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Anatomy & Physiology of the Brain (Encephalon): Preparing for ICD-10-CM/PCS
© Irene Mueller EdD, RHIAMay 2, 2013
Review Brain Anatomy and Physiology for ICD-10-CM/PCS Coding Overlap of Circulatory and Nervous Systems Functions of Brain Components of Brain Cells of Brain Brain Nerves
ICD 10 CM Terminology ICD 10 PCS Terminology
Integrated into presentation
Objectives
Have you completed the Pre-Test????
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Connected through organ & bodily function control All body functions are regulated by brain through nervous
system W/o messages from brain, circulatory system does not
work Heart function & fluid circulation triggered by nervous
system Messages sent from the brain control both blood and
lymphatic parts of circulatory system Blood provides energy for brain
Brain = 2% of mass, uses 20% of energy Avg weight of adult brain is about 3 pounds
Overlap of Circulatory and Nervous Systems in Brain
Blood pressure and heart rate regulation Vagus nerve controls pumping of heart As heart pumps, blood moves through blood passageways
around body to organs Baroreceptors pass information about blood pressure to
brain so brain makes adjustments to heart rate
Dependent on each other to ensure homeostasis Nervous system may have control, but circulatory
system must relay information for adjustments Both systems need to function properly & work together
to ensure proper body functions
Examples of Overlap in brain
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Cerebral Arteries AKA Intracranical Middle Cerebral Anterior /Posterior
Communicating Anterior/Posterior
Cerebral Cerebellar Other specified
Precerebral Arteries AKA Extracranial Leading to cerebrum, but NOT in
cerebrum Right vs Left for coding Basilar artery Carotid (Common, Internal)
External does NOT feed brain)
Vertebral Other
Anterior spinal Auditory internal
Circulatory System Components of Brain
Basilar Internal carotid Vertebral artery
Circle of Willis
http://etc.usf.edu/clipart/15400/15496/bldbrnvessls_15496.htm
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Control Center of body
Maintains homeostasis (w/endocrine system)
Functions of Brain
http://etc.usf.edu/clipart/8100/8171/human_brain_8171.htm
Nervous system = 2 parts CNS = Brain and Spinal Cord (not part of this
webinar) Cerebrum, cerebellum, brain stem
PNS = Nerves and Ganglia Somatic – connect CNS with skeletal muscles and skin Autonomic – connect CNS with cardiac/smooth muscle
and glands
Nervous System Components of Brain
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Largest Part of brain Cortex = Gray Matter on surface
6 layers of nerve cell bodies Millions of cells
Cerebral White Matter Under cortex Myelinated axons of nerve cells Transmit in 3 directions
Association = within same hemisphere Commissural = from one hemisphere to other Projection = from cerebrum to other parts of CNS
Cerebrum (L, brain)
3 general functions Motor = Govern muscle movement
Sensory = Interpret sensory input Vision = 30 % of cortex Touch = 8 % Hearing = 3 %
Association = Emotional and intellectual processes
Functions of Cerebrum
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As brain grows, more gray matter Cortex folds on itself, creating
Gyri (AKA convolutions) Gk, gyro,circle Upfolds winding over surface
Fissures – Deep downfolds Sulci –sulcus /sul·cus/ (sul´kus) pl. sul´ci [L.] a groove, trench, or furrow shallow downfolds separating gyri
Cortex
http://www.nlm.nih.gov/medlineplus/traumaticbraininjury.html
Right and Left halves of brain Divided by Longitudinal Fissure Connected by Corpus Callosum
Large bundles of transverse nerve cell fibers Each hemisphere divided into 4 lobes
Frontal, Parietal, Temporal, and Occipital Fifth lobe = Insula
Oval region of cerebral cortex overlying extreme capsule, lateral to lenticular nucleus, buried in depth of the fissura lateralis cerebri(sylvian fissure)
Separated from the adjacent frontal, parietal, and temporal opercula by circular sulcus of insula.
Synonym(s): insular area, insular cortex, island of Reil
Hemispheres of Cerebrum
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L, - callous, hard AKA colossal commissure of brain
A tract of nerve fibers passing from one side to other of spinal cord or brain
Larger in women Can transfer data between R & L
hemispheres faster than men Woman’s intuition
Corpus Callosum
Lobes of Cerebrum
http://en.wikipedia.org/wiki/Lobes_of_the_brain
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Responsible for higher cognitive functions, including: Problem solving Memory Language Judgment
Spontaneity Motivation Impulse Control Social and Sexual
Behavior
Frontal Lobe Functions
Role in emotions Responsible for
Smelling Tasting Perception Memory Understanding music Aggressiveness Sexual behavior
Language areas of brain
Temporal Lobe Functions
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Broca’s area French surgeon, 1861 Frontal lobe Motor neurons Control of Speech
Wernicke’s area German pathologist, 1874 Temporal lobe Motor neurons Comprehension of
Language, Speech sounds
Language areas of Brain
http://www-rohan.sdsu.edu/~gawron/intro/course_core/lectures/aphasia_cases_slides.html
L. – uncus – hook From Gk onkos Hooklike anterior end of hippocampal gyrus
on temporal lobe of brain
Uncus
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Role in sensations of touch, smell, and taste Processes sensory & spatial awareness Key part of eye-hand co-ordination & arm
movement Wernicke’s area
Matching written words to sound of spoken speech
Parietal Lobe Functions
Controls vision and recognition Visual perception Color recognition
Receives visual input from retina Retina is part of brain
Visual signals are interpreted in occipital lobes Each optic nerve
has million fibers
Occipital Lobe Functions
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Sited below back of cerebrum
Transverse fissure separates from cerebrum
2 hemispheres separated by vermis
Both gray and white matter Connected to brain stem by
cerebellar peduncles (paired fiber bundles)
Cerebellum
http://etc.usf.edu/clipart/15500/15558/brainbase_15558.htm
Motor area of brain Controls unconscious movements in
skeletal muscles Coordination, Posture, Balance
Functions of Cerebellum
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Located below cerebrum & in front of cerebellum
Structures (from top to bottom) Thalamus Hypothalamus Midbrain Pons Medulla oblongata
Brain Stem
http://birthinjury.org/brain-injury-cerebral-palsy-tour-of-brain.html
Oval-Shaped, Large, Located above midbrain
Relays all sensory impulses (EXCEPT smell) to cerebral cortex “Gateway”
Interprets and produces conscious Pain recognition
Thalamus (Gk: Inner Room)
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Striped mass of white & grey matter located in front of thalamus in each cerebral hemisphere Consists of caudate nucleus and lenticular nucleus
Corpus striatum
Controls many homeostasis-relatedbody actions Controls Body temperature Regulates Biorhythms (Wake/Sleep) ANS – heartbeat, food movement, urinary
bladder Interprets viscera-based sensory impulses
Regulates food intake (Hunger/Satiety) Regulates fluid intake (Thirst)
Monitors/Works with endocrine system Responds to Mental states – Fear, etc.
Hypothalamus
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Connects Pons and Cerebellum Short, Constricted Origination of 2 Cranial Nerves
III – Oculomotor IV - Trochlear
Midbrain
Located anterior to Cerebellum, above Medulla
Bridge between spinal cord & Brain Connects other parts of brain as well Origination for 4 cranial nerves
V – Trigeminal VI – Abducens VII – Facial VIII –Vestibulocochlear
Pons (L. Bridge)
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Lowest part of brain Form upper part of Spinal Cord Main Conduction Pathways
2 pyramids - ventral aspect Motor tracts from cortex to cord Nerve fibers cross to other side Extrapyramidal = functional, not
anatomical, unit comprising nuclei & fibers (excluding pyramidal tract) involved in motor activities; control/coordinate especially postural, static, supporting, & locomotor mechanisms.
2 nuclei on dorsal aspect Receive sensory impulses from spinal cord
(ascending) Relay to OPPOSITE side of medulla
Origination for 4 cranial nerves IX – Glossopharyngeal X –Vagus XI – Accessory XII - Hypoglossal
Medulla oblongata
Reflex Centers
Cardiac – Regulates Heartbeat Respiratory – Rate and Depth of
Breath Vasoconstrictor – Regulates
Diameter of Blood Vessels
Medulla oblongata, cont.
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3 sets of paired bundles of hindbrain, connecting cerebellum to Midbrain (superior) Pons (middle) Medulla oblongata (inferior)
Cerebellar peduncles
L. tapeta - a carpet Layer of fibers of corpus callosum forming
roof of part of lateral ventricle
Tapetum of brain
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Pineal (L., Pine cone)
Pituitary L. - pītuītārius pertaining to/secreting phlegm
Glands in the Brain
Endocrine gland Source of melatonin
Hormone derived from tryptophan Regulates circadian rhythm (sleep cycle)
Located behind 3rd cerebral ventricle Midline of brain
Pineal Gland
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Master gland Central role in homeostasis,
maintaining reproductive cycle, directing activity of other glands Anterior, intermediate, and posterior lobes function as 3
separate endocrine organs Distinct cell populations, secretory products, & regulatory
mechanisms Anterior lobe secretes thyroid stimulating hormone, corticotropin,
luteinizing hormone, follicle stimulating hormone, growth hormone, and prolactin. Regulated by hypothalamus via portal vascular system
Posterior lobe releases oxytocin & vasopressin from axon terminals originating in cell bodies located in hypothalamus
Intermediate lobe rudimentary in humans, but produces several hormones (which are just now being studied).
Pituitary Gland
Thalamus Hypothalamus Cingulate gyrus Amygdala Hippocampus Basal Ganglia
Limbic System of Brain
http://en.wikipedia.org/wiki/Lobes_of_the_brain
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Regulates emotion and memory Directly connects lower & higher brain
functions Influences
Emotions Visceral responses to emotions Motivation and Mood Sensations of pain and pleasure
Limbic System Functions
Cingulate gyrus , L. - Girdle (surrounding), Gk. - Circle
Amygdala, Gk. – Almond (also used for tonsil)
Hippocampus, Gk. – seahorse
Basal Ganglia, Gk. - knot
Limbic System Components
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Part of cerebrum gray matter Surrounds, directly connected to parts of inner
Limbic System
Serves as conduit for messages to and from inner Limbic System
Cingulate gyrus
Makes associations across different modes of stimulus Smell of lilacs = visual memory of my house in Great
Falls
Appears responsible for influence of emotional states on sensory inputs Same stimulus = Different perceptions Sound of USAF Jets not noise – memory of childhood
Thought responsible for face recognition
Amygdala
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VERY important in transition of information from short to long term memory Search Engine of brain Learning and consciously remembering everyday
facts and events
Also part of Temporal Lobe Damage to that lobe can result in memory loss
Hippocampus
AKA Substantia nigra, Subthalmic nucleus Important in planning & coordinating motor
movements and posture Basal Ganglia linked with Cerebral Cortex via
complex neural connections Major effect of Basal Ganglia = Prevention of
unwanted muscular activity Basal Ganglia Disorders result in exaggerated,
uncontrolled movements
Basal Ganglia
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Network of connected cavities filled with cerebrospinal fluid (CSF)
2 Lateral Ventricles Third Ventricle Cerebral Aqueduct
AKA Aqueduct of Sylvius
Fourth Ventricle
Ventricles (Ependyma)
http://emedicine.medscape.com/article/1923254-overview
Choroid plexuses located in ventricles produce CSF, which fills ventricles & subarachnoid space Cycle of production and re-absorption (toxic wastes)
Buoyancy, Protection, & Chemical stability Protection = CSF in meninges protects brain from
striking cranium when head jolted Buoyancy = CSF and brain have similar density, so
brain is suspended neutrally, allowing growth without sitting on bone
CSF has protein, glucose, electrolytes, etc 500 ml per day, space for 130 ml in system
Functions of Ventricles
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Protect brain and spinal cord 3 membranes
Dura mater = Outermost, tough, thick, fibrous Arachnoid = Middle, delicate, fibrous Pia Mater = Inner, transparent, tender
Contains blood vessels Only layer that adheres to brain surface
Leptomeninges – 2 innermost; CSF circulates between them Gk – Small, thin
Meninges
CELLS OF THE BRAIN
http://www.ninds.nih.gov/disorders/brain_basics/ninds_neuron.htm
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100 billion neurons (nerve cells) Sensory (afferent) – messages TO brain Motor (efferent) – messages FROM brain
Trillions of Glia (Gk: Glue) (glial cells) AKA Neuroglia Connective tissue of brain 4 main types
Astrocytes, ependymal cells, microglia, oligodentrocytes
Common tumors of nervous system
Cells of Brain
Sensory neurons carry information from sense organs (such as eyes and ears) to brain
Motor neurons control voluntary muscle activity (ex: speaking) carry messages from nerve cells in brain to
muscles
All other neurons are Interneurons
3 classes of neurons
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Cell body - includes nucleus, cytoplasm, and cell organelles Nucleus has DNA & information needed for growth, metabolism, and repair Cytoplasm = substance filling cell, including all chemicals/parts needed for cell
to work properly Cell organelles = small structures (chromosomes, Golgi bodies, etc.)
http://library.thinkquest.org/12413/structures.html
Dendrites Branch from cell body, act as point of contact for receiving impulses
(chemical/electrical signals) from neighboring neurons
Axon Sends impulses, extends from cell body to meet/deliver impulses to another
nerve cell Range in length from fraction of inch to several feet Sciatic nerve axons extend from buttock to top of foot
Neurons - 3 basic parts
Microglia = Brain’s immune system Schwann cells/Oligodendrocytes form insulating
sleeves around neurons to keep electric signals from diffusing (Myelin)
Radial glia in developing brain After helpng neurons move around Then become astrocytes
Ependymal cells (ependymocytes) Cells lining central canal of spinal cord (pyramidal
shape) or brain ventricles (cuboidal shape) Produce/absorb/move (cilia) CSF
Types of Glia cells
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Insulating material wrapped around axons Complex mixture of proteins and fats Nodes of Ranvier – gaps in myelin Electrical signal jumps from node to node
Increases conduction speed of electrical signals along nerve fibers to muscle
Made by Glial cells Oligodendrocytes in CNS Schwann cells in PNS
Myelin
http://frcables.blogspot.com/
Transmission electron micrograph of a myelinated axon, generated at the Electron Microscopy Facility at Trinity College, Hartford, CT
Have starlike rays Reach out in all directions
Most abundant type of glial cells So, most abundant of all brain cells
One astrocyte can wrap its rays around a million+ synapses
Astrocytes fuse together Conduits for molecules moving from cell to cell
Astrocytes
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Cells in Cerebrum generate electrical potentials Pass thru skull; Can be detected by electrodes EEG = recording/graph of brain waves
Beta - consciously alert, or feeling agitated, tense, afraid Frequencies from 13 to 60 pulses/second in Hertz scale
Alpha - state of physical and mental relaxation, but aware of surroundings Frequencies around 7 to 13 pulses/second
Theta - state of somnolence w/reduced consciousness +/- 4 to 7 pulses/second
Delta - unconsciousness, deep sleep or catalepsy 0.1 to 4 cycles/second
Brain Waves
http://en.wikipedia.org/wiki/Epilepsy
NERVES OF THEBRAIN
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Cranial Nerves
http://en.wikipedia.org/wiki/Cranial_nerve
AKA Auditory
ICD-10-CM Indexuses numerical order (first,
fourth, etc), but also provides names
ICD-10-PCS uses NAMES only
IX
X
XI
XII
VIII
V
VIVI
III
IV
I
II
Only First and Second Cranial Nerves originate in Cerebrum
On Old Olympus’ Towering Top A Famous Vocal German Viewed Some Hops.
On Old Olympic Towering Tops A Finn And German Viewed Some Hops
OLd OPie OCcasionally TRies TRIGonometry And Feels VEry GLOomy VAGUe And HYPOactive
Some Say Marry Money, But My Brother Says Big Business Makes Money
Some say my mother bought my brother some bad beer, my, my S= Sensory, M = Motor, B = Both
Mnemonics for Cranial Nerves
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Some Lovers Try Positions That They Can't Handle!!!
Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate
Bonus Mnemonic for MS
Chemicals that run brain 60+ affect memory, learning, relationships Thoughts, Food, Drugs effect brain chemicals
Stored in sacks near synapse at end of axon Electrical charges from cell body free
chemicals, propel them across synapse Special receptors at end of dendrites form to
accept certain neurotransmitters
Neurotransmitters
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Serotonin Aids in smooth transmission
of messages in brain/body Large role in regulating mood,
appetite, memory & learning Lack of serotonin may result
in low self-esteem, depression, aggression
Dopamine Helps information flow to
higher brain levels Key role in regulating
pain/pleasure Melatonin
Related to wake/sleep cycles
Epinephrine Moving body when needs instant
action, - fear/danger Acetylcholine
Enhances memory (chemical responsible for many dreams)
Endorphin (neuropeptide) Body’s natural pain killer -lots of
endorphin can create euphoric feelings
Cortisol (neuropeptide) Released when under stress Can be dangerous at high levels –
interrupts transmission of messages from neuron to neuron
Important Neurotransmitters
Laterality Specific Arteries Site
Must use proximal branch for nerve that does not have separate body part value in ICD-10-PCS
Ex: mandibular nerve is branch of trigeminal nerve, only the trigeminal nerve has a body part value When procedure performed on mandibular nerve, must
assign trigeminal nerve for body part value
Documentation Requirements for Coding
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Alphabetical listing of body parts shows PCS Description to use with Table Rows when constructing a ICD-10-PCS code
Artery/Nerve Families, etc. (ICD-10-PCS Body Key)
Anatomical Term PCS Description
Caroticotympanic artery Internal Carotid Artery, R/L
Carotid sinus nerve Glossopharyngeal nerve
Leptomeninges Cerebral/Spinal meninges
Mammillary body Hypothalamus
Middle cerebral artery Intracranial artery
QUESTIONS?
