- This presentation case study is covering the content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
Screening [Immunizations are to be addressed explicitly-ie. up to date- and define, or not up to date- management]
Health Education
Nutrition Counseling for Health Promotion
Exercise
Stress Management
Complementary and Alternative Strategies.
Incorporate the application of a mobile app either by practitioner or population (ie, use of CDC Immunization App to reference Catch Up Schedule, or Fitbit© App and mobile technology for fitness tracking).
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- Presentation criteria:
Work within your group to develop the project
9-10 slides with speaker notes
10 minute Voice Over PPT presentation to be uploaded by one member of the group.
Required Textbook and Readings
Edelman, C. L., & Kudzma, E. C.. (2018). Health Promotion Throughout the Life Span, 9th edition. St. Louis, MO: Elsevier, Mosby. ISBN: 978-0-323-416733
Case Study of Mrs. Hernandez
Hello everyone. We are group 4 and we are here to present the case study of Mrs. Hernandez.
Case Study of Mrs Hernandez
68 year-old Hispanic Female
Widowed, caretaker for grandchildren ages 4 and 5
PMH: Hypertension, Hyperlipidemia, Arthritis
PSH: Hysterectomy
NKDA, no current medications
℅ knee pain, swelling after walking, fatigue, sleeping less
Monica Heisler
Mrs. Hernandez is a 68-year-old Hispanic female who presents to the clinic with knee pain. She states that the pain comes and goes, and sometimes hinder her walking. She stated that home remedies usually relieves her pain. Also, she is not taking any OTC medications for the pain or any other medications. Her last check-up was 2 years ago. The patient has a past medical history of hypertension, hyperlipidemia, and arthritis. The patient also had a hysterectomy. The patient has no known drug allergies.
Screenings
Hypertension
Hyperlipidemia
Arthritis
Obesity
David Apolinario
Hello, my name is David Apolinario, and I will be discussing screening strategies for Mrs. Hernandez. A 68-year-old Hispanic female comes into the clinic and complains of knee pain. The patient verbalizes that knee pain usually comes and goes and sometimes hinders her walking. The patient also verbalizes that she tried home remedies with some relief but does not take any OTC medications for pain. The patient is not currently taking any prescribed medications. The patient was last seen by her provider 2 years ago. Past medical history includes Hypertension, Hyperlipidemia, and Arthritis. The patient is also unsure of her vaccination records. A review of systems showed an increase in fatigue, knee pain when bending and walking long distances. Other abnormal finding shows a weight of 215 lbs and blood pressure of 178/94.
HYPERTENSION
David Apolinario
Screening for high blood pressure is done with a manual or automated sphygmomanometer. Proper protocol is to use the mean of 2 measurements taken while the patient is seated. We will also do a physical assessment and a thorough family history for Mrs. Hernandez to obtain information and other risk factors. According to Viera (2020), screening for hypertension is recommended for 18 years and older adults. The 2015 US Preventive Services Task Force (USPSTF) guidelines also recommend hypertension screening every year for adults that are 40 years old and above and for those who are at high risk for high blood pressure, such as patients with high-normal blood pressure [130 to 139/85 to 89 mmHg], who are overweight or obese, and African Americans (Viera, 2020)
Hyperlipidemia
David Apolinario
Screening for hyperlipidemia is done via a blood test that checks the amount of cholesterol and triglycerides in the blood (Viera, 2020). For Mrs. Hernandez, we will screen her by checking her lipid profile, including total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. We will also screen her by obtaining a thorough family history to check for other risk factors. Although Vijan (2020) suggests that screening hyperlipidemia stops at 65, we will still screen Mrs. Hernandez to get a baseline of her lipid profile.
Arthritis
David Apolinario
Provider does screening for arthritis by performing a physical exam to check for swollen joints or loss of motion and use blood tests and X-rays to confirm the diagnosis (Doherty & Abhishek, 2019). X-rays are used to diagnose osteoarthritis, typically revealing a loss of cartilage, bone spurs, and in extreme cases, bone rubbing against bone (Doherty & Abhishek, 2019). Since Mrs. Hernandez’s chief complaint is knee pain during ambulation and movement, we will focus on this screening. Screening for arthritis will be included in the overall physical assessment.
