hyaline membrane disease - a case study

8/10/2019 Hyaline Membrane Disease - A Case Study

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INTRODUCTION

About 1 in 20,000-30,000 newborn US infants will have RDS. Not all,but the vast majorit are the result of !"D. A##ro$imatel half of neonates

born at %estation a%e of 2&-2' wee(s will )evelo# RDS, while about 30* of

30-31 %estation wee( neonates will )evelo# it. Althou%h #rematurit is the

#rimar ris( fa+tor, there are several other ris( fa+tors in+lu)in% maternal

)iabetes, +esarean se+tion, as#h$ia, ra#i) labor, an) +om#li+ations that

re)u+e bloo) flow to the fetus . nternationall, RDS o++urs less freuentl

than in the US but overall, it is more +ommon in white #remature infants

U/hi+a%o, 2013.

RDS almost alwas o++urs in newborns born before 3 wee(s of

%estation. he more #remature the bab is, the %reater is the +han+e of

)evelo#in% RDS. RDS is more li(el to o++ur in newborns of )iabeti+ mothers.

Ra#i), labore), %runtin% res#irations usuall )evelo# imme)iatel or within a

few hours after )eliver, with retra+tions above an) below the breastbone an)

flarin% of the nostrils an) the e$tent of atele+tasis lun% +olla#se an) the

severit of res#irator failure#ro%ressivel worse. Not all infants with RDS

have si%ns of res#irator )istress e$tremel low birth wei%htnewborns i.e., 4

1000 % ma be unable to initiate res#irations at birth be+ause their lun%s are

so stiff the ma fail to initiate breathin% in the )eliver room.

he in+i)en+e of RDS +an be re)u+e) b assessment of fetal lun%

maturit to )etermine the o#timal time for )eliver. 5hen a fetus must be

)elivere) #rematurel, %ivin% betamethasone sstemi+all to the mother for at

least 26 hours before )eliver in)u+es fetal surfa+tant #ro)u+tion an) usuall

re)u+es the ris( of RDS or )e+reases its severit.

f untreate), severe RDS +an result in multi#le or%an failurean) )eath.

!owever, if the newborn7s ventilation is a)euatel su##orte), surfa+tant

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#ro)u+tion will be%in an) RDS will resolve b 6 or 8 )as. Re+over is

hastene) b treatment with #ulmonar surfa+tant "e)i+ine, 2012

he in+i)en+e is estimate) at & #er 1000 births. Res#irator )istress

#resents in the first few hours of life in a #remature bab. Sm#toms

in+lu)e ta+h#noea, e$#irator %runtin%, nasal flarin%. he infant ma or ma

not be +anose). Substernal an) inter+ostal retra+tions ma be evi)ent.

Ris( fa+tors in+lu)e maternal )iabetes, %reater #rematurit, #renatal as#h$ia

an) multi#le %estation.

Asso+iate) abnormalities are those that +an o++ur in #rematurit9

intra+ranial haemorrha%e,ne+rotisin% entero+olitis, #atent )u+tus arteriosus,

)elae) )evelo#mental milestones, h#othermia an) h#o%l+aemiaA%rawal, : ;ni#e, et. Al 2016.

RDS o++urs in more than half of babies born before 2' wee(s

%estation, but onl in less than one-thir) of those born between 32 an) 3&

wee(s. Some #remature babies )evelo# RDS severe enou%h to nee) a

me+hani+al ventilator breathin% ma+hine. he more #remature the bab is,

the hi%her the ris( an) the more severe the RDS reviousl (nown as haline membrane )isease, this

+on)ition is #rimaril seen in #remature infants oun%er than 32 wee(s?

%estation.

he ra)io%ra#hi+ features of RDS are seen in the ima%es below. A

normal film at & hours of life e$+lu)es the )ia%nosis of RDS. /lassi+

res#irator )istress sn)rome RDS is a bell-sha#e) thora$ is )ue to

%enerali@e) un)er aeration.


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Severe res#irator )istress sn)rome RDS is a Reti+ulo%ranular

o#a+ities are #resent throu%hout both lun%s, with #rominent air bron+ho%rams

an) total obs+uration of the +ar)ia+ silhouette. /sti+ areas in the ri%ht lun%

ma re#resent )ilate) alveoli or earl #ulmonar interstitial em#hsema >.

he in+i)en+e an) severit of RDS are inversel relate) to %estational a%e.