http://www.nimh.nih.gov/health/educational-resources/brain-basics/nimh-brain-basics.pdf
Homework
1. Review Powerpoint before taking post-test
2. Go online to at least two of the Resource sites with Games and/or Quizzes and see what A&P about the brain you have learned/reinforced
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Amar AP, Weiss MH. Pituitary Gland Anatomy and Physiology. Abstract. Neurosurg Clin N Am. 2003 Jan;14(1):11-23, v. http://www.ncbi.nlm.nih.gov/pubmed/12690976?report=abstract
Anatomy of the Brain. American Association of Neurological Surgeons. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments
/Anatomy%20of%20the%20Brain.aspx
Anatomy of the Brain and Skull. Philips Medical Games. http://www.theonlinelearningcenter.com/free-medical-games/AP001/anatomy-
physiology-brain-skull.html
Brain Anatomy. Game. http://www.purposegames.com/game/brain-anatomy-quiz
Brain Anatomy and Functions. Tutorial and Quiz. Getbodysmart. http://www.getbodysmart.com/ap/nervoussystem/cns/brain/menu/menu.html
Resources
Cliff Notes. Anatomy & Physiology. Well-organized and includes quizzes. http://www.cliffsnotes.com/study_guide/Anatomy-
Physiology.topicArticleId-277792.html Cranial Nerves: Review Info. Quizzes.
Cranial Nerves: Review Info http://www.gwc.maricopa.edu/class/bio201/cn/cranial.htm
Cranial Nerves Dirty Mnemonic Tutorial. Video. http://www.youtube.com/watch?v=LTUHTxWG6EQ
Crisan, E. Ventricles of the Brain. Jun 27, 2011. Medscape Reference. http://emedicine.medscape.com/article/1923254-overview
Resources
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Division of Disability and Aging Services. Vermont. Brain 101: The neurotypicalbrain. http://www.ddas.vermont.gov/ddas-policies/policies-tbi/policies-tbi-
documents/tbi-trng-modules-workbks/training-module-1-brain-101 Gray, H. Anatomy of the Human Body. 1918.
http://www.bartleby.com/107/ Human Brain Anatomy. Study and Quiz Modules.
http://www.psych.ualberta.ca/~ITL/brain/ Interactive Tour of the Brain. National Brain Tumor Society.
http://www.braintumor.org/patients-family-friends/about-brain-tumors/index8.html
Intro to the Brain. ITS. San Diego State Univ. Includes Test. http://its.sdsu.edu/multimedia/mathison/index.htm
Kean, M. L. The Brain. Tutorial. http://www-
rohan.sdsu.edu/~gawron/intro/course_core/lectures/aphasia_cases_slides.html
Resources
Match a Brain. Game. http://www.anatomyarcade.com/games/matchingGames/MatchABrain/
matchABrain.html McGuire, N. ICD10 Session 11 Chapter 6. Codapedia. 32 Minute video.
http://codapedia.com/article_548_ICD-10-Session-11-Chapter-Six-Diseases-of-the-Nervous-System.cfm
Neuron-Glia Interactions in Nerve Development and Disease. http://www.ngidd.eu/public/index.html
NIMH. Brain Basics. http://www.nimh.nih.gov/health/educational-resources/brain-
basics/brain-basics.shtml Pineal Gland. Encyclopedia Brittanica.
http://www.britannica.com/EBchecked/topic/460967/pineal-gland
Resources
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Secret Life of the Brain. PBS. 3-D brain anatomy. http://www.pbs.org/wnet/brain/history/index.html
Tamarkin, D. A. Glia. http://faculty.stcc.edu/AandP/AP/AP1pages/nervssys/unit10/glia.htm
University of Bristol. How the Brain Works. Video, 6+ min. 2010. http://www.youtube.com/watch?v=9UukcdU258A
WebMD. Brain & Nervous System Health Center. http://www.webmd.com/brain/default.htm
WebMD. Medical References Related to Brain & Nervous System. http://www.webmd.com/brain/medical-reference-index
Wernicke area. Encyclopedia Britannica. Videos, Animations. http://www.britannica.com/EBchecked/topic/639879/Wernicke-area
Resources