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I-Anoremics engundoqo

  • Qaphela izizukulwana zomthi we-tracheal-bronchial, ii-lobes, iisegmenti, kunye neentanda. Qaphela i-lobule yesibini yemiphunga (1.5-2-cm)-iyunithi esisiseko yokusebenza kwemiphunga eqatshelwe kwi-HRCT. Qaphela ulungelelwaniso olubalulekileyo lwezithuba ze-alveolar kunye nonxibelelwano phakathi (iipore ze-Kohn kunye nemijelo yaseLambert) evumela ukukhukuliseka komoya kwaye ngendlela efanayo ivumela ulwelo oluphumayo okanye oluguquguqukayo ukuba lusasazeke kwimiphunga kwaye lume kwindawo yokuqhekeka. Qaphela i-anatomy ye-pleura: i-parietal eyinxalenye ye-endothoracic fascia kunye ne-visceral eyenza i-lung edge � isithuba sepleural phakathi.

 

isifuba somfanekiso esifubeni

 

  • I-Mediastinum: ijikelezwe yi-pleura kunye nomphunga. Izibonelelo ezinkulu ziqukethe i-lymph nodes ezininzi (jonga umzobo obonisa i-nodes mediastinal kunye nokubandakanyeka kwabo eLymphoma

 

isifuba somfanekiso esifubeni

 

Iindlela eziqhelekileyo zoPhando lweziPhulo

  • Uviwo lwe-Radiographic (i-X-ray CXR); 1st inkulu. Iindleko eziphantsi, ukunyuka kwamayeza emancinci, ukuhlaziywa kwezikhalazo zeeklinikhi ezininzi
  • I-CT scan: isifuba CT, High-Resolution CT (HRCT)
  • Indlela yokukhubazeka kwesifuba:
  • I ngxaki
  • Sulelo
  • Neoplasms
  • Edema
  • Emphysema
  • Atelectasis
  • Ukukhubazeka kwempilo
  • Mediastinum

I-PA kunye ne-CXR esecaleni

isifuba somfanekiso esifubeni

 

  • Iimbono ezongezelelweyo zingasetyenziswa:
  • Umbono we-Lordotic: unceda ukuvavanya imimandla ye-apical
  • Iimbono zeCububitus ngakwesokudla nangesesinxele: uncedo lokuhlola ukunyakaza kwamanzi okuphambuka, i-pneumothorax kunye nezinye izifo

 

isifuba somfanekiso esifubeni

 

isifuba somfanekiso esifubeni

 

  • I-CXR PA eqhelekileyo kunye nembono yeLateral. Qinisekisa ukubonakaliswa okuhle: Iidiski ze-T-spine kunye neenqanawa ngentliziyo zibonwa kumbono we-PA. Bala i-9-10 yeembambo zangasekunene ukuqinisekisa iinzame ezaneleyo zokukhuthaza. Qalisa uphando olucokisekileyo usebenzisa le ndlela ilandelayo: Ngaba Zininzi Izilonda zemiphunga A-isisu / uvalo, udonga lweT-thorax, M-mediastinum, L-lungs ngokukodwa, Imiphunga yomibini. Phuhlisa ipatheni elungileyo yokukhangela

 

isifuba somfanekiso esifubeni

 

  • 1) Isifo se-Airspace aka alveolar lung disease? Ukuzaliswa kwe-alveoli yomphunga, i-acini kunye nayo yonke i-lobe ene-fluid okanye into ebonakalayo nayiphi na into (i-blood, ipus, amanzi, iproteinaceous material okanye iiseli) I-Radiographically: i-lobar okanye isabelo esisodwa, i-airspace nodules ingaqatshelwa, ukuthambekela kokubambisana, umoya i-bronchograms kunye nesalathisi sesalathisi. Ukusabalalisa kweBatwing (ibhathengwane) echazwe apha (CHF). Ukutshintsha ngokukhawuleza ngexesha, oko kukuthi, ukwanda okanye ukunciphisa (iintsuku)
  • I-2) Isifo esisisigxina: ukungena kwe-pulmary interstitium (i-alveoli septum, i-lung parenchyma, iindonga zetyana, njl njl.) Umzekelo ngeentsholongwane, ibhaktheriya encinci, iiprotozoans. Kwakhona ukungena ngamaseli afana nesibalo sokuvuvukala / esilumkileyo (umz., I-lymphocytes) Echazwe njengophawu lomgca we-lung emzimbeni kunye nomzobo oxubileyo, odibeneyo, odibeneyo. Iimpawu ezahlukeneyo: ukuvutha izifo, i-fibrosing isifo sesifo se-lung, isifo sesifo somphunga, isifo se-viral / mycoplasma, i-TB, i-sarcoidosis lymphoma / leukemia nezinye ezininzi.

