional road should be upgraded. The Consultant recommends building a construction road to avoid heavy transport on the existing village road. The construction road can be built avoiding settlements and join the existing asphalted road between the villages. The access road from the highway to the landfill would pass grassland and no residences are in the vicinity. In fact, the delineation of the access road is almost the same as the earth road used by the local people today for commuting between villages Ochkhmahuri and Tsetskhlauri.

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Hypochromic Anemias 129 Insufficient iron absorption: Chronic bleeding and pathological G loss of iron in the following diseases: Lower than normal acidity, no acidity, stomach resection, G Disorders of the stomach and accelerated passage from intestines (positive benzidine stomach to intestines test) G Substances that inhibit abG Diseases of the urethra sorption of iron, such as citric (hematuria! If samples are being sent away to a laboratory, it is preferable to send serum produced by low-speed centrifugation, since the erythrocytes in whole blood can become mechanically damaged during shipment and may then release iron. Only chronic bleeding or earlier serious acute blood loss leads to iron deficiency manifested as hypochromic anemia. Iron Deficiency and Blood Cell Analysis Focusing on the erythrocyte morphology is the quickest and most efficient way to investigate hypochromic anemia when the serum iron has dropped below normal values. In hypochromic anemia with iron and hemoglobin deficiency (whether due to insufficient iron intake or an increased physiological iron requirement), erythrocyte size and shape does not usually vary much (see. Cells with the appearance of relatively large polychromatic erythrocytes are reticulocytes. Since this anemia results from another disorder, it is also called secondary anemia. In contrast to exogenous iron deficiency anemias, the following phenomena are often observed, depending on the severity of the underlying condition: Anisocytosis, i. The result is that in almost every field view, some erythrocytes are either half the size or twice the size of their neighbors. In addition to the normal round shape, numbers of oval, or pear, or tear shaped cells are seen. The reticulocyte count is usually reduced in infectious or toxic anemia, unless there is concomitant hemolysis or acute blood loss. The information is so nonspecific that usually bone marrow aspiration is not performed. So long as all other laboratory methods are employed, bone marrow cytology is very rarely needed in cases of hypochromic anemia. Hypochromic erythrocytes of very variable morphology indicate secondary anemia, usually in cases of infectious disease or tumor a b c. Cell counts in the white cell series are elevated (promyelocytes =1), eosinophils (2), and plasma cells (3); erythropoiesis is reduced (4). Bone marrow cytology is rarely strictly indicated after all other available diagnostic methods have been exhausted (Table 22, p. However, in doubtful cases it can usually at least help to rule out malignant disease. In iron deficiency anemias of the most various etiologies, erythropoiesis is stimulated in a compensatory fashion, and the distribution of the markers shows the expected increase in red cell precursors. The erythropoiesis to granulopoiesis ratio increases in favor of erythropoiesis from 1:3 to 1:2, but rarely further. Usually, these red cell precursors do not show any clearly atypical morphology, but the cytoplasm is basophilic even in normoblasts, according with the poor hemoglobinization. Iron staining of the bone marrow shows no sideroblasts (normoblasts containing iron granules), or only very few (! A constant finding in anemia stemming from exogenous iron deficiency is absence of iron in the macrophages of the bone marrow reticulum. Megakaryocyte counts are almost always increased in iron deficiency due to chronic hemorrhaging, but can also show increased proliferation in iron deficiency from other causes (which can lead to increased thrombocyte counts in states of iron deficiency). In infectious or toxic (secondary) anemia, unlike exogenous iron deficiency anemia, erythropoiesis tends to be somewhat suppressed. Depending on the trigger of the anemia, the monocyte, lymphocyte, or plasma cell counts are often moderately increased, and megakaryocyte counts are occasionally slightly elevated. However, combinations do exist, when a pre-existing iron deficiency means that the iron depositories are empty even in an infectious or toxic process. Where there is concomitant alcoholism or vitamin deficiency, secondary anemia may be normochromic or hyperchromic. Hypochromic Anemias 137 Hypochromic Sideroachrestic Anemias (Sometimes Normochromic or Hyperchromic) In a sideroachrestic anemia existing iron cannot be utilized (achrestic=useless). Only a few of them appear to be hereditary or have exogenous triggers (alcoholism, lead poisoning). Although target cells are also nonspecific, since they can occur in such conditions as severe iron deficiency or obstructive jaundice, this overall picture should prompt hemoglobin electrophoresis. A significant increase in the HbA2 fraction confirms a diagnosis of thalassemia minor, the heterozygous form of the disease. Hbelectrophoresis shows a predominance of HbF (the other hemolytic anemias are usually normochromic, see p. Hypochromic anemia without iron deficiency, sometimes with