Download Week 3 Lecture Notes File

Disorders of the Musculo-skeletal
Systems
Compiled by Venina Navuta
30/1/17
Bone Structure & Function
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Main functions
Support
Protection of internal organs
Voluntary movement
Blood cell production
Mineral storage
• Internal & external growth &
remodeling are ongoing processes
• Skeleton consists of 206 bones
• Joint is a place where ends of two
bones are in proximity and move in
relation to one another
• Cartilage
• Muscle –types
• Ligaments and tendons
• Fascia
• Bursae
Common Signs and Symptoms of
Musculo-Skeletal Disorders
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Pain
Weakness
Deformity
Limitation of movement
Stiffness
Joint crepitation
Assessment of the Musculo-Skeletal
Systems
• Subjective data
- Important health information
- Functional health patterns
• Objective data
- Physical examination
Effects of Aging on the Musculoskeletal System
• Mild discomfort and decreased
ability to perform daily activities of
living
• Severe chronic pain and immobility
• Risk of falls
• Bone remodeling process is altered
Other effects
• Decrease in bone density
→ osteopenia, osteoporosis
• Muscle mass & strength decrease
• Loss of motor neurons
• Tendons & ligaments become less
flexible, movements become more
rigid
Common Diagnostic Tests
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X-ray
common test for any abnormality
Monitor effectiveness of treatment
Evaluation of hereditary,
developmental, infectious,
inflammatory, neoplastic, metabolic
& degenerative disorders
• Magnetic Resonance Imaging(MRI)
- View soft tissues
- Assist in diagnosis of avascular
necrosis, disc disease, tumors,
osteomyelitis, ligament & cartilage
tears.
• Arthroscopy
• Arthrocentesis & synovial fluid analysis
• Muscle enzymes: ascertain site of tissue
damage
• Serological tests: ascertain rheumatoid
factor(RF) for rheumatoid arthritis,
higher with increased disease activity
- RF directed against IgG
- ↑erythrocyte sedimentation rate & Creactive protein-non-specific indicators
of active inflammation
Common Causes of Diseases
• Traumatic event
→ fracture, dislocation & associated
soft-tissue injuries
→ pain, disability, medical expenses &
lost wages is huge
→homes: falls & related injuries for
adults 65years & over
 PREVENTION OF MS PROBLEMS IN
OLDER ADULTS
Other Causes of Diseases
 Infection: osteomyelitis
 Bone tumors: benign & malignant
Muscular Dystrophy: genetically transmitted
diseases→symmetrical wasting of skeletal muscle
without evidence of neuro involvement
Low back pain
Neck pain
Foot disorders
Metabolic bone diseases: osteomalacia, osteoporosis
Arthritis & connective tissue diseases:
spondyloarthropathies, SLE, systemic sclerosis
Soft tissue rheumatic syndromes: myofascial pain
syndrome, fibromyalgia syndrome, chronic fatigue
syndrome
SOFT-TISSUE INJURIES
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Usually caused by trauma
Sprains
Strains
Dislocations
Subluxations
SPRAINS & STRAINS
• Sprain: injury that affects the
tendons and ligaments surrounding
the joint
• Usually associated with abnormal
twisting and stretching
• Common areas affected: wrist and
ankle
CLASSIFICATION OF A SPRAIN
- According to the number of ligament
fibres torn
• First degree sprain: few fibers involved,
mild tenderness, minimal swelling
• Second degree: partial disruption of
involved tissue, more swelling,
tenderness
• Third degree: complete tearing of
ligament, moderate to severe swelling
Strain
• Excessive stretching of a muscle and
it’s fascial sheath
- Often involves the tendon
• First degree: mild /slightly pulled
muscle
• Second degree: moderately torn
muscle
• Third degree: severely ruptured or
torn muscles
Clinical Manifestations
• Pain
• Oedema
• Decrease in function
• Contusion
Sprain and Strain S/S Similiar
Diagnostic Tests
• X-Ray: to rule our fracture or
widening of the joint structure.
• ‘Ottawa rules’: assessment protocol
for the examination of an injured
ankle or knee before an x-ray.
TREATMENT
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Limit movement
Apply ice compresses
Compress involved extremity
Elevate extremity
Provide analgesia prn
• Acute injury phase: 24-48hours
• After acute phase
- Apply warm moist heat to reduce
swelling for 20-30minutes only; allow
for cool down time between
applications
- Administer mild analgesic to
promote comfort
Dislocation and Subluxation
• Dislocation: severe injury of the
ligament surrounding a joint.