 

isifuba somfanekiso esifubeni

 

  • Ukuqaphela iipateni ezahlukeneyo zesifo se-pulmonary kunokunceda ngeDDx. IMisa ngokuBambisana nokuQinisa (ngasekhohlo). Qaphela iipatheni ezahlukeneyo zezifo zepulmoni: isifo se-airspace njengesigxina sokudibanisa esibonakalisa inkemoniya, ukudibanisa i-diffuse yokubonisa i-edema ye-pulmona. I-Atelectasis (ukuwa kunye nokulahleka kwevolumu). Iipatheni zesigxina se-pulmonary disease: i-reticular, nodular okanye ixutywe. I-SPN ngokudibanisa ngokubanzi kweengqungquthela (iigununu) ngokubhekiselele ukumela amamitha angene kwi-septic engena ngaphakathi

 

isifuba somfanekiso esifubeni

 

  • A = intraparenchymal
  • B = ukukhala
  • C = i-extrapleura
  • Qaphela indawo ebalulekileyo yezilonda zesifuba

 

isifuba somfanekiso esifubeni

 

  • Izimpawu ezibalulekileyo: Uphawu lwesilathisi: uncedo kunye nolwazi lweDDx. Umzekelo: Umfanekiso osezantsi osekhohlo: i-radiopacity kumphunga wesokudla, phi na? Ngokufanelekileyo MM ngenxa yokuba umda wentliziyo entle ophantsi kwendawo ye-lobe ephakathi ayibonakaliyo (ayikhoyo) I-bronchogram ye-Air: umoya oqukethe i-bronchi / bronchioles ejikelezwe ngamanzi

 

isifuba somfanekiso esifubeni

 

I-Chest Trauma

  • I-Pneumothorax (PTX): umoya (i-gas) kwindawo yesikhalazo. Ezininzi izizathu. Iingxaki:
  • Intlawulo ye-PTX: ukunyuka okuqhubekayo komoya kwindawo evulekileyo eyenza ngokukhawuleza i-mediastinum kunye nemiphunga ngokukhawuleza ekunciphiseni ukubuyela kwintliziyo. Ingaba yingozi xa ingaphathwa ngokukhawuleza
  • I-PTX yokuzenzekelayo: iiprayimari (abantu abadala abancinci (30 -40) ikakhulu abade, abhityileyo.Oonobangela abongezelelekileyo: Isifo seMarfan s, i-EDS, iHomocystinuria, ukusilela kwe-1 -antitrypsin.Secondary: Iipts ezindala ezinesifo se-parenchymal: neoplasms, abscess, emphysema , lung fibrosis kunye ne-honeycombing, i-catamenial PTX d / t endometriosis kunye nezinye.
  • I-pneumothorax ephazamisayo: ukuphazamiseka kwemiphunga, ukuphazamiseka okukhulu, iatrogenic (iibhobho zesifuba, njl.
  • I-CXR: inqaku elibhekiselele kwi-pleural line aka aka lung edge. Ukungahambi kwamathambo / iinqanawa ezingaphaya komgca we-visceral pleural. I-pneumothorax epholileyo ingabikho. Kwiindawo ezimileyo, umoya okhulayo kunye ne-PTX kufuneka ifunwe phezulu.
  • I-Rib fractures: v.common. Ukuxhatshazwa okanye ukugula (umz., Imitha, MM) Iingqungquthela zeebhanki x - ii-ray ayiluncedo kakhulu kuba i-CXR kunye / okanye ukutshekisha kwe-CT kubaluleke kakhulu ukuvavanya i-PTX ye-posttraumatic (ngaphantsi kwesobunxele)

 

isifuba somfanekiso esifubeni

 

Sulelo

  • I-pneumonia: ibhaktheriya okanye i-virus okanye i-fungal okanye kwi-immunocompromised host (umzekelo, i-Cryptococcus kwi-HIV / AIDS)