target cells, suggests thalassemia a b c. Normochromic Hemolytic Anemias Hemolytic anemias result from a shortened erythrocyte life span with insufficient compensation from increased erythrocyte production (Table 24). Usually, hematopoiesis in the bone marrow is increased in compensation, and, depending on the course of the disease, may make up for the accelerated cell degradation for all or some of the time by recycling the iron as it becomes free. Accordingly, counts of the young, newly emerged erythrocytes (reticulocytes) are always raised, and usually sporadic normoblasts are found. A common cellular phenomenon after extended duration of hemolytic anemia is the manifestation of macrocytic hypochromic disorders (p. Bone marrow analysis shows both relative and absolute increases in erythropoietic activity: among the red cell precursors, in acute severe hemolysis the more immature forms often predominate more than in normal bone marrow, and in chronic hemolysis the maturer forms do (orthochromatic normoblasts). In addition, the normoblasts in hemolytic bone marrow often are markedly clustered. A basophilic erythroblast shows loosened nuclear structure (arrow), a sign of secondary folic acid deficiency. Distribution pattern and shape of erythrocytes can be relevant in the diagnosis of hemolysis a b c. If this is the picture in all regions of the smear, an artifact is unlikely and serogenic (auto)agglutinationshouldbesuspected(inthiscaseduetocryoagglutininsinmycoplasmic pneumonia). Fragmentocytes (1), target cell (2), and echinocytes (3) (this last has no diagnostic relevance). Blood analysis shows erythrocytes which appear strikingly small in comparison with leukocytes. The central light area is absent or only faintly visible, since they are spherical in cross-section rather than barbell-shaped. The extremely reduced osmotic resistance of the erythrocytes (in the NaCl dilution series) is diagnostic. In addition to target cells, smears from patients with sickle cell anemia may show a few sickle-shaped erythrocytes, but more usually these only appear under conditions of oxygen deprivation. Sickle cell anemia is a dominant autosomal recessive hemoglobinopathy and is diagnosed by demonstrating the HbS band in Hb-electrophoresis. Homozygous patients with sickle cell anemia always suffer from chronic normocytic hemolysis. If provoked by oxygen deficiency or infections, severe crises may occur with clogging of the microvasculature by aggregates of malformed erythrocytes.

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It enlarges relatively rapidly to form a giant angioma that is dark red to purple. Clinical features Angioma occurs most frequently on the extremities and the head and neck region. Extremely firm, light pink subcutaneous induration first occurs in the first 3 months of life. It is followed by intratumor bleeding and edematous enlargement, resulting in the formation of a giant, dark purple, tense tumor. Pathogenesis Intratumor bleeding is caused by rapid enlargement of a large angioma in newborns, leading to platelet consumption. Premature cutaneous angioma is thought to result in congestion, platelet consumption and coagulation-factor consumption. Radiation therapy is effective, because the angioma in Kasabach-Merritt syndrome is highly sensitive to radiation. Cutaneous arteriovenous malformation Congenital vascular deformity and several embryonic arteriovenous fistulae are the underlying condition. It begins to enlarge at a certain point, and swelling accompanied by heat sensation on the surface of the lesion occurs. When the extremities are involved, the lesion enlarges and may cause Klippel-Trenaunay-Weber syndrome. Tufted angioma Synonym: Angioblastoma of Nakagawa It begins as erythema that gradually enlarges to form a flatly elevated, infiltrating plaque. Tufted angioma is a vascular tumor in which immature endothelial cells and peritcytes proliferate. A bluish subcutaneous tumor occurs, most frequently in the distal areas of the extremities in young persons. Histopathologically, it is composed of dilated vascular lumens and portions of proliferated spindle cells. Multiple tumors are caused in localized areas; however, it is benign and does not metastasize. Hemangiomas and vascular malformations 377 the neuromyoarterial glomus of skin on the distal fingers. Clinical features Glomus tumors are either solitary or multiple, with most being solitary. A solitary glomus tumor occurs most frequently under the nail plate of individuals older than age 20. A firm, painful nodule of 1 cm or less in diameter and ranging in color from dark Clinical images are available in hardcopy only. Glomus tumors are characterized by extreme pain from pressure or exposure to cold water. In multiple glomus tumors, the tumors are autosomal dominantly inherited and can occur in persons of any age. Asymptomatic, disseminated, soft tumors of normal skin color to blue and about 1 cm in diameter appear on the whole body. Pathogenesis A glomus tumor is a hamartoma caused by proliferation of glomus cells. Pericyte-originated smooth muscle cells proliferate, and the luminal structure is surrounded by single-layered endothelium in the tumor. Differential diagnosis Multiple glomus tumors are differentiated from cavernous hemangioma and blue rubber-bleb-nevus syndrome. Glomus tumors underneath the nail plate should be differentiated from 21 subungual exostosis. Hemangiopericytoma A firm, elastic, relatively sharply margined nodule