85188976 case-study

Homework Help
https://www.homeworkping.com/
Research Paper help
Online Tutoring
click here for freelancing tutoring sites
INTRODUCTION
HYPERTENSION
Hypertension (HTN) or high blood pressure is common disorder that is a
known cardiovascular disease risk factor, characterized by elevated blood
pressure over the normal values of 120/80 mm Hg in an adult over 18 years of
age. This elevation in blood pressure can be divided into three classes of
hypertension.
Prehypertension describes blood pressure measurements of greater than
120 mm Hg systolic or 80 mm Hg diastolic and less than 130 mm Hg systolic or
90 mm Hg diastolic. Persons exhibiting prehypertension are encouraged to
explore life-style modifications to lower blood pressure, but blood-pressure
lowering agents are not generally prescribed without compelling indications.
The second classification of hypertension is Stage 1 hypertension and is
defined by a blood pressure of over 130 mm Hg systolic or 90 mm Hg diastolic
but less than 160 mm Hg systolic or 100 mm Hg diastolic. Patients with Stage 1
hypertension are also encouraged to make life-style modifications, and initial
drug therapy may include thiazide-type diuretics, ACE inhibitors, calcium channel
blockers, beta blockers, and angiotensin-receptor blockers, or a combination of
these.
Stage 2 hypertension is defined by a blood pressure greater than 160 mm
Hg systolic or 100 mm Hg diastolic. Persons with Stage 2 hypertension are

encouraged to make life-style modifications. Two-drug combination therapies (of
thiazide-type diuretics, ACE inhibitors, calcium channel blockers, beta blockers,
and angiotensin-receptor blockers) are indicated for these patients.
Essential hypertension, the most common kind, has no single identifiable
cause, but risk for the disorder is increased by obesity, a high serum sodium
level, hypercholesterolemia, and a family history of high blood pressure. Known
causes of secondary hypertension include sleep apnea, chronic kidney disease,
primary aldosteronism, renovascular disease, chronic steroid therapy, Cushing's
syndrome, pheochromocytoma, coarctation of the aorta, and thyroid or
parathyroid disease.
The incidence of hypertension is higher in men than in women and is twice
as great in African-Americans as in Caucasians. People with mild or moderate
hypertension may be asymptomatic or may experience suboccipital headaches,
especially on rising; tinnitus; lightheadedness; ready fatigability; and palpitations.
With sustained hypertension, arterial walls become thickened, inelastic, and
resistant to blood flow, and the left ventricle becomes distended and
hypertrophied as a result of its efforts to maintain normal circulation against the
increased resistance. Inadequate blood supply to the coronary arteries may
cause angina or myocardial infarction. Left ventricular hypertrophy may lead to
congestive heart failure. Malignant hypertension, characterized by a diastolic
pressure higher than 120 mm Hg, severe headaches, blurred vision, and
confusion, may result in fatal uremia, myocardial infarction, congestive heart
failure, or a cerebrovascular insult. Patients with high blood pressure are advised
to follow a low-sodium, low-saturated-fat diet; to control obesity by reducing
caloric intake; to exercise; to avoid stress; and to have adequate rest.

PATIENT’S PROFILE
NAME: Medina, Crisanta Gamboa
BIRTHDAY: March 25,1948
AGE: 63 years old
SEX: Female
ADDRESS: Brgy. Marawoy, Lipa, City
RELIGION: Roman Catholic
NATIONALITY: Filipino
DATE OF ADMISSION: February 26, 2012
ATTENDING PHYSICIAN: Dra. Ma. Lovely M. Cacho
CHIEF COMPLAINT: chest pain, dizziness

HEALTH HISTORY
Present Health History
The present health history started 3 days prior to confinement at Metro
Lipa Medical Center when the patient, experienced general body weakness,
chest pain, and dizziness. She was admitted under the service of Dra. Ma.
Lovely M. Cacho and stayed at the said hospital for 2 days and was treated as a
case of hypertension stage II. Her physician ordered her to have some laboratory
examinations like Serum Test, Troponin Test, electrolytes, urinalysis, CBC and
ECG. She was given Betahistine, Losartan, Clopidogrel, Finofibrate, Vastarel,
Allopurinol, Vytorin, Corolan, NTG Patch, Omeprazole and Celebrex as her
medication.
Vital Signs upon admission are as follows:
T = 36.2 PR = 120 bpm BP = 170/100 mmHg RR = 20 cpm
Past Health History
Prior to her hospitalization, she denies in having any record or medical
history of being admitted due to trauma, accident and disease. She also denies
having allergies to food and drugs.