 

isifuba somfanekiso esifubeni

 

  • I-pneumonia: i-community-acquired vs. hospital-acquired. I-tynetic bacterial pneumonia okanye i-Lobar (engekho i-segmental) i-pneumonia enezinto ezihlambulukileyo zokuzalisa i-alveoli kwaye isasazeka kuyo yonke i-lobe. I-M / C i-OrganicStreptococcus I-Pneumonia okanye i-Pneumococcus
  • Abanye: (Staph, Pseudomonas, Klebsiella esp. Kwizidakwa ezinokuthi zikhokelela kwi-necroSIS / imiphunga yesiphunga) I-Mycoplasma (i-20-30s) ihamba nge-pneumonia, njl njl.
  • Iiklinikhi: ukukhwehlela okuvelisayo, umkhuhlane, intlungu yesifuba sentlungu ngezinye ihemoptysis.
  • I-CXR: i-confluent airspace opacity egcinwe kuyo yonke i-lobe. I-bronchograms yomoya. Uncedo lwezandla lwezandla kwindawo.
  • Intsholongwane: I-Influenza, i-VZV, i-HSV, i-EBV, i-RSV, njl. Ikhokelela ekuphelelweni kokuphefumula
  • I-pneumonia ye-Atypical kunye ne-Fungal Pneumonia: I-Mycoplasma, isifo seLegionnaire, kunye nesinye isifo / i-Cryptococcus pneumonia ingabonisa isifo se-lungs.
  • Ikhefu lokuphanga: ukuqokelela okuthelelekileyo kwezinto ezihlambulukileyo emiphakeni evame ukuhamba. Inokukhokelela kwiinkxalabo eziphambili ze-pulmonary and system / life-threating.
  • Kwi-CXR okanye kwi-CT: iqoqo elijikelezayo kunye nemida ebanzi kunye ne-necrosis ephakathi enezinga lomoya. DDx kwi-empyema ephazamisa umphunga kunye nesiseko esekelwe
  • I-Rx: i-antibiotics, i-antitifungal, i-anti-antial agents.
  • I-pneumonia idinga ukulandelwa kunye nokuphinda iCXR ukuqinisekisa ukugqiba ngokupheleleyo
  • Ukungabi nokuphuculwa kwe-radiographic ye-pneumonia kungabonisa ukukhulelwa komzimba, ukuchasana kwamagciwane, i-pulmonary carcinoma okanye ezinye izinto ezinzima

Pulmonary TB

isifuba somfanekiso esifubeni

 

  • Usulelo oluqhelekileyo emhlabeni jikelele (ihlabathi lehlabathi le-3rd). I-1 kubantu be-3 emhlabeni wonke ichaphazeleka yi-TB. I-TB ibangelwa nguMycobacterium TB okanye i-Mycobacterium Bovis. I-bacillus ye-Intracellular. I-Macrophage idlala indima ephambili.
  • I-TB yamayeza ePrayimari kunye ne-TB yasemva kweprayimari. Ifuna ukubhengeza okuphindaphindiweyo ngokuphefumla. Kwiindawo ezininzi ezingenakukwazi ukuzikhusela, intsholongwane esebenzayo ayikhuli
  • I-TB ibonisa njenge-1) igqitywe ngumphathi, i-2) igxothwe kwi-Latent Tuberculosis Infection (LTBI) i-3) ibangela i-TB esebenzayo. Izigulane nge-LTBI azifaki i-TB.
  • Ukucinga: CXR, HRCT. I-TB yaseprayimari: ukudityaniswa kwendawo yomoya yemiphunga (60%) yeelobes ezisezantsi, i-lymphadenopathy (95% - hilar & paratracheal), ukungxengxezeleka kwesicelo (10%). Ukusasazeka kwesifo sephepha esisisiseko ikakhulu kukungaziphathi kakuhle nabantwana.
  • I-TB yezigidi: i-pulmonary and system complication broadcast that can be deadly
  • I-post-primary (yesibini) okanye ukusuleleka kwintsholongwane: Ininzi kwi-Apices kunye namacandelo angaphantsi kwe-lobes) phezulu i-PO2), i-40% -kukhupha izilonda, isifo okanye i-confluent airspace isifo, i-fibrocalcific. Iimpawu zeLatent: ukubalwa kwamanqaku.
  • I-Dx: i-bacidi-fast bacilli (AFB) ne-culture (sputum). I-serology ye-HIV kuzo zonke izigulane ezine-TB kunye ne-HIV engaziwayo
  • I-Rx: I-regimen ye-4-drug: isoniazid, rifampin, pyrazinamide, kunye ne-ethambutol okanye i-streptomycin.