• Complete displacement or separation
of the articular surfaces of the joint
• Causes
- Congenital anomaly
- Pathological origin
Clinical Manifestations
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deformity,
local pain,
tenderness,
loss of function of injured part,
swelling of soft tissues
Diagnostic test: x-ray
Major Complications
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Open joint injuries
Intra-articular fractures
Fracture dislocation
Avascular necrosis
Damage to adjacent neurovascular
tissue
 neurovascular assessment is
important
Subluxation
• partial or incomplete displacement
of joint surface
• s/s are similar to dislocation but with
less severity; similar treatment too
but require less healing time
Nursing & Collaborative Management
• Traumatic dislocation are orthopedic
emergencies
• Treatment crucial otherwise untreated
dislocation can result in avascular
necrosis
• Realignment of joint: closed or open
reduction under local or general
anesthesia
• Immobilization of affected extremity:
bracing, splinting, taping or sling to
allow proper healing
• Pain relief
• Movement restricted
• Regulated rehab program needed to
prevent fracture instability & joint
dysfunction
• Gentle ROM can be started if joint is
stable & well supported
ROTATOR CUFF TEARS
• tears may result from an acute
injury or from chronic joint
stresses.
• involves the four major muscles
that stabilise the shoulder joint
(supraspinatus, teres minor and
major, and subscapularis).
• Causes can include
- degeneration of the joint with
age,
- repetitive stress,
- sporting injuries (throwing,
bowling, overhead motions as in
tennis and squash)
- falls on an outstretched hand.
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Clinical Manifestations
pain, severe pain when arm is
abducted 60-120°
limited ROM and some
joint dysfunction, including
Shoulder muscle weakness.
Sometimes night pain and
sleeplessness
unable to perform over-the-head
activities
Medical Management
• nonsteroidal anti-inflammatory
drugs (NSAIDs),
• rest with modification of activities,
• injection of a corticosteroid into the
shoulder joint, and
• progressive stretching, ROM and
strengthening exercises
(Shelby, 2010)
• arthroscopic debridement (removal of
devitalized tissue)
• arthroscopic or open acromioplasty with
tendon repair.
• Postoperatively, the shoulder is
immobilized for several days to 4 weeks.
NB: Immobilization necessary but not for
too long otherwise frozen shoulder can
occur
Meniscus Injury
• Associated with ligament sprains
• injuries leave loose cartilage in the knee
joint that may slip between the femur and
the tibia, preventing full extension of the
leg. If this happens during walking or
running, patients often describe their leg as
‘giving way’ under them.
• Can hear or feel a click in the knee on
walking, especially when leg that is bearing
weight, is extended.e.g. going upstairs.
Nursing & Collaborative Management
• Conservative treatment: ambulate as
tolerated, knee brace
• Crutches can be used
• Analgesic prescribed
• If symptoms persist MRI can be
ordered before an arthroscopy is
done – meniscus surgery
Bursitis
• Inflammation of the bursa
• Bursae closed sacs lined
with synovial membrane & contain
small amount of synovial fluid
• Located at sites of friction: between
tendons and bones & near joints
Causes
• Repeated or excessive trauma or
friction
• Gout
• Rheumatoid arthritis
• infection
Clinical Manifestations
• Warmth
• Pain
• Swelling
• Limited ROM in affected part
Common sites
• Hand,knee,greater trochanter of hip,
shoulder and elbow
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Treatment
Rest
Apply cold pack
Immobilisation of affected part
Use of NSAIDS to reduce inflammation
and pain
• If symptoms persist: bursectomy
maybe necessary
• If sepsis occurs: surgical incision and
drainage
FRACTURES
• Complete- a break across the entire crosssection and is frequently displaced.
• Incomplete (Greenstick)-break occurs through
only part of the cross-section of the bone.
• Closed Fracture (simple)
- doesn’t break through the skin.
• Open fracture (compound)
- extends through the skin
• Comminuted- splintered into fragments
• Depressed- fragment(s) is(are) indriven
• Pathologic- through an area of diseased bone
Clinical Manifestations
• Pain & Tenderness- • Deformity
continuous and
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Ecchymosis/
increases in
contusion
severity after
injury.