RDS is the most +ommon +ause of res#irator failure )urin% the first )as after

birth. n a))ition to #rematurit, other fa+tors +ontributin% to the )evelo#ment

of RDS are maternal )iabetes, +esarean )eliver without #re+e)in% labor

bein% the se+on) born of twins, #erinatal as#h$ia, #erinatal infe+tion, an)

#atent )u+tus arteriosus.

/om#li+ations of RDS are numerous, both a+ute an) +hroni+. nfantswith RDS are at ris( of )evelo#in% alveolar ru#ture an) #ulmonar interstitial

em#hsema, infe+tion, intra+ranial hemorrha%e, +hroni+ lun% )isease

bron+ho#ulmonar )s#lasia, retino#ath of #rematurit, neurolo%i+

im#airment, an) su))en )eath Do, >.,


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Significance of the Study

he si%nifi+an+e of the stu) is to learn )ee#er re%ar)in% the +ase of

the #atient how the +om#li+ation starte) an) how it affe+ts the #hsiolo%i+

as#e+t of the #atient?s bo).

his will serve as an instrument to %ain more (nowle)%e that will hel#

the #atient to be+ome aware about the #ro#er mana%ement an) +are for

en)ometriosis. t will also e)u+ate the #eo#le es#e+iall with those

en)ometriosis an) vulnerable in)ivi)uals to see( me)i+al +are in or)er to

#revent su+h )isease. he #atient +an also alleviate her +on)ition throu%h

+om#lin% with the re+ommen)ations su%%este) b the resear+hers.he hos#ital institutions +an also benefit with this +ase stu) for it

#rovi)es information about haline membrane )isease also (nown as

res#irator )isease sn)rome in newborn. he +oul) also use this as

referen+es for it #rovi)es thorou%h assessment fin)in%s that ma be

asso+iate) when e$#erien+in% en)ometriosis. he +ase stu) +oul) also

#rovi)e the institution with the i)eal me)i+ations an) interventions or

mana%ement.

he +ase stu) is also essential for us nursin% stu)ents for it #rovi)es

information about the +on+erne) )isease an) su##lies the la+(in% (nowle)%e

of the stu)ents. hrou%h the stu), we were able to i)entif +ues relate) to the

#re+i#itatin% fa+tors an) #re)is#osin% fa+tors of the )isease, in whi+h we were

able to %ive nursin% )ia%nosis base) on our un)erstan)in%.

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Case Objectives

Beneral Cbje+tive9

his stu) aims to )etermine what is haline membrane )isease

s#e+ifi+all in the newborn.

S#e+ifi+ Cbje+tives9

1 Dis+uss the intro)u+tion of the )isease in+lu)in% its in+i)en+e an)

#revalen+e rate of !"D2 /on)u+t review of the sstems.3 /on)u+t a #hsi+al e$amination from hea) to toe.6 Define the what !"D all about8 Dis+uss the anatomi+al #arts of affe+te) area an) e$#lain fun+tions

of ea+h #art& ra+e the #atho#hsiolo% of the )isease numerate an) +on)u+t a )ru% stu) on )ru%s a)ministere) to the

#atient with its #harma+olo%i+al uses an) effe+ts as well as nursin%

res#onsibilities to be observe in relation to the #atient?s +on)ition' ormulate effe+tive nursin% +are #lansE Dis+uss the #ro%nosis about the +ase with its justifi+ation

DEFINITION OF DIAGNOSIS

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!aline membrane )isease !"D, more +ommonl +alle) res#irator

)istress sn)rome RDS, is one of the most +ommon #roblems of #remature

babies. t +an +ause babies to nee) e$tra o$%en an) hel# breathin%. he

+ourse of illness with haline membrane )isease )e#en)s on the si@e an)

%estational a%e of the bab, the severit of the )isease, the #resen+e of

infe+tion, whether or not a bab has a #atent )u+tus arteriosus a heart

+on)ition, an) whether or not the bab nee)s me+hani+al hel# to breathe.

RDS t#i+all worsens over the first 6' to 2 hours before im#rovin% with

treatment


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not be +anose). Substernal an) inter+ostal retra+tions ma be evi)ent

A%rawal : ;ni#e, et. al 2016.