I-Pulmonary Neoplasms (umdlavuza oyimpompo oyintloko kunye nemetastasis yamapulmata)

  • Umdlavuza womlenze: umdlavuza wam / c kumadoda kunye ne-6 yesifo somdlavuza oqhelekileyo kubasetyhini. Unxulumano olunamandla kunye ne-carcinogens inhalation. Iikliniki: ukufumanisa emva kwexesha, kuxhomekeke kwindawo yesikhumba. Iipathology (iintlobo): Incinci encinci (SCC) kunye ne-Non-small cell cell
  • Incinci encinci: (i-20%) ivela kwiseli ye-neuroendocrine aka Kultchitsky, ngoko iyakwazi ukukhupha izinto eziphilayo ezisetyenziswayo kunye ne-paraneoplastic syndrome. Eyona ndawo ingundoqo (i-95%) okanye kufuphi ne-system / lobar bronchus. Uninzi lubonisa ukunyanzeliswa kwezinto ezimbi kunye nokungaqiniseki.
  • I-cell engeyiyo encinci: I-adenocarcinoma ye-Lung (i-40%) (Umhlaza wesi-M / C), i-M / C kubasetyhini nabangabhemi. Abanye: i-squamous cell (ingabonisa nge-lesion cavitation), inkulu enkulu kunye nabanye
  • Ifilimu ye-Plain (CXR): i-lesion entsha okanye eyandisiweyo, ekhulisa i-mediastinum icetyiswa ngokubandakanyeka kwe-lymph node, ukuxhatshazwa kwenzondo, i-atelectasis kunye nokudibanisa. I-SPN-inokuthi imele umhlaza wesifo somphunga ikakhulu xa iqulethe imida engafanelekanga, iinqanawa zokutya, udonga oluninzi, kumaphaphu aphezulu. Amanqamu amaninzi emiphunga amele ukuba amele i-metastasis.
  • Ukuziphatha ngokufanelekileyo: HRCT ngokuchasene.
  • Ezinye izifuba zesifuba: I-lymphoma i-v. Eqhelekileyo esifubeni ngokukodwa kumanqaku amancinci angaphakathi.
  • Ngokubanzi i-M/C pulmonary neoplasms yi-metastasis. Amanye amathumba abonisa ukuthambekela okuphezulu kokuhlangana kwemiphunga, umzekelo, iMelanoma, kodwa nawuphi na umhlaza unokumetastasize emiphungeni. Ezinye iimet ezibizwa ngokuba yi "Cannonball" metastasis
  • I-Rx: i-radiation, i-chemotherapy, i-resection

 

isifuba somfanekiso esifubeni

 

  • I-edema yePulmonary: Ixesha eliqhelekileyo lichaza ukuqokelela okungekho ngokwemvelo ngaphandle kwezakhiwo ze-vascular. Ukwahlukana ngokubanzi kwiCardiogenic (umz., I-CHF, i-mitral regurgitation) kunye ne-Non-cardiogenic enezinto ezininzi (umz., Ukugqithiswa kwamanzi, ukutshatyalaliswa emva kwegazi, izizathu ze-neurological, i-ARDS, kufuphi nokucwina / ukuphazamiseka kwemvelo, i-heroin overdose, kunye nabanye)
  • Iimbangela: ukwanda kwinycinezelo ye-Hydrostatic vs. ukunciphisa kwixinzelelo lwe-oncotic.
  • Ukucinga: I-CXR kunye ne-CT: I-2-iintlobo zeentlobo zezikhukhula ze-Interstitial and Alveolar. Ukubonakalisa ukubonisa kuxhomekeke kwizigaba
  • Kwi-CHF: Inqanaba loku-1: ukuhanjiswa kwakhona kwe-vascular flow (10- 18-mm Hg) kuphawulwe njenge-�cephalization� ye-pulmonary vasculature. Inqanaba lesi-2: I-edema ye-Interstitial (18-25-mm Hg) I-edema ye-Interstitial: i-cuffing ye-peribronchial, imigca ye-Kerley (i-lymphatics ezaliswe ngamanzi) A, B, C imigca. Inqanaba lesi-3: I-Alveolar edema: isifo sendawo yomoya: ukudityaniswa okungamabala kukhula kube sisifo sendawo yomoya: I-Batwing edema, iibronchograms zomoya.
  • I-Rx: Iinjongo eziphambili ze-3: I-O2 yokuqala ukugcina i-O2 kwi-90%
  • Okulandelayo: (1) ukunciphisa ukubuyiswa kweengxowankulu zamapulmoni (ukuphungulwa kwangaphambili kwezinto), (2) ukunciphisa ukunyanzeliswa kwe-vascular system (i-postload reduction), kunye ne-3 inkxaso ye-inotropic. Ukuphatha izizathu ezisisiseko (umzekelo, i-CHF)