• Loss of function
• Oedema &
• Crepitation
Swelling- usually
over affected area, • Muscle spasm
but can also occur
in adjacent
structures.
Treatment
• Reduction- open or closed
• Casting and/or traction
EXTERNAL FIXATION
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Provides rigid fixation and reduction with the
ability to manage severe soft tissue wounds.
INDICATIONS
Severe open fractures
Highly comminuted closed fractures.
arthrodesis
infected joints
infected non union
fracture stabilization to protect arterial or
nerve
anastomosis
- major alignment and length
deficits
- congenital contractures
COMPONENTS OF EXTERNAL FIXATOR
- bone anchoring devices (e.g.
threaded pins, Kichner wires).
- longitudinal supporting devices
e.g. threaded or smooth rods.
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External Fixation
Manipulation & Skin/Skeletal Traction
Internal Fixation
To correct long bones fractures
- Application of compression plates
and screws and insertion of pins,
intramedullary rods, nails or wiring.
Fracture Complications
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Infection
Fat embolism syndrome
Compartment syndrome
Venous thrombosis
Casts
Used to immobilize a body part so that a
fracture of a bone or dislocation can heal.
Pressure from hard casting materials can
produce complications such as:
• Pain
• Decreased sensation
• Skin breakdown
Casting materials- plaster or fiberglass
Cast
Indications
• Provide protection and healing of
fractures
• Maintain therapeutic alignment- body
parts
• Protect soft tissue injuries
• Provide support after orthopedic surgery
• Correct skeletal malformations
Nursing Management
 Wet cast takes 24-48 hrs to dry completely
 Elevate extremity & support entire length of
injured body part
 Look out for sharp cast areas & pressure to tissue
• Perform regular neurovascular assessmentWarmth, color, pulses, capillary refill, swelling.
• Motion checks- ask pt. to wiggle fingers or toes.
• Sensation checks- can pt. feel pressure, ask about
pain, this may detect if cast is too tight.
• Check for odor and drainage
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Patient & Family Teaching
Do not place any object in the cast
Keep cast dry if made of POP
Use blow drier to dry cast made of fiber glass
Assess the injured extremity for:
Coolness
Changes in color
Increased in pain
Increased in swelling
Loss of sensation
Traction
• Used to minimize muscle spasm
• Used to reduce, align, and
immobilize fractures
• Used to correct/prevent deformity
• Treatment of dislocated,
degenerated, ruptured intravetebral
discs and compression
Nursing Goals
• Maintain line of pull.
• Pt. is in center of bed, with good
alignment
• Weights hanging freely.
• Prevent complications
Types of Traction
• Skin traction (straight) - Buck’s, Bryant’s,
pelvic girdle. The pull is transmitted to
muscle structure, indirect traction.
• Skeletal traction – pins or wires inserted in
bone and attached to traction, may be used
to treat fractures of humerus, tibia, fibula
• Continuous- for fractures
• Intermittent- for back muscle sprains
5Ps Assessment for Orthopedic
Patients
Symmetric comparison:
• Pain- location, severity
• Pulse- distal to injury, check bilaterally.
• Parasthesia- numbness, tingling, compare
bilaterally. Sensation check
• Pallor- check skin color and temp.
• Paralysis- Assess mobility, watch for foot drop,
compartment syndrome
Documentation
• Traction, type, weight, changes in
treatment
• Patient tolerance and pain
• Patient assessment of NV checks, skin
condition, respiratory status, elimination
pattern
• Note condition of any pin sites and any
care given
NURSING CARE PLAN
• Formulate a nursing care plan for a
patient who is on a traction – prep for
clinical lab
COMMON TYPES OF FRACTURES
 COLLES’ FRACTURE – Fracture distal radium
– common with adults.
 FRACTURE OF THE HUMERUS – involves
the shaft of the humerus.
 FRACTURE PELVIS – can be life threatening
depends on the mechanism of injury.
 FRACTURE OF THE TIBIA – vulnerable to
injury because it lacks anterior muscle
covering.
HIP FRACTURES
• High incidence in elderly due to risk for
falls, osteoporosis.
• Intracapsular- fx. Neck of femur, may
damage blood supply, aseptic necrosis.
• Extracapsular- base of neck and lesser
tronchanter of femur- heals more easily.