!aline membrane )isease9 A res#irator )isease of the newborn,

es#e+iall the #remature infant, in whi+h a membrane +om#ose) of #roteins

an) )ea) +ells lines the alveoli the tin air sa+s in the lun%, ma(in% %as

e$+han%e)iffi+ult or im#ossible. he wor) GhalineG +omes from the Bree(

wor) GhalosG meanin% G%lass or trans#arent stone su+h as +rstal.G he

membrane in haline membrane )isease loo(s %lass. !aline membrane is

now +ommonl +alle) res#irator )istress sn)romeRDS. t is +ause) b a

)efi+ien+ of a mole+ule +alle) surfa+tant "e)i+inet, 2012.

Res#irator )isease sn)rome RDS, also (nown as halinemembrane )isease, is the +ommonest res#irator )isor)er in #reterm infants.

he +lini+al )ia%nosis is ma)e in #reterm infants with res#irator )iffi+ult that

in+lu)es ta+h#nea, retra+tions, %runtin% res#irations, nasal flarin% an) nee)

for N/RAS C2. n the last three )e+a)es, intro)u+tion of antenatal

steroi)s an) e$o%enous surfa+tant has %reatl im#rove) out+omes in RDS

however, it remains a #rin+i#al +lini+al #roblem /N!S, 2006.

EA!T ISTOR"

#iog$a%hica& Data

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Na'e(Hb. Ho rovin+ial !os#ital, Amas ;i)a#awan /it

Re&igion(Horn A%ain

Citi,enshi%( ili#ino

T$ibe( llon%%oea&th Insu$ance(>hil !ealth

os%ita&( /otabato >rovin+ial !os#ital, Amas ;i)a#awan /it

C&assification( >hil !ealth N/U

Ad'ission( De+ember E, 2016

Chief Co'%&ain( etal Distress

Ad'itting Diagnosis( !aline "embrane Disease of Newborn

Reason fo$ See-ing ea&thca$e

he mother was a)mitte) at the hos#ital last De+ember E, 2016 )ue to

labor #ain. She )elivere) her bab the #atient as Normal s#ontaneous

va%inal )eliver NS=D. Due to fetal )istress of the bab after he was born,

the health +are #ra+titioners )e+i)e) that the bab must be a)mitte) for further

mana%ement an) evaluation of the +ase.

Cu$$ent ea&th Status

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>rior to a)mission, the bab was )elivere) via normal s#ontaneous

va%inal )eliver. After whi+h, fetal )istress o++urs.

+ast ea&th isto$y

Sin+e the #atient was a newborn, he has no #ast health histor but the

mother has. !er mother is a farmer. She tol) me that she was e$#ose) from

heat of the sunli%ht. She was %oin% to the %ravel area where her husban) is

wor(in%. Sometimes the mother was %oin% outsi)e with her frien)s an) havin%

fun. he mother was o++asionall smo(in% but not )rin(in%.

Gyneco&ogica& isto$yhe mother is a 1E ear ol), marrie) an) has a livin% +hil) B 1>1A0.

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Fa'i&y isto$y

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Grandfath

er, 57 y.o,

Osteoporosis

Grandmother, 58

y.o, rheumatoid

arthritis

Grandmother, 58

y.o, rheumatoid

arthritis

Grandfath

er, 54 y.o,

Asthmatic

Pts Mother,

1 y.o, !e""

and a"i#e

$uya, %5

y.o,

a"coho"ic

, cou h

&ister 1,

%8 y.o,

!e"" and

a"i#e

&ister, '%

y.o, !e""

and a"i#e

$uya 1,

'4 y.o,

!e"" and

Pts

(ather,

%1 y.o,

Patient, ne!)orn, diagnosed of ha#ing

*ya"ine Mem)rane +isease


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Revie. of Syste's

Gene$a& Su$vey

he #atient was manifestin% )iffi+ult of breathin%, has an en)otra+heal

tube atta+he) to him with me+hani+al ventilator, has no lesion, s(in is inta+t,

#ositive bloo) se+retion after #ressin% the amboba%. here was no mass on

hea), ne+( an) no si%ns of an injuries or fra+tures. !is hea) an) e$tremities

were fle$e) with a hea) +ir+umferen+e of 3& +m, +hest +ir+umferen+e of 2

+m, ab)ominal +ir+umferen+e of 23 +m, wei%ht of 1.8 (%, a hei%ht of 66 +m

an) a re+tal tem#erature of 3&.' / manifest that his re+tum is #atent. !is

res#irator rate was '& ++les #er minute with nasal flarin% an) has anirre%ular heart beat that were #lain% at a minimum of ' beats #er minute an)

a ma$imum of 16& beats #er minute.

