ANGELES UNIVERSITY FOUNDATION

AngeIes City
COLLEGE OF NURSING





A case report presented to the
CoIIege of Nursing







Submitted by
Nuqui, Rolan A.

BSN 4, GROUP NO. 39

Submitted to
Adrian W. de Leon, RN, MN
Clinical Ìnstructor


I. INTRODUCTION

Cellulitis is a spreading bacterial infection of the skin and tissues beneath the skin.
Cellulitis usually begins as a small area of tenderness, swelling, and redness. As this
red area begins to enlarge, the person may develop a fever, sometimes with chills and
sweats, and swollen lymph nodes ("swollen glands") near the area of infected skin.

Cellulitis may occur anywhere on the body, but the leg is the most common site of the
infection (particularly in the area of the tibia or shinbone and in the foot), followed by the
arm, and then the head and neck areas. Ìn special circumstances, such as following
surgery or trauma wounds, cellulitis can develop in the abdomen or chest areas. People
with morbid obesity can also develop cellulitis in the abdominal skin. Special types of
cellulitis are sometimes designated by the location of the infection. Examples include
periorbital (around the eye socket) cellulitis, buccal (cheek) cellulitis, and perianal
cellulitis.

The majority of cellulitis infections are caused by either staph (Staphylococcus) or
strep(Streptococcus) bacteria. Staph (Staphylococcus aureus) is the most common
bacteria that causes cellulitis. There is a growing incidence of community-acquired
infections due to methicillin-resistant S. aureus (MRSA), a particularly dangerous form
of these bacteria that is resistant to many antibiotics and is more difficult to treat.

Strep (Streptococcus) is also a common cause of cellulitis. A form of rather superficial
cellulitis caused by strep is called erysipelas; it is characterized by spreading hot, bright
red circumscribed area on the skin with a sharp raised border. The so-called ³flesh
eating bacteria" are, in fact, also a strain of strep that can sometimes rapidly destroy
tissues.

Cellulitis can be caused by many other types of bacteria. Ìn children under 6 years of
age, H. flu (Hemophilus influenza) bacteria can cause cellulitis, especially on the face,
arms, and upper torso. Cellulitis from a dog or cat bite or scratch may be caused by the
Pasteurella multocida bacteria, which has a very short incubation period of only four to
24 hours. Aeromonas hydrophilia, Vibrio vulnificus, and other bacteria are causes of
cellulitis that develops after exposure to freshwater or seawater. Pseudomonas
aeruginosa is another type of bacteria that can cause cellulitis, typically after a puncture
wound.

Cellulitis can affect anyone of any age; cellulitis of the face is more common in children
and adults over age 50 (Cunningham). The actual incidence of cellulitis is unknown
because cases are seldom reported. Orbital cellulitis is uncommon but potentially very
serious.

The incidence of infection by methicillin-resistant Staphylococcus aureus (MRSA) and
other antibiotic-resistant bacteria has increased dramatically in recent years (Mayo
Clinic Staff).Ìnfection by these organisms is much more serious.

New Trends on Treating CeIIuIitis
Vancomycin Is the Drug of Choice for Treating CeIIuIitis, Study Suggests
28 Oct. 2010

For some time, medical practice guidelines have been ambiguous about whether
vancomycin or so-called B-lactam antibiotics like penicillin or cephalosporins was the
more appropriate therapy for treating patients admitted for cellulitis. Ìf left untreated and
infection spreads, cellulitis could become life threatening.

The Henry Ford study found that 226 patients treated intravenously with vancomycin
between December 2005 and October 2008 fared better and were discharged on
average one day earlier than 199 patients treated intravenously with the B-lactam
antibiotics.

The study is being presented Oct. 23 at the 48th annual meeting of the Ìnfectious
Diseases Society of America Oct. 21-24 in Vancouver.

"We believe vancomycin is the better treatment option for managing patients
hospitalized with cellulitis," says Hiren Pokharna, M.D., an Ìnfectious Diseases fellow at
Henry Ford Hospital and the study's lead author.

With MRSA skin and soft tissue infections increasing, researchers sought to compare
the two groups of antibiotics commonly used for treating hospitalized patients with
cellulitis. The common bacterial skin infection is caused by many types of bacteria
including staphylococcus and streptococcus. Symptoms include redness, swelling,
tenderness and pain.

MRSA strains have proven resistant to common antibiotics like penicillin and other
drugs. However, they have been shown to be susceptible to vancomycin

Reason for choosing such case for presentation
Our group is assigned in Angeles University Foundation Medical Center, particularly in
the Pediatric Ward, 5
th
floor MT. As a requirement in this rotation we have to make a
case study. A case study is the collection and presentation of detailed information about
a particular participant or small group which is emphasize on exploration and
description. As much as we want to choose a case which is easy to handle or will at
least get our interest, cases are limited. We had difficulty in choosing our case study
because we really wanted something that will get our attention, but since there are
limited cases available we choose the one that at least seems interesting to us and the
one that we think will be best for conducting our study.

Last June 27, 2011 we were able to handle a patient with Right Leg Cellulitis. We
agreed to choose this case for the following reasons:

The case, Cellulitis, is a common disease condition especially among the pediatrics. A
lot of them experienced such condition and people are not aware of what this condition
may bring to their health. People who are aware of this kind of disease are continuously
seeking information about it. This case study then will be helpful in presenting cellulitis
to the people. Ìt will help in presenting certain information that may somehow answer
the question of the people.

Another reason why we chose such presentation is because the SO's are easy to
approach. They readily answered our questions and cooperated with us. Ìt was easy to
build rapport with her, the same way she trusted us. We believe that to present a case
properly one should have built a good rapport with the patient so as to fully determine
her condition and be able to assess her properly.























II. NURSING PROCESS

A. PersonaI Data

This is a case of a 4 year old Filipino, boy named Prince Cellulitis. He was born
full term at 37 weeks on July 20, 2006 via Normal Spontaneous Delivery (NSD) in a
secondary hospital in Angeles City. He is the eldest child of King and Queen Cellulitis.
They are currently residing at Lourdes Sur, Angeles City and affiliated under the Roman
Catholic Religion.
Prince Cellulitis was brought by his parents in a tertiary hospital in Angeles City
at around 5:40 in the afternoon last June 25, 2011 because there is a presence of
erythema on the right leg. He was then admitted with an initial diagnosis of Right Leg
Cellulitis.
The data that was being collated are based from the interview conducted with
Prince Cellulitis' parents during his stay at the hospital where he was admitted and from
the review of charts for some data needed to study his disease condition.

B. Pertinent FamiIy History

1. FamiIy HeaIth-IIIness History

The family health illness history traces back from the grandparents of Prince Cellulitis.
The figure below presents paternal and maternal side family's health-illness history up
to the third degree relationship.

With regards to the family health-illness history, there was no reported case of Cellulitis
in maternal and paternal side but there are factors that contributed to Prince Cellulitis
present condition since they have an environmental factors.

2. Size and Type of the FamiIy

Prince Cellulitis belongs to a nuclear family, which consists of four (4) members
including him. King Cellulitis, his father, 38 years old, is a college graduate and now
works as a office and earns Php01 , 500 per month as estimated by the mother. Queen
Cellulitis on the other hand, 35 years old, college graduate serves as a full-time
housewife. Prince Cellulitis the eldest who is 4 years old and the youngest was Princess
Cellulitis who was 1 year old.

3. Living Condition

Prince Cellulitis' family is considered as nuclear type because he is living with his
mother, father and siblings. Their house is made up of concrete and it has one bedroom
and one comfort room, which they all use and share in using it. The house is well
ventilated because it has five windows. They have clean sanitation, in which according
to her mother, the house is kept clean and free from pollution except for their open
drainage which is located in their neighbor's front gate, in which according to the
mother, the open drainage is not clean and the mother assumes that her daughter got
her illness because of stagnant water in that area. They have a regular garbage
collector trice a week. Their source of water supply is NAWASA. King Cellulitis is
working as a office worker in an university at Angeles City and earns P10, 500/month,
which is sufficient for their everyday needs.

4. CuIturaI Factors Affecting the HeaIth of the FamiIy

They believe in herbolarios and they also use medicinal plants like guava leaves when
treating cough. Queen Cellulitis used the decoction of guava leaves when his daughter
had cough. Though they believe in herbolarios and herbal medicines, they prefer to go
to hospital immediately when problem worsens.

B. MaternaI and ChiId History

1. PrenataI History

The mother has not experienced any complications during her previous pregnancies
and both her babies had an AOG of nine months. She delivered her children all through
NSD. During her pregnancy she has completed the required pre-natal visits at a hospital
in Angeles. Walking as her exercise and taking vitamin supplements and ferrous sulfate
to keep her and her baby healthy. She had her monthly check-up in her doctor's clinic.

2. Feeding

Prince Cellulitis receives his daily nourishment through eating nutritious foods. Queen
Cellulitis feeds her child at three to four times a day.

3. Growth and DeveIopment

Growth and development are continuous processes from conception until death. Ìt
proceeds in an orderly sequence. Different children pass through the predictable stages
at different rates. All body systems do not develop at the same time and the
development is cephalocaudal. Ìt proceeds from proximal to distal, from gross to refined
skills. There is an optimum time for indication of experiences or learning, where in
neonatal reflexes must be lost before development can proceed. A great deal of skill
and behavior is learned by practice.

Prince Cellulitis is four (4) year old, thus is within the period from one moth to one year
of age which is the Preschool Stage.

Erik Erikson - PsychosociaI DeveIopment

Erik Erikson was trained in psychoanalytical theory but developed his own theory of
psychosocial development. This theory stresses the importance of culture and society in
development of personality. One of the main tenets of his theory is that a person's
social view of himself or herself is more important than instinctual drives in determining
behavior allows for more optimistic view of the possibilities for human growth. Erikson
described eight developmental stages covering the entire lifespan. At each stage, there
is a conflict between two opposing forces. The resolution of each conflict or
accomplishment of the developmental task of that stage allows the individual to go to
the next phase of development.

At 4 years of age, Prince Cellulitis is under the Initiative vs Guilt Stage. Ìt is the stage
when the child develops the ability to initiate and direct own activities. Erikson was
influenced by Freud, he downplays biological sexuality in favor of the psychosocial
features of conflict between child and parents. Nevertheless, he said that at this stage
we usually become involved in the classic "Oedipal struggle" and resolve this struggle
through "social role identification."

Prince Cellulitis elicited this stage by playing cars and making up stories. The most
significant relationship is with the basic family.

Jean Piaget - Cognitive DeveIopment

Jean Piaget, a Swiss psychologist, he is best known for his pioneering work on the
development of intelligence in children. His studies have had a major impact on the
fields of psychology and education. To progress from one period to the next, the child
reorganizes his thinking processes to bring them closer to adult thinking. With his age,
Prince Cellulitis belongs to Piaget's !7eope7ational Stage. At this stage, the child is
applying his new knowledge of language, the child begins to use symbols to represent
objects. Early in this stage he also personifies objects. He is now better able to think
about things and events that aren't immediately present. Oriented to the present, the
child has difficulty conceptualizing time. His thinking is influenced by fantasy -- the way
he'd like things to be -- and he assumes that others see situations from his viewpoint.
He takes in information and then changes it in his mind to fit his ideas. Teaching must
take into account the child's vivid fantasies and undeveloped sense of time. Using
neutral words, body outlines and equipment a child can touch gives him an active role in
learning.

