PREVENTION AND TREATMENT OF HYPERTENSION IN ADULT

PATIENTS

A Research Paper
In Partial Fulfillment of the Requirement in
English 102 – Advanced Composition

Submitted by:

Ma. Kristal Gale Aldemita

Karla Charmaine Barrameda
Mylene Refuerzo
Jackylin Tan

Submitted to:

Ms. Lina Hervas

Professor

TRINITY UNIVERSITY OF ASIA

March 2008
 TABLE OF CONTENTS

PAGE

Approval sheet…………………………………………………………………………i

Abstract.......................................................................................................................ii

Acknowledgement ……………………………………………………………………iii

I. INTRODUCTION

Background…………………………………………………..…………………….1

Statement of the Problem…………………………………………………………..2

Scope and delimitation……………………………………………………………..3

Significance of the Study…………………………………………………………..3

Definition of terms…………………………………………………………………4

II. COLLECTION OF READINGS

Local literature…………………………………………………………………..….5

Foreign literature…………………………………………………………………….7

Relevance of the study……………………………………………………….…….10

III. SUMMARY, CONCLUSION, RECOMMENDATIONS…………………….…..12

IV. Bibliography………………………………………………………………………..

13

V. Resume ……………………………………………..…………………………...…

16
 APPROVAL SHEET

This research, entitled Prevention and Treatment of Hypertension in Adult

Patients, prepared by Ma. Kristal Gale S. Aldemita, Karla Charmaine P. Barrameda,

Mylene B. Refuerzo and Jackylin L. Tan, in fulfillment of the requirements in English

102- A Advanced Composition and submitted to the department of English and Foreign

Languages is hereby accepted.

_________________________________
Ms. Lina Hervas
Professor
 Acknowledgement

We would like to thank the Lord God, who provided us the strength, hope and

courage to continue doing our work. Ms. Lina Hervas, who helped and guided us as we

are writing our paper, Also to the librarians who lend us some books about Hypertension.

Refuerzo and Barameda family welcomed us warmly to their house, for the food we have

enjoyed there. This term paper is a product made possible though the contributions of

many writers. The names of the authors are listed in the bibliography.
 Prevention and Treatment of Hypertension in Adult Patients 1

I. INTRODUCTION

Background of the Study

People should be more conscious of their heart nowadays. Clinical studies show

that cases of Cardiovascular Disease (CVD) continue to increase. The World Health

Organization predicts that by the year 2020, up to 40 percent of all deaths will be

cardiovascular disease related. The leading cause of death in the World is cardiovascular

disease account for almost 15 million deaths approximately, 30 percent of death

worldwide in 1995. According to the World Heart Federation, the number of

cardiovascular diseases is quite alarming, there are about 17 million deaths annually

caused by cardiovascular disease. It is even more dramatic, when compared to other

causes of death. The World Health Organization said that 30 percent of deaths are due to

cardiovascular disease, as against HIV/AIDS five percent, and malaria two percent.

In the United States, the diseases of the heart and circulation are the leading cause

of death and disability, afflicting more than 27 million children and adults, and killing

more than 1 million annually. Among the 27 million people having heart and blood vessel

diseases, high blood pressure is present in about 21 million, coronary heart disease and

heart attack in over 4 million, rheumatic heart disease in 1.6 million, and stroke in 1.6

million. Cardiovascular diseases claim more lives than all other causes of death

combined, and heart attack alone is the largest single cause of death in the United States,

accounting for one-third of all male deaths between the ages 35 and 65.

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 Prevention and Treatment of Hypertension in Adult Patients 2

Cardiologists warn that the rapid change in people’s lifestyle and diet are causing

the prevalence of different heart disease not only among older but also younger people.

The Pharmaceutical companies continue to seek better means of discovering new and

effective drugs for the treatment of cardiovascular diseases. Pfizer, a global health-care

company has budget of $4.7 billion and 12,000 highly-skilled researchers working at

research and development facilities in more than 20 countries around the world. The

Pfizer is able to discover safe and cost-effective medicines for hypertension and high-

cholesterol, the tow main causes of cardiovascular disease. Its investment in the study of

the human genome will allow them to know other causes of cardiovascular disease in the

future, and help develop new drug treatments for the said disease. Pfizer is a union

between Pfizer Inc. and Warner-Lambert. It is a global research base company that

discovers, develops, and manufactures innovative medicines.