Obesity
David Apolinario
Although obesity was not mention on the case study, we noticed that Mrs. Hernandez’s weight is not proportionate to her height. All adult patients should be screened for overweight and obesity by measuring height, weight and calculating body mass index as part of the routine physical examination (Perreault, 2020). Because of Mrs. Hernandez’s current weight of 215 lbs and height of 62 inches, we calculated her body mass index by dividing body weight and height. BMI shows 39.32, which is categorized as class II obesity (Perreault, 2020).
Immunization
David Apolinario
Influenza Vaccine
Tdap or Td
RZV (Zoster)
Pneumococcal (PPSV23)
The Centers for Disease Control and Prevention suggest that adults 50 years old and older who meet age requirements, lack documentation or vaccination, or lack evidence of past infection should receive the following vaccination (The Centers for Disease Control and Prevention, 2019). For the case of Mrs. Hernandez, she is a 68-year-old adult with no vaccination record. We will offer and educate her on the following vaccines.
Influenza vaccination – 1 dose given annually.
Tdap or Td – For special situation, If she previously did not receive primary vaccination series for tetanus, diphtheria, or pertussis. 1 dose Tdap will be offered followed by 1 dose of Td or Tdap at least 4 weeks after Tdap and another dose Td or Tdap 6-12 months after last Td ot Tdap. Td or Tdap booster every 10 years (The Centers for Disease Control and Prevention, 2020). I
RZV(Zoster) – 2 doses series RZV 2-6 months apart (minimum interval: 4 weeks; repeat if administered too soon) or 1 dose ZVL if not previously vaccinated..
Pneumococcal – 1 dose for 65 an older. If given before 65, administer 1 dose at least 5 years after previous dose.
Hypertension
Condition in which the force of blood against the walls of arteries is too high
Measured through blood pressure readings
Increased risk for heart attack and stroke
“Silent Killer”
Dietary and lifestyle modifications
Medication management
Sharlene De Castro
Hello, my name is Sharlene De Castro and I will be discussing Mrs. Hernandez’s health condition of hypertension. Mrs. Hernandez presented to the clinic due to complaints of knee pain. She was not seen in the clinic for 2 years. Upon vital sign assessment, Mrs. Hernandez was found to have a blood pressure of 178/94. This is consistent with her medical history of hypertension. Hypertension is defined as a condition in which the force of blood against the walls of the arteries is too high (Gabb et al., 2016). Blood pressure is measured during wellness health visits using a blood pressure cuff, gauge, and stethoscope. There are two numbers associated in a blood pressure reading. Systolic pressure is the number representing the pressure as the heart beats while diastolic pressure is the number representing the pressure when the heart is at rest (Gabb et al., 2016). A normal blood pressure reading is less than 120/80 as depicted in the chart on the slide. Hypertension increases the risk for heart attack, stroke, heart failure and kidney failure (Gabb et al., 2016). Hypertension is considered a silent killer because oftentimes, patients do not feel any symptoms. Treatment for this health condition includes dietary and lifestyle changes as well as medication management. Common antihypertensives include diuretics, ACE inhibitors, angiotensin II receptor blockers, and calcium channel blockers (Gabb et al., 2016).
Nutrition and Exercise for Hypertension
DASH diet
Limit salt intake
Drink alcohol in moderation
Stop smoking
Increase physical activity
Maintain healthy weight
Sharlene De Castro
Based on Mrs. Hernandez’s clinical presentation, a Dietary Approaches to Stop Hypertension also known as DASH diet would be beneficial in managing Mrs. Hernandez’s hypertension. This diet consists of fruits, vegetables, whole grains, poultry, fish and low-fat dairy foods (Gabb et al., 2016). We would also educate Mrs. Hernandez to limit her salt intake to less than 2,300 mg a day as well as instruct her how to read food labels in order to prevent consumption of hidden sources of salt such as those found in processed foods and canned goods. Limiting alcohol intake to one drink a day for women and two drinks a day for men should also be emphasized (Gabb et al., 2016). Smoking can speed up the process of plaque formation within the arteries which can further develop health complications alongside having hypertension (Gabb et al., 2016). Smoking cessation programs must be introduced as part of the treatment plan for hypertension. Lastly, having an active lifestyle and maintaining an ideal healthy weight should be emphasized. Mrs. Hernandez’s weight is 215 lbs. Educating her on having a daily exercise routine such as brisk walking, jogging, swimming, or muscle strengthening exercises will help keep her blood pressure under control and lower her risks of developing other health related problems.