• ORIF- open reduction with internal fixation
Symptoms of Fractures
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Deformity
Swelling
Bruising
Muscle spasms
Tenderness
Pain
• Impaired
sensation
• Loss of normal
function
• Abnormal mobility
• Crepitus
• Shock
• Abnormal Xrays
Nursing Diagnoses
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Risk for injury: subluxation or dislocation
Pain related to surgical incision
Risk for infection: impaired skin integrity
Impaired physical mobility
Risk for Peripheral Neurovascular
Dysfunction
Amputation
• More advancement in the
surgical amputation techniques,
prosthetic design and
rehabilitation programs
Nursing Management
• Assessment – most important part to assess is
the vascular and neurological status.
• Nursing Diagnosis
- disturbed body image related to
amputation and impaired mobility
- impaired skin integrity
• Objectives
• Nursing Intervention
• Evaluation
Care Of The Patient Undergoing An
Amputation
• Pre-op monitor N/V status both extremities
• Observe for ulceration, edema, necrosis.
• Baseline VS and lab data, doppler studies,
angiography, ECG, chest x-ray.
• Time for verbalization fears, anxieties.
• Teach re; overhead trapeze, incentive
spirometer.
Types of Joint Surgery
• Synovectomy – removal of synovial fluids
• Osteotomy – removing or adding a wedge
or slice of bone to change alignment and
shift weighting bearing, thereby
correcting deformity and relieving pain.
• Debridement – removal of degenerative
debris such as loose bodies, osteophytes,
joint debris and degenerated menisci.
ARTHROPLASTY
• Reconstruction or replacement of a joint
 Hip arthroplasty
- relief of pain
- improve function
 Knee Arthroplasty
- unremitting pain and stability as a
result of severe destructive deterioration
of the knee joint.
 Finger Joint Arthroplasty
- device used to help restore
function in fingers.
 Elbow and Shoulder Arthroplasty
• COMPLICATIONS
- infection
- deep venous thrombosis
Discharge Teaching
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Assess home environment for safety reason
Social support must also be assessed
Rehabilitation services – elderly
Educate the patient and relatives on how to
look after the patient at home.
- Teach the patient/relative on when and
how often to take medications.
Bloopers
• On the second day, the knee was better,
and on the third day, it had completely
disappeared.
• While in the emergency department, she
was examined, X-rated, and sent home
• The patient will need disposition, and
therefore, we will get Dr. Blank to dispose
of him.
• Patient seen in the floor.
• I saw your patient today, who is still
under our car for physical therapy.
• She slipped on the ice and apparently her
Arthritis
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Degenerative Joint Disease
Arthritis= joint inflammation.
Arthralgia= joint pain
Different types of arthritis:
–Osteoarthritis
–Rheumatoid arthritis
–Gouty arthritis
Osteoarthritis
• Most common form of arthritis, noninflammatory, non-systemic disease
• One or many joints undergo degenerative and
progressive changes, mainly wt. bearing
joints.
• Stiffness, tenderness, crepitus and
enlargement develop.
• Deformity, incomplete dislocation and
synovial effusion may eventually occur.
• Treatment: rest, heat, ice, anti inflammatory
drugs, decrease wt. if indicated, injectable
corticosteroids, surgery.
Osteoarthritis- Risk Factors
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Age
Decreased muscle strength
Obesity
Possible genetic risk
Early in disease process, OA is difficult to
dx from RA
• History of Trauma to joint
Clinical Manifestations
• Joint pain and stiffness that resolves with rest
or inactivity
• Pain with joint palpation
• Crepitus in one or more joints
• Enlarged joints
• Heberden’s nodes enlarged at distal
Interphalangeal (IP)joints
• Bouchard’s nodes located at proximal IP joints
Diagnostic Tests
• ESR, Xrays, CT scans. Assess for
o Pain
o Degree of functional limitation
o Levels of pain/fatigue after activity
o Range of motion
o Proper function/joint alignment
o Home barriers
Treatment
• Pharmacotherapy- panadol, NSAIDS, ASA
• Intra-articular injections of corticosteroids
• Glucosamine- acts as a lubricant and shock
absorbing fluid in joint, helps rebuild cartilage
• Balance rest with activity
• Use bracing or splints
• Apply thermal therapies
• Arthroplasty
Auto-Immune Disease
• Inflammatory and immune response are
normally helpful
• BUT these responses can fail to recognize self
cells and attack normal body tissues.