 

isifuba somfanekiso esifubeni

 

  • Lung atelectasis: ukwandiswa okungaphelelanga kwepramonary parenchyma. Igama elithi "ukuphazamisa imiphunga" ngokuqhelekileyo ligcinwa xa yonke imiphunga iphela
  • I-1) I-atelectasis yokukhusela (yokuphazamiseka) iyenzeka ngenxa yesithintelo esipheleleyo somoya (isib. Isisu, izinto ezifakwe ngaphakathi, njl.
  • I-2) Ukuphumla (ukuphumla) i-atelectasis yenzeka xa unxibelelwano phakathi kweparietal kunye ne-visceral pleura luphazamiseka (pleural effusion & pneumothorax)
  • I-3) I-atelectasis enoxinzelelo iqhutyelwa ngenxa yeso siphene esine-thoracic-compressing compressing the pulp and forcing air out of the alveoli
  • I-4) I-atelectasis yamacandelo: ivela ngenxa yesigqabi okanye i-fibrosis eyanciphisa ukwandiswa kwemiphunga njengesifo segranulomatous, pneumonia ne-radiation fibrosis
  • I-5) I-adhesive atelectasis i-Adhesive atelectasis ivela kwi-infactant lack and collapse alveolar
  • 6) I-plate-like or discoid yayivame ukuphuhliswa emva kokulandela i-anesthesia jikelele
  • I-7) Impawu yokucinga: ukuwa kwempompo, ukufuduka kwemiphunga yemiphunga, ukuphambuka kwe-mediastinum, ukunyuka kwesithsaba, ukunyuka kwe-hyperinflation kwimiphunga engaphazamiseki

 

isifuba somfanekiso esifubeni

 

  • I-Mediastinum: i-pathology ingahlukaniswa kwizinto ezibangelwa kukukhululeka okanye ezo ziza kubangela izifo ezahlukileyo ezibandakanya i-mediastinum. Ukongezelela, umoya ungangena kwi-mediastinum kwi-pneumomediastinum. Ulwazi lwe-mediastinal anatomy lunceda iDx.
  • Izidumbu zasemdeni zangaphambili: i-thyroid, thymus, i-teratoma / i-germ tumors tumors, i-lymphoma, i-lymphadenopathy, inyuke kwi-aortic aneurysms
  • Abantu abaphakathi kwe-mediastinal: i-lymphadenopathy, i-vascular, iilononalons etc.
  • Amasundu omzimba osemva: ama-tumor neurogenic, i-aortic aneurysms, i-mass-esophageal masses, i-spinal mass, i-aortic chain adenopathy

 

isifuba somfanekiso esifubeni

 

  • I-pulmonary emphysema: ukulahlekelwa kweethambo eziqhelekileyo ze-elastiki / i-elastic recovery of the lungs ngokutshabalalisa i-capillaries kunye ne-septum / interstitium.
  • Ukutshatyalaliswa kwemiphunga yephampyrama ngenxa yokuvuvukala okungapheliyo. Ukutshatyalaliswa kweprotease-elastin. Ukubanjwa komoya / ukwandiswa kwe-airspace, i-hyperinflation, i-pulmonary blood pressure, kunye nezinye iinguqulelo. Iiklinikhi: i-dyspnea eqhubekayo, engenakuphikiswa. Ngethuba ixesha lokunyanzeliswa komqulu kwi-1 yesibini (FEV1) liwile kwi-50% isigulane siphefumula xa sisebenza ngokuncinci kwaye sitshintshela kwiindlela zokuphila.
  • I-COPD yimbangela yesithathu yokubangela ukufa kwabantu emhlabeni jikelele. Ichaphazela i-1.4% yabantu abadala base-US. M: F = 1: 0.9. I-Pts 45 iminyaka kunye nangaphezulu
  • Izizathu: Ukutshaya kunye ne-1-Antitrypsin ukusilela (ihlukaniswe kwi-centrilobula (ukutshaya) kunye ne-panacinar.
  • Ukucinga; iimpawu ze-hyperinflation, ukuxhamla umoya, i-bullae, i-pulperary hypertension.