Hyperlipidemia
High level of lipids in blood
Lead to hypertension, heart attack, stroke
Screening: blood test, every 5 years
Treatment: diet, exercise, medication
Goal: lower cholesterol, reduce risks
Monica Heisler
Hello, my name is Monica Heisler and I am addressing Mrs. Hernandez’s issue of hyperlipidemia. Hyperlipidemia is commonly called high cholesterol. Hyperlipidemia is a chronic, but treatable, condition resulting from high levels of lipids, or fat particles, in the blood. There are no symptoms associated with high cholesterol but it can be linked genetically (Bello-Chavolla et al., 2018). For adults over 20 years of age, the Centers for Disease Control and Prevention (CDC) recommends screening with a routine blood test every 5 years (Centers for Disease Control and Prevention, 2020). Screening should occur more often when the patient is at risk for cardiovascular disease like Mrs. Hernandez. The fasting lipid profile will show the total cholesterol, LDL level, HDL level, and triglyceride levels. (Centers for Disease Control and Prevention, 2020). Educating Mrs. Hernandez that cholesterol and triglycerides can deposit in the walls of blood vessels making blood vessels narrower can help her understand the disease (www.heart.org, 2021). Cholesterol restricts blood flow and can increase blood pressure. The lipids (fat particles) can cause a blood clot that could break off and travel to the heart or brain causing a heart attack or stroke (www.heart.org, 2021). High cholesterol can be treated by changing the diet and increasing exercise. The goal of treatment is to lower the cholesterol level and reduce the risk for heart disease, heart attack, and stroke (www.heart.org, 2021). Treatment with medication could include using drugs called the “statins” that work in the liver to prevent the formation of cholesterol (www.heart.org, 2021). Other medications can keep cholesterol from being absorbed in the intestines or bind up the cholesterol to help the intestines get rid of cholesterol (www.heart.org, 2021).
Nutrition and Exercise for Hyperlipidemia/Obesity
Change diet to lower cholesterol level
Eat 2 servings fish per week
Limit saturated fats
Limit alcohol
Increase exercise, walking, swimming, biking
Monica Heisler
When suggesting dietary changes to decrease cholesterol levels, we should encourage Mrs. Hernandez to include avoiding foods high in cholesterol such as fried foods, processed foods, red meat, ice cream and cheese (Centers for Disease Control and Prevention, 2020). To help lower her cholesterol, Mrs. Hernandez should increase her intake of high fiber foods such as oatmeal, bananas, apples, beans, lentils and chickpeas Centers for Disease Control and Prevention, 2020). Exercise can lower cholesterol levels. Mrs. Hernandez should strive to increase her activity level to include moderate exercise like walking, swimming, or biking for 30 minutes daily (Centers for Disease Control and Prevention, 2020). We could also suggest Mrs. Hernandez download My Fitness Pal application. She can track all of her food and exercise on this app, making it easier to count calories and track her diet and possibly motivate her.
Arthritis
Exercise
Be Active every day
Increase amount gradually
Improves symptoms
Improves health
Nutrition
Increase fiber intake
Glendon Pedersen
My name is Glendon Pedersen, and I’m addressing the issues of arthritis through exercise and nutrition. Arthritis is a progresive disease that cannot be reversed, physical exercise does help restore some health to the cartilage, it increases strength, and flexibility to the affected joints. Arthritis symptoms and pain can be improved by keeping active and exercising the affected joints. “Try to do some physical activity every day. You can start off gently, and gradually increase what you do – both in terms of the length of time you exercise and the effort levels you feel able to put in”(Kaminska, 2019). In a recent study at Boston University researchers have found that a high-fiber diet decreases arthritis symptoms by at least 30 percent (Bakalar, 2017). These are recommendations that I would give Mrs. Hernandez.