Family Health History
The patient has family health history of hypertension on her mother’s side.
LABORATORY EXAMINATIONS
January 26, 2012
SERUM TEST
RESULT
NORMAL VALUE
INTERPRETATION
Cholesterol 6.6mmol/L 0.0- 5.2mmol/L High cholesterol
accelerates the
progression of
atherosclerosis of certain
arteries that is thought to
contribute significantly to
hypertension.
Triglycerides 2.79 mmol/L 0.0- 1.69 mmol/L High triglyceride levels can
increase your risk of
arteriosclerosis that
reduces the space
available for blood flow,
which can cause high
blood pressure.
Uric Acid 408 umol/L 149- 369 umol/L Hyperuricemia has now
been
found to be an
independent risk factor for
hypertension.
ALT 4.42 mmol/L 3.59- 3.88 mmol/L

January 26, 2012
TROPONIN TEST
(-) Negative
January 26, 2012
CBC
RESULT NORMAL VALUE INTERPRETATION
Segmenters 0. 36 % Elevation of
segmenters may
indicate presence
of infection; means
that many band
(immature) cells
are present as the
body fights
infection.
Lymphocyte 0. 55 % A low lymphocyte
count indicates that
the body's
resistance to fight
infection has been
substantially lost
and one may
become more
susceptible to
certain types of
infection.
Monocyte 0. 09 %
January 26, 2012
Urinalysis – DONE. Result not secured.

ECG – DONE. Result not secured.
ANATOMY AND PHYSIOLOGY
CENTRAL NERVOUS SYSTEM
Medulla Oblongata; relays motor and sensory impulses between other parts of
the brain and the spinal cord. Reticular formation (also in pons, midbrain, and
diencephalon) functions in consciousness and arousal. Vital centers regulate
heartbeat, breathing (together with pons) and blood vessel diameter.

Hypothalamus; controls and integrates activities of the autonomic nervous
system and pituitary gland. Regulates emotional and behavioral patterns and
circadian rhythms. Controls body temperature and regulates eating and drinking
behavior. Helps maintain the waking state and establishes patterns of sleep.
Produces the hormones oxytocin and antidiuretic hormone.
CARDIOVASCULAR SYSTEM
Baroreceptors, pressure-sensitive sensory receptors, are located in the aorta,
internal carotid arteries, and other large arteries in the neck and chest. They
send impulses to the cardiovascular center in the medulla oblongata to help
regulate blood pressure. The two most important baroreceptor reflexes are the
carotid sinus reflex and the aortic reflex.
Chemoreceptor, sensory receptors that monitor the chemical composition of
blood, are located close to the baroreceptors of the carotid sinus and the arch of

the aorta in small structures called carotid bodies and aortic bodies, respectively.
These chemoreceptor detect changes in blood level of O2, CO2, and H+.
Heart. The main functions of the heart can be summarized as follows: The right-
hand side of the heart receives de-oxygenated blood from the body tissues (from
the upper- and lower-body via the Superior Vena Cava and the Inferior Vena
Cava, respectively) into the right atrium. This de-oxygenated blood passes
through the tricuspid valve into the right ventricle. This blood is then pumped
under higher pressure from the right ventricle to the lungs via the pulmonary
artery The left-hand side of the heart receives oxygenated blood from the lungs
(via the pulmonary veins) into the left atrium. This oxygenated blood then passes
through the bicuspid valve into the left ventricle. It is then pumped to the aorta
under greater pressure (as explained below). This higher pressure ensures that
the oxygenated blood leaving the heart via the aorta is effectively delivered to
other parts of the body via the vascular system of blood vessels (incl. arteries,
arterioles, and capillaries).
Blood. Our blood carries oxygen to cells. It carries waste (carbon dioxide, Urea
and lactic acid - via diffusion) away from cells and carries various disease-
fighting cells such as the "white" blood cells. It is part of the body's self-repair
mechanism (blood clotting after an open wound in order to stop bleeding - using
'Platelets') and regulates our body PH. It also regulates our core body
temperature.
Blood vessels. The point of blood vessels is to carry blood throughout the body.
Arteries and veins are the largest of the blood vessels. Arteries move blood,
which contains oxygen and nutrients to muscles and organs and veins carry the
blood back to the heart.