occurs in the lower leg, the thigh in particular. Histopathologically, round or spindled cells that resemble peritcytes proliferate around the capillary lumens, which are covered by a single-layered endothelium. Lymphangioma Synonym: Lymphatic malformation Outline fi It is a benign lesion caused by lymphangial hyperplasia and dilation resulting from dysplasia of lymph vessels. Bleeding in the vesicles may result in papules whose color ranges from red to black. Lymphangioma circumscriptum: Transparent vesicles of several millimeters in diameter aggregate to form irregularly shaped plaques. Histopathologically, irregular lymphagiectasia occurs in the subcutaneous and deep dermal layers. Lymphangioma cysticum: the lateral region of the head is most Clinical images are available in hardcopy only. Synonym: Telangiectatic granuloma Clinical features An angioma whose main symptoms are proliferation of capillaries and dilation of vascular lumens is induced by injury. It is elevated in a dome shape, with a diameter of 5 ing in color from bright red to dark red mm to 20 mm. The face of children and the trunk and extremities of adults are most commonly involved. Pathology Pathologically, there is an angioma accompanied by secondary inflammatory granuloma, or there is granuloma that is nonangiomatous in structure. Treatment Excision, cryotherapy and laser therapy are conducted; there may be recurrence in cases of incomplete treatment. Intravascular papillary endothelial hyperplasia the blood vessels proliferate as a result of thrombotic recanalization in the dilated venulae. A purplish-red nodule occurs, most frequently in the veins of the palmar surfaces of fingers. Soft fibroma Synonyms: Fibroma pendulans, Acrochordon, Skin tag Clinical images are available in hardcopy only. Clinical features A soft, dome-shaped or pedunculated tumor with wrinkles on the surface and a color of normal skin or light brown occurs on the neck, axillary fossae or groin. Small, multiple, threadlike tumors 2 mm to 3 mm long on the neck and axillary fossae are called acrochordon. A solitary, relatively large tumor of about 1 cm on the trunk is called soft fibroma. An enlarged 21 soft fibroma hanging from the skin is called a soft fibroma penClinical images are available in hardcopy only. Soft fibroma tends to occur in obese persons and women; it is thought to relate to skin aging. Pathology the primary condition of soft fibroma is proliferation of collagen bundles with few fibroblasts. The peduncle of the soft fibroma may be excised and the site treated by cryotherapy. Nevus anemicus A sharply circumscribed white patch occurs, often on the upper chest, when the skin is flushed by bathing or rubbing. Neurofibroma, pigmentation and nervous tumor in multiple organs are the main symptoms. A cafe-au-lait spot with a diameter of about 10 cm is called a large Recklinghausen spot; one with a diameter of 1 cm or less is called a small Recklinghausen spot. Neurofibroma first appears between childhood and puberty, after which it gradually enlarges and increases in number. Nodular plexiform neurofibroma, neurofibroma in the peripheral nerves, is a slightly palpable, spindle-shaped tumor that appears on the skin over the subcutaneous nerves. It may appear in a beaded linear pattern and be accompanied by tenderness or radiating pain. Small yellow tumors may appear on the face and scalp of infants and disappear spontaneously in several years (juvenile xanthoendothelioma). Bone abnormality, including scoliosis, deformity or bone defect in the thorax, occurs in about half of all cases. Pathology Neurofibroma is formed by Schwann cells and intraneural fibroblasts, with thin undulating collagen fibers in the middle. Schwann cells test positive for S-100 protein antiClinical images are available in hardcopy only. Cafe-au-lait spots are treated by laser therapy and dermabrasion; nevertheless, they tend to recur. Neurofibromas on highly visible areas such as the face or extremities are surgically removed.

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Following transection, initially there is accumulation of organelles in the proximal and distal ends of the transection sites. Subsequently, the axon and myelin sheath distal to the transection site undergo disintegration upto the next node of Ranvier, followed by phagocytosis. Segmental demyelination is loss of myelin of 618 the segment between two consecutive nodes of Ranvier, leaving a denuded axon segment. However, if the process of regeneration is hampered due to an interposed haematoma or fbrous scar, the axonal sprouts together with Schwann cells and fbroblasts form a peripheral mass called as traumatic or stump neuroma. Motor features in the form of muscle weakness and loss of tendon refexes may be present. M/E Polyneuropathy may be the result of axonal degeneration (axonopathy) or segmental demyelination (demyelinating polyneuropathy). Multifocal neuropathy represents part of spectrum of chronic acquired demyelinating neuropathy. It is generally the result of local causes such as direct trauma, compression and entrapment. An acoustic schwannoma or acoustic neuroma is an intracranial schwannoma located within the internal auditory canal originating from vestibular portion of the acoustic nerve. In the peripheral nerves, they occur as solitary nodule on any sheathed sensory, motor, or autonomic nerve. G/A A schwannoma is an encapsulated, solid, sometimes cystic, tumour that produces eccentric enlargement