Stress and CAM
(Complementary and Alternative Medicine)
Acupuncture
Yoga (as knee will allow)
Meditation
Deep-breathing
Yvonne Walton
I am addressing stress and the use of complementary and alternative medicine. Since Mrs Hernandez is presenting with complaints of knee pain along with her other symptoms, I would provide all pertinent information about alternative medicine treatment such as acupuncture. Acupuncture has been proven to be effective since it focuses on points along your body where nerve endings intersect and manipulates these points using painless hair-thin needles. Mrs.Hernandez’s physiological pain is one form of stress (Edelman & Kudzma, 2018). Her insomnia, fatigue, and overeating can be also associated with stress (Edelman & Kudzma, 2018). Relaxation methods could help with her conditions. They include yoga, as her knee will allow, and deep breathing to promote relaxation (Edelman & Kudzma, 2018). I would discuss acupuncture and other alternative and complementary modes of therapy on a trial basis for Ms. Hernandez to review and come to a confident decision.
Mrs. Hernandez Office Visit
Hyperlipidemia
Hypertension
Knee Arthritis
Obesity
Sleep/Fatigue
Immunizations
Diet Exercise
Monica Heisler
This is Monica Heisler to summarize the issues we will address during Mrs. Hernandez’s visit. Her ethnicity has not been a decisive factor in her hypertension, hyperlipidemia, or arthritis since Hispanic women have a lower or similar percentage of incidence in all three conditions compared to non-hispanic blacks women and non-hispanic white women (Centers for Disease Control and Prevention, 2019). However, Hispanic women have a higher risk of diabetes (Centers for Disease Control and Prevention, 2020).We will ask for a hemoglobin A1C test to test for diabetes and prediabetes. After explaining how her hypertension, her high cholesterol, her knee arthritis, her obesity, her fatigue, and possibly her sleep, as well as her possible type 2 diabetes, can all be improved by modifying her diet, losing weight, and increasing her exercise, we want to recommend starting high blood pressure medication to manage her hypertension immediately. Physical therapy can be started to strengthen muscles supporting the knee. Low weight-bearing exercise, such as water aerobics or using a stationary bike, are recommended until her knees can tolerate more vigorous exercise. Her physical therapist can assist in her exercise. Avoid fluids after 7pm to help with sleep. Alternative or complementary treatments, such as acupuncture or relaxation techniques, are optional but please advise us before implementing. Catching up on immunizations can be started at this visit. A fitness monitor could help monitor and track her dietary and exercise progress as well as motivate her. Some fitness monitors can track blood pressure as well. She should take her blood pressure medication every day, refills are important, and reschedule a visit in six months so we can assess her progress.
References
Bakalar, N. (2017, Jun 06). Nutrition: Fiber may help knee arthritis: [science desk]. New York Times Retrieved from https://search.proquest.com/newspapers/nutrition-fiber-may-help-knee-arthritis/docview/1906031465/se-2?accountid=100141
Centers for Disease Control and Prevention. (2020). Getting Your Cholesterol Checked. Centers for Disease Control and Prevention. https://www.cdc.gov/cholesterol/cholesterol_screening.htm
Centers for Disease Control and Precention. (2019). Health, United States Spotlight. https://www.cdc.gov/nchs/hus/spotlight/HeartDiseaseSpotlight_2019_0404 .
Centers for Disease Control and Prevention. (2020). Hispanic and Asian Subgroups Are at Higher Risk for Diabetes. https://www.cdc.gov/diabetes/library/socialmedia/infographics/diabetes-race-ethnicity.html.
Centers for Disease Control and Prevention. (2019). Recommended vaccines for adults | cdc.