RENAL SYSTEM
Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to
the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the
bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act
on their substrates to produce the active hormone angiotensin II, which raises
blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it
raises blood pressure by increasing systemic vascular resistance. Second, it
stimulates secretion of aldosterone, which increases reabsorption of sodium ions

and water by the kidneys. The water reabsorption increases total blood volume,
which increases blood pressure.
Antidiuretic hormone. ADH is produced by the hypothalamus and released from
the posterior pituitary in response to dehydration or decreased blood volume.
Among other actions, ADH causes vasoconstriction, which increases blood
pressure.
Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers
blood pressure by causing vasodilation and by promoting the loss of salt and
water in the urine, which reduces blood volume.

PATHOPHYSIOLOGY OF HYPERTENSION
RISK FACTOR
Family History Obesity
Age Excess Alcohol Consumption
High Salt Intake Smoking
Stress Low Potassium Intake
Changes in Arteriolar Bed
Systemic Vascular Resistance
Afterload
Blood Flow to Organ
Blood Pressure
Juxtaglomerular cells
Renin
Angiotensin- Converting Enzyme (ACE)
Angiotensin
(Renin substrate)
Angiotensin I
(Renin substrate)
Angiotensin II

Aldosterone
Na+ Reabsorption
Blood Volume
Vasoconstriction
TPR
Pressure towards normal

Blood pressure is generated by cardiac contraction against the vascular
resistance. Having one or more of the risk factors of hypertension contributes in
some changes in arteriolar bed which will then increase the systemic vascular
resistance. As the systemic vascular resistance increase, the afterload also
increases, therefore heart works harder. Afterload is inversely proportional to
stroke volume. During a heartbeat, the heart muscle contracts. This causes the
blood to be pumped out, which causes increased pressure in the arteries. There
is a stronger than normal force of contraction since the filling pressures is greater
and so the SV is greater. Starling’s Law states that the greater the tension or
stretch the greater the contraction. Therefore wall tension is chronically increased
and this results in remodeling of the ventricular wall again but this time the CXR
shape is elongated and off center. This thickness is also associated with an
increase in radius to keep their ratio equal. The peripheral blood vessels will
return their blood flow back to normal after a sudden increase within less than a
minute. There is the metabolic theory that states when the art pressure becomes
too great, there is an excess flow of oxygen and nutrients which causes the blood
vessels to constrict and flow to return to normal and there is the myogenic theory
that states the sudden stretch of small blood vessels cause the smooth muscle of
the vessel wall to contract and this reduces the blood flow. Renin will then be
released by the juxtoglomerular cells in afferent arterioles of the kidney in
response to SNS stimulation. The receptors that mediate this are beta receptors
on cells. Renin will then increase the production of angiotensin I which will lead to
Angiotensin II which is a potent vasoconstrictor which then increases total
peripheral resistance. Angiotensin II will also stimulate the release of aldosterone
from the medulla which will increase sodium reabsorption so less Na leaves the
body and more stays in which increase ECF volume. There is also progressive
increase in TPR while at the same time the CO is decreased back to normal.
(Changes almost certainly caused by the long-term blood flow autoregulation
mechanism). CO has risen to high level and had initiated the hypertension, the
excess blood flow through the tissues than caused progressive constriction of the
local arterioles, thus returning the local blood flow and the CO almost back to
normal, but simultaneously causing a secondary increase in TPR. The increased
TPR occurs and will lead to increase pressure towards normal.

