1
Q
What are the conductive causes of hearing loss?
A
o Wax production
o Eardrum perforation
o Chronic otitis media with effusion
o Nasopharyngeal tumours blocking eustachian tube
o Otosclerosis
o Eustachian tube dysfunction
o Cholesteatoma
o Exostoses
2
Q
Sensorineural causes of hearing loss
A
o Presbyacusis
o Idiopathic hearing loss
o Noise exposure
o Inflammatory diseases
o Ototoxicity from drugs (loop diuretics, gentamicin, chemotherapy)
o Acoustic tumours (vestibular schwannoma)
o Meniere’s disease
o Labyrinthitis
o Neurological conditions (stroke, multiple sclerosis, brain tumours)
o Infections (meningitis)
3
Q
What is weber’s test?
A
Tuning fork in middle of patient’s forehead
o Conductive deafness = louder in affected ear
o Unilateral sensorineural deafness = louder in normal ear
o Symmetrical hearing loss = heard in middle
4
Q
What is Rinne’s test?
A
o Normal sound louder at ear, air conduction is better than bone conduction, also in sensorineural deafness (POSITIVE)
o Abnormal sound louder on mastoid process, bone conduction better than air conduction (NEGATIVE)
5
Q
What is presbycusis?
A
Age related hearing loss
6
Q
Risk factors for presbycusis
A
- Male
- Family history
- Loud noise exposure
- Diabetes
- Hypertension
- Ototoxic medications salicylates, chemo
- Smoking
- Stress
7
Q
Presentation of presbycusis
A
- Gradual symmetrical hearing loss
- Loss of high-pitched sounds can make speech difficult to hear and understand
- Patients noticed not paying attention or missing details of conversations
- Need for increased volume on TV/radio
- Loss of directionality of sound
- Concerns about dementia
- Hyperacusis heighted sensitivity to certain frequencies (less common)
- Tinnitus (uncommon)
8
Q
Investigations for presbycusis
A
- Audiogram = sounds have to be made louder before they are heard in high frequencies = bilateral sensorineural pattern hearing loss
- Weber’s test = bone conduction localisation to one side if sensorineural hearing loss not completely bilateral
9
Q
Management of presbycusis
A
- Cannot be reversed
- Optimising environment
- Hearing aids may be prescribed if significant
- Cochlear implants
10
Q
Prevention of presbycusis
A
Hearing protection should be worn in environments where there is exposure to loud noises for prolonged periods (woodworking, construction)
11
Q
Presentation of impacted ear wax
A
- feeling of fullness in ear
- Conductive hearing loss
- Tinnitus
- Can cause pain if excess or has been impacted by cotton buds
- Otoscope = wax cover tympanic membrane
12
Q
Management of impacted ear wax
A
- No intervention needed in most cases
- Avoid inserted cotton buds
- Olive oil or bicarbonate 5% drops for 2-3 days
- Irrigation/syringing (after softening)
13
Q
Management of foreign bodies in the ear
A
- Soft foreign bodies may be grasped with crocodile forceps
- Solid foreign bodies passing a wax hook or Jobson-Horne probe beyond object and pulling it back towards you
- Irrigation (as long as not trauma to ear canal or ear drum
- Insects drowned and floated out with oil
- Never probe blind
14
Q
Cause of auditory exostosis (surfer’s ear)
A
Local bone hypertrophy from cold exposure
15
Q
Presentation of auditory exostosis
A
- Smooth, multiple, bilateral swellings of bony canals
- Symptomless as long as lumen of EAC is sufficient for sound conduction
- If hinder passage of wax can cause clogging and conductive hearing loss
16
Q
Causes of sudden onset sensorineural hearing loss
A
- Idiopathic
- Vestibular schwannoma
- Infection (meningitis, HIV, mumps)
- Menieres disease
- Ototoxic medications
- Multiple sclerosis
- Migraine
- Stroke
- Cogan’s syndrome
17
Q
Management of sudden onset sensorineural hearing loss
A