https://www.cdc.gov/vaccines/adults/rec-vac/index.html
Doherty, M., & Abhishek, A. (2019). Clinical manifestations and diagnosis of osteoarthritis (D. Hunter & M. R. Curtis, Eds.). UpToDate. Retrieved January 30, 2021, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteoarthritis
Edelman, C. L., & Kudzma, E. C. (2018). Health promotion throughout the life span, (9th ed), Elsevier
Gabb, G. M., Mangoni, A. A., Anderson, C. S., Cowley, D., Dowden, J. S., & Arnolda, L. (2016). Guideline for the diagnosis and management of hypertension in adults—2016. Medical Journal of Australia, 205(2), 85-89. Retrieved from https://www.mja.com.au/system/files/issues/10.5694mja16.00526
Kaminska, K. (2019). Arthritis: Three simple exercises to improve knee arthritis pain and strengthen the joints. Express (Online) Retrieved from https://search.proquest.com/newspapers/arthritis-three-simple-exercises-improve-knee/docview/2189132541/se-2?accountid=100141
Kaminska, K. (2019). Arthritis: Three simple exercises to improve knee arthritis pain and strengthen the joints. Express (Online) Retrieved from https://search.proquest.com/newspapers/arthritis-three-simple-exercises-improve-knee/docview/2189132541/se-2?accountid=100141
Perreault, L. (2020). Obesity in adults: Prevalence, screening, and evaluation (F. X. Pi-Sunyer & L. Kunins, Eds.). UpToDate. Retrieved January 31, 2021, from
https://www.uptodate.com/contents/obesity-in-adults-prevalence-screening-and-evaluation
Viera, A. J. (2020). Overview of preventive care in adults (J. G. Elmore, J. Givens, & L. Kunins, Eds.). UpToDate. Retrieved January 30, 2021, from https://www.uptodate.com/contents/overview-of-preventive-care-in-adults
Vijan, S. (2020). Screening for lipid disorders in adults (M. W. Freeman, J. G. Elmore, & J. Givens, Eds.). UpToDate. Retrieved January 31, 2021, from
https://www.uptodate.com/contents/screening-for-lipid-disorders-in-adults
American Heart Association. (2021). What is Cholesterol? https://www.heart.org/en/health-topics/cholesterol/about-cholesterol
American Heart Association. (2021). Prevention and Treatment of High Cholesterol (Hyperlipidemia). https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia
Centers for Disease and Control Prevention. (2020, September 22). Flu vaccine and people with egg allergies. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/prevent/egg-allergies.htm
New Recording 3
com.apple.VoiceMemos (Sharlene’s iPhone (null))
New Recording 2
com.apple.VoiceMemos (Sharlene’s iPhone (null))
2021
Voice Recorder
slide 11
2021
Voice Recorder
slide 12
2021
Recording
Voice Recorder
2021
Voice Recorder
slide 15
Mrs. Little is a 72 year old Hispanic female who presents to the clinic for an annual exam. She reports she has done well since her last visit. States she only checks her blood sugar twice a week, when she remembers. Has not been following her diabetic diet for the last few months. She denies any other issues.
Allergies: Strawberries, NKDA
Current medications: Metformin 1000mg bid, Amaryl 2 mg daily, Lisinopril 10mg daily
PMH: Diabetes, Hypertension
PSH: Hysterectomy, Rt Wrist surgery after MVA
Social: Tobacco: quit 2002, Denies alcohol or illegal drug use. Retired since 2015, worked as a bank teller.
Immunizations: Flu shot 9/2019
Family: Father: died at 92 of natural causes, Mother: died at 80 of stroke
ROS:
Constitional:
HEENT: Denies any headache, nasal congestion, ear pain. Does report blurry vision at times
Cardiovascular: Denies chest pain
Respiratory: Denies any SOB, DOE, orthnopenia
GI: Denies any abdominal pain.
GU: Denies any painful urination, urgency, hesitancy
Musculoskeletal: Reports some knee pain with bending, walking long distances. Denies any swelling or redness
Neurological: Denies
Psychiatric: Denies suidicial ideations, depression. Does report difficulty falling asleep
Endocrine: Reports she has gained 15 pounds over the last year.
Hematologic/ Lymphatic: Denies any bruising
OBJECTIVE:
Vital signs: Ht: 62, Wt: 198, BP 166/82, HR 84, Resp: 16, SaO2: 96%
Constitutional: Well developed, overweight female
HEENT: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth with dental cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses
Cardiovascular: RRR, No murmurs or rubs noted. No peripheral edema noted
Respiratory: Clear bilaterally all fields.
GI: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted.
GU: Deferred
Musceloskeletal: Heberden and Bouchard nodes noted to bil hands.