Statement of the Problem

The researchers’ study about “Prevention and Treatment of Hypertension in Adult

Patients” tends to find and seek best answers and solutions to the following questions:

1. How can hypertension in adult patients be prevented?

2. Why does hypertension commonly experienced by adult patients?

3. What are the treatments in order to remedy hypertension?

4. What are the programs needed to be develop and implemented to remedy

hypertension in adults?

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 Prevention and Treatment of Hypertension in Adult Patients 3

Scope and Delimitation

The researcher will discuss the common illness suffered mostly by people called

“Hypertension”. The research is limited only on the prevention on how to stay away from

hypertension on adult patients. The researchers will discuss all preventive ways in order

to avoid hypertension. These preventions will help the readers especially those who are

concern understand and gain knowledge about the topic which in one way they can also

apply to hypertension. Furthermore, the readers will also elaborate some effective and

useful treatments in order to remedy hypertension.

Significance of the study

This study would be beneficial not only to the researchers, but also to the

following people:

To the students, this study will give them some relevant information about

hypertension.

To the adult patients, they will be aware of the possible risks of having

hypertension. This paper will serve as their guide in preventing hypertension.

To the nursing students, that they will attain some useful information and facts

about hypertension.

To the non hypertensive people, this paper will serve them as a warning that

hypertension is a silent killer and to change their lifestyle as early as possible. This will

be an informative paper for them to know the importance of their heart while they are

young.
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 Prevention and Treatment of Hypertension in Adult Patients 4

To the government, they will implement more programs to remedy hypertension.

It is also to give awareness to the country concerning hypertension.

Definition of Terms

These are the following terms that the researchers used in this study:

Blood pressure. This refers to the force exerted by circulating blood on the

walls of blood vessels, and constitutes one of the principal vital signs.

Cardiovascular. A system that regulates the circulation of blood in our body

Chlamydia pneumonia bacteria. A type of bacteria that is the chief suspect

behind many strokes and heart attacks.

Complications. Any disease or disorder that occurs during the course of (or

because of) another disease.

Dyslipidemia. The elevation in cholesterol or thyglycerides

HBP. It stands for High Blood Pressure.

Hypertension. Is a repeatedly elevated blood pressure exceeding 140 over 90

mmHg with a systolic pressure above 140 with a diastolic pressure above 90.

LDL cholesterol. Is more likely to clog blood vessels because it carries the

cholesterol away from the liver into the bloodstream, where it can stick to the blood

vessels.

Lifestyle. A way or style of living that reflects the attitude and values of a

person or group.

Sagittal abdominal diameter. It is a measure of visceral obesity, also called

Supine Abdominal Height.

Sphygmomanometer. Is an instrument used to measure the blood pressure.

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 Prevention and Treatment of Hypertension in Adult Patients 5

II. COLLECTION OF READINGS

The readings presented are the collection of related literatures that were by the

researchers. It is a collection of books, encyclopedia, magazines and periodicals which

were published locally and internationally. The readings are related to the topic

Prevention of Hypertension in Adult Patients.

Local Literature

Dr. Francisco Tranquilino, a cardiologist and training officer at the Philippine

General hospital says that in managing patients, doctors also consider the long-term

effects and complications of a particular medicine on the illness like hypertension.

As said by Dr. Mariano Lopez, the most common ailment nowadays is

hypertension which damages the heart and kidneys, both vitals organs. He also stated that

if we want to live our lives longer, invest in ourselves. We should have less-sodium and

fat-trimmed diet. Avoid smoking and drinking. But he added also that diet and lifestyle

may not be enough to control our high blood pressure thus, we have to maintain drug

which we have to take at the same time everyday. Based on research studies conducted by

the Cardiology Division of the Department of Health (DOH), cardiovascular disease

claims thousands of lives in the Philippines, caused by risk factors.

In an article found in Manila Bulletin, 21 percent of Filipinos are hypertensive

and that the prevalence in the elderly population is near half. This means that every one

out of two elderly Filipinos are Hypertensive.