Integu'enta$y Syste'

No lesion was note) when the resear+her +on)u+te) #hsi+al

assessment but was note) a +left li# li(e sha#e that is mabe )ue to the

tube that was +onne+te) to the #atient. !is s(in was )r but warmth to tou+h

with uneven s(in tone an) has a re))ish +olor on his +hee(. !e has no si%ns

of +anosis, there were +hees li(e substan+es verni$ +aseosa on his ne+(,

his hair was euall )istribute) an) his nails were alrea) lon%.

EENT

he #atient was still a newborn. A++or)in% to the mother, the bab has

smmetri+al hea) an) ees with no ee e$u)ates. 5hen the #atient +alle), he

turns to si)e but +an?t vo+ali@e. here were no e$u)ates on the nose.

Res%i$ato$y Syste'

5hen the wat+hers as(e) about the #atients breathin% #attern, the

answere) that sometimes the observe fast +hest #um#in% an) sometimes

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slow. A++or)in% to the vital si%n, his RR was '& ++les #er minute an) it

in)i+ates ta+h#nea sin+e the normal ran%e of res#irator rate in newborn was

30 I &0 ++les #er minute onl.

Ca$diovascu&a$ Syste'

5hen the mother was as(e) about the a+tivit of her bab, she re#lie)

usahay active, usahay dili sometimes a+tive but sometimes he isn?t. she

)i)n?t observe) an bluish )is+oloration in the +hil).

Gast$ointestina&

he mother tol) the resear+her that the #atient #oo#s on+e but noteatin% nor )rin(in% et.

Genitou$ina$y

he #atient was alrea) urinates an) +onsume) 1 )ia#er onl.

*uscu&os-e&eta&

he #atient was still a newborn. !e has alrea) #ositive in almost all

refle$es normall foun) in newborn.

Neu$o&ogica&

he #atient was still a newborn. he mother tol) the resear+her that

she )i)n?t noti+e) an tremors or unusual movements of the bab but she was

worrie) be+ause the bab )i) not su+( et.

Infections

he #atient was still a newborn. here was no infe+tion o++urs et as

evi)en+e) b the latest tem#erature of 3&.' / with no other si%ns of infe+tion.

Hut an in+rease of 5H/ on the lab results in)i+ates that there are infe+tion

#resent but the leu(o+tes of the #atient is fi%htin% it.

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Re&ationshi%

5hen the mother as(e) about what she feels about the bab, she

re#lie) that the are ha## be+ause there were new %ift the have ha)

re+eive) from %o) but lonel be+ause of the situation of their bab.

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+S"COSOCIA! +ROFI!E

ea&th +$actices and #e&iefs

he #atient was still a newborn. !is mother +laime) that she is

un)er%one a +om#lete #renatal +he+(-u# in the hos#ital.

Ty%ica& Day

he #atient was still a newborn.

Nut$itiona& +atte$n

he #atient was still a newborn. !is mother was eatin% nutritious foo) 3times a )a with 2 I 3 times of her sna+(s.

Activity and E)e$cise +atte$n

he #atient was still a newborn. !er mother was wal(in% ever)a

usuall earl in the mornin%.

Rec$eation and obbies

he #atient was still a newborn.

S&ee%/ Rest +atte$n

he #atient was still a newborn. !is mother was wa(in% u# earl in the

mornin% at aroun) 8900 am.

+e$sona& abits

he #atient was still a newborn. !er mother was smo(in% o++asionall

but not )rin(in% al+oholi+ bevera%es.

Occu%ationa& ea&th +atte$ns

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he #atient was still a newborn. !er mother was a ven)or an)

sometimes e$#ose) to )ust an) sun for her husban) is wor(in% at san) an)

%ravel an) +onstru+tion.

Envi$on'enta& ea&th +atte$ns

heir environment +an be )es+ribe) as not free with +hemi+als be+ause

the are surroun)e) b farms. Hut the still observe sanitation.

Cu&tu$a&/ Re&igious Inf&uences

he #atient was still a newborn. 5hen her mother as(e) about

reli%ious influen+es, she answere) that if its %o)?s will then it will ha##en.

Fa'i&y Ro&es and Re&ationshi%s

!e has a ver su##ortive famil. !is mother )i)n?t left him alone.