Prince Cellulitis is under the substage Ìntuitive Thought. During this time, the child tend
to become very curious and ask many questions

Sigmund Freud - PsychosexuaI Theory

Sigmund Freud, founder of psychoanalytic offered the first real theory of personality
development. He described child development as being a series of psychosexual
stages in which the child's interests become focused on a particular body site. At his
age the prominent region of the body is his genitals (!allic Stage), where in this stage
the boy develops unconscious sexual desires for their mother. He becomes rivals with
his father and sees him as competition for the mother's affectation. During this time,
boys also develop a fear that their father will punish them for these feeling, such as
castrating them.

This is exhibited by Prince Cellulitis during nurse patient interaction when kept on calling
his mother to ask him to feed him.

4. Immunization Status

The Department of Health (DOH) launched in July 1976 its program regarding
immunization in which a certain routine immunization schedule is followed. According to
the mother, Baby Pneumonia has not yet received any vaccine including BCG÷a
vaccine that is given in a single dose at birth or any time after pregnancy to protect the
infant against the possibility of acquiring bacilli infection from other family members;
DPT, OPV and Hepa B vaccines which are given to avoid occurrence of diphtheria,
tetanus pertussis, poliomyelitis, and hepatitis B.
1
st
dose 2
nd
dose 3
rd
dose
BCG


DPT


OPV


HEPA B


MEASLES


C. HISTORY OF PAST ILLNESS

Ìn terms of patients past illness history, there was no reported illness of any kind. Ìt was
only lately after he was diagnosed of Right Leg Cellulitis.

D. HISTORY OF PRESENT ILLNESS

Three to four days prior to admission, Prince Cellulitis had an insect bite and few days
later he develops erythema on the lower leg promting to consult. He also had fever due
to the inflammation of the body.

E. PHYSICAL EXAMINATION

June 25, 2011- Upon admission- Lifted from the chart
Vital signs: Temp ÷ 37.6 ´C per axiIIa, HR- 86cpm, RR-23bpm
SKIN: (-) cyanosis, (-) jaundice, (-) pallor, presence of erythema on right Ieg
EENT: Anicteric Sclerea, pink palpebral conjunctiva, (-) NAD
LYMPH NODE: (-) CLAD
CHEST: Lungs: SCE, (-) retractions, harsh breath sounds, (-) crackles
CARDIOVASCULAR: Adynamic, normal rate, regular rhythm
ABDOMEN: Flat, soft, nontender, normo active,
RECTUM: Patent
GENITALIA: Grossly hole
MUSCULO-SKELETAL: (-) limitation in movement extremities, (-) peripheral edema
NEUROLOGICAL: Awake

JUNE 27, 2011- First day of Nurse- Patient Ìnteraction

GeneraI Appearance
Prince Cellulitis was received lying on the bed, awake, conscious and
coherent, aferbrile, (-) cyanosis, (-) DOB, with insect bites on right leg scattered over the
lower limb
Vital signs: Temp- 36 HC per axilla, HR-91bpm, RR- 22bpm
Head
a. Hair: He has fine black hair with even distribution over head.
b. Skull: the head is normal in shape and size, symmetrical and normal
configuration
c. Face: He has a symmetrical facial features and movements
d. Eyes:
His eyebrows are evenly distributed. Eyelashes are curled slightly
outward. His eyelids are intact with pink palpebral conjunctiva. His lacrimal
sac exhibits no edema.
e. Ears: His ears are symmetrical and clean. His ears are at the level of the eye
canthus.
f. Nose: His nostrils are symmetrical and clean
g. Mouth
g.1.) Lips; His lips are moist, symmetrical in shape and pink
g.2.) Palate and Uvula: His palates are fused with smooth and pink in
color
g.3.) Tongue: His tongue has normal color
g.4) Teeth: Few teeth are shown
g.5) Gums: No swelling, sores or lesions
Neck
His head is centered with equal size of neck muscles.
Thorax and Lungs
His nipples are symmetrical. The baby exhibits symmetrical chest expansion and
no presence of rales is noted over both lung fields upon auscultation.
Extremities
Symmetrical, normal size and shape, no edema, with presence of erythema on
right Ieg
Ìntegumentary System
a.) Skin; He has a fair complexion with soft texture and good skin turgor.
b.) Nails: He has short fingernails and a capillary refill time of >2 secs.









G. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC /
LABORATORY
PROCEDUES
DATE
ORDERED
DATE
RESULTS
INDICATION/S OR PURPOSE/S RESULT
NORMAL
VALUES (UNITS
USED IN THE
HOSPITALS)
ANALYSIS AND
INTERPRETATION
OF RESULTS
HEMATOLOGY:
HEMOGLOBIN
(Hgb)








HEMATOCRIT
(Hct)




D.O.:
06-25-11
D.R.:
06-25-11






D.O.:
06-25-11
D.R.:
06-25-11


Hemoglobin delivers oxygen
through circulation to the body
tissues and returns CO
2
from
tissues to lungs. This was
indicated for Shrek because Hgb
count is a usual test done as an
index of the oxygen carrying
capacity of the blood.


Hematocrit indicates relative
proportions of plasma and RBCs
in the blood. Hct count was done
to the patient because this test is
a fast way determining the

117g/L









0.35





115-155g/L









0.38-0.48





Hemoglobin is in the
normal range which
indicates blood's
ability to carry oxygen
throughout the body.





Hematocrit level is
below normal. This
indicates that there is
insufficient RBC that
circulates within the





White BIood
CeIIs
(WBC)








WHITE BLOOD
CELLS
DIFFERENTIAL
COUNT:

NeutrophiIs





D.O.:
06-25-11
D.R.:
06-25-11












D.O.:
percentage of RBC in the plasma;
it also indicates the hydration
status of Shrek.


White blood cells are the fighting
soldiers of the body. WBC count
was indicated for Shrek to
determine the presence of
inflammation and infection. Ìt was
also used to determine factor of
inflammation and also to
determine and evaluate body's
physiologic capacity to resists and
overcome infection.






Neutrophils are the most common





14,150m
m
3















0.65





5,000-10,000mm
3
















0.45-0.65
blood, nevertheless,
there is no
dehydration present.


There is a significant
increase in the level of
WBC in the blood.
This is due to Prince
Cellulitis diagnosis of
Cellulitis. The body's
defense is increased
whenever there is
infection.







Results indicate that






Lymphocyte









PIateIet count





06-25-11
D.R.:
06-25-11



D.O.:
06-25-11
D.R.:
06-25-11






D.O.:
06-25-11
D.R.:
06-25-11


PMN. Their primary function is to
kill and digest bacterial
microorganisms. Neutrophil count
is done to determine presence of
bacterial infection.

Lymphocytes are type of white
blood cell in the vertebrate
immune system. Lymphocyte
count is done to determine if there
is presence of infection.





Platelet count is used to diagnose
a bleeding disorder or a bone
marrow disease.









0.22









330,000
mm
3











25%-35%









150,000-450,000
mm
3




neutrophil count is
within the normal
range.



Lymphocytes are part
of the primary
defenses of the body.
When there is
infection,
Lymphocytes are one
of the first WBC to
combat infection.


The value suggests
that the Platelet count
is in the normal range.



Monocyte









EoisinophiI
D.O.:
06-25-11
D.R.:
06-25-11






D.O.:
06-25-11
D.R.:
06-25-11

Monocytes are a type of white
blood cell (WBC). This test is
used to evaluate and manage
blood disorders, certain problems
with the immune system, and
cancers, including monocytic
leukemia. This test may also be
used to evaluate for the risk of
complications after a heart attack.

An absolute eosinophil count is a
blood test that measures the
number of white blood cells called
eosinophils. Eosinophils become
active when you have certain
allergic diseases, infections, and
other medical conditions.
10%









2%
2 ÷ 8 %









1 ÷ 4 %
A high monocyte is a
generally a sign of
infection. Monocytes
are a type of white
blood cells. Ìt could
indicate an infection
with the mono-
nucleosis virus.


a value of 1 to 4
percent eosinophils is
considered a normal
relative range and 50
to 400 eosinophils per
cubic millimeter of
blood represents a
normal absolute range




NURSING RESPONSIBILITIES for CBC
PRIOR:
1. Check the doctor's order.
2. Determine the prescribed test and other restrictions prior to the test.
3. Get the laboratory requisition slip.
4. Explain to the patient what the procedure to be done is.
5. Ìnform the patient that this requires a blood sample.
6. Ìnform the patient how the procedure is performed, the equipment to be used.

DURING:
1. Explain to the patient what test should be done.
2. Prepare all the equipments to be used.
3. Tell the patient when to insert the needle for her to be prepared.
4. Encourage the patient to remain calm during the test.
5. Assist the patient if necessary.
6. Ensure a sterile blood sample from the patient.
7. Apply pressure on the puncture site.

AFTER:
1. Send the blood sample to the laboratory immediately.
2. Proper documentation.

III. ANATOMY AND PHYSIOLOGY


This most extensive organ system has the skin and accessory structures, including hair,
nails, glands (sweat and sebaceous), and specialized nerve receptors for stimuli
(changes in internal or external environment) such as touch, cold, heat, pain, and
pressure. Ìts functions include protection of internal structures, prevention of entry of
disease-causing microorganisms, temperature regulation, excretion through
perspiration, pigmentary protection against ultraviolet sunrays, and production of vitamin
D. The body stores about half its fat in the underlying hypodermis.




Skin Layers Properties Function
Epidermis Outer layer of skin, composed of 5 zones
of stratified epithelium (keratinocytes);
contains melanocytes and Langerhans
cells.
Responsible for the continual
replenishing of skin, resists
friction, waterproof, prevents
water loss.
Stratum
corneum
(Horny Iayer)
15-25 layers of dead, flat, keratinized
squamous epithelial cells, without nuclei.
Normally thin but thick over the soles of
the feet and palms of the hands.
Resists friction, waterproof,
prevents water loss.
Stratum
Iucidum (CIear
Iayer)
Only found in thick skin (palms and soles
of the feet). Transition between the
corneum and lucidum layer.
Resists friction, waterproof,
prevents water loss.
Stratum
granuIosum
(GranuIar
Iayer)
3-5 layers of keratinocytes containing
keratin granules.
They form keratin and expel
lipids which stick the cells
together and form a waterproof
barrier.
Stratum
spinosum
(PrickIy Iayer)
Usually the thickest layer of keratinocyte
cells, they are joined together by
desmosomal connections. Also contains
Langerhans cells.
Langerhans cells are part of the
immune response.
Stratum basaIe
(BasaI ceIIs)
A layer of cuboidal-shaped cells, lined up
on a basal membrane. Ìt contains stem
cells, keratinocytes, and melanocytes
(pigment cells).
Keratinocyte cell division occurs
here to replenish skin.
Melanocytes protect the skin
from UV.
Dermis Deep layer of skin, composed of
collagen and elastin rich connective
tissue. Ìt contains hair follicles,
sebaceous glands, blood vessels and
sense receptors.
Ìt is responsible for the elasticity
and mechanical support of skin.
Supplies the epidermis with
nutrients. Ìmportant in
thermoregulation.
PapiIIary Projections push into the epidermis.
Highly vascular and innervated.
Forms finger prints, brings
capillaries closer to the
avascular epidermis.
ReticuIar Dense, interlacing connective tissue,
predominantly parallel to the skin's
surface.
Forms lines of skin tension,
cleavage lines.
Hypodermis Not part of skin layer. Subcutaneous
connective tissue, rich in fat and vessels.
Protective cushion and
insulator.