Integrementary: Skin warm and dry, No rashes noted
Neuro: Follows commands without difficulty
Working with your group, utilize the above case study a, develop a Voice Over PowerPoint presentation for your patient covering the covering problems identified and the content in Unit 3 of Edelman, Kudzama, & Mandle (2018). Include the following:
· Screening [Immunizations are to be addressed explicitly-ie. up to date- and define, or not up to date- management]
· Health Education
· Nutrition Counseling for Health Promotion
· Exercise
· Stress Management
· Complementary and Alternative Strategies.
· Incorporate the application of a mobile app either by practitioner or population (ie, use of CDC Immunization App to reference Catch Up Schedule, or Fitbit© App and mobile technology for fitness tracking).
OPTIMAL HEALTH
United States University
FNP 590 Health Promotion, Education, and Disease Prevention Across the Lifespan
Immunizations (yearly flu shots covid vaccine)
Health education (importance check bs regularly)
Exercise in relation to hypertension
Stress management in relation to hypertension
Complementary and
Alternative Methods
Relaxation Techniques
Qi gong
Yoga
Meditation
Tai Chi
Herbs, Supplements, Minerals
Cinnamon
Omega-3
Magnesium
In conjunction with diet and exercise, there are several Complementary and Alternative methods of treatment to choose from which will also help high blood pressure and diabetes. Relaxation techniques such as Qi gong, Yoga, Meditation and Tai chi have shown to show improvements with fasting glucose, blood pressure and lipid profiles (Thalmeier, 2017). Herbs and supplements such as Cinnamon, Omega-3 and Magnesium which have been shown to improve blood sugar and cholesterol (Thalmeier, 2017).
6
HELPFUL TOOLS
-Beneficial foods
-iPhone & Android compatible
-Easy to use
-Manage diabetes
– Sync with your glucose monitor
– Share information with provider
This Photo by Unknown Author is licensed under CC BY-SA
This Photo by Unknown Author is licensed under CC BY-NC
Fooducate is a phone app that one can use as a reference to see what foods are beneficial in maintaining a healthy blood sugar range (Doyle, 2020). Fooducate is easy to use simply by scanning and searching for your foods and it also reveals additional information such as added sugars and ingredients that may be hidden (Doyle, 2020). The Fooducate app is compatible with both iphones and androids. (Doyle, 2020). The MySugr app allows you to manage your diabetes through a convenient dashboard (Doyle, 2020). MySugr has the ability to be compatible with any glucose monitor and allows you to share your information with your provider (Doyle, 2020). The MySugr app is also available through iPhone and Android ( Doyle, 2020).
Fooducate is a phone app that one can use as a reference to see what foods are beneficial in maintaining a healthy blood sugar range (Doyle, 2020). Fooducate is easy to use simply by scanning and searching for your foods and it also reveals additional information such as added sugars and ingredients that may be hidden (Doyle, 2020). The Fooducate app is compatible with both iphones and androids. (Doyle, 2020). The MySugr app allows you to manage your diabetes through a convenient dashboard (Doyle, 2020). MySugr has the ability to be compatible with any glucose monitor and allows you to share your information with your provider (Doyle, 2020). The MySugr app is also available through iPhone and Android ( Doyle, 2020).
7
Conclusions
References
Afolayan, A. J., & Wintola, O. A. (2016). Dietary supplements in the management of hypertension and diabetes – a review. African journal of traditional, complementary, and alternative medicines : AJTCAM, 11(3), 248–258. https://doi.org/10.4314/ajtcam.v11i3.35
Doyle, A. (2020, August 24). Best Diabetes Apps of 2020. Retrieved from https://www.healthline.com/health/diabetes/top-iphone-android-apps
High Blood Pressure Alternative Remedies: Yoga, Acupuncture, Hypnosis Efficacy. (2019, May 25). Retrieved from https://www.webmd.com/hypertension-high-blood-pressure/guide/hypertension-complementary-alternative-treatments#1
Thalheimer, Judith C., (2017, July/August). Top 5 Alternative Diabetes Therapies: Are Patients Undermining Their Treatment? Retrieved from https://www.todaysgeriatricmedicine.com/archive/JA17p14.shtml