• Called an auto-immune response
• Can severly damage cells, tissues and organs
• e.g. RA, SLE, Progressive systemic sclerosis,
connective tissue disorders and other organ
specific disorders
Rheumatoid Arthritis
• Chronic, systemic, progressive inflammatory
disease of the synovial tissue, bilateral,
involving numerous joints.
• Synovitis-warm, red, swollen joints resulting
from accumulation of fluid and inflammatory
cells.
• Classified as autoimmune process
• Exacerbations and remissions
• Can cause severe deformities that restrict
function
RA- Risk Factors
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Female gender
Age 20-50 years
Genetic predisposition
Epstein Barr virus
Stress
Rheumatoid Arthritis
• Rheumatoid Factor antibody- High titers
correlate with severe disease, 80% pts.
• Antinuclear Antibody (ANA) Titerpositive titer is associated with RA.
Cont’d
• C- reactive protein- 90% pts.
• ESR: Elevated, moderate to severe
elevation
• Arthrocentesis- synovial fluid
aspirated by needle
Clinical Manifestations
• Joints- bilateral and symmetric stiffness,
tenderness, swelling and temp. changes
in joint.
• Pain at rest and with movement
• Pulses- check peripheral pulses, use
doppler if necessary, check capillary refill.
Cont’d
• Edema- observe, report and record
amt. and location of edema.
• ROM, muscle strength, mobility,
atrophy
• Anorexia, weight loss
• Fever- generally low grade
Treatment
• Rest, during day- decrease wt.
bearing stress.
• ROM- maintain joint function,
exercise –water.
• Medication- analgesic and antiinflammatory (NSAIDS), topical
meds. Immunosuppressive drugsImuran, Cytoxan, methotrexate.
Monitor for toxic effects
• Biological response modifiers
(BRM):Inhibit action of tumor
necrosis factor (Humira, Enbrel,
Remicade)
• Ultrasound, diathermy, hot and cold
applications
• Surgical- Synovectomy, Arthroplasty,
Total hip replacement.
Nursing Interventions
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Assist with/encourage physical activity
Provide a safe environment
Utilize progressive muscle relaxation
Refer to support groups
Emotional support
Complications
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Sjogrens’s syndrome
Joint deformity
Vasculitis
Cervical subluxation
Gout
• Maybe classified as
primary or secondary
• Caused by ↑ in uric acid production or
under excretion of uric acid by the
kidneys
• Deposits of sodium urate crystals in
articular, periarticular and
subcutaneous tissues
Clinical Manifestations
• May occur in one or more joints, usually
fewer than 4 joints
• Joints are dusky/cyanotic, extremely
tender
• Inflammation of big toe(podagra) most
common initial problem
• Other sites: midtarsal of foot, ankle, knee
& wrist
Diagnostic Tests
• History & physical
examination
• Family history of gout
• Presence of sodium urate crystals in
synovial fluid
• Elevated serum uric acid levels
• Elevated 24-h urine for uric acid
Treatment
• Meds- colchicine, NSAIDS, Indocin
(indomethacin), glucocorticoid drugs,
• Allopurinol, Probenecid-reduce uric acid
levels
• Febuxostat
• Corticosteroids(prednisone); intrarticular
corticosteroids
• Adrenocorticotrophic hormone(ACTH)
• Joint immobilisation
• Local application of heat or cold
• Joint aspiration & intraarticular
corticosteroids
• Diet- excludes purine rich foods, such
as organ meats, anchovies, sardines,
lentils, sweetbreads, red wine
• Avoid ASA and diuretics- may
precipitate attacks
Systemic Lupus Erythematosus
• SLE- Chronic Inflammatory disease affecting many
systems.
• Women between 18-40, black>white, child bearing
years
• Autoimmune process- antibodies react with DNA,
immune complexes form- damage organs and blood
vessels.
• Includes: vasculitis; renal involvement; lesions of skin
and nervous system.
• Initial manifestation- arthritis, butterfly rash,
weakness, fatigue, wt. loss
• Symptoms and tx. depend on systems involved.
Systemic Lupus Erythematosus
Pathologic changes-Autoimmune process
• Vasculitis in arterioles and small arteries
• Granulomatous growths on heart valves- non
bacterial endocarditis.