DRUG STUDY
GENERIC NAME: Betahistine
BRAND NAME: Serc
DOSAGE AND ROUTE: 24mg tab PO
CLASSIFICATION: Antiemetic/Antivertigo
ACTION: Betahistine has a very strong affinity as an antagonist
for histamine H3 receptors and a weak affinity as an
agonist for histamine H1 receptors. Betahistine seems
to dilate the blood vessels within the middle ear which
can relieve pressure from excess fluid and act on the
smooth muscle.
INDICATION: Meniere’s disease, Meniere-like syndrome (with
symptoms of vertigo, tinnitus and sensorineural
deafness) and vertigo of peripheral origin.
CONTRAINDICATION: Hypersensitivity to any component of the product.
ADVERSE
REACTION:
 Headache.
 Low level of gastric side effects.
 Nausea can be a side effect, but the patient is
generally already experiencing nausea due to the
vertigo so it goes largely unnoticed.
 Decreased appetite, leading to weight loss
NURSING
CONSIDERATION:
 Avoid contact of oral solution or injection with skin
 Raise bed rails, institute safety measures, supervise
ambulation
GENERIC NAME: Losartan

BRAND NAME: Anzar
CLASSIFICATION: Angiotensin II Antagonists
ACTION: Angiotensin II receptor blocker/antihypertensive.
INDICATION: Losartan is used in the management of hypertension
and may have a role in patients who are unable to
tolerate ACE inhibitors. It has also been tried in heart
failure and myocardial infarction.
CONTRAINDICATION: Patients who are hypersensitive to any component of
this product. Losartan also contraindicated in pregnancy
and breastfeeding. If pregnancy is detected, losartan
should discontinued immediately.
ADVERSE
REACTION:
Adverse effects of losartan have been reported to be
usually mild and transient, and include dizziness and
dose related orthostatic hypotension. Hypotension may
occur particularly in patient with volume depletion, (eg
those who have received high-dose diuretics).
NURSING
CONSIDERATION:
Observe for symptomatic hypotension and tachycardia
especially in patients with CHF; hyponatremia, high-
dose diuretics, or severe volume depletion
GENERIC NAME: Clopidogrel
BRAND NAME: Antiplar

CLASSIFICATION: Anticoagulants, Antiplatelets & Fibrinolytics
(Thrombolytics)
ACTION: Clopidogrel is an inhibitor of platelet aggregation. A
variety of drugs that inhibit platelet function have been
shown to decrease morbid events in people with
established cardiovascular atherosclerotic disease as
evidenced by stroke or transient ischemic attacks,
myocardial infarction, unstable angina or the need for
vascular bypass or angioplasty.
INDICATION: Prevention of atherosclerotic events in peripheral
arterial disease or w/in 35 days of MI, or w/in 6 mth of
ischemic stroke, or in acute coronary syndrome w/o ST-
segment elevation.
CONTRAINDICATION: Patients w/ active pathological bleeding eg peptic ulcer
or intracranial hemorrhage.
ADVERSE
REACTION:
Headache, dizziness, pain, fatigue, flu-like symptoms,
edema, HTN, abdominal pain, diarrhea, nausea,
hemorrhage, arthralgia, back pain, upper resp
infections, dyspnea, rhinitis, bronchitis, coughing,
purpura, epistaxis & skin rash.
NURSING
CONSIDERATION:
• Provide small, frequent meals if GI upset occurs (not
as common as with aspirin).
• Take daily as prescribed. May be taken with meals.
• Report skin rash, chest pain, fainting, severe
headache, abnormal bleeding.
GENERIC NAME: Allopurinol
BRAND NAME: Llanol

CLASSIFICATION: AntiGout
ACTION: Reduces uric acid production by inhibiting biochemical
reactions preceding its formation.
INDICATION: Primary uncomplicated hyperurecemia; mild gout;
severe tophaceous gout; uric acid nephropathy; uric
acid nephrolithiasis; and in the prevention of renal
Calcium oxalate stones.
CONTRAINDICATION: Hypersensitivity.
ADVERSE
REACTION:
Allergic skin reactions, GI disturbances, diarrhea, and
joint pains
NURSING
CONSIDERATION:
•Monitor serum uric acid levels to evaluate drug’s
effectiveness
•Monitor fluid intake and output; daily urine output of at
least 2 liters and maintenance of neutral or slightly
alkaline urine are desirable
•If the patient is taking allopurinol for treatment of
recurrent calcium oxalate stones, advise him to also
reduce his dietary intake of animal protein, sodium,
refined sugars, oxalate-rich foods, and calcium.
•Tell patient to discontinue at first sign of rash, which
may precede severe hypersensitivity or other adverse
reaction. Rash is more common in patient taking
diuretics and in those with renal disorders. Tell the
patient to report all adverse reactions.
GENERIC NAME: Allopurinol
BRAND NAME: Simvastatin