Functions of the skin:

O ThermoreguIation - Evaporation of sweat & Regulation of blood flow to the
dermis.
Cutaneous sensation - Sensations like touch, pressure, vibration, pain, warmth or
coolness.
O Vitamin D production - UV sunlight & precursor molecule in skin make vitamin
D.
O Protection ÷ The sin acts as a physical barrier.
O Absorption & secretion ÷ The skin is involved in the absorption of water-soluble
molecules and excretion of water and sweat.
O Wound heaIing - When a minor burn or abrasion occurs basal cells of the
epidermis break away from the basement membrane and migrate across the
wound. They migrate as a sheet, when the sides meet the growth stops and this
is called 'contact inhibition'.
O Ìn deep wound healing - A clot forms in the wound, blood flow increases and
many cells move to the wound. The clot becomes a scab; granulation tissue fills
the wound and intense growth of epithelial cells beneath the scab. The scab falls
off and the skin returns to normal thickness.


Skin: EpidermaI Layers
The skin is the largest organ of the body, with a surface area of 18 square feet. Ìts two
main layers are the epidermis (outer layer) and dermis (inner layer). The epidermis has
several strata (layers) that contain four cell types. Keratinocytes produce keratin, a
protein that gives skin its strength and flexibility and waterproofs the skin surface.
Melanocytes produce melanin, the dark pigment that gives skin its color. Merkel's cells
are probably involved with touch reception. Langerhans' cells help the immune system
by processing antigens (foreign bodies).

The deepest layer of the epidermis, the stratum basale, is a single layer of cells resting
on a basement membrane (layer between the dermis and epidermis). The stratum
basale cells divide continuously. As new cells form, older ones are pushed toward the
skin surface.

The epidermis does not have a direct blood supply; all nutrients that feed these cells
come from the dermis. Only the deepest cells of the stratum basale receive
nourishment. The cells that are pushed away from this layer die. When the cells reach
the skin surface, they are sloughed off in a process called desquamation.

The next layer, the stratum spinosum, consists of spiny prickle cells that interlock to
support the skin. The stratum granulosum, the thin middle layer, initiates keratinization
(production of keratin). This process starts the death of epithelial cells (the cell type that
makes up skin).

During desquamation, keratinocytes are pushed toward the surface. These cells begin
to produce the keratin that eventually will dominate their contents. When these cells
reach the epidermis outer layer, they are little more than keratin-filled sacs. Millions of
these dead cells are worn off daily, creating a new epidermis every 35 to 45 days.
The stratum lucidum protects against sun ultraviolet-ray damage. This thick layer
appears only in frequently used areas such as palms of the hands and soles of the feet.
Thick skin epidermis has all five strata. Thin skin covers thinner epidermal areas such
as eyelids. Thin skin has three or four of the five strata; it never has stratum lucidum.
The stratum corneum, the fifth, outermost layer is thick with rows of dead cells. These
cells contain soft keratin, which keeps the skin elastic and protects underlying cells from
drying out.

Skin: DermaI Layer
The dermis, called "true skin," is the layer beneath the epidermis. Ìts major parts are
collagen (a protein that adds strength), reticular fibers (thin protein fibers that add
support), and elastic fibers (a protein that adds flexibility). The dermis has two layers:
the papillary layer, which has loose connective tissue, and the reticular layer, which has
dense connective tissue. These layers are so closely associated that they are difficult to
differentiate.

The papillary layer lies directly beneath the epidermis and connects to it via papillae
(finger-like projections). Some papillae contain capillaries that nourish the epidermis;
others contain Meissner's corpuscles, sensory touch receptors. A double row of papillae
in finger pads produces the ridged fingerprints on fingertips. Similar patterns in the
ridged fingerprints on fingertips are on palms of the hands and soles of the feet.
Fingerprints and footprints keep skin from tearing and aid in gripping objects.

The reticular layer of the dermis contains criss-crossing collagen fibers that form a
strong elastic network. This network forms a pattern called cleavage (Langer's) lines.
Surgical incisions that are made parallel to cleavage lines heal faster and with less
scarring than those made perpendicular.
Parallel incisions disrupt collagen fibers less
and require less scar tissue (cells that aid in
healing) to close up a wound.

The reticular layer also contains Pacinian
corpuscles, sensory receptors for deep
pressure. This layer contains sweat glands, lymph vessels, smooth muscle, and hair
follicles, described in the discussion on hair follicles later in this overview.

The hypodermis (subcutaneous layer) lies beneath the dermis. Loose connective tissue
such as adipose tissue (fat) insulates the body, conserving heat. Ìt also contains blood
vessels, lymph vessels, and the bases of hair follicles and sweat glands. The fat
distribution in this layer gives the female form its characteristic curves.

Sudoriferous (sweat) and sebaceous (oiI) gIands
Skin produces associated structures such as sudoriferous (sweat) glands and
sebaceous (oil) glands. Ìt also produces fingernails, hair, and sensory receptors that
enable humans to feel pressure, temperature, and pain.

Both groups of sudoriferous glands (sweat glands) are in most of the body: eccrine
glands are coiled ducts deep in the skin that connect to the surface; apocrine glands are
in armpits, areolae of nipples, and the genital region. Eccrine glands secrete sweat, a
mixture of 99 percent water and 1 percent salts and fats. Ìn warm conditions with low
humidity, perspiration (secretion of sweat) and evaporation cool the body.

Apocrine glands, which become active at puberty, are larger, deeper, and produce
thicker secretions than eccrine glands. The apocrine glands secretions contain
pheromones, substances that enable olfactory (sense of smell) communication with
other members of the species. This communication provokes certain behavioral
responses such as sexual arousal. Unlike eccrine glands that respond to heat, apocrine
glands respond to stress and sexual activity by secreting sweat with a characteristic
odor. This odor differs from body odor that results from bacteria decomposing skin
secretions on the skin.

Ceruminous glands are modified apocrine glands in the external ear canal lining. They
secrete cerumen (earwax), a sticky substance that is thought to repel foreign material.
Mammary glands in female breasts are
modified apocrine glands. These
glands are adapted to secrete milk
instead of sweat.

Sebaceous glands (oil glands) are all over
the body except on the palms of hands
and soles of feet. The glands empty via
ducts into the bases of hair follicles and
secrete sebum (a mixture of fats, waxes, and hydrocarbons). Sebum keeps hair moist
and prevents skin from drying. Sebaceous glands are numerous on the face and scalp.
During puberty, increased sex hormone levels in the blood may produce excessive
sebum. This over secretion plugs the gland and hair follicle, producing a skin disorder
called acne.

Hair and naiIs
Hair is composed of cornified threads of cells that develop from the epidermis and cover
most of the body. Each hair has a medulla, cortex, and cuticle. The medulla in the
center contains soft keratin and air. The cortex, the innermost thickest layer, has the
pigment that gives hair color. The cuticle, the outermost layer, has cells that overlap like
scales. Both the cuticle and cortex have hard keratin.

The hair root in a hair follicle is embedded beneath the skin. The hair shaft protrudes
from the skin. Hair sheds and is replaced constantly during growth and rest phases.
Hair has a protective function: eyebrows keep sweat from running into the eyes, nose
and ear hairs filter dust from the air, and scalp hairs protect against abrasion and
overexposure to sun rays.

Hair follicles extend into the dermis; the deep ends expanded parts are called hair
bulbs. A papilla (connective tissue protrusion that contains capillaries) protrudes into the
hair bulb and provides nutrients for the growing hair. The hair follicle walls have an inner
epithelial root sheath and an outer dermal root sheath. The epithelial root sheath has an
inner and an outer layer that thins as it approaches the hair bulb. Ìt becomes the matrix,
the actively growing part of the hair bulb that produces the hair.

Arrector pili muscles are smooth muscle cells attached to hair follicles. When they
contract, they pull the hair into an upright position, causing skin dimples (goose bumps).
The nervous system regulates these muscles; cold temperatures or fright can activate
them.

Hair development begins in the third fetal month.
By the fifth month, lanugo (thin hair) covers the
fetus. At 5 months, lanugo disappears from
every area except the scalp and eyebrows where
coarser hair replaces it. Vellus (a film of delicate
hair) eventually covers the rest of the body.
Terminal hair is the early coarse scalp and
eyebrow hair and later armpit and genital hair
that grow during puberty. No new hair follicles develop after birth.

Like hair, nails develop from the epidermis. These hard plates of keratinized cells are at
the ends of fingers and toes. Nails appear pink because their translucency reveals the
vascular tissue beneath. They aid in grasping objects, scratching, and protecting fingers
and toes.

The components of the nail are the lunula, body, root, and free edge. The lunula is the
white half-moon shaped part at the nail base. Both the body and free edge region that
overhangs the end of the finger or toe are visible. The nail rests on the thick layer of
epithelial skin called the nail bed. The root is hidden under skin folds. Under the root lies
the matrix (thick layer of skin). Eponychium (thin layer of epithelium) covers the nail
during development; in the adult, it remains at the nail base only and is called the
cuticle. The hyponychium is the epithelium of the nail bed.
Skin coIor
Skin color results from the presence of
melanin, carotene (yellow to orange
pigment), and underlying blood reflected
through skin. Melanin keeps excessive
ultraviolet rays from burning the skin.
Exposure to sunlight causes the skin to
produce more melanin, causing suntan, a
temporary change in skin color. Melanin- rich
cells continually move toward the surface, where they are sloughed. Too much sun is
dangerous to skin; it increases the risk of cancer by affecting the genetic material of
cells.

Variety of skin color is caused mainly by the number and distribution of melanocytes.
Darker skin has more melanin that is produced by more melanocytes. However, the
different skin colors among individuals and races do not reflect different numbers of
melanocytes; instead, they show different kinds and amounts of melanin production by
melanocytes. Oriental skin has a greater amount of carotene in the stratum corneum,
producing a yellowish tinge. Albinism is a condition where skin does not produce
melanin.
