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 Prevention and Treatment of Hypertension in Adult Patients 6

Hypertension is found more often in men than in women. Postmenopausal women

are affected as well. It tends to run in families (Dr. J. J. Pujalte Jr., 2004). There are some

conditions that may lead to hypertension as follows: pregnancy, use of hormones like

estrogen (found in birth control pills), and tumors that secrete hormones that raise blood

pressure (for example, the adrenal glands). He also enumerates the following symptoms:

headaches, nape pains, chest pain or tightness, nosebleeds, blurring of vision, confusion,

and memory loss. These are the warnings of severe hypertension. The following may lead

to secondary hypertension such as: palpitations or the sensation of the heart jumping, too

much perspiration, muscle cramps, weakness and frequent urination.

A researcher named, Tyrone Reyes have long suspected a connection between

heart disease and some sort of chronic inflammation affecting the arteries. One leading

theory is that the chlamydia pneumonia bacteria, a common source of respiratory

infections, also causes heart attacks by disrupting the plaques that build up and narrow

diseased arteries. Large trials are under way to see whether giving antibiotics to heart-

disease patients will show tangible results. Pfizer Inc. is testing its popular antibiotic

arzithromycin (Zithromax) as a heart-disease treatment in a clinical trial nicknamed the

wizard trial.

Ms. Julie E. Buring stated that the multivariate relative risks across increasing

quintiles of high-fat dairy product intake, in contrast, were 1.00, 1.02, 1.01, 1.00, and 0.97

(P for trend: 0.17). It was found that intakes of low-fat dairy products, calcium, and

vitamin D were each inversely associated with risk of hypertension in middle-aged and

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 Prevention and Treatment of Hypertension in Adult Patients 7

older women, suggesting their potential roles in the primary prevention of hypertension

and cardiovascular complications.

In fact, people with hypertension actually appear to be eating worse than before

the government-approved guidelines were introduced, according to the report published

in the Feb. 11 issue of the Archives of Internal Medicine. The study said young people,

blacks and the obese fared the worst in their dietary habits.

A diet high in fruits, vegetables and low-fat dairy products has been shown to help

significantly lower blood pressure, according to background information in the article.

This Dietary Approaches to Stop Hypertension (DASH) method, first published in 1997,

complements other lifestyle changes, such as reducing sodium and losing weight, and can

also help lower cholesterol levels, previous studies have shown.The DASH diet is

recommended by the Joint National Committee on Prevention, Detection and Treatment

of High Blood Pressure for all patients with hypertension.The study analyzed dietary,

health and personal data of adults collected in surveys done by the U.S. Centers for

Disease Control and Prevention from 1988 to 1994 and from 1999 to 2004. Using the

DASH guidelines, researchers identified goals for eight target nutrients and calculated

scores ranging from zero to nine for individuals with and without hypertension from the

surveys; those who scored a 4.5 or higher were considered to be following the diet.

Foreign Literature

In an article of Malaya, the World Heart Federation states that the number of

cardiovascular diseases cases is quite alarming. There are about 17 million deaths

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 Prevention and Treatment of Hypertension in Adult Patients 8

annually caused by Cardiovascular diseases particularly, hypertension. According to their

recent study, without effective intervention or prevention activities, cases of heart

diseases will continue to rise sharply.

As stated by Dr. Ronald Santos, the prevalence rate of Hypertension in the United

States. Europe and Japan is 3:5, while in Lebanon and Saudi Arabia it is 2:5. A data

obtained from National Center for Health Statistics, Hypertension and other

cardiovascular diseases are the leading causes of death rates in United States.

The study, based on data collected on 10,874 Chicago men ages 18-39 who were

studied from 1967 to ’73 and then followed for an average of 25 years, is comprehensive

yet on the long term effects of high blood pressure in young men said Dr. Martha

Daviglus.

Referring to New York Reuters Health, the more belly sticks out the greater your

risk of developing heart disease. A new study shows that the more Sagittal Abdominal

Diameter, the stronger the risk to have a heart disease.

The Losartan Intervention for Endpoint Reduction of Hypertension (LIFE) study,

which was conducted in 9,193 patients with hypertension and left ventricular hypertrophy

(enlarged heart), showed that losartan significantly reduced the combined risk of

cardiovascular death, heart attack and stroke.

In an article found in Manila Star, said by British researchers, it’s the brain and

not the heart that is responsible for high blood pressure. In details, the scientist said that

hypertension can lead to heart attacks, strokes, and kidney damage is an inflammatory

vascular disease of the brain rather than the heart. Professor Julian Paton from Bristol

University Western England states that finding lead to new ways of treating condition. A
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 Prevention and Treatment of Hypertension in Adult Patients 9

statement from Boston (Reuters) says a blood test that detects damage caused by a heart

attack is far more reliable than previously thought because it works in people with kidney

problems, researchers reported in the New England Journal of Medicine.

Another article found in Manila Bulletin, according to a Harvard Medical School

Study, showed that losing the weight will lessen the risk for hypertension. An increase in

weight, about 10 – 20 pounds, will put the life in danger.

According to New York (Reuters Health), in African-Americans with poorly

controlled high blood pressure (hypertension) and high cholesterol, treatment with a

single pill containing a blood pressure-lowering drug and a cholesterol-lowering drug

may prove particularly useful, researchers say.

Getting blood pressure and "bad" LDL-cholesterol under control has been harder

to do in African Americans than in the overall U.S. population, note the researchers in a

report in Mayo Clinic Proceedings, a medical journal. The current study, they say,

suggests that the single-pill option may help more of them reach their goals.

The single pill combo is marketed as Caduet by Pfizer, the company that

supported the study. Caduet contains the drug amlodipine, used to treat high blood

pressure and atorvastatin, used to lower cholesterol.

In the study, 499 African Americans with uncontrolled hypertension and

"dyslipidemia" (elevations in cholesterol or triglycerides) received Caduet in eight

different dosage strengths, which were flexibly increased as needed.

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 Prevention and Treatment of Hypertension in Adult Patients 10

"We have shown, in a study designed to approximate 'real world' practice in

African Americans with poorly controlled hypertension and dyslipidemia that single-pill

amlodipine/atorvastatin provides substantial improvement in both risk factors," Dr. John

M. Flack, from Wayne State University Health Center in Detroit and colleagues report.

"Control of hypertension and dyslipidemia had been achieved in fewer than 1

percent of patients at study entry but was attained by almost half by week 20," they

further note.

More specifically, they report that 236 (48.3 percent) of 489 patients reached both

their blood pressure and LDL-cholesterol goals, versus 4 (0.8 percent) of 484 at baseline.

Separately, they found that 280 (56.8 percent) of 493 patients reached BP goals,

versus 7 (1.4 percent) of 494 at baseline, while 361 (73.7 percent) of 490 reached LDL-

cholesterol goals compared with 138 (28.5 percent) of 484 at baseline.

The single-pill combination was well tolerated; the most common treatment-

related adverse events were peripheral swelling (3.4 percent), headache (2.2 percent),

muscle pain (2.2 percent) and constipation (2.0 percent), none of which were considered

severe.

Relevance of the study

This study is relevant to adults because they have the greater chances of having

hypertension. Adults are more prone of having this disease because as they get older,

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 Prevention and Treatment of Hypertension in Adult Patients 11

their bodies get weak also. Therefore, they have less ability to fight that specific disease.

In other words, their immune system weakens. This study also states that it is highly

recommended to have a lifestyle change. It is recommendable to stop smoking; drinking

alcohol, eating high-cholesterol foods and even stress can damage the heart by blocking

the arteries, causing to pump blood harder.

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 Prevention and Treatment of Hypertension in Adult Patients 12

III. SUMMARY, CONCLUSION, RECOMMEDATIONS

The following stated below are the summary, conclusion, and the

recommendation of the researchers for the readers in the topic Prevention and Treatment

of Hypertension in Adult Patients.

Summary

In this study, the researchers found out that the hypertension in adult patients can

be prevented by changing the bad habits like: smoking, drinking alcohol, eating too much

fatty foods, too much drinking of coffee. It can also be prevented by exercising, balnce

diet, and avoiding stress.

Hypertension can be treated by antibiotic arzithromycin (Zithromax) an antibiotic

produced by Pfizer Inc. The writers also found out that hypertension can be treated if the

high blood person will lose weight, stop eating fatty foods, exercising daily and

continually taking medicines prescribe by their doctors.

The researchers found out that hypertension can be found more often in men than

in women. Postmenopausal women are affected as well. There are some conditions that

may lead to hypertension as follows: pregnancy, use of hormones like estrogen and

tumors that secrete hormones that raise blood pressure.