of the nerve root from where it arises. There are areas of dense and compact cellularity (Antoni A pattern) alternating with loose acellular areas (Antoni B pattern). Nerve fbres are usually found stretched over the capsule but not within the tumour. Solitary neurofbroma is a tumour of adults but multiple neurofbromas or neurofbromatosis is a hereditary disorder with autosomal dominant inheritance. Neurofbromatosis type 1 is a genetic disorder having mutation in chromosome 17 while type 2 has mutation in chromosome 22. Neurofbromatosis may involve a group of nerves or may occur as multiple, oval and irregular swellings along the length of a nerve (plexiform neurofbroma). M/E A neurofbroma is composed of bundles and interlacing fascicles of delicate and elongated spindle-shaped cells having wavy nuclei. Histologic appearance of Antoni B pattern of schwannoma may be seen in neurofbroma and cause diagnostic diffculty. Neurilemmoma virtually never turns malignant, while sarcomatous transformation in neurofbroma, particularly in neurofbromatosis, is not unusual. M/E the tumour has the general appearance of tumour cells resembling a fbrosarcoma. The following viral infection of the brain produces intracytoplasmic inclusions: A. The lowest limit of critical level of systolic pressure upto which the brain continues to be perfused is: A. Small foci of calcifcation are frequently seen on X-ray of the following glioma: A. The following brain tumour has a tendency to metastasise by haematogenous route: A. An 84 years old man, after an evening walk in the garden, is seen wandering in the street in search of his way back home and is helped by a passerby to fnd his way to home. There is no history of any head injury, diabetes, hypertension or cardiovascular disease. Histopathology of the resected mass shows the tumour composed of numerous proliferating small round blue cells with occasional Homer-Wright rosettes. This generated interest of workers towards obtaining cellular material by non-biopsy techniques to arrive at the diagnosis. As a result, diagnosis by cytopathologic technique was initially introduced in the 1920s by Dr. Papanicolaou on cells naturally shed off (exfoliated) into cervical and vaginal secretion; subsequently its use was extended to cells shed off into other body cavities. Identifcation of cell of origin For cytomorphological recognition of cancer, nuclear characteristics are used to determine the presence or absence of malignancy. In addition, cells for study may also be obtained by scraping, brushing, or washing various mucosal surfaces (abrasive cytology). Urinary tract i) Urinary sediment ii) Bladder washings iii) Retrograde catheterisation iv) Prostatic massage (secretions) 4. These smears may be prepared by different methods depending upon the purpose for which they are intended. Endocervical cells appear either as single dispersed nuclei, or as clusters of columnar cells. Other cells Besides epithelial cells, other cells in cervical smears are leucocytes and Doderlein bacilli. Ideally, at least 3 smears obtained on alternate days should be scrutinised and cytologic indices determined for each smear for accurate assessment. Criteria followed in the Bethesda system has three basic components in recommendations: 1. Specimen adequacy It is an important component of quality assurance and provides feedback regarding sampling technique. It implies properly labelled, adequately fxed smears having suffcient number of evenly spread, well preserved cells as evaluated microscopically. General categorisation It includes categorising the smear in one of the three broad categories: within normal limits, benign cellular changes, and epithelial cell abnormalities. Descriptive diagnosis Final aspect of the Bethesda system includes detailed description of the benign cellular changes or epithelial cell abnormalities in the smear. Based on it, the cellular changes in cervical smears are described under 2 headings: non-neoplastic (or benign) and neoplastic epithelial cell abnormalities. Vast majority of cervical cancers are of the squamous cell type, and the diagnosis of squamous cell carcinoma of the cervix and its precursor lesions is considered as the most important application of exfoliative cytology. Morphogenesis and nomenclature the earliest recognisable change is hyperplasiaof basal or reserve cells which normally constitute a single layer at the deepest part of the epithelium. The proliferating reserve cells next develop certain atypical features and progres sive involvement of more and more layers of the epithelium is known as dysplasia (disordered growth). Previously, depending on the degree of epithelial involvement, three grades of dysplasia were recognised: mild, moderate and severe. Cytomorphology In dysplastic epithelium, stratifcation and matura tion of cytoplasm occurs above the layers of proliferating primitive cells while the nuclear abnormalities persist. These cells show cytoplasmic vacuolation as perinuclear halo (koilocytosis) and nuclear enlargement. Automation offers routine pre-screening of hundreds of Pap smears, decreasing the workload of cytopathologists and at the same time providing quality assurance. For the oesophagus, stomach and duodenum, cytologic samples are obtained under direct vision by brushing or lavage through fbreoptic endoscopes. This distinction is important in diagnostic cytology as malignant effusions are invariably exudates with a protein content greater than 3 gm/dl.

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Question for consideration: Clinical examination is to a degree an exercise of logical deduction where muscles belonging to the 1. Motor nerve conduction study of the right fibular nerve showed a reduction of compound musthe result of focal demyelination leading to failure of impulse propagation along the affected region. Motor tibial and sural sensory studies the affected side shows that apart from the localized were normal. Examination of the right tibialis posterior and medial Our patient demonstrated reduced recruitment of gastrocnemius was normal. How would you interpret the results of the elecvation of damaged muscle tissue from sprouting of trophysiologic studiesfi Alternarate, fasting blood glucose levels, and hepatic and renal tively, the articular theory posits that fibular ganglia function tests were normal. Serum protein electrophoresis and joint as a result of trauma or other disorders that is thyroid function were also normal. A lobulated cystic mass of longitudiment of the superficial peroneal nerve or even the nal diameter approximately 2. Further support to the articular theory space between the proximal tibia and the fibular neck, is the identification of a pathologic articular branch was revealed (figure, B). An inciClinicians should retain a high index of suspicion sion posterior to the fibular neck dissected the underfor intraneural ganglion cysts in atypical cases of fiblying fascia. Long-term success of tion of the common fibular nerve and the superficial surgical treatment relies to a great extent on performfibular nerve (figure, C). Skafida: electrodiagnostic testing, literature search, analysis of case discussion. Petsanas: design and implementation of surgical only minor weakness of foot dorsiflexion remained. KatsoulaAfter 1 year, her condition remains stable without kou: diagnostic evaluation, clinical follow-up. Guidelines in electrodiagnostic medicine: 58 Neurology 84 February 17, 2015 consensus criteria for the diagnosis of partial conduction 7. She was born full-term and had normal early developShe had mild facial weakness (Medical Research Council mental milestones. She would fatigue easily after waddling gait, elbow and ankle contractures, and rigid walking short distances. What testing would be helpful to narrow the There is no history of parental consanguinity; her parents, differentialfi Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Muscle biopsy of the quadriceps (perthe localization in her case could involve anterior horn formed previously and reviewed at our institute) showed cells, motor nerve roots, neuromuscular junction, and increased number of fibers harboring single or multiple muscles. Given the childhood onset of symptoms, internal nuclei, fiber splitting, and increased endomysial acquired disorders are unlikely (inflammatory or infiltraconnective tissue. The above information helped to rule tive polyradiculoneuropathies, autoimmune disorders of out neurogenic processes, such as disorders of the antethe neuromuscular transmission such as myasthenia gravis rior horn cells, and neuromuscular junction transmisor Lambert-Eaton myasthenic syndrome, inflammatory sion defects, such as congenital myasthenic syndromes. Questions for consideration: the lack of affected family members does not exclude the genetic etiology of the disease. What testing would you perform to clarify the showed myopathic motor unit potentials and sparse diagnosisfi The is predicted to result in an in-frame alteration, consisting additional clinical clues that help narrow the differential of deletion of 3 amino acids and insertion of a missense diagnosis in this case were the early onset of elbow conamino acid (p. In addition, a premutations in 6 different genes with an X-linked recessive viously reported missense mutation, p. There were no vacuolar changes or other dromes with systemic involvement, mandibuloacral dysstructural abnormalities suggestive of any specific congenplasia, and insulin resistance with lipodystrophy. Rigid spine syndrome: a muscle syndrome in after she had a cerebral ischemic infarct and was found search of a name. Nuclear lamins: laminopathies and their which our patient had) and scoliosis are also important role in premature ageing. The rest of monary sarcoidosis at age 24 years, which remained the results of the neurologic examination, particularly in remission after treatment with corticotropin and the sensory examination, were normal. Steroid myopathy was also unlikely, because the prednisone was stopped several years previously. Over the following years, his muscle weakness progressed and spread to the distal legs and finger flexor of 2 digits of his right hand. Three years later, the patient was partially wheelchair Muscle biopsy in hematoxylin & eosin stain, showing the bound. He reported difficulties with swallowing rimmed vacuoles (white arrow) and invasion of lymphocytes in nonnecrotic muscle fibers (black arrow). Although the prevalence is low (5 to fatty infiltration of the shoulder, limb-girdle, and leg 10 patients per million inhabitants), it is considered musculature (figure 1). Most patients present with weakness of quadriceps muscles or finger flexors or dysphagia. Drugdisease or due to the patchy nature of the histologic induced myopathies: an overview of the possible mechaabnormalities. Inclusion body myositis: clinical features and clinical there are clues suggesting an autoimmune and degencourse of the disease in 64 patients. Inflammatory, immune, and viral aspects of the usefulness of repetitive nerve stimulation and single inclusion-body myositis. Fernandez-Seara, unsteadiness during walking, as well as stiffness and was 4/5 in both iliopsoas, and 41/5 in the remaining PhD cramping pain in his legs. He also had erectile dysmuscles of the lower limbs, with increased muscle Maria A. In middle and tent with a chronic spastic paraparesis syndrome, beginlate adult life, a slow compression of the spinal cord by ning in the adulthood, and progressing steadily. Transcranial magnetic stimulation showed greater delay in the lower than the upper limbs. Empiric therapy with coenzyme Q (100 mg, 2 times a day) and symptomatic therapy with baclofen to reduce spasticity (10 mg, 3 times a day) and sildenafil citrate to treat erectile dysfunction were initiated. Questions for consideration: Images show no white matter lesions or other abnormalities (A), except for an incidental right 1. Tocheckwhetherthereexistedanydifferencesinterms ofregionalatrophy, a volumetric comparison with the supratentorialwhite mattervolume of 10 healthy subjects with similar age (47. X-linked paraplegia with cerebellar ataxia: a complex phenotype adrenoleukodystrophy. The patient reported an involuntary 25years ago, he noted bilateral lower extremity numbness pound weight loss in the last year. At the time he His medical history included bilateral cataract surreprint requests to Dr. Chafic also had a right transcarpal ligament release at an outgery at 75 years but was otherwise negative. This procedure did not provide any relief of his College of Medicine, Phillips Ambulatory Care Center, 10 right-hand numbness. Question for consideration: A Foley catheter was placed 1 year ago because of urinary retention and bilateral hydronephrosis, 1. Most polyneucause neuropathy may be the only manifestation of ropathies have some involvement of the autonomic the disease. What tests should be ordered to narrow the differential ropathy, and amyloid neuropathy due to multiple diagnosisfi Karam serves on the editorial board of the Neurology Resident & chronic polyneuropathy and autonomic neuropathy Fellow Section. Utility of subcutaneous fat aspiration for the diagnosis of systemic amyand died of complications of liver transplantation.

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These types of stitches may also be useful in children to prevent the need for future stitch removal or when Wound Irrigation patient follow-up is doubtful. When taking care of patients with heavy beards or dark facial hair, it is best Once anesthesia takes effect, the wound should be irrito use a skin suture color other than black to facilitate gated to help prevent future infection. Blue proline suture works well in these tion can only be done effectively if the patient is comcircumstances. Saline can usually be used to irrigate the If wound coverage is difficult because of lost skin, wound with a 60-mL syringe. Howforeign material is suspected to be in the wound, a finever, these flaps are rarely necessary. If they are ger can be used to probe the wound and remove the required, it is often best to accomplish the closure in foreign material. Sometimes the skin is abraded so the operating room setting as instrument sets and nursbadly that the area needing to be anesthetized would be ing assistance become more critical. The risk in using too large to safely administer lidocaine to the patient transposition flaps is that the wound is usually contamiwithout causing lidocaine toxicity. In these cases, it is nated; utilizing these flaps may increase the risk of tisbest to proceed to the operating room so that general sue loss if the wound becomes infected. In some wounds contaminated by tar, tracture process with a subsequent plan, if necessary, for as sometimes occurs in motorcycle accidents or other wound revision. Once the wound is Allowing a bite injury to heal by first-intention healing thoroughly clean, povidone-iodine, commonly known should be considered carefully because the wound is likely as Betadine, can be used to create a sterile environment to be contaminated. Any small bleeding areas can be mary closure is still recommended for these wounds after handled with a disposable electric cautery or by using thorough irrigation and with concomitant antibiotic individual clamps and suture ties. The antibiotic coverage should be directed at a polymicrobial spectrum including Wound Closure hemolytic streptococci, Staphylococcus aureus, and anaerFacial wound closure should heal by first intention (priobes such as Bacteroides. A severe laceration may sometimes require general anesthesia to properly identify cut nerves and provide a stable condition for operative closure. It is likely that the result will be no worse if an of the airway because airway obstruction may develop attempt at closure is made, even if the wound eventually rapidly after inhalation injury. Surgical treatspace, evidence of soot in the oral cavity, production of ment of facial dog-bite injuries in children. J Craniomaxillofacarbonaceous sputum, and concomitant facial and body cial Surg. In management of burn patients, there should be a low threshold for early intubation. These burns are extremely painful and present with blistering and open, During the acute management of patients with facial weeping surfaces of skin. As such, they are characterized as insensate, swollen, and white or gray in color. Inpatient management is universally required for secondor third-degree burns of the face. Early treatment goals involve the prevention of infection via sterile dressings, burn excision, and wound closure if permissible. To attenuate contracture and scar formation, temporary wound cover may be accomplished with cadaver grafts, porcine grafts, and a variety of synthetic skin substitutes. Permanent wound coverage is obtained by split-thickness skin grafts, local flaps, or microvascular free tissue transfer. Microstomia commonly results from perioral facial burns, or thermal burns that occur when small children chew electric cords. Oral splints are available for prevention of microstomia, but the efficacy of these appliances is controversial. Contracture of the eyelid, or ectropion, occurs when the eyelids are everted from the globes following burn injury. Factors that predict the need for intubation in patients with smoke inhalation injury. The successful repair of midface skeletal fractures requires an understanding of the impact of forces on the skeletal buttresses; it also requires a recognition of the weakness patterns common to this buttress system. Orbital fractures may occur either as a part of massive Titanium is also biocompatible. Conchal or nasal cartifacial trauma, in conjunction with Le Fort fractures, or lage is autologous and is therefore a good material for they may occur as isolated fractures. The mechanism of should be performed to ensure that any entrapment of injury for these fractures is usually from direct anterior the extraocular muscles is relieved. Classiconnected by very thin bones that include maxilla, fication and surgical management of orbital fractures: exsphenoid, lacrimal, frontal, zygomatic, ethmoid, and perience with 111 orbital reconstructions. Sudden anterior pressure midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segon the orbital contents can cause a fracture of the mental fractures. The nasoethmoid complex involves both a horizontal Not all orbital floor fractures require exploration and a vertical buttress. Orbital fractures need surgical intervention nasal root and the vertical buttress is the frontonasal under the following circumstances: (1) they cause maxillary pillar. Nasoethmoid complex fractures usually entrapment of the extraocular muscles, resulting in gaze require high velocity and a more powerful force in limitation or diplopia; (2) the patient has sagging of the order to be produced compared with isolated nasal fracorbital contents, causing enophthalmos and subsetures or orbital floor fractures. It