CLASSIFICATION: Dyslipidaemic Agents
ACTION: Simvastatin is a prodrug metabolised in the liver to form
the active β-hydroxyacid derivative. This inhibits the
conversion of HMG-CoA to mevalonic acid by blocking
HMG-CoA reductase, an early and rate-limiting step in
cholesterol biosynthesis. It reduces total cholesterol,
LDL-cholesterol and triglycerides and increases HDL-
cholesterol levels.
INDICATION: Hyperlipidaemias, Prevention of cardiovascular events
and Homozygous familial hypercholesterolaemia
CONTRAINDICATION: Acute liver disease or unexplained persistent elevations
of serum transaminases. Pregnancy, lactation.
Porphyria.
ADVERSE
REACTION:
Headache, nausea, flatulence, heartburn, abdominal
pain, diarrhoea/constipation, dysgeusia; myopathy
features like myalgia and muscle weakness; serum
transaminases and CPK elevations; hypersensitivity;
lens opacities; blurring of vision; dizziness; sexual
dysfunction; insomnia; depression and upper respiratory
symptoms.
NURSING
CONSIDERATION:
• Advise patients that blood and eye tests will be
necessary throughout treatment.
• Blurred vision, severe gastrointestinal problems,
dizziness or headaches must be reported.

REVIEW OF SYSTEMS
Body Part Assessed Technique Used Actual Finding Interpretation
Skin Inspection  Skin color is fair and even. Normal
Palpation  Skin is smooth with fair skin turgor. Normal
HEENT Head
Inspection
 Normocephalic
 Evenly distributed hair, no dandruff, lesions
nor infection.
Normal
Normal
Palpation  Sinuses non-tender Normal
Eyes
Inspection
 Symmetrical eyelids
 Pinkish conjunctiva
 Anicteric sclera
 Cornea and lens slightly cloudy PERRLA
 presence of new retinal hemorrhages,
exudates, or papilledema
Normal
Normal
Signs of Aging
Normal
suggests a hypertensive
urgency.
Nose
Inspection  PERRLA Normal
Palpation  Normoset
 No discharge
 Non tender
Normal
Normal
Normal

HEENT  No presence of mass or nodules
 Symmetrical nasal folds
 Nasal septum at midline
 Mucosa is moist, pinkish, intact and no
discharge
 Airways patent on both nares
 Non tender sinuses
Normal
Normal
Normal
Normal
Normal
Normal
Mouth, Pharynx and
Neck
Mouth
Inspection  Lips pinkish and dry
 Tongue at midline
 Gums and mucosa pink
 Presence of dentures
Normal
Normal
Normal
Aging (decalcification)
Pharynx
Inspection  Uvula at midline
 Tonsils not inflamed
Normal
Normal
Neck
Inspection
 Neck symmetrical with full ROM Normal

Palpation  Trachea at midline
 Lymph nodes non tender
 Thyroid gland non palpable
Normal
Normal
Normal
Pulmonary Inspection  Symmetric AP:L ratio = 1:2 Normal
Palpation  Symmetrical lung expansion Normal
Percussion  Symmetrical tactile fremitus
 Resonant
Normal
Normal
Auscultation  Clear lung sounds
 No adventitious breath sounds
Normal
Normal
Cardiovascular Inspection  Jugular venous distension,
 Peripheral edema
presence of heart failure
Auscultation  Apical pulse at 5thICS MCL
 Presence of palpitation
Normal
Due to cardiac compensation
Abdomen Inspection  Flat and symmetrical
 No lesions
Normal
Normal
Auscultation  Normoactive burbogorhythmic sounds (26 on
4 quadrants in 1 full min)
Normal
Percussion  Tympanic over LLQ Dull at RUQ, LUQ and
RLQ
Normal