• Fibrosis of the spleen, lymph node
adenopathy
• Thickening of the basement membrane of
glomerular capillaries.
SLE
• Renal- Lupus nephritis
• Pleural effusion or PN
• Raynaud’s phenomenon- about 15%
cases
• Neuro- psychosis, paresis, migraines,
and seizures
Diagnosis
• ANA- hallmark test, + in 98% pts.
Medications• NSAIDS
• Antimalarial meds- hydroxychloroquine
(Plaquenil)
Immunosuppressive
agents- pt teaching
corticosteroids, methotrexate,
cyclophosphamide
• Antidepressants
Systemic Lupus- Education
Encourage to avoid undue emotional/ physical
stress and to get enough rest
• Alternate exercise; planned rest periods.
• Teach how to recognize the symptoms of a flare
• Teach how to prevent and recognize infection
• Avoid sunlight, use sunscreen
• Eat a well balanced diet,vitamins and iron.
• Establish short term goals
• Teach re: meds.
• Meds avoid- Pronestyl, Hydralazine.
Joint Replacement Indications
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Rheumatoid arthritis
Trauma
Congenital deformity
Avascular necrosis
Total Hip Replacement
Indications for surgery:
• Arthritis
• Femoral neck fractures
• Congenital hip disease
• Failed prosthesis
Pre-op management
• Assess medication history.
• Assess Respiratory, neurovascular,
nutritional and integumentary status.
• Presence of other diseases- COPD, CAD,
Hx. Of DVT or pulmonary embolism.
• Discuss surgical procedure, informed
consent.
• Prepare for autologous blood donation.
Pre-op teaching
• Presence of drains and hemovac
postoperatively.
• Pain management (epidural/PCA).
• Coughing and deep breathing.
• Use of incentive spirometer
• ROM exercises to unaffected extremities.
• Post-op restrictions:
Need to avoid bending beyond 90 degrees
Importance of leg abduction post-op.
Post-op Management
• Assess neurovascular status of involved
extremity.
• Incision site, wound drains, hemovac.
• Note excessive bleeding or drainage
• Respiratory status- elderly population.
• Position of affected joint and extremity
• Mental alertness
• Assess Hgb and Hct
• Pain management
Osteomyelitis
• Infection of the bone
Endogenous:
• Extension of soft tissue infectioninfected pressure ulcers or incision.
• Blood borne (spread from other body
sites)
Cont’d
• At risk- poorly nourished, elderly,
obese, impaired immune systems,
corticosteroid therapy, chronic
illnesses.
• Prevention- proper tx. of infections,
aseptic post op wound care
Exogenous:
• Organism enters from outside the
body. eg. Open fracture
Osteomyelitis
Signs and symptoms• High fever, chills, increased HR, general
malaise, swelling, tenderness, heat and
erythema, painful movement.
• Draining ulcers, bone pain
• Diagnostic Tests- increased WBCs, elevated
ESR, positive blood cultures, X-rays, bone
scan, MRI.
Treatment
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Long term IV antibiotics
Hickman or other CVAD catheter
Strict sterile technique for treatment
Hyperbaric oxygen treatment
Surgery- bone exposed and necrotic
tissue removed, debridement, bone
grafts, amputation
‘The study concluded that mobile phones
and gadgets that promoted the
predominant usage of thumb or only one
finger while texting or using the controls
were associated with a higher prevalence
of MSDs. Treatment using a sequenced
rehabilitation protocol was found to be
effective’.
Ann Occup Environ Med. 2014; 26: 22.
Published online 2014 Aug 6. doi: 10.1186/s40557-014-0022-3
PMCID: PMC4387778
Musculoskeletal Disorders of the Upper Extremities Due to Extensive Usage of
Hand Held Devices
Deepak Sharan,
1
Mathankumar Mohandoss,
2 Rameshkumar Ranganathan,2 and Jeena Jose2
End of
Presentation
Reference
• Brown, D., & Edwards, H (2012).
Lewis’s
Medical-Surgical Nursing: Assessment
and
Management of
Clinical
Problems (3rd ed.).Sydney. Elservier
• Dempsey, Maureen Farrell and J. S meltzer &
Bare's Textbook of
Medical Surgical
Nursing, 3rd Edition. Lippincott Williams &
Wilkins, 10/2013. VitalBook file