- High dose steroids
- Urgent referral to ENT within 24 hrs of presenting with sudden sensorineural hearing loss within 30 days of onset
18
Q
What is otosclerosis
A
Autosomal dominant,
replacement of normal bone by vascular spongy bone
19
Q
Presentation of otosclerosis
A
- Conductive hearing loss (typically lower-pitched sounds)
- Tinnitus
- Tympanic membrane flamingo tinge cause by hyperaemia
20
Q
Management of otosclerosis
A
- Conservative hearing aids
- Surgical (stapedectomy or stapedotomy)
21
Q
Risk factors for Eustachian tube dysfunction
A
- URTI
- Allergies (hayfever)
- Smoking
22
Q
Presentation of eustachian tube dysfunction
A
- Reduced or altered hearing
- Popping noises or sensations in ear
- Fullness sensation in ear
- Pain or discomfort
- Tinnitus
- Symptoms worse when external air pressure changes (flying, climbing a mountain, scuba diving)
23
Q
Management of eustachian tube dysfunction
A
- Conservative waiting for it to resolve spontaneously
- Valsalva manoeuvre
- Decongestant nasal sprays
- Antihistamines and steroid nasal spray (allergies/rhinitis)
- Surgery
o Adenoidectomy
o Grommets
o Balloon dilatation Eustachian tuboplasty
24
Q
Secondary causes of tinnitus
A
o Impacted ear wax
o Ear infection
o Meniere’s disease
o Noise exposure
o Medications = loop diuretics, gentamicin, chemotherapy drugs (cisplatin)
o Acoustic neuroma
o Multiple sclerosis
o Depression
o Anaemia
o Diabetes
o Hypothyroidism or hyperthyroidism
o Hyperlipidaemia
25
Objective tinnitus causes
o Carotid artery stenosis
o Aortic stenosis
o Arteriovenous malformations
o Eustachian tube dysfunction
26
Tinnitus Red Flags
- Unilateral tinnitus
- Pulsatile tinnitus
- Hyperacusis = hypersensitivity, pain or distress with environmental sounds
- Associated unilateral hearing loss
- Associated vertigo or dizziness
- Headaches or visual symptoms
- Associated neurological symptoms or signs = facial nerve palsy or signs of stroke
- Suicidal ideation related to tinnitus
27
Risk factors for otitis externa
- Excess canal moisture (swimming)
- Trauma from fingernails or cotton buds
- Absence of wax from self-cleaning
- Eczema
28
Causes of otitis externa
- Pseduomonas aeruginosa
- Staph aureus
- E.coli
29
Presentation of otitis externa
- Discharge
- Itch
- Pain
- Tenderness when moving jaw/ear
- Feeling of fullness in ear
- Tragal tenderness due to acute inflammation of skin of meatus
- Mild scaly skin with some erythema, normal diameter of EAC
- Moderate painful ear, narrowed external auditory canal, malodourous creamy discharge
- Severe EAC completely occluded
30
Management of otitis externa
- General Cleaning and topical steroids/antibiotics
- Mild
o Cleaning of EAC increases penetration of drops and reduces bacterial load
o Gentle syringing or irrigation to remove debris (as long as tympanic membrane intact
o Dry mopping under direct vision using Jobson-Horne probe with small piece of cotton wool on its end
o Microsuction (may need ENT referral)
o Avoid swimming and prevent water entering ear
- Moderate
o Cleaning
o Swab for microscopy
o Prescribe topical antibiotics and steroid drops for 1w
Ciprofloxacin
Chloramphenicol drops
Gentamicin drops (avoid if perforated ear drum due to ototoxicity)
- Severe
o Cleaning, swabs and topical treatment
o Thin ear wick inserted with aluminium acetate few days later meatus will be open enough for microsuction or careful cleansing
o May have persistent unilateral otitis externa in diabetes/immunocompromised
31
Criteria for referral of otitis externa
- Non responsive
- Canal oedematous
- Needs aural toilet
- Suspicion of invasive OE
32
Complications of otitis externa
- Fungal infection post antibiotics
- Malignant OE
33
What is malignant otitis externa?