Palpation  No tenderness Normal
Extremities Inspection  Skin smooth
 Skin intact
 Nails convex curved
 Pink nail beds
Normal
Normal
Normal
Normal
Palpation  Normal capillary refill
 Skin cool to touch
 Bounding pulses
 Muscles with slight atrophy
 Fair muscle strength
 Full active ROM
<3 sec.
Decreased perfusion
Cardiac compensation
Aging process
Normal
Normal
Motor Sensory Inspection  100% intact
 12 cranial nerves responsive
Normal
Normal

NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
S> “Nanghihina ako at
madaling mapagod kaya
maghapoh lang akong
nakahiga,” as verbalized
by the client.
O>
• Generalized weakness
• Extreme stress
• Lethargic
• Decreased stroke
volume
• Increased peripheral
vascular resistance
• VS taken as follows:
T: 37.2 PR: 83
RR: 18 BP: 180/100
Activity Intolerance
related to disease
process as manifested
by generalized body
weakness.
After a shift of nursing
interventions, the patient
will be able to
report/demonstrate an
increase in activity
tolerance as evidenced
by increased movement
and increased
participation to activities.
•Monitor the patient’s
condition.
•Note client’s report of
weakness, fatigue,
difficulty accomplishing
tasks, and/or insomnia.
•Assist client to adjust
activities to prevent
over exertion.
•Increase exercise/
activity level gradually.
•Provide patient
adequate rest periods
to conserve energy.
• Promote comfort
measures to alleviate
pain if any and
alleviation of pain
leads to increase
activity tolerance
• Provide an
Goal met: After a shift of
nursing interventions,
the patient was able to
report/demonstrate an
increase in activity
tolerance as evidenced
by increased movement
and increased
participation to activities.

environment
conducive for rest
•Instruct client to
increase oral fluid
intake
•Instruct client to have
proper hygiene
•Advise client to eat
nutritious foods
•Administer medication
as per doctors order:
- Serc 24mg PO
- Ansar 50mg tab PO
- Antiplar 75mg tabPO
- Llanol 140mg tab PO
- Simvastatin 10mgPO
•Encourage client to
maintain a positive
attitude
•Encourage
participation in
recreation, social
activities, and hobbies
appropriate for
situation.

NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
S> “ Laging sumasakit
ang aking ulo at parang
nanlalabo ang aking
paningin”, as verbalized
by the patient.
O>
• Extreme stress
• Lethargic
• Restlessness
• Cool, clammy skin
• Optic disc
papilledema
• Increased blood
pressure
• Decreased stroke
vol.
• Increased peripheral
vascular resistance
• VS taken as follows:
T: 37.2 PR: 83
Ineffective Tissue
Perfusion: related disease
process as manifested by
blurred vision and
increased blood pressure.
STG: After 8 hrs of
blood pressure will be
within set parameters
for the client
LTG: After 6 days of
the client will have an
adequate tissue
perfusion to his body
systems.
• Monitor VS at least q
1-2 hrs
• Encourage patient to
decrease intake of
caffeine, cola and
chocolates.
• Administer vasoactive
drugs and titrate as
ordered to maintain
pressures at set
parameters for
patient.
• Observe for
complaints of blurred
vision, tinnitus or
confusion.
• Monitor I&O status
• Monitor for sudden
onset of chest pain.
• Monitor ECG for
STG: After 8 hrs of
blood pressure
maintained within set
parameters for the client.
Goal was met.
LTG: After 6 days of
nursing interventions, the
client had an adequate
tissue perfusion to his
body systems.
Goal was met.

RR: 18 BP: 180/100 changes in rate,
rhythm, dysrhythmias
and conduction
defects.
• Observe extremities
for swelling, erythema,
tenderness and pain.
• Observe for
decreased peripheral
pulses, pallor,
coldness and
cyanosis.
• Instruct client in
signs/symptoms to
report to physician
such as headache
upon rising, increased
blood pressure, chest
pain, shortness of
breath, increased
heart rate,
visual changes,
edema, muscle
cramps and nausea
and vomiting.

Homework Help
Math homework help
Research Paper help
Algebra Help
Calculus Help
Accounting help
Paper Help
Writing Help
Online Tutor
Online Tutoring

85188976 case-study

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (14)

Similar to 85188976 case-study

Similar to 85188976 case-study (20)

More from homeworkping3

More from homeworkping3 (20)

Recently uploaded

Recently uploaded (20)

85188976 case-study