IV PATIENT AND HIS ILLNESS

A Schematic Diagram

PathophysioIogy (Book Centered)









































Cell Ìnjury: Pathogens, surgery, hypoxia, trauma, toxins, extreme temperature, or chemicals.
Ìnflammatory Response
Spasm of the arterioles constriction vasodilation of the
arterioles, venules increased capillary permeability
leukocytes line vessel walls migration of leukocytes into
interstitial spaces phagocytosis exudates and fibrin
meshwork wall of area

Platelet release serotonin
Mast cells release histamine,
chemotactic factors,
leukotrienes, and prostaglandin
Kinin system release bradykinin
Complement system
releases histamine and
alters cell membrane
Clotting system
builds a fibrin
meshwork
Exudate serous (plasma), sanguineous (bloody), purulent (pus)
Pain exudates and edema stimulate nerve endings
Edema increased blood supply and capillary permeability
Heat blood vessel dilation and increased metabolic rate

Phagocytosis begins
PathophysioIogy (CIient Centered)













































Modifiable Factors:
- Lifestyle
- Environmental
- Socio Economic
Non Modifiable Factors:
- Age (4 years old)
- Sex (Male)
- Ìmmune system
Bite of an Ìnsect

GABHS enters the body

Enzyme breaks down the skin and
allows the bacteria to spread
Produce toxin from the bacteria

Ìnflammatory
response

Ìmmunosuppression of the body

Cytokine and
prostaglandin release

Fever 37.6
June 25, 2011

Presence of Ìnfection

WBC: 14.15
Monocytes: 0.10

Extravasation of fluid
in the lower leg
Swelling leg
Decrease tissue
perfusion

Presence of erythema
on Right Leg

B SYNTHESIS OF THE DISEASE

The Non modifiable and Modifiable Factors presented have put the patient into
his current disease condition, which is Cellulitis. A bite of an insect was the onset of the
disease, which GAHBS invade the body. After the invasion, enzyme begins to break the
skin and allows the bacteria to enter the body, which the body produce toxin from the
bacteria that lead to immunosuppression of the body. The invasion of bacteria
stimulated an inflammatory response which Prince Cellulitis manifested fever. After the
immunosuppresion, cytokines and prostaglandin were released that resulted to
presence of infection, were the patient's WBC is 14.15 and monocyte is 0.10. This
resulted to extravasion of fluid in the lower leg, which resulted to presence of edema.
Due to presence of infection, tissue perfusion decreased which resulted to erythema on
the right leg.

B.1 Definition of the Disease

Cellulitis is a common infection of the skin and the soft tissues underneath the skin. Ìt
occurs when bacteria invade broken or normal skin and start to spread under the skin
and into the soft tissues. This results in infection and inflammation. Ìnflammation is a
process in which the body reacts to the bacteria. Ìnflammation may cause swelling,
redness, pain, and/or warmth.

B.2 Predisposing and Precipitating Factors

Predisposing Factor

4 Age ÷ pediatric age increase the incidence of cellulitis
4 Sex ÷ There is no predilection known. Mostly male are diagnosed.
4 Ìmmune system ÷ The patient has a past illness of cough and colds so he
is immunocompromised, increasing her risk to infection


Precipitating Factor

o Environmental factors such as artificial containers commonly found around
their homes.
o The low socio economic status plays a role in health- wellness because
this affects the family's ability to give nutritious foods to every member of
the family.
o Lifestyle the patient doesn't use repellants and any protection to avoid
insect bite

B.3 Signs and Symptoms

O Ìncreased WBC count (14,150/mm
3
)÷body's defense mechanism to fight
infection
O Fever÷due to the inflammatory response.


B.4 HeaIth Promotion and Preventive Aspect of the Disease

To help prevent cellulitis and other infections, follow these measures anytime you have
a skin wound:
O Wash your wound daiIy with soap and water. Do this gently as part of your
normal bathing.
O AppIy an antibiotic cream or ointment. For most surface wounds, a single- or
double-antibiotic ointment provides adequate protection.
O Watch for signs of infection. Redness, pain and drainage all signal possible
infection and the need for medical evaluation.

People with diabetes and those with poor circulation need to take extra precautions to
prevent skin wounds and treat any cuts or cracks in the skin promptly. Good skin-care
measures include the following:
O Inspect your feet daiIy. Regularly check your feet for signs of injury so you can
catch any infections early.
O Moisturize your skin reguIarIy. Lubricating your skin helps prevent cracking
and peeling.
O Trim your fingernaiIs and toenaiIs carefuIIy. Take care not to injure the
surrounding skin.
O Protect your hands and feet. Wear appropriate footwear and gloves.
O PromptIy treat any superficiaI skin infections, such as athIete's
foot. Ìnfections on the surface of the skin (superficial) can easily spread from
person to person. Don't wait to start treatment.





















V. THE PATIENT AND HIS ILLNESS

A. MEDICAL MANAGEMENT
a. ÌVF

b. Drugs
NAME OF
DRUGS;
GENERIC
NAME
BRAND
NAME
DATE
ORDERED
DATE
TAKEN/GIVE
N
DATE
CHANGED/
D/C
ROUTE OF
ADMINISTRATI
ON
DOSAGE AND
FREQUENCY
OF
ADMINISTRATI
ON
GENERAL
ACTION
FUNCTIONAL
CLASSIFICATI
ON
MECHANISM
OF ACTION
INDICATION(S) OR
PURPOSE(S)
CLIENT'S
RESPONSE TO
THE MEDICATION
WITH ACTUAL
SIDE EFFECTS
MEDICAL
MANAGEMENI
DAIE
OkDEkED
GENEkAL
DESCkIFIION
INDICAIIONJ
FbkFOSE[S}
INIIIAL
kEACIION IO
IkEAIMENI
CLIENI'S
kESFONSE IO
IkEAIMENI

1. lVF D5 lM8
500 CC x 1ó-17
GII:/MlN

0ó - 2ó - 11

/ hyperIcnic Iype
cf :c|uIicn IhcI hc:
c higher :c|uIicn
ccncenIrcIicn cnc
c |cwer :c|venI
ccncenIrcIicn.

Ihi: ccu:e ce||:
Ic :hrink in Ihe
|ung: Ihu:
ci|cIing Ihe
|ung: IhcI cre
inf|cmec.

Ihere were nc :ice
effecI: ncIec.

Ihe |ung: cec:ec
frcm
inf|cmmcIicn
Ihu: mcinIcin
cnc prcvice: c
pcIenI cirwcy.
Clindamyci
n

(Dalacin
C)
DO: June 26,
2011
300 mg ÌV q 8°
SÌVP
Dalacin C is an
antibiotic. Ìt is
used
to treat infections
in different parts
of
the body caused
by bacteria.
Upper & lower resp infections,
skin & soft tissue infections,
bone & joint infections,
gynecological & intra-
abdominal
infections, septicemia, endocar
ditis, dental infections,
toxoplasmic encephalitis in
patients w/ AÌDS,Pneumocystis
carinii pneumonia in patients
w/ AÌDS.
The client did not
show any sign
related to gastric
irritation caused by
intake of other
medications.


c. Diet






























http://www.scribd.com/doc/37287261/Case-Pres-Cellulitis
http://www.scribd.com/doc/49512040/cellulitis
http://www.scribd.com/doc/38038410/cellulitis
http://www.scribd.com/doc/48455757/CASE-STUDY-2011-cellulitis
http://www.scribd.com/doc/54577465/Cellulitis-Patho-Map

 %# &%    0:98 8 , 8570,/3 -,.907, 310.943 41 90 83 ,3/ 988:08 -030,9 90 83  0:98 :8:, -038 ,8 , 82, ,70, 41 903/073088  803  ,3/ 70/3088  8 98 70/,70,-0389403,70 905078432,/0;045,10;07 842092089.8,3/ 80,98 ,3/84032534/08 8403,3/8 30,790,70,41310.90/83   0:982,4..:7,30704390-4/ -:99008902489.422438904190 310.943 5,79.:,7390,70,41909-,4783-430,3/3901449 1440/-90 ,72  ,3/ 903 90 0,/ ,3/ 30. ,70,8  3 850., .7.:289,3.08  8:. ,8 1443 8:7074797,:2,4:3/8 .0:98.,3/0;045390,-/420347.089,70,8 !0450 9 247-/ 4-089 .,3 ,84 /0;045 .0:98 3 90 ,-/423, 83  $50., 9508 41 .0:98 ,70 84209208 /083,90/ - 90 4.,943 41 90 310.943  ,2508 3.:/0 50747-9, ,74:3/ 90 00 84.09  .0:98  -:.., .00  .0:98  ,3/ 507,3, .0:98   %0 2,479 41 .0:98 310.9438 ,70 .,:80/ - 0907 89,5 $9,54.4..:8  47 89705 $970594.4..:8  -,.907,  $9,5 $9,54.4..:8 ,:70:8  8 90 2489 .42243 -,.907, 9,9 .,:808 .0:98  %070 8 , 743 3./03.0 41 .422:39
,.6:70/ 310.9438 /:0 94 209.3
70889,39 $  ,:70:8 #$  , 5,79.:,7 /,3074:8 1472 419080-,.907,9,9870889,39942,3,39-49.8,3/82470/11.:994970,9   $9705 $970594.4..:8 8,84,.42243.,:8041.0:98 1472417,9078:5071., .0:98.,:80/-897058.,0/07850,898.,7,.9070/-8570,/349 -79 70/ .7.:28.7-0/ ,70, 43 90 83 9 , 8,75 7,80/ -47/07  %0 84
.,0/ 108 0,93 -,.907, ,70  3 1,.9  ,84 ,897,3 41 89705 9,9 .,3 84209208 7,5/ /08974 988:08   0:98 .,3 -0 .,:80/ - 2,3 4907 9508 41 -,.907,  3 ./703 :3/07  0,78 41 ,0  1: 0245:831:03, -,.907,.,3.,:80.0:98 0850.,43901,.0  ,728 ,3/:550794784 0:981742,/447.,9-90478.7,9.2,-0.,:80/-90

!,890:70,2:94./,-,.907, .,8,;0784793.:-,9435074/414314:794  4:78  074243,8 /745,  '-74 ;:31.:8  ,3/ 4907 -,.907, ,70 .,:808 41 .0:98 9,9 /0;0458 ,1907 0548:70 94 1708,907 47 80,,907  !80:/4243,8 ,07:348,8,3490795041-,.907,9,9.,3.,:80.0:98 95.,,1907,5:3.9:70 4:3/   0:98.,3,110.9,343041,3,0.0:9841901,.082470.422433./703 ,3/ ,/:98 4;07 ,0   :333,2  %0 ,.9:, 3./03.0 41 .0:98 8 :3343 -0.,:80.,808,7080/427054790/  7-9,.0:988:3.42243-:9549039,;07 8074:8   %0 3./03.0 41 310.943 - 209.3
70889,39 $9,54.4..:8 ,:70:8 #$  ,3/ 4907 ,39-49.
70889,39 -,.907, ,8 3.70,80/ /7,2,9., 3 70.039 0,78 ,4 3.$9,11 310.943-908047,382882:.24708074:8   0%703/843%70,930:98 ',3.42.38907:414.0147%70,930:98 $9:/$:0898  .9     47 8420 920  20/., 57,.9.0 :/0308 ,;0 -003 ,2-:4:8 ,-4:9 0907 ;,3.42.3 47 84
.,0/  
,.9,2 ,39-49.8 0 503.3 47 .05,4854738 ,8 90 2470,557457,90907,5147970,935,90398,/2990/147.0:98 1019:3970,90/,3/ 310.9438570,/8 .0:98.4:/-0.42010970,9033   %0 037 47/ 89:/ 14:3/ 9,9  5,90398 970,90/ 397,;034:8 9 ;,3.42.3 -09003 0.02-07   ,3/ .94-07   1,70/ -09907 ,3/ 070 /8.,70/ 43