The writers discovered some symptoms of hypertension like headaches, nape

pains, chest pain or tightness, nosebleeds, blurring of visions, confusion and memory

loss. The following may lead to secondary hypertension such as palpitation or the

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 Prevention and Treatment of Hypertension in Adult Patients 13

sensation of heart jumping, too much perspiration, muscle cramps, weakness and frequent

urination.

The researchers also discovered that intakes of low-fat dairy products, calcium,

and vitamin D were each inversely associated with risk of hypertension in middle age and

older women, suggesting their potential roles in the primary prevention of hypertension

and cardiovascular complications. A diet high in fruits, vegetables and low-fat dairy

products has been shown to help significantly lower blood pressure.

Conclusion

Hypertension in adult patients can be prevented by kicking the bad habits in order

to have a healthy heart: quit smoking, exercise, maintain, reduce dietary cholesterol,

reduce coffee intake and avoid stress. The researchers have found that the DASH diet

(Dietary Approaches To Stop Hypertension), which is very similar to the Pritikin Eating

Plan, lowers blood pressure as well as or better than any drug. Both DASH and Pritikin

promote menus that are low in fats, salt, cholesterol, red meat, and sweets; high in fruits,

vegetables, whole grains, and beans; and moderate in seafood, poultry, nuts, and low-fat

or nonfat dairy foods.

Adult patients are more hypertensive because of unhealthy lifestyle practices and

reckless diet in their younger age. Hypertension in adult patients can be prevented by

kicking the bad habits in order to have a healthy heart: quit smoking, exercise, maintain,

reduce dietary cholesterol, reduce coffee intake, and avoid stress.

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 Prevention and Treatment of Hypertension in Adult Patients 14

Adult patients are more hypertensive because of unhealthy lifestyle practices and

reckless diet in their younger age. Adults are more prone of having of having this disease

because as they get older, their bodies will also get weak.

Recommendations

Here are the recommendations that the researchers would like to share to all the

readers.

1. The adult patients it is highly recommended that they should change their lifestyle.

They should avoid smoking, drinking alcohol, exercise daily, and reduce coffee intake

and stress. By having the right kind of food, hypertension and other diseases can be

prevented. Eating too much of fatty foods which contains bad cholesterol that can clog

the arteries in the heart, thus preventing the blood to flow normally.

2. The government should endorse about stop or drinking moderately, making programs

like exercising, jogger’s lane, aerobics, Taebo, walking marathon, eating low and non-fat

foods, and reducing weight. So that people will be encourage to lessen their weight and to

prevent hypertension.

3. The nursing students should have knowledge about hypertension for they will be

handling hypertensive patients. Nurses are the one who will take charge of the patients

while the doctor is not around so they should be well informed about this disease they are

supposed to know the first aids when hypertension had started infecting the patients’

health.

4. And lastly, the non hypertensive people should watch on their diet and lifestyle. They

should stop abusing their health and stop their bad habits. And to keep their body fit and
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 Prevention and Treatment of Hypertension in Adult Patients 15

healthy, they should find time for exercising. In the times they are at the party and can’t

help but to eat too much fatty food, they must drink supplements that can help their

digestion. Or most likely, they should control the intake of these fatty foods. One last

thing is to reduce coffee intake.

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 Prevention and Treatment of Hypertension in Adult Patients 16

Resume

Aldemita, Ma. Kristal Gale S.

98-B Main Ave. Murphy Cubao Quezon City

k2rzhe@yahoo.com
09176068064

Birth date : July 28, 1990 Birth place : Mandaluyong City

Age : 17 Sex : Female
Nationality : Filipino Language/s : Filipino, English
Civil Status : Single Religion : Christian
Height : 5’4 Weight : 110 lbs.

FAMILY BACKGROUND

Father’s Name: Gilluermo Montelora Mother’s Name: Marvelyn Aldemita

Age : 59 Age : 47
Occupation : sea man Occupation : civilian employee
Contact No. : ---- Contact No. : 09154012113
No. of siblings: ----
Name of Siblings: ---- Age: ----

EDUCATIONAL BACKGROUND
____________________________________________________________________

Primary School : San Joaquin Central School.

Address : Iloilo City
Year Graduated : 2003
Awards : most industrious, Drum corp. member

Secondary School : Stella Maris College

Address : Cubao, Quezon City
Year Graduated : 2007
Awards : pep squad member
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 Prevention and Treatment of Hypertension in Adult Patients - 17
-

Resume

Karla Charmaine P. Barrameda

14-F East Road Cubao Quezon City
keiceemaine08@yahoo.com/ no_ordinary_charm@yahoo.com.ph
09224011754

Birth date : December 8, 1990 Birth place : Quezon City

Age : 17 yrs. old Sex : Female
Nationality : Filipino Language/s : Filipino/ English
Civil Status : Single Religion : Born Again Christian
Height : 5’3” Weight : 120 lbs.

FAMILY BACKGROUND

Father’s Name: Dioscoro B. Barrameda Mother’s Name: Merlyn P. Barrameda

Age : ---- Age : 47 yrs. old
Occupation : ---- Occupation : Government Employee
Contact No. : ---- Contact No. : 09228333077
No. of siblings: 2
Name of Siblings: Sheryl May P. Barrameda Age : 27 yrs. old
Name of Siblings: Dennis Alvin P. Barrameda Age : 23 yrs. old

EDUCATIONAL BACKGROUND
____________________________________________________________________

Primary School : Aguinaldo Elementary School

Address : 18th avenue Murphy Quezon City
Year Graduated : April 2003
Awards : glee club member

Secondary School : Juan Sumulong High School

Address : 18th avenue Murphy Quezon City
Year Graduated : March 2007
Awards : glee club member, GSP officer

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Resume

Mylene B. Refuerzo
208 J. Ruiz Street
San Juan Metro Manila
ensonmylene_chad14@yahoo.com
09176057557

Birth date : March 7, 1990 Birth place : San Juan

Age : 18 Sex : Female
Nationality : Filipino Language/s : Filipino, English
Civil Status : Single Religion : Catholic
Height : 5’4 Weight : 120bs.

FAMILY BACKGROUND

Father’s Name: Glenn J. Refuerzo Mother’s Name: Edelyn B. Refuerzo

Age : 41 Age : 40
Occupation : businessman Occupation : Housewife
Contact No. : 7443842 Contact No. : 7443842
No. of siblings: 7
Name of Siblings: Age:
Francis B. Refuerzo 22 yrs. old Glenn B. Refuerzo, Jr. 13 yrs. old
Michelle Ann B. Refuerzo 19 yrs. old Jake B. Refuerzo 11 yrs. old
Jayvee B. Refuerzo 14 yrs. old Myra Mae B. Refuerzo 9 yrs. Old
Madel B. Refuerzo 8 yrs. Old

EDUCATIONAL BACKGROUND
____________________________________________________________________

Primary School : Salapan Elementary School

Address : St. Veloso Street San Juan
Year Graduated : 2002
Awards : 3rd honorable and Best in EPP

Secondary School : Central Colleges of the Philippines

Address : Quezon City
Year Graduated : 2006
Awards : Overall Top 8, Co-Curricular Award.
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 Prevention and Treatment of Hypertension in Adult Patients
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Resume

Jackylin L. Tan
56 Scout Limbaga Street
Timog Ave., Quezon City
jackylintan@yahoo.com/candy_tan88@yahoo.com
09162340523

Birth date : December 19, 1988 Birth place : Quezon City

Age : 19 Sex : Female
Nationality : Filipino Language/s : Filipino, English
Civil Status : Single Religion : Christian
Height : 5’3 Weight : 100 lbs.

FAMILY BACKGROUND

Father’s Name: Bobby C. Tan Mother’s Name: Priscilla L. Tan

Age : 56 Age : ----
Occupation : businessman Occupation : ----
Contact No. : 4166138 Contact No. : ----
No. of siblings: 6
Name of Siblings: Age:
Elizabeth L. Tan 21 yrs. old Clara Jane M. Tan. 13 yrs. old
Caroline L. Tan 16 yrs. old Antoinette M. Tan 8 yrs. old
Mark Anthony M. Tan14 yrs. old Bernadtte M. Tan 6 yrs. Old

EDUCATIONAL BACKGROUND
____________________________________________________________________

Primary School : Grace Christian High School

Address : Grace Village, Sto. Domingo, Quezon City
Year Graduated : 2003
Awards : glee club member

Secondary School : Grace Christian High School

Address : Grace Village, Sto. Domingo, Quezon City
Year Graduated : 2007
Awards : glee club member

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 Prevention and Treatment of Hypertension in Adult Patients
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Department of English, Literature and Foreign Languages