Aggressive, life-threatening invasive infection of bone of external ear
34
Risk factors for malignant otitis externa
- Diabetes
- Immunocompromised
- Increased age
35
Presentation of malignant otitis externa
- Otitis externa resistant to treatment
- Temporal headaches
- Deep boring night pain
- Otorrhoea
- Possible dysphagia/hoarseness
- Cranial nerve palsies VII, IX, X, XI, XII
- Inferior granulation tissue at bony cartilaginous junction of ear canal
36
Investigation for malignant OE
CT = see extent of disease in skull base
37
Management of malignant OE
- Hospital admission if non-resolving/worsening
- Surgical debridement
- Systemic IV antibiotics high dose ciprofloxacin for 12wks
- Specific immunoglobulins
38
Complications of malignant OE
- Osteomyelitis (base of skull)
- Temporal bone destruction
39
Causes of otitis media
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
40
Presentation of otitis media
- Acute onset
- Recent viral URTI common
- Otalgia
- Fever
- Hearing loss pain subsides
- Ear discharge if tympanic membrane perforates
- Bulging tympanic membrane = loss of light reflex
- Opacification or erythema or tympanic membrane
- Perforation with purulent otorrhoea
- Decreased mobility if using pneumatic otoscope
41
Management of otitis media
- Generally self-limiting and does not require antibiotics
- Simple Analgesia
- Advise parents to seek medical help if symptoms worse or do not improve after 3 days
- Oral Antibiotics (5-7 days amoxicillin)
42
When should antibiotics be prescribed in otitis media?
Symptoms lasting >4 days or not improving
o Systemically unwell but not requiring admission
o Immunocompromise or high risk of complications
o <2yrs with bilateral otitis media
o Otitis media with perforation and/or discharge in canal
43
Complications of otitis media
- Mastoiditis
o IV Coamoxiclavulanic aicd + analgesia
o Urgent referral and surgical drainage
- Meningitis
- Brain abscess
- Facial nerve paralysis
- Hearing loss
- Labyrinths
44
Management of a perforated eardrum
- Conservative = if asymptomatic, reassurance and water precaution advice
- Medical = topical antibiotics drops in patients with intermittent episodes of discharge
- Surgical = myringoplasty if recurrent discharge/ patient wants surgical intervention
45
What is glue ear?
Otitis media with effusion
Presence of fluid in middle ear without symptoms and signs of ear infection
46
Risk factors for glue ear
- More common in children
- Recurrent acute otitis media
- Down syndrome
- Cleft lip children
- Cystic fibrosis
- Allergic rhinitis
47
Presentation of glue ear
- Painless
- Hearing loss (mild)
- Behavioural issues
- Poor speech development
- Variable appearance of tympanic membrane on otoscopy retracted or bulging drum
- Can look dull, grey, yellow, may be bubbles of fluid level
48
Investigations for glue ear
Tympanometry
49
Cause of subperichondrial haematoma
Shear force trauma
50
Management of subperichondrial haematoma
- Drain before cartilaginous necrosis
- Leave drain
- Antibiotics
- Bolster dressing
- Monitor for 24 hrs
51
Complications of subperichondrial haematoma
Cauliflower ear
52
Causes of vertigo
Viral labrinthitis
Vestibular neuronitis
BPPV
Meniere's disease
Vertebrobasilar ischaemia
Acoustic neuroma
Posterior circulation stroke
TRauma
Multiple sclerosis
Ototoxicity drugs (gentamicin)
53
Epidemiology of Meniere's disease
Middle aged adults
54
Presentation of meniere's disease
- Recurrent episodes of vertigo, tinnitus, sensorineural hearing loss
o Vertigo lasts 20 mins to several hrs before settling
o Episodes come in clusters over several weeks
- Sensation of aural fullness or pressure now recognised as being common
- Unexplained falls without loss of consciousness
- Imbalance
- Spontaneous unidirectional Nystagmus,
- positive Romberg test
- Symptoms typically unilateral
55
Management of Meniere's disease
- ENT assessment
- Inform DVLA cease driving until satisfactory control of symptoms achieved
- Acute attacks buccal or IM prochlorperazine, antihistamines
- Admission sometimes required
56
Prevention of Meniere's disease
Betahistine
Vestibular rehabilitation exercises
57
Epidemiology of Benign Paroxysmal Postitional Vertigo
Older adults
58
Risk factors for BPPV
Viral infection
Head trauma
Ageing
59
Presentation of BPPV