,;07,0 430 /, 0,707 9,3  5,90398 970,90/ 397,;034:8 9 90  
,.9,2 ,39-49.8   %0 89:/ 8 -03 57080390/ .9   ,9 90 9 ,33:, 20093 41 90 310.94:8 

80,808$4.0941207., .9  
3',3.4:;07 

706:702039398749.801475708039.89 :30     0 070 .89800283907089394:8.54.0:98  %0 .3/ /08.:.3 . 5.80 89:/ -0.42243 :80/ 147 970.0/31472.390/ 842093 9.7041../.3/ 8419 988:0 310. 0 -00.80.4480904309.:8 .:/3 89..0 574.07 90..3   #$ 897.:.93 4859.4393:4:8 . .907..059-094.9903943  -:9 83.70. 5.:80 0 70.80 .8 0 503.5.3/90 4309..-4:9 .843147.3/ 4907 /7:8 40...907.4483 4:7 .44838:.0 ..0-00384394-08:8.-73949070.-0 94 .943 :774:58.-00.9 0.3310.8014790144370.39 47 82.94341/09..3/0 47  ..3/5.39-49.0/9.:80/ - 2..8438  %0...42243 -..90.9 03747/4859.39-49.43/943 2..7 5.9.943 8 .943..0 9070 .094 2..70 290/  0 .92039 45943 147 2.80 0:98 8.3 5.42243/80. . 83 310.:/0 70/3088  803  903/073088.3 9508 41 -.70.8089:/ .8 0 ..808104.70 90 94 74:58 41 .448098.7.9430/..42243 .38 .4.9 !04504.3 8 90 -09907 970.39 94 .43/9430850.70 290/..8 ..73 90!0/.3  #0.. 8 0.3/9089:/ 80.79.0. .   .700/94.8089:/890.8703!4.7041983/41/80.808.9093-0-089147.934:789:/   .43/:.8  4941902050703.8 94 .83  7080.40.42.. .0:98 8.90398 4859.42.70349.943 .808 ..2439050/.07894:3/.7/ 91447% 8.97.03907 5.3/5708039....75943  8 2:.3..03 70889.79.9438 3.43/943.8830/33008&3.97.:9 3 . 8 025.39 94 ..4480 .79.0/ 5..998.9039 9 #9 0 0:98  0 . 3.943.94:880.80.89 09 4:7 3907089  .3/0 ./ /11.3/ 8970594.9  09 4:7 ..4.73.70.425. 74:5 ..078 84:9 94 .3/50450.90398 9 .9430..:947   9 #$ 83 .3.80 43 0547.:8  $259428 3.3.0/8:.

43/943.0-:9.55479907 908.5574.9 2.-094.079.8089:/903-0051:357080393.20.44507.554799905.80 57450743084:/.8097:890/:8 0-00.38070/4:76:089438.3/.90/9:8 9...9945708039..80.8808807574507                         . %070..3 31472.70 0.480 8:.8941:/0907230 07.09.843  0 .0:98 94 90 50450  9  05 3 57080393 .943.894 -:/7.943 8 -0.:80 90 $ 8 ./. 5708039.903984.800331472.8 94 .3807 906:08943419050450   34907 70.44/7. 84204 .943 9.3/-0...-4:99 %8.

90/ 9 !73.9.9073.8-473 1: 9072 .9 3088 8947 :5 949097//070070.3488 41 #9 0 0:98  %0 /. .19073443 .303.70 1.. $5439.0 ... .90/:3/0790#42./2990/..1742907.0 0:98 5708039.00:98 0.703983.70 -.330089 08900/089.9. /.20.8 -03 .43/94383.3/ 2..1.20.80410:98 3 2. 570803.00:98  %0 1:70 -04 57080398 5.00:98 5.0.041.9 30888947 9070.8347054790/..43/.80. 8/0 1.9 .9 30888947  %01.94.9 .94385   970.0700.8041.7432039.74/534 -43.300/0/9489:/8/80...9  008 43 :     .43/943    !0793039.9073.94:7/08$:7 30089.3/.20/!73.3/1742 9070..9478     .20.9073. 8/0 -:9 9070 .08-.8 903 .090. 80.9079.9073.9. 472.74859.9478 9.0 41 07902.70.74:3/   3 90 .9904859.  &#$!# $$    !07843.74859.3/ 5.0.70398/:73889.07 $  3 ./413.93088894797.3/":0030:98  %0.43/:.330089 .  %88.8-74:9-85. 9./2990/ 9 .304:8 0.3 .80/ 1742 90 3907.9 .89 :30     -0.8.339..3/5..7/894901.2 80.00:98.4397-:90/ 94 !73.11.7981478420/..28947    .:77039708/3..90/ .:80 9070 8 . 43 90 790  0 .#043  !73.4.7039841!73.

3/ 1700 1742 54:943 0.3/9024907.39 .0.3.08 . 3:.3/0.059 147 907 4503 /7.8430-0/7442 .0.3/ 430 .930089. .3/ 34 478. 70:.738!  .907 3 9.411.3.438898 41 14:7   202-078 3.3. 8 4..7 1.81.7 950 -0...0.3/9.784/. 1: 920 4:8010 !73.90/-9024907 ":003 0:98 43 90 4907 .78 4/  8 .0..47/3 94 90 24907 904503/7.0 .3/   0.0 ./0:541.08349. :80 .0.0 .90/-0.3/904:3089.90 807.0 0:98  1.3 .38.400 7.8 .738!5   5072439..0.0 0:98 -0438 94 .8.43.0 41 .907.400 7.0 .80892.3/8-38 %074:8082.2  .039.907   0.:/3 2  3 0:98  8 1.:90749 07 3088 -0.8.00:98900/089480.3 9 8 24907 1.80.3/ 8.7-.70.3/0.438/070/ .:80 0 8 .47/3 94 07 24907  90 4:80 8 059 .  %0 .40.90  3 .88:2089.047073./:.2 8 .  $0.947 97.7090.943 3.411./:.39.907 8:55 8 $  3 0:98 8 473.90/ 3 907 30-47 8 17439 .:809.78 4/  .7 .421479 7442  ..9 .907/..8!73.3/%504190.343/943  !73.90 .8 3:.. .3:3.03/48 %0.74/     .3.0..:80 41 89. 00  %07 84:7. 90 ...2  !73.70 3 :83 9  %0 4:80 8 0 . .088 0:984.0789.

3980:.2439  .0803 970..220/./.9003574-02478038     .4: ":0030:98:80/90/0.93900.3/07-.94341:.0391479070.0...20/.5.0307-4.3//8947 .94190.308 90570107944 944859.4.4: %4:90-00....0307-4.748.84:8020/.3/90..2  %0-00.9478110.0.08038/..:907 ..3.93.300/8     :9:7.07/.748.88:11.9073.

0   77843 !8.974: $ :73075703.43.733  070 3 3043.8947  %0 24907 .3.0../.30/ 3 58.00/83.94/89.045 .00:98814:7  0.9 $0.80.9.     749.3/84.484.-08.3/0.9438 /:73 07 570.08 .0452039  749 ..3.425090/90706:70/570 3. 174274889470130/ 88  %070 8 .20 920 .8 97.   !703.0.9.05943 :39 /0./703.3/-0.3/07-.93 3:9794:8 144/8  ":003 0:98100/807.3.0452039 %89047897088089025479.0   !73.-089.9..74/ 9:8893905074/1742430249944300.8 349 050703.947 8. 33008 ...3./7035.9./..041.9 90 8. 41 8 .9.08 .08 8 /.0.943 41 050703.3/ 90 /0.4.4393:4:8 574.0452039  7 7843 .9.90 9400507.4780.093 .4:8 5703.3/10774:88:1.0 0:98 70.484.9.     00/3  !73.05.3.3 4133024398 $0/0. :5307/4.0452039 .890!708.3/ /0.88974:90570/.80../0. 9574.08 47 0.7 41. 9047 -:9 /0. 34:782039 974: 0.9  9 574.3 .807007.00/   70.0452039 .0/ .0 1107039.3/9.:9:70.3.9.347/07806:03.238:55020398.730/-57. 701008 2:89 -0 489 -01470 /0.70 .00/817425742./.908   -4/ 889028 /4 349 /0.070/07.3..:/.9 /0.997009414:79208.0450/ 8 43 9047 41 58.4859.3 574./072439.4.425.08808 1742 .44$9.9 /1107039 7.-0.898.0..8.3/-4907-..04520398.3 4592:2 920 147 3/.

.0 .09 439.90 5708039  70390/ 94 90 5708039  90 .3/903.88.4.88:208 9..47 .8.3970.0  90 .8 %0.041280147078018247025479.399..0880894-73902./:9933 98.3 90..0/3 90 . 0 /0 938 94 -0  .9 3 1.8:9$9./-03894:8082-4894705708039 4-0.1.431.8 41 9.059:./.703 9 220/./9.9. 507843 8 84.4..943  %4 5747088 1742 430 5074/ 94 90 309  90 .9 47 ./703  8 89:/08 .89.3/ /70.84 507843108 4-0.8 -44./ /0.43.3920 8933831:03.9 89.7841.98  0 8 34 -09907 .9:./ 7047.89.3/ 2.553830340/041..05439  09.98  ./ . -0.70398 0.. 94 4 94 903095. 2.8 90.09 8 !704507.9  30 41 90 2.30893823/94198/0.0398 9.3/ 0 .48 147 2470 459289.3088933574.3 :5 894708  %0 2489 831..0  !73.3 903098 41 8 9047 8 9.0790088 08.7-0/09/0.99889.78 .0452039 41 507843.08  %0 7084:943 41 0./.908  7843 .. .09  ./7.0 - 5.480794..8041/0.740/0391.8/11.00.32:89 .9 .083/0907233 -0.0 41 90 5488-908 147 :2.07390039701085.431.0 03 90 .:9.-0 94 93 .0 3 .44 .0 98 897:0 974:84..0452039  0.42582039 41 90 /0.  0/5.0452039.943858990-.0458 90 ..0 0 .3:.48 90 3/.90 .0 0:98 0./:. 897:0 .0/-1./0.0 0 :8:.. $9..2   0.943.0452039   90.47 25.3/ 0.08331472.3/ 7084.0.9.3!.8 31:03.-4:9 938 .39..9438 1742 8 .4489  0 8 -089 343 147 8 5430073 47 43 90 /0.-9 94 39.9..0452039./ 8 ..9-09003.9:70841..9 49078 800 89:.3/ 0/:.7 3 98 89.0 9070 8 .90/ 98 89..0452039 41 39003.420 3.0 989089.3/5..9 .47 41 90 58. 80:.3 .9 43 .0 90. $88 58.0 ..9 43 90 10/8 4158.08.9 -09003 94 455483 147.943   !73.484. .0 0:98 -0438 94 !. 9. .0 !73.943.0/ - 70:/  0 /435.33893.0  9 98 89.431.3 !. 10.3 749  7843 /08.00:988:3/079039.

07.3.79. 310.420 14.42509943 147 90 24907 8 ..89 8 1.08 3 .0 41 /5907.82.  .039:9. 10.03 94 ..4:880:.308 . 89.8 ..36:089438  $2:3/70:/ !8.9433.0452039  0 /08.2 202-078 !%  !' .079...90393907..4.480:.39.$9.30 3. .70 .990 31.8294100/2     22:3./0870814790724907 0-0.897.0458:3..374:93022:3..3/ 05..907  5:38 902 147 9080 1003  8:... 9047 41 507843.0 07039889.9430305943.389 90 5488-9 41 .792039 41 0..394:.0/ 3 :  98 5747.943 1742 4907 1..9438./ 8 .480:..0.9.8 ./ 8 39070898 -0.6:73 -..420.943  :73 98 920  -48 . 80708 41 58.42087.438.309.:7703..9:8  %0 05..830/480.9.0 394 .7 9.19075703.8 -03 .7-0/ .4:39 90 .3.3920..%047  $2:3/ 70:/  14:3/07 41 58. .00:98/:733:7805. 90 .7 -4/ 890  9 8 .47/8 -4/4:9308.8 !.0905742303970434190-4/88039.9-7947.3:85079:888 5442098 .. 5.9.:/3  ..9.00:988:3/07908:-89.9    ..0/:081440/ ..84 /0.2 70.7/3 22:3.0 90-4/0..- !30:243.808 .0450/ 80380 41 920  &83 30:97.:74:8.3/ :3/0.0/ .998   89/480 3//480 7//480 .9 /0.045 .033.39 .3/ 8008 2 ..9 907 1./ /0.3 . .0%4:9 :7398920 90.943$9..0452039 ..:..:80/ 43 .110. .8 349 09 70. 411070/ 90 1789 70.93902   %880-90/-!73.733   !73.3 82490794.082.3/06:52039.  909.3/05.907 ././903/ 94-0.07403 0.:3.3/.9457490.4/ 4..3.47/394 90 24907  ..98./ 1.

9438 .8 .:3/.43:3..4390407057429394.9 8419 343903/07 34724.7.07/:0 949031.3488  .   !   $%:38$  7097. 535.$.47 570803./.7792  .8/./28843 !73.045807902.3480/41#900:98     $% # !#$%$$  %7009414:7/...8 43. 3472. !% !' ! $$     $% # !$%$$                 390728415.8347054790/308841. # .438:9 0.9039 .9070/0.7.903985.00:98..907.0  5./28843 190/174290.9.79 '9.9-90.08 # '$&#/3.8930888947 9070./10.3380.90 70:.78-70.0  #%&!.9.33/ 9.50-7.984:3/8  .9434190-4/     !$%   :30   &543.838%025   507.19070.84.8574794.04107902.43790 %3..22...070.3/10/.2.52 ## -52 $ .90..

1.39:8  1  4808348978.99070/4.020398 /  08 8 00-748 . 8.3..50-7.9 90 0.0203909702908  507507.70 822097.  .83472.0.90 .70 .447   %00909009.70.4:8 ..38.43:3.3/ 80  822097.0-98340/02.78 ..407039 .8130-.9.3/.10.3  8 0.3   4:9   58858.3/24.838%025 H507.  0  .90393907..50 .72.41:780 !.0 41 90 00 . .0/02.943324.943 ...447   %43:08943:0..50.00..0790 4072-   '9.3488    9380.431:7.9:708..3/ .8...107-70  ..702489 822097.70843   :284803 847084708438 .908 ..03/897-:9434.7/ 800/8./ 8 3472..070..:..%748840 &$& $% 29.  .943  0307....:70/ 89 4:9. 8 5.70 1:80/ 9 82449 .70 0.78 8 0.3/ &..0 0:98 .70 .. . 3 8.0.0.3/ 3472. # -52 ## -52 0.0  !73.790.78 .0  &   789/. 8.808 ...0  .438.3/53    !. .550./  -  $:  90 0.822097.9-908437908.3/ 53 3 .70822097..7. &#  .99535.3/ .0/ 3 43 90 -0/  .03 /897-:90/  0./ ..8 70.7039.

2:8.80.  80. %0-..3/ 34570803.8847913073.5.3/.8.:9.08  %47.8           . 3472..43 790 390:2039...7.1..:8.08905.3/44/839:747  - ..42504398419909:70.80.8. $30.77019204180.0.70822097..07-49:310/8:543.3/8.804130.7$8902 . 9570803.50 340/02./8.3/:38  835508.-0-98822097.943  9702908  $22097.039070/906:.3843.0417.04107902.0883490/4.

  $% #% #!# &#$   $%  #% # !# &$ %      .         % #% .9     .

 % ## % #$&%$        #                 #       0244-3 /0.078  403 .

 1742  % .

$ #!&#! $.

$ #$&%  # '&$ &%$ &$  %  $!%$    .

                 0244-3 8 3 90 3472.89 ...0 8 -04 3472.30 ..77 403 974:4:990-4/       02. 7..79 0.. 3/.  %8 3/.9 .4:39 8 .9.94..:.908 93 90 5745479438 41 5. .7. 1.8 .4:39 . 9089 /430 .79 3/.5. :8:.8 /430  94 90 5. /0907233 90  .039 # 9.82.0  .9039 -0.94190-44/    02.3  3/0 41 90 403 .90/ 147 $70 -0.908    70.:.943 94 90 -4/  988:08 .-9 94 ..94..8  3/.9 .9 9070 8 38:11.3/ 709:738   988:08 94 :38  %8 .:80 -  ...3/ #8  3 90 -44/  .908 9.773  .7.908 -44/ 8 $$ #$&%$  %#!#%%  974: .:80 98 9089 8  .

943  89.943  9 .39 84/078 41 90 -4/   .0 41                   3.  9 .70902489.42243  .8  ..82.4:39 2 .8 3/..08 .90/ 147 $70 94  /0907230 90 570803.943         #08:98 3/.0 0:98 /.994708898.84 3/.3/ .     90 08           % $ #%  &%  0:97458       44/       #                    507..943 .3/310..70.943 .943               0:97458.9 9070 8 31.803900.908 90 /7.420310. 831.041  3 90 -44/  %8 8 /:0 94 !73.3488 41 0:98  %0 -4/ 8 /010380 8 3.90 -4/ 8  5844.07 310.039.947 41  31.3/ 0..70.84 :80/ 94 /0907230 1..041#3905..90 9.0790088  8 34 /0/7.07.22.9:841$70            -44/  9070 30..:..22.5.80/ 030.70 90 193   2   22 %070 8 .9435708039    90 -44/ .3/  4.84 94  /0907230 .

79 41 90 572. -00/3 /847/07 47 .90  22:30 88902  254..943 8 94   .90          !.90        .4:39          #              #                 #       !  %07 572.4:398:80/94/.4:39  8 /430 94 /0907230 570803.3480      ..908 .7.041310.4:39 83903472.7 90 3472.907.3828  0:9745 .943       /0103808 41 90 -4/  03 310.0 41  -.  2.943                      22     30:9745 .42-..0 3 90 .70 950 41 90  -44/ .      254.4:398/43094/090723019070  8570803.80         .9009.908 .30     254.943  254.9009.:0 8:0898 9.70 5.0790-7.3/ /089 -.30     9070 8 !.908 .943    %0 .7447.9310.4:39 8 93 7. 254.907.9009 .9 90 !.310.70 430 41 90 1789  94 . -430 22 2.774/80.7 1:3.

90 147 90 78 41  .08.90 8 .9.438/070/ .9 20.:0 41  94  507.079.90 .84 -0  :80/ 94 0..943 9 90 2434 3:.9.:.1907.90          48345       #                 #      434.43/9438                 2434.. 950 41 90 -44/ . 220907 41 -44/ 7057080398 .908 .9438  ..:.3/   94 0483458507 .  %8 9089 2..99.30     .07.3 310.3 . 3472.434.0.9438.420 ..:/3 2434.-84:90 048345 .425..0/ 0483458  483458 -0.908 ..79...0 7. 950 41 90   -44/ .0   %8 9089 8  :80/ 94 0.0488.70 .808  310. 0307.4:/ 3/.0 03 4: .3/ 2. 83 41 310.3. /80. ..3/  . 3472. 70.  0:02..90 .078  3. ..0  -44/ /847/078  .4:39 8 .8:708 90 3:2-074190-44/..3 574-028  9 90 22:30 88902  .  -44/ 9089 9.0 .-84:907.:-.039 0483458 8 .     3 . .3.30 .08  9 .079.943  434.7:8    .70 .9.3/ 490720/.

90/4.903994702.-47.394905.947706:894385    5..943    .-44/8.70.088.4:7.3.903903943807990300/01470794-05705.0905.2/:73909089    8889905.0/:70850714720/ 9006:5203994-0:80/   &#   5.0/:7094-0/4308    31472905.998706:708.9039    5557088:7043905:3.:2039.947220/.9039.947 847/07    0907230905708.-47.7-0/9089.9:70890   %#   $03/90-44/8.2509490.9006:52039894-0:80/    %0905.9039130.90399.9908984:/-0/430    !705.394905.9039.990574.90    !74507/4.89070-44/8.9438574794909089    0990.3/490770897.70/    3.250    31472905.&#$#$! $%$147 !# #   0.9039490574.2501742905.7    38:70.

047..08847897:..03943 41 0397 41 /80.9:70 70:.1981.  ..757490.9  5.  % !$     %8248909038.4/  0.8 .9:708 3.943 41 39073.943  0.9438 3.0/ 307.3/8 80.:/3.:/0 57490.7  3.3/.943.23  %0-4/894708.-4:9.9:708  570...04:8  .389:97. 897:.70943 974: 507857.. 47 09073.7432039  8:. 03.308 3 39073.0 70.8 94:.9390:3/07354/0728      .3/ 57088:70  98 1:3.9.3  .943 52039.9 .:83 2.3/574/:.388902.8  .89083.3/ 80-.4098:37.7447...3/ 850. .94341.3828  902507.059478 147 892: .80 .

9:2 85348:2 314:3/39.078 5/0728 !74507908 :3. 90 .425480/ 41 987085438-0147900.90757441 -.38 20. .908 .910/ 0590:2 07.0 .937.078 41 /0.38 .9  07.30  9.9..08  90 .08  .074107. 41 897.307.08 940907 .7 41 90 1009  %7.07    .4330.83 5.38 8902 070 94 705038 83  .934.93 .3/8408 #08898 17.908 57490. 8.307.8434.90 .04:8 .08.3:.8:554794183  988:0  9.439.439.0  570.0741.03 .38 .943  .08  $97.3/ 0.907488  .08 30/:5 07. .34.3/20.3/5.3/ 3:970398  8038070.0/.0 . 89.7 14.38.425480/414308 #085438-0 147 90 .4330.934.907488  472.:-4/.39 3 80-.07841 07.38943 -09003 90 570./  1. -.4393:.34.07 41 83  .9:2 .934.8.34.934.907488  17.24:80590.38.08  0728 1742&'  005 . 202-7.90757441  $97.90.07   .07  /0824842.439.9:2 -.3:08  !7.284190.9 ...9 90 83 52039.08 94:93:.7 .50/.439.705.3/ 050 5/8 .3/:.0398.3:48:2 7.28.909.08  $:5508 90 05/0728 9 25479.33 %0 1472 07.90757441  :.908  7050383 41 83  708898 .08  43 .930/ #08898 86:.9:2 7.908  .943  .38 17.89.08  07.307.8..08808 .07  $97.4.3/8  -44/ .0398.0398 .07  $97.8.908.439.943  . .9:2 .3/ .059478  9072470:.07 90 8408 41 901009.9438  84 .:78 . 93 -:9 9.074183 .893 7.934..943  . 4.70 430/ 940907 - 22:3070854380  07.794190 ../:2 0.3/ 1472 .4730:2 473.3/8  $97.90757441  570..908 0.3/ 20.089.943 :907.$3.7707  &8:.3.4730:2./:2.

443088  '9.9438 5:8 394 90 05/0728  4728 1307 57398  -738 ..0824.3.!.9.9  4:3/ 0.8. 57088:70 .-7.58.0 988:0  4728 308 41 83 903843  570/423.843 4.3   .70943 %08383.08 41 90 05/0728 -70.9.3/98 8.-1.:7847240.79 41 83 .:.:08.943  .7488 90 4:3/ %027.439... .23574/:.8 411.943 $038.:03832.8.08808  38:.30 .8.3088    .49 14728 3 90 4:3/  -44/ 14 3.0..:9..5..7.3/9083709:738943472..70.304:8 !7490.907.4330.9908.8.0308  8:71.3/ %072470:..08-030.3/80..8009 03908/0820099074989458..7 !740.4208.947    :3.943 5.7707  -8475943 80.90.547.705/0728  #09..-7.3/0.3 .-.802039 202-7.8.:78 -.943 41 -44/ 14 94 90 /0728  :9.0/ .943 41 80..- %08.72947 .304:88038..0988:0 7..9  #0:..98..49-0.23   !7490.943 %083.907 84:-0 240.:.9438419083  O .0 94 90 83 8 .9.094904:3/ %0.93-943  O O O O O 3 /005 4:3/ 0.4330.31.3  03 .3 ..7094341.0  54/0728 49 5.9.943988:018 904:3/.3/3307..0 .7 0380  3907.:.708 .9. 2347 -:73 47 .4.5.3:.39 5..90/  .4807 94 90 . .3/.7...-847594341.07  $:-. 1742 90 -.3/ 2.8.0/390.808 .9438094:.:843 .9.90 .3/ 27.-7.943 &'8:39 570.0.3/390380749410590.

943  07.07 .0 .934.08 1472  4/074308 .70. .3005/07280.438898 41 853 57..0   %0 05/0728 /408 349 .4390398  03 9080 .284190.9:2-.88:.70473411/.0 8.7/ 90 8:71.9 39074..07  90 897.70990 2470 9.0/994:.08:583   :73 /086:.4186:./0 .3.39038 14703-4/08   %0/005089.0 07.$35/072.-3.447 070 8.0870893 43 . 574903 9.3 14:7 .420 1742 90 /0728  3 90 /005089 .907574418 90 83 8:71.8  438 41 9080/0.8:71.05943 .  /423.08 83 98 897039 .8.3/ 05/0728  %0 897.0 . 90838:71..943   %0 309 .8.3/ ..08 41 90 897...0  %8 9..9 2.9 -44/ 8:55 .0794/.08 90.93.38 .7084:0/4113.9 0.943 574/:.089.8  %0 897. /.07.93  .2.08 70.4393:4:8  830 .078  9.078 %083890.98 .07  90 .70574-.0 %080 .0.9410590.3//0728 3307.93.08889.908 .3:48:2 90932//0.9:2 -.9:2 85348:2  .70 5:80/ 94.34. 3:970398 9.0  0.07 39.79890/0..9.439.0 70. /70.8.85.90807.34190-4/ 9.09509.0//086:.0 34:782039 %0.088.9.389 8:3 :97.020.08 -03 94 574/:.08059022:3088902 -574.70.3/ 10-9 .0883..307.0 .08.93 9.0741.07 -09003 90 /0728 .078.3/8.3 07..9:2 :.174298.07419005/0728 90897.908 574/:..9 . .9434107.709005/0728 4:907..409 7. 897..9005/0728 4:907. .7520399.705:80/. 94 8:554799083 %0897.934.2.0870.4./:2 57490.9:27.3/840841901009  .07/0 0390..93 10/ 8..9 100/ 9080 .70. -.08 .08 9.550.90 907 .0 90 07../.08 /.9:2 -.908574/:.70.2.0 90.07 .7/ 90 838:71.07 %005/0728.9 .08 .0 9508  07.574.039:.708947.802039 202-7.830.701009 9894 2.93 %8574.088398.70 5:80/ 94.8 80.784331706:039:80/.30 .0.33 90/.9.

059478 /4:-074415.439.7 ..3088307 8.0 308 0. 89743 0.4.0.28 41 90 .98:3/073.9 34:78 90 05/0728 49078.90   %0 5.9 90 05/0728 .0 897.90/9.9 90 05/0728  98 2.73..439.0 94 .  %383 .0 1307 0 5740.08 %080 .7 .4330.3 94.93 .:.475:8.7..480.798 .3.4730:2 90119 4:9072489.98 94 9 .70/11./8 574/:.08 80384794:.89.07 .5./375534-0.03 .84480.0/ 97:0 83  8 90 .708 9.03 1-078 088 .0/ . 5.8 /0380.788 ..70 2.5.3/ 8408 41 90 1009  30757398.480:5.8907 .9:2.9:2:.03 1-078 9.7  !.4.9 -030.08  803847 70.059478 147 /005 .7 5.9..884.3841907.70 .//8 897039  709.5.38 !.3/14495739800583174290.3/57490.3 .0789.07.0988:0 .990738 3 90 7/0/ 130757398 43 1307958 .9.3/ 9 088 8.9 .0897.8 94 ..930.47 5...800/8 %383.9 .7.3/ 706:70 088 8.7 1-078 93 574903 1-078 9.7. 83 05/0728 ..8 8:..9 .. 574903 9.9.8438 /87:59 .7 .38 ..7 988:0 .9 .08 90 7/0/ 130757398 43 1307958  $2./0 507503/.70. 1..0 3 1307 5..9 1472 .07 41 90 /0728 ./0 5.%.7084.8897.5.:.89.0 .081742 /734:9   $3072.773 9.3/ .. 30947  %8 30947 14728 .89.439.3/.08.84 .7.990.07 08 /70.078 905. 1-078 ./:2  %0897.307 8  308  $:7.4330.8 .07 ./..08 9.07 -030.98   %0 709.70.5.4.974841/0.005890830. 5.3/90709.:.4:3/   %0 709.0988:0 %080.:994 /1107039.07 %0 /0728  .078.3/8 .9. 574903 9.0 .0 3. 3.70 43 5./ 3 0.// 8:55479  .99073 .0.4.475:8.9 .5.9438  $420 5.:. .439.8438 9.3 .74883 .439.897004714:741901.:..078 9330705/072..07 . 1.//8 10-9  %0 /0728 .3/ 0.4330.3 9480 2.

.3/8.7024/10/.3/ 80.:884343.079..:9.08808  82449 2:8.0 41 35508  .304:8..9 9.-0 41.884.9:70 .08808  25 .7.07.3/8 .74:8.9.3/  507.70 3 ..730 . 4/47  %8 4/47 /11078 1742 -4/ 4/47 9.3/8  %0 1.3/8  25 . .547.9708543/940.3/8 708543/ 94 897088 .3/ .9073984.9. .0.422:3.3.70 3 2489 41 90 -4/ 0.90789..422:3.0..3/8  .9 5:-079  .730 .:7.9 9 .730 .907 .43/9438 94 :2/9 507857.8:-89.3.808 41 .54.7 14.08   $:/471074:8 80.0988:0 8:.57088:70  %8 ..07 ..08 /08.947 80380 41 820  .3/8  %0 ..880:.38 80.9 .408 .9  .730 .714.7-0/390/8.89.08 .730. /0.0 9.70.70 .439.7090 80.709434180.3/8.09.9.9 .7..9 38:.9 . .730 .-0:2.0890102.98/005390839.7 14.994908:71.08.3/8 80.9 708:98 1742 -.704.90/ 897:.4330.7..7093 80.3/89.72598  .04:8 4  .3/ 80-.3/8 80.40//:..3/8  9 .730.72 .9894:9947050147032.3/ 803847 70.4330.990/0728 4480.3/ 1..3 0.3/80-.9 /897-:943398.3/ 574/:.0  .3/8. 29:70 41  507. 7085438088:.059478 9.9:708 8:.9 03.8  .9 .08 .709438 9.0   %054/0728 8:-.54..709438 .943 80...9 - 80.7..07:203 0.3/8 $3 574/:.8.33 %0 80.0147298.7  .90789.0 .7090.943 9 4907 202-078 41 90 850. 7043  .07.039 .3/839009073.38-44/ .9 .  .4490-4/   54.943. .3/8  .730.907.943 574.08808  .54.709438439083   07:234:8.425483 83 80. &300....90890-4/ .3/0.43807.9 .08 9..98  3 ..47.07 80.08 13073.730 .84 574/:..07 08-030.3/ 90 -.98 .3/5.707  /00507  ..439.3 -0.3/8 80.3/ 80:.439..420 .907.30.08  %8 .039 8.3/ 90 039.389410057088:70 902507./5480988:0 1.9 03.8 8:/471074:8 80.9. -0.3.54.3 507424308  8:-89.3   49 74:58 41 8:/471074:8 .9  .84.04:8 4 .

059 43 90 5.7 14.07.7 .07 80.08. 29:70 41 1.088.08 3 90 -44/ 2.3/ /74.08  .7 -:-8 5.4.07 2489 41 90 -4/  .3/3.0398831742/73 $0-.47310/970.:9.7.04:8.943 00-748 005 80.78 1907 /:89 1742 90 .70.03907 .3/.0 904:9072489.39 /:73 749 .3/8.0 -70.7090 80-:2 .7 .3/0/ 5.7-:-. ..3/ 7089 5.4790  .7.0..3/ 8408 41 1009  %0 .7 80/8 .9.:9. 57490.07 ..0 0.3/8 .33307 .447 %0.70 4.38.9 90 83  %0 .3/8 3 102.07 .3/ .7 7449 3 .4790..01:3.70943 5:8 90 .4790  90 33072489 9. .5 .0/ .28 41 .07  .50 8.7 14.7.54. 3 90 ...590/ 94 80.3/ 8 705.7090 2 3890.0. .3/ .5.94.843 . .3/.898 24/10/ .703:2074:843901..:9..7 2489 .8.9./4180.9   $0-.9.70 .0  574/:.9 1742 7:333394 90 008  3480 . 83 /847/07 .0  %0 20/:..7 .7/07.3/570.3/574.3/ 8. 90 -4/ 0./.3/8 0259 /:.3/..04517429005/0728.7  %0 ../083:97039814790743.0.19 57497:/08 1742 90 83  .3/ 4.78 57490.730 .0/ .3 .7-438  $0-:2 0058 .70..425480/41.089.08 02-0//0/ -030.808 41 .3/8.089 .98  .0.3/8 .. 574/:.08 .8   .9.3/ 0.9/0.-7.9 .4389.0988:057497:8439.798 .0/.98 394 90 -.93   %0 .8 .3/8  %080 .5.7 14.808  .070548:70948:37.0...7 8.3/ 80.4330.8 90 520399.0 80-:2  %8 4../841.3/ .93 . 20/:.08 4990.439.  .7 14.08 0903/ 394 90 /0728 90 /005 03/8 05.78.3/8 4.389 .70 .439.3/8 .22..04:8.7  .089.5  :73 5:-079  3.30   .80/ 80 472430 0.708 57497:/0839490 .8.8 ..8 .38 8419 07.7 %0.714.

-0/ %074498//03:3/078314/8 &3/0790744908 90 2.4.089 '0:8 .:8090797.3 3307.04517429005/0728 %080.0.5 .0890.1 24438.780 8./37.3/17000/0 %0:3:.8.9 905:90.03.99.078 90 3.1241/0.9.9 4.744980..:2 93 .-.9.97  90..3/17000/070439..7 3.7 8 90 0.8-0  %0 3.0/903.0590.38 . .0452039-03839097/109.70.83.70 .714.:8383/2508 4480-:258  %0 307.. .7988:0-030..7 .4397.8.0.08.98 8.38 90 03/ 41 90 1307 47 940 .90 902   .7 14.:28900590:241903..930/.97 9.7259 .7-:-9.078 90 109:8  9  24398  .9938.059908.0452039 3 90 .9313078 .:9...7/5.550.744980.0 .3:4 93 .08 .0890.3/ 039..4.80 4990-4/.3 .908 9080 2:8.890 .794190.3/00-748070 .7  .07 41 0590:2  .08 ..3/9408 .90 .3/ 8 .8534-0.0/ 90 .79.9 %00590.3 .3/ .70.5.3/57490.7090:3:.07..08/0.-0/  .9084107.9 90 3.753-0.4/ 902507.7394.89.70.4:8 88902 70:.34:907/072.7-:- 9-0./:9  9 702.550.9 %0.08 .08  03 90 ..78 1742 0.079.3:4 /8.:.8.70 82449 2:8..34:907..7  0.3/ 00-74 . .7 .9 9003/84113078.7 9. .039:. .890 90.4208902.4.9574/:.80 43 .0 %0543.7705.078 90 7089 41 90 -4/  %0723.0/ 94 .3/.9.2439   90 119 2439  .8/0. -4/ 7449 .9.1907-79   0.9:708 47 179 ..07 41 0590. -.07435..07 41 83  543.4.947 5 2:8.7.42543039841903.9903.3:579548943 .907 .744980.7807.045.974/:735:-079 430.9.7/0.4. /:73 /0.38:.3/9408   %0.07..3/. 70898 43 90 9.7   770.5574.50/5.

90/ 974: 83  0.33574/:.3/ /897-:943 41 20..447 8 .:80/ 2.93 90 0309.409 7.3/./ 9084/11070393/8. 048 930  -382 8 .7/ 90 8:71.943- 20.70 84:0/  %44 2:.749030 3 90 897. 83 .$3.24:3984120.8 .088.08   '.33                  .3074:8 94 83 9 3.110.70.30 52039 .. 24.:83 8:39.8 2470 20.8 .08 .07 - ..33 9. 7.9083890. 8:3 8 /.34.33  .907.33  .707 83 .3.33 .908  7039...243 3/.34..908  .908  40.07  90 /1107039 83 .4393:.447 $3 .8 1742 -:733 90 83  548:70 94 8:39 .0/ - 2470 20.08 /4 349 7010. .3  902547.9:2 .24:39 41 .749030 04 94 47.808 90 78 41 .43/943 070 83 /408 349 574/:.30383..4478 . 70.447 708:98 1742 90 570803.0  070 90 .33 0058 0.0 2470 20.0 :97./:.0 20..0 41 20.3/:3/073-44/7010.4730:2  574/:.447 0.. 41 .9 8 574/:.:808 90 83 94 574/:.34.3 - 90 3:2-07 . .907 .0 94.3/ 7.9 /1107039 3:2-078 41 20.34.3 .7. 2.709 41 83 ..

-9   0:4.'!%%$$$  $.0880/.3/  !.70.003/38 /02..08700.9.1-73  0:4970308 ./33  .3/0/02.80-7.3/1-73  20847.230  499388902 3388902700.1.3/3.750720...-4.5.        .80/-44/8:55.3/3 20847      !.9.230.90830.3 0:/.947#0854380  4250203988902  700.-9 0.89.908394  3907899.:2.7907408 .70.9009700.8089.9:70 47.908.03:08 3.9078.9 -44/.80/209.750720. 97.02.70.3:304:8 -44/ 5:7:039 5:8   !.82.43897.90307.824190.9488-038       :/.85.9478  -:/8.4.08 5.8080749433 .80889.94038 8:707 54.70.945844 44039070/    03:7!.7.8        31.80/.2  !.90 8074:8 5...41.9488 0:/.908.0249.3/57489.8 27..5. 3.943 .7907408 .4.943. 9438 097020902507.7.22.84/.30      $5..02.0880. 8.943410:4.90 .3/..892:.9434190  ..0202-7.

/    !74/:.9478  10890  0 0.041310.  22:3088902       9041.3/  .  43#90   .     22:348:557088434190-4/       31.947 9430.948570...943411:/ 0.-0..-0.04107902.9      $03907890-4/     320-70.!.22.4890-.943 434.9478  4/1.80988:0  3904070 5071:843     $030 !70803.3/  57489.907..945844 039039070/    434/1.7432039.4342.784/    3.907.3/3700.70.0943174290-..0    $4.908    :30          97.3380.4.07  !70803.8.8/439083.80 70854380        0.  $0 ...

9039 8  8   ..22.9432.3 .3/908419988:08:3/0730.943 31.907. 90-4/ 574/:.843 41 1:/ 3 90 407 0  .90 83 .22.22.90 8   %8 708:90/ 94 097. 94 03907 90 -4/  .3/.!73.83.943419083. 708:90/ 94 570803.43/943 . 892:.-0 . 31.94308 .9039 394 8...  :094570803..3...843 0320-03894-70.943.70.9438.:77039/80.3/ 2434.. 574..9./ 94 22:348:55708843 41 90 -4/  %0 3..43 90790    013943419080.3380.310890/10..708:90/9407902..80/ 9.:80803  70/3088 5.80..3/ 4/1.0 41 0/02..3/ 57489.48 90 -.90/./0-7403473472.-0 ..041310.$3.0 943 1742 90 -.:7803-.80  0:988.3/31..80/.3/89.907.07 190790 22:348:5570843  ..$%$$ %$$  %0 43 24/1.79948570.0 41 310.9 708:90/ 94 570803.890438094190 /80.42243310.0883..80:98 -9041.331.943  070 90 5.943 988:05071:843/0.843 41 -.907.9 0.3/3 070 700.3/ .907./:3/079083 .9478 57080390/ ./090-4/ 1907903.90-4/70.00:982.989490-.0 5:9 90 5.94770854380.. 9.22.3/394908419988:08 %8708:983310.907..80 .99083 9 4.

4:.47.4/8840 822:34.3480/  4 22:3088902 %05.9039..3/!70.0.70.3/.89308841..70/.729    !70/85483.947  4 0 50/.97.42574280/ 3.943   .93.83077894310.70.0:98 4 $0 %070834570/0.9478  !70/85483.03.943343 4892.041..80903.5.59./03.8.

2 8.398..1.3/$259428  O 3....94394.110.74:3/ 9074208  4 %0484.9-90   $38.791.89.94788:.4:39   .4224314:3/.59.3/.4342.74030.93.3078.:80 98.07202-0741 901.80/.03:9794:8144/8940..439.40.947  4 3.98901.-994.8.8.9 03088-0.7432039.2  4 10890905..9039/4083 9:807050..357490.70.4/ 380.9:85.!70.

93  55.0 .943  O O  !04509/.83.9057490.943 -4/ 8/01038020.943 #0/3088 5.039.3/970.3.7.3/!70.3/90300/14720/.22 310.70.3.9.07 /:0949031.79414:7 3472.80  %405570.039834:3/8.9!7424943.:9847.14783841310..8:7083.570..8:708.0.:/0901443 .-..5488-0 310.85.39-49...3//7.39-49.3/948095447.984./06:.:.-0908.:943894 570..5.9419080.04:3/8 .22.4392039574.0.94770854380     0.9.839083574259 44/83 .943300/949.3/4907310..7.3.84:74:3//.830 47 /4:-0 .0:98.2474392039 4724898:71.834:3/ O .907 498039..3829419 O 0.3.3/.:./08.0850.943.0097.943  .70 20.9438 144908020..039.39204:.

94:71009/.3/1009 0.0.9090 8 1449 310.38:5071.79970.0.94:7.O 3850...99489.8.7.0419083 8:5071..7.8.70349943:7090 8:774:3/383  !7490.3/5003  %724:713073.943843908:71.../1742 50784394507843 43 9.7  489:704:78370:.3/8.3/4.. #0:.7.30.88570.9438 8:.7..3310.9.934:783058570.3 .039.92039  O O O O                      .9014490.4:71009147838413:7844:... .3/9403.9.8...7 :-7.83310.701: %..08  !74259970.3 .94380.557457.

'  %   '    %%8.' %!%%$$$   % .

 % ##     # $#!%   507943.40784.943.943  % .039 .9.8 .0397.43.43.3/ .950 4184:9439.0397.0784:943 .

/08.39.22.70 31.983490/  % $ #$! $%  %#%%  %0:38. 5. !&#! $ $   %8.:80.80/ 1742 31.3/574.9.7.0.20/  % #% %  %#%%  %070070348/0 0110.9039.9390 :389.08 94873390 :389:8 /.3 .   - 7:8   % #&$ #  #  ## % %..943 9:82.

'  % .

 .

 # &%  $%#%   $ #"&  $%#%  # %  &%  $$%  $ %  %  $  # !&#! $ $  % $ #$! $%  %%  %%& $%$ .

943...9438  --..383 70...310.9438  %0.798 41 ..82..39-49.9438 8059.039//349 84.  9445.3    $'! .  :30   2'6S 3  . 397. 03/4.9438 30..90/94. 310.44.02.983 5. 3/11070395.05.3 .897..9438  83 8419988:0310.907.:80/ /98 /039.2.90398.9438  -430 439310.03. 98 :80/ &5507 4077085310.-/423.0414907 20/.9310.38.9438  94970.:80/- 39.. 779.7 90-4/.3/.

$ !30:24.90398 .73530:243.898 .35..

$    . 09         .

                      995.

.

7-/ .42. 8.

/4.

.

.80 !708 0:98 .

995.

.

7-/ . 8.42.

/4.

  .

.0:98 995.

.

 8.7-/ .42.

/4.

  .

.0:98 995.

.

7-/ .42. 8.

/4.

.

$ $%&   .0:98 995.

.

42. 8.7-/ .

/4.

.

0:98 !.5  .94 .

Sign up to vote on this title
UsefulNot useful