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+"SICA! ASSESS*ENT

Date Assessed( De+ember 0E, 2016

Gene$a& Su$vey

Hab Ho < was aslee# with an on%oin% = of D105 J /a infusin% well

at ri%ht meta+ar#al vein. !e has an ube +onne+te) to me+hani+al

ventilator on his mouth.

0ita& Signs

De+ember 0E, 2016 at 2900 #mem#erature I 3&.'K/

Res#irator Rate RR - '& ++le #er minute +#m

>ulse Rate >R - 16& beats #er minute b#m

Anth$o%o'et$ic *easu$e'ent

!ea) /ir+umferen+e I 3& +m

/hest /ir+umferen+e I 2 +m

Ab)ominal /ir+umferen+e I 23 +m

5ei%ht I 1.8 (%

!ei%ht I 66 +m

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ead1to1Toe Scan

Assessing the Integu'enta$y Syste's

No lesion was note) when the resear+her +on)u+te) #hsi+al

assessment but was note) a +left li# li(e sha#e that is mabe )ue to the

tube that was +onne+te) to the #atient. !is s(in was )r but warmth to tou+h

with uneven s(in tone an) has a re))ish +olor on his +hee(. !e has no si%ns

of +anosis, there were +hees li(e substan+es verni$ +aseosa on his ne+(,

his hair was euall )istribute) an) his nails were alrea) lon%.

Assessing the EENT

5hen his anterior fontanels was %entl #al#ate), there was a )iamon)

sha#e li(e that the resear+her was observe) an) a trian%ular sha#e li(e on the

#osterior #ortion. !e has soft fa+e with smmetri+al fa+ial movements. !e has

#ositive toni+ refle$. !is ees are e)ematous mabe )ue to va%inal )eliver

was o++ur, ees were eual an) smmetri+al. !is #inna ere fle$ible, without

)eformit an) ali%ns with the e$ternal +anthus of the ees. !is nares were

#atent with a small amount of white to +olorless )is+har%es. "u+ous

membrane were #in( an) moist, frenulum of ton%ue an) li# were inta+t but

wasn?t a %oo) su+(er, with minimal saliva an) +rin% so lou) but interru#te)

sometimes.

Assessing the Chest

!is +hest when #al#ate) has no lesion or masses note). !e has

antero#osterior9lateral +hest with eual +hest e$+ursion but in+reases ra#i)l

)ue to )iffi+ult of breathin%.

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Assessing the Abdo'en

!is ab)omen is roun) in sha#e, warm to tou+h with no lesions note).

!e has #ositive bowel soun). !is liver e)%e is #al#able 2 I 3 +m an) also the

ti# of the s#leen an) (i)nes.

Assessing the Rectu'

he #atient?s anus is #atent with me+onium stool an) #ositive anal

refle$.

Assessing the *a&e Genita&iahe #atient alrea) urinates. 5hen the #re#u+e was retra+te) the bab

+ries. !is urethral o#enin% is at the ti# of #enis s+rotum is e)ematous an) has

#al#able testes.

Assessing the *uscu&os-e&eta&

he #atients toes an) fin%ers are +om#lete as +ounte) 8 +ounts on the

left han),8 +ounts on the ri%ht han)s an) 8 +ounts ea+h on both feet has full

ran%e of motion with no +li+(s hear), eual %luteal fol)s, / +urve of s#ine with

no )um#lin%. 5hen arms an) le%s are e$ten)e), the resear+her note) that

mus+les are smmetri+al an) with eual mus+le tone an) arms an) le% are

smmetri+al in si@e an) movement.

Assessing the Neu$o&ogica&

5hen +he+(e) with refle$ test, the #atient are #ositive with moro refle$,

(nee refle$, startle refle$, toni+ ne+( refle$, #almar %ras# refle$es, #lantar

%ras# refle$, an) babins(i refle$.

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FOCUSED ASSESS*ENT

Assessing the Res%i$ato$y Syste'

!is res#irator rate is '& ++les #er minute an) it was above the normal

ran%e. !e was e$#erien+in% )iffi+ult of breathin%. U#on aus+ultation, there is

a s+attere) +ra+(les hear) on the +hest. /ou%h refle$ is absent an) bron+hial

an) bron+hovesi+ular breath soun)s were au)ible.

!abo$ato$y and Diagnostic Resu&tA2 E*ATO!OG"

Date( 34 5 67 5 38Tab&e No2

Hasi+ est Result Referen+e=alues

Lustifi+ation

5H/ 16.E 8-10 $ 10%Fattern

m#aire)Bas$+han%e

At the en)of ' hr.s#an of m+are the #t.will be able

)emonstrate im#rove)ventilationan)a)euateo$%enation of tissuesb AHB?swithin+lient?snormalran%e an)be freefrom ansi%ns of

res#irator)istress..

Cbserve for

lo+ali@e) si%nsof infe+tion atsur%i+alinfe+tions.

Stress #ro#er

h%iene.

/han%e

sur%i+alwoun))ressin% )ail.

m#hasi@e

ne+essit ofta(in%antibioti+s as

)ire+te).

n+lu)es

tea+hin% aboutwas to re)u+e#otential for

o assess +ausative

or +ontributin%fa+tors aboutinfe+tion.

o limit e$#osuresan) re)u+e+ontamination

o re)u+e ba+terial

+oloni@ation.

>remature

)is+ontinuation oftreatment when +lientsfeel well ma result inreturn of infe+tion an)#otentiation of )ru%resistantstrains.

o re)u+e #otential

infe+tion.

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#ost o#erativeinfe+tion.

ASSESS*ENT NEED NSG2DIAGNOSIS

+!AN NSG2INTER0ENTION

RATIONA!E

Date(12 I 0E - 16

Ti'e( 6930 #m

Subjective(

may ara sang tubonga gikabit sa akongbata

Objectives( ube

atta+he) tothe mouth ofthe bab.

Re)ness an)

swellin% onthe si%ht

!ealth

#er+e#tion I

healthmana%e

ment#attern

Ris( for

trauma FSuffo+ation

Scientificbasis(nvasive#ro+e)uresmain+rease)ris( fortrauma

At the en)

of ' hr.s#an of m+are the #t.will be abletore+o%ni@e#t?swat+hernee) foran) see(assistan+eto #revent+om#li+ation.

Cbserve for

lo+ali@e) si%nsof infe+tion atsur%i+alinfe+tions.

Stress #ro#er

h%iene.

/han%e

sur%i+alwoun))ressin% )ail.

m#hasi@ene+essit ofta(in%antibioti+s as)ire+te).

o assess +ausative

or +ontributin%fa+tors aboutinfe+tion.

o limit e$#osures

an) re)u+e+ontamination

o re)u+e ba+terial

+oloni@ation.

>remature

)is+ontinuation of

treatment when +lientsfeel well ma result inreturn of infe+tion an)#otentiation of )ru%resistantstrains.

o re)u+e #otential

infe+tion.

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n+lu)es

tea+hin% aboutwas to re)u+e#otential for#ost o#erativeinfe+tion.

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+$ognosis

#i+all, the sm#toms worsen a few )as after birth but slowl

im#rove afterwar)s. he %oal is to su##ort the infant while the lun%s be%in

#ro)u+in% surfa+tant. >rovi)in% a)euate nut$itiona& $e@ui$e'ents is also

im#ortant for re+over an) %rowth.

"an infants with !"D suffer the +om#li+ations of o$%en an)

ventilation thera# but re+over within the first +ou#le of ears of life as the lun%

tissue is re#la+e) with new an) fun+tional tissue.

Dama%e to other or%ans su+h as the brain ma also o++ur whi+h is )ue

to a +ombination of fa+tors in+lu)in% h#o$ia an) intraventri+ular hemorrha%e,

so it is im#erative to be%in thera# earl an) monitor or%an )ama%e

U/hi+a%o, 2013.

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#ib&iog$a%hy

A%rawal, R. ;ni#e, !. et. Al 2016 !aline membrane )iseaseOhtt#9FFra)io#ae)ia.or% Farti+lesFhaline-membrane-)isease

Davis, />, 2016. !emato+rit Hloo) estO . htt#9FFwww.eme)i+inehealth.+omF

hemato+ritQbloo)QtestF#a%e8Qem.htm

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http://www.emedicinehealth.com/%09hematocrit_blood_test/page5_em.htmhttp://www.emedicinehealth.com/%09hematocrit_blood_test/page5_em.htmhttp://www.emedicinehealth.com/%09hematocrit_blood_test/page5_em.htmhttp://www.emedicinehealth.com/%09hematocrit_blood_test/page5_em.htm


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Do, >.,

hyaline membrane disease - a case study

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