 

isifuba somfanekiso esifubeni

 

Umgangatho wobuchule wokuSebenza *

Ulwazi olulapha ku "Izifo Zendlela Yokusondeza Ukujonga Ukuxilongwa"Akujoliswanga ukuthatha indawo yobudlelwane obubodwa kunye nomntu oqeqeshiweyo wezempilo okanye ugqirha onelayisensi kwaye akusiyo isiluleko sonyango. Sikhuthaza ukuba wenze izigqibo zezempilo ngokusekelwe kuphando lwakho kunye nentsebenziswano kunye nochwepheshe bezempilo abaqeqeshiweyo.

Ulwazi lweBlog kunye neengxoxo zoMda

Umda wethu wolwazi ilinganiselwe kwiChiropractic, i-musculoskeletal, amayeza omzimba, impilo, igalelo le-etiological ukuphazamiseka kwe-viscerosomatic ngaphakathi kweentetho zeklinikhi, ezinxulumene ne-somatovisceral reflex clinical dynamics, i-subluxation complexes, imiba yezempilo ebuthathaka, kunye / okanye amanqaku amayeza asebenzayo, izihloko kunye neengxoxo.

Sibonelela kwaye sibonise intsebenziswano yeklinikhi neengcaphephe kumacandelo ahlukeneyo. Ingcali nganye ilawulwa ngumsebenzi wabo wobugcisa kunye negunya labo lokufumana iphepha-mvume. Sisebenzisa iiprothokholi ezisebenzayo zempilo kunye nempilo entle ukunyanga nokuxhasa ukhathalelo lokwenzakala okanye ukuphazamiseka kwenkqubo ye-musculoskeletal.

Iividiyo zethu, izithuba, izihloko, imixholo, kunye nokuqonda zibandakanya imiba yezonyango, imiba, kunye nezihloko eziyelelene kwaye zixhase ngokuthe ngqo okanye ngokungathanga ngqo umda wokuziqhelanisa wethu.

I-ofisi yethu izamile ngokufanelekileyo ukubonelela ngeengcaphulo ezixhasayo kwaye ichonge uphando olufanelekileyo lophando okanye izifundo ezixhasa izithuba zethu. Sinikezela ngeekopi zophando ezixhasayo ezifumanekayo kwiibhodi ezilawulayo nakuluntu ngesicelo.

Siyaqonda ukuba sigubungela imicimbi efuna inkcazo eyongezelelweyo yokuba inganceda njani kwisicwangciso esithile sokhathalelo okanye inkqubo yonyango; ke, ukuqhubeka nokuxoxa ngombandela ongentla, nceda ukhululeke ukubuza UDkt Alex Jimenez, DC, okanye qha ga mshelana nathi 915-850-0900.

Silapha ukunceda wena kunye nosapho lwakho.

Iintsikelelo

UDkt Alex Jimenez D.C., I-MSACP, RN*, I-CCST, IFMCP*, I-CIFM*, I-ATN*

email: qeqeshi@elpasofunctionalmedicine.com

Ilayisenisi njengoGqirha weChiropractic (DC) kwi Texas & New Mexico*
Texas DC Ilayisensi # TX5807, New Mexico DC Ilayisensi # I-NM-DC2182

Unikwe Ilayisensi njengoMongikazi oBhalisiweyo (RN*) in Florida
Florida License RN Ilayisensi # I-RN9617241 (Nombolo yolawulo. 3558029)
Ubume obubambeneyo: ILayisensi yeeNkcazo ezininzi: Ugunyaziswe Ukuziqhelanisa I-40 States*

UGqr. Alex Jimenez DC, MSACP, RN* CIFM*, IFMCP*, ATN*, CCST
Ikhadi lam loShishino lweDijithali