is Because the anterior ethmoid cells have an impact highly recommended to obtain a baseline ophthalmoon frontal sinus drainage, patients with severe nasoethlogic exam of vision acuity and range of motion for all moid complex fractures may require follow-up to patients with orbital fractures, especially before proensure that the frontal sinus drainage is physiologically ceeding with operative repair. The key to repairing nasoethmoid after the injury; much of the edema from the trauma complex fractures is the reestablishment of the midline will have subsided and the repair technique will be easvertical height of the nasal root. The operative technique involves line vertical height prevents late deformity and restores either a subciliary or transconjunctival incision, both of the medial canthal tendon to an anatomically funcwhich give access to the orbital periosteum. Many permanent plex fracture is often accomplished through a bicoronal orbital implant materials have a long history of use, forehead flap, which gives an excellent exposure of the including Medpore (ie, porous polyethylene), Marlex nasal root to allow fracture reduction. Zygomatic complex be retrieved and reapproximated with fine-gauge stainfractures can also be approached with the same transless-steel wire, either to titanium plates or to holes drilled gingival buccal sulcus incision, which can give access as in the lacrimal bone. One four-hole, midface titamedial orbital attachments are not replaced optimally. Midfacial degloving approach for redesirable to expose at least two of the four buttresses in pair of naso-orbital-ethmoid and midfacial fractures. Aesthetic management of the buttress; alternately, a transconjunctival or subciliary nasal component of naso-orbital ethmoid fractures. Nasoethmoid complex fractures: diagnosis approach may be used to obtain direct access to the and management. Subunit principles in isolated zygomatic arch fracture; however, more severe midface fractures: the importance of sagittal buttresses, softforce can fracture the entire zygomatic complex.

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By measuring effusion, the possibility of a nasopharyngeal carcinoma the compliance of the middle ear transformer mechashould be considered. Tympanometry produces a peak (ie, Treatment maximal compliance) when the pressure in the external ear canal equals that of the middle ear. If there is an effusion in the middle ear, Spontaneous resolution occurs in a significant proportion then compliance does not vary with changes in canal of patients. A period of watchful waiting of 3 months pressure, and a flat (Type B) tympanogram is produced. Negative middle ear pressure results in a Type C patients in whom spontaneous resolution is unlikely. Medical emy of Pediatrics Subcommittee on Otitis Media with Effutreatments include antibiotics, steroids, decongestants, and sion. The online version and updated information can be accessed at shown to be effective in a small proportion of patients, but Risk factors for persisbenefit from antibiotic therapy needs to be considered tence of bilateral otitis media with effusion. Clin Otolaryngol along with the fact that a number of patients treated with Allied Sci. Steroids are therefore not recommended in the systematic review and meta-analysis to estimate the natural history of acute otitis media and otitis media with effusion. Myringotomy and aspiration of middle ear effusion without ventilation tube insertion has a short-lived benefit and is not recommended. The prolonged ventilation of the middle ear may also allow resolution of chronic inflammation of the middle ear mucosa. Complications include myringosclerosis, purulent otorrhea, General Considerations and residual perforation after extrusion. There are two main Chronic suppurative otitis media is defined as a persistypes of tympanostomy tubes: short-term tubes (eg, gromtent or intermittent infected discharge through a nonmets), which remain in the tympanic membrane for an intact tympanic membrane (ie, perforation or tympaaverage of 12 months, and long-term tubes (eg, T-tubes), nostomy tube). However, because of the potential risks There are a number of mechanisms by which a persisassociated with adenoidectomy (primarily hemorrhage tent tympanic membrane perforation may develop. This weakness of the tympanic membrane both predisposes to perforation and reduces the likeliDifferential Diagnosis hood of spontaneous healing. Although most tympanic the primary differential diagnosis is the presence of a membranes heal spontaneously after the extrusion of cholesteatoma. Both pathologies present with a very simventilation tubes, a small percentage do not. Traumatic ilar clinical course, and the presence of severe inflammaperforations, particularly if large, may fail to heal. Reexamination after a course of medical treatperforation can lead to continuous or repeated middle ment usually provides an accurate diagnosis. Biopsy of the granulation or polyp in these reflux of nasopharyngeal secretions into the middle ear circumstances is recommended. Both medical and of otorrhea, which may be either intermittent or continusurgical interventions play a role in achieving these aims ous, and hearing loss. Clearing the discharge from the Inspection may reveal scars from previous surgery for external auditory canal allows the topical agent to reach chronic ear disease. Ototoxicity has been demonIf the perforation is of sufficient size, it may be possible strated in animal models, and the use of gentamicin for to identify the presence of ossicular discontinuity due to vestibular ablation in Meniere disease is well docunecrosis of the long process of the incus. This circumstance is probably due to a combiA swab of the discharge should be sent for culture and nation of the relatively low concentration of aminoglycosensitivity, preferably before beginning antimicrobial side reaching the middle ear and edema of the middle ear therapy. An audiologic evaluation is necessary, because mucosa, which prevents the direct absorption of the drug the majority of patients have an associated conductive through the round window. Interventions for chronic suppurahave a poor penetration of the middle ear and are therefore tive otitis media (Cochrane Review). However, if otorrhea recurs or deposition of calcium in the tympanic membrane, middle persists despite medical treatment or if the patient feels ear, or both. It often occurs as a result of inflammation or handicapped by a residual conductive hearing loss, surtrauma and is therefore commonly seen after recurrent epigical therapy should be considered. The typical clinical appearance is of white plaques in ried out when the infection has been adequately treated the tympanic membrane. If the process is limited to the and the middle ear mucosa is healthy, since the chance tympanic membrane (ie, myringosclerosis), then hearing is of a successful outcome is increased. However, if the middle ear is involved, tympanoplasty, with repair of the tympanic membrane then the ossicular chain can become immobilized, resultand ossicular chain (if required), is recommended. The aims of this procedure are to Atelectasis aerate the middle ear and mastoid, remove chronically Atelectasis refers to the presence of a grossly retracted or inflamed tissue, repair the tympanic defect, and reconcollapsed tympanic membrane. The achievement of all of these result of prolonged negative middle ear pressure secongoals often requires more than one procedure. The infection may then progress to periostitis Sequelae Tympanosclerosis and subperiosteal abscess, or to a more serious intracranial Atelectasis infection. Pain and tenderness over the masPetrositis toid process are the initial indicators of mastoiditis. As Facial nerve paralysis the infection progresses, edema and erythema of the Suppurative labyrinthitis postauricular soft tissues with loss of the postauricular Intracranial Complications crease develop. Fullness of the posterior wall Intracranial abscess of the external auditory canal is frequently seen on otosBrain abscess copy as a result of the underlying osteitis. If a subperiExtradural osteal abscess has developed, fluctuance may be elicited Subdural in the postauricular area. Prothe formation of subperiosteal abscess, and the presence longed contact between the tympanic membrane and the of intracranial complications. When there is no clinical or tent atelectasis is that the normal migration pattern of radiologic indication of a subperiosteal abscess or an squamous epithelium from the tympanic membrane may intracranial extension of disease, then high-dose broadbe disrupted, leading to the accumulation of squamous spectrum intravenous antibiotics should be commenced. This situation is a If, after 24 hours of treatment, there is no evidence of particular risk if the retraction pocket is located in the resolution or if symptoms progress, a cortical mastoidecpars flaccida or the posterosuperior pars tensa. If spontaneous perforation of the tympanic membrane has eustachian tube dysfunction is still considered to be not occurred. If a subperiosteal abscess or an intracranial present, the insertion of ventilation tubes could potenextension of disease is suspected, surgery in combination tially reverse the changes in the tympanic membrane by with high-dose intravenous antibiotics should be the normalizing the pressure in the middle ear space. The symptoms and signs are procedure is not uncommon; therefore, prolonged equivalent to those of acute mastoiditis, but are less observation is advised. Most cases resolve with ventilation of the middle ear combined with appropriate anti2. If this treatment fails to resolve the infection, cortical mastoidectomy is indicated. Despite this fact, once an intracranial complicaBecause of the close relationship of the ophthalmic tion develops, it carries a significant risk to life. Theredivision of the trigeminal nerve and the abducens nerve fore, early recognition and treatment are vital to to the petrous apex, the classic features of petrositis are improve the prognosis. It is not uncommon for more otorrhea associated with retroorbital pain and lateral than one intracranial complication to occur simultarectus palsy (Gradenigo syndrome). The most common early symptoms of intraBecause of the high incidence of an intracranial cranial extension of infection are persistent headache extension of infection from petrositis, a combination of and fever. Other features include lethargy, irritability, antibiotics and surgical drainage of the petrous apex is and neck stiffness. This situation should be Acute otitis media is the most common cause of bactemanaged by myringotomy with aspiration of pus from rial meningitis. It can occur as a result of hematogenous the middle ear along with antibiotic therapy, which will spread, of direct extension from the middle ear through mostly result in the rapid resolution of paralysis. The most common organisms responindicated unless the paralysis fails to resolve.

References:

  • http://www.ccas.net/files/public/Publications/Curriculum_Guide_Version3.pdf
  • https://www.amherst.edu/media/view/248654/original/sexualENDTARGET+pleasure+as+a+HR.pdf
  • https://www.ncshguide.org/downloads/NCSH-Sexual-Health-Guide-National.pdf
  • http://www.mitcop.com/wp-content/uploads/2020/02/Ross-and-Wilson-ANATOMY-and-PHYSIOLOGY-in-Health-and-Illness-Eleventh-Edition-Anne.pdf

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