- Head movements can trigger attacks of vertigo, Often turning over in bed
- Vertigo settles in 20-60s
- Patients asymptomatic between attacks
60
Investigation of BPPV
Dix-Hallpike Manoeuvre
61
Management of BPPV
- Epley maneouvre
- Brandt-Daroff Exercises
62
PResentation of vestibular neuronitis
- Acute onset of vertigo
- History of recent viral URTI
- Nausea and vomiting
- Balance problems
- No hearing loss
63
Investigation of vestibular neuronitis
Head impulse test
64
Management of vestibular neuronitis
- Sx Mx for up to 3 days = prochlorperazine, antihistamines
- May require admission if severely dehydrated
- Referral if Sx do not improve after 1 week or resolve after 6 weeks
o Vestibular rehabilitation therapy
65
What is Labyrinthitis
Inflammation of bony labyrinth of inner ear including semiciruclar canals, vestibule and cochlea
66
Triggers of labyrinthitis
- Viral URTI
- Otitis media
- Meningitis
67
Presentation of labyrinthitis
- Acute onset vertigo
- Hearing loss
- Tinnitus
68
Investigation of labyrinthitis
Head impulse test
69
Management of labyrinthitis
- Sx control prochlorperazine, antihistamines
- Abx if bacterial labyrinthitis
70
What is an acoustic neuroma
Benign tumours of Schwann cells surrounding auditory nerve that innervates the inner ear
71
Associations of acoustic neuromas
If bilateral, neurofibromatosis type 2
72
Presentation of acoustic neuroma
- Typically aged 40-60
- Gradual onset
- Unilateral sensorineural hearing loss
- Unilateral tinnitus
- Dizziness or imbalance
- Sensation of fullness in ear
- Facial nerve palsy
73
Investigation of acoustic neuroma
- Audiometry sensorineural hearing loss
- MRI of cerebellopontine angle
74
Management of acoustic neuroma
- Urgent referral to ENT specialist
- Conservative monitoring
- Surgery to remove tumour
- Radiotherapy to reduce growth
75
Complications of treatment of acoustic neuroma
- Vestibulocochlear nerve injury with permanent hearing loss or dizziness
- Facial nerve injury with facial weakness
76
What is cholesteatoma?
Abnormal collection of squamous epithelial cells in middle ear
77
Presentation of cholesteatoma
- Foul discharge from ear
- Unilateral conductive hearing loss
- Infection
- Pain
- Vertigo
- Facial nerve palsy
78
Investigations of cholesteatoma
- Otoscopy abnormal build-up of whitish debris or crust in upper tympanic membrane
- CT /MRI head
79
Triggers of epistaxis
- Nose picking
- URTIs Colds, Sinusitis, Vigorous nose-blowing
- Trauma
- Changes in weather
- Coagulation disorders thrombocytopenia or Von Willebrand disease
- Anticoagulant medication aspirin, DOACs, warfarin
- Snorting cocaine
- Tumours SCC
80
Presentation of epistaxis
- Bleeding usually unilateral
- May be vomiting blood if swallows blood during nose bleed
81
Where does bleeding usually originate from in nosebleeds?
Klesselbach's plexus / Little's area
82
Management of epistaxis
- General advice
o Sit up and tilt head forwards
o Squeeze soft part of nostrils together for 10-15 mins
o Spit out any blood in mouth rather than swallowing
- If bleeding does not stop, nosebleed is severe, bleeding from both nostrils, haemodynamically unstable
o Hospital admission
o IV access and may require cross match blood
o Nasal cautery using silver nitrate sticks if source of bleed visible
o Nasal packing using nasal tampons or inflatable packs if source of blood not visible
o Sphenoplatine ligation in theatre
- Medication
o Naseptin nasal cream (chlorhexidine and neomycin) 4x daily for 10 days
83
Complications of epistaxis
- Risk of aspiration
- Septal haematoma surgical drainage by ENT
84
Risk factors of sinusitis
- Asthma
- Infection (viral URTI)
- Allergies (hayfever)
- Obstruction of drainage (foreign body, trauma, polyps)
- Smoking
85
Presentation of sinusitis
- Acute or chronic
- Nasal congestion
- Nasal discharge
- Facial pain or headache
- Facial pressure
- Facial swelling over affected areas
- Loss of smell
- Tenderness to palpation of affected areas
- Inflammation and oedema of nasal mucosa
- Discharge
- Fever
- Other signs of systemic infection = tachycardia
- Nasal polyps (chronic)
86
Management of sinusitis
- Most cases are viral and will resolve in 2-3 wks
- If Sx not improving after 10 days
o High dose steroid nasal spray for 14 days
o Delayed Abx prescription if worsening or not improving within 7 days
- Chronic sinusitis
o Saline nasal irrigation
o Steroid nasal sprays or drops
o Functional endoscopic sinus surgery
87
Complications of sinusitis
- Periorbital/Orbital cellulitis = Systemic broad-spec antibiotics, otrivine, analgesia
- Subperiosteal/ intraorbital abscess
- Cavernous sinus thrombosis
- Pott’s puffy tumour
- Meningitis
- Brain abscess
88
Associations of nasal polyps
- Chronic rhinitis or sinusitis
- Asthma
- Samter’s triad nasal polyps, asthma and aspiring intolerance/allergy
- Cystic fibrosis
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
89
Presentation of nasal polyps
- Usually bilateral (unilateral is red flag)
- Chronic rhinosinusitis
- Difficulty breathing through nose
- Snoring
- Nasal discharge
- Loss of sense of smell
90
Investigations of nasal polyps
- Nasal speculum round pale grey/yellow growths on mucosal wall
- Otoscope with large speculum attached
- Nasal endoscopy (specialist)
91
Management of nasal polyps
- Intranasal topical steroid drops or spray
- Surgery
o Intranasal polypectomy
o Endoscopic nasal polypectomy
92
Management of allergic rhinitis
- Allergen avoidance
- Oral or intranasal antihistamines
o Non-sedating certirizine, loratadine, fexofenadine
o Sedating chlorphenamine, promethazine
- Intranasal corticosteroids fluticasone, mometasone
- Short course oral corticosteroids
- Short courses of topical nasal decongestants (oxymetazoline)
o Increasing doses required to achieve same effect tachyphylaxis
o Rebound hypertrophy of nasal mucosa may occur upon withdrawal
- Referral to immunologist
93
Causes of tonsillitis
- Viral infection
- Group A strep
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
94
Presentation of tonsillitis
- Sore throat
- Fever (>38)
- Pain on swallowing
- Red, inflamed and enlarged tonsils ± exudates
- Anterior cervical lymphadenopathy
95
Centor criteria for tonsillitis
o Fever over 38
o Tonsillar exudates
o Absence of cough
o Tender anterior cervical lymph nodes
Score of 3+ offer Abx
96
FeverPAIN score for tonsillitis
o Fever during previous 24 hrs
o Purulence
o Attended within 3 days of onset of Sx
o Inflamed tonsils
o No cough or coryza
2-3 delayed abx, 4+ give abx
97
Management of tonsillitis
Safety netting advice
o Simple analgesia
o Return if pain not settled after 3 days or fever >38.3
- Penicillin V for 10 days if centor >3 or feverPAIN >4
o Or if at risk = young infants, immunocompromised patients, significant co-morbidity, history of rheumatic fever
o Delayed prescriptions can be considered
o Clarithromycin if penicillin allergy
98
When to consider admission for tonsillitis?
Consider admission if patient is:
Immunocompromised
Systemically unwell
Dehydrated
Stridor
Respiratory distress
Evidence or peritonsillar abscess or cellulitis
99
Complications of tonsillitis
- Peritonsillar abscess (quinsy)
- Otitis media
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
100
What is a peritonsillar abscess/quinsy?
Cellulitis of space behind tonsillar capsule extending onto soft palate leading to abscess
101
Causes of a quinsy
- Streptococcus pyogenes
- Staph aureus
- Haemophilus influenzae
- Anaerobes
102
Presentation of a quinsy
- Severe throat and neck pain, which lateralises to one side
- Painful swallowing
- Fever
- Referred ear pain
- Swollen tender lymph nodes
- Deviation of uvula to unaffected side
- Trismus (difficulty opening mouth)
- Reduced neck mobility
- Change in voice due to pharyngeal swelling (hot potato voice)
- Swelling and erythema in area beside tonsils
103
Management of a quinsy
- Urgent review by ENT
- Needle aspiration or surgical incision and drainage
- IV Abx (co-amoxiclav)
- Tonsillectomy considered to prevent recurrence
- Sometimes dexamethasone to reduce inflammation
104
Indications for a tonsillectomy
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing or snoring
105
Complications of a tonsillectomy
- Sore throat where tonsillar tissue removed
- Damage to teeth
- Infection
- Post-tonsillectomy bleeding
o Encourage spit blood rather than swallow
o IV fluids
o Severe or airway compromise intubation and return to theatre
o Less severe bleeds hydrogen peroxide, topical adrenalin soaked swab
- Risks associated with general anaesthetic
106
Causes of neck lumps
- Normal structures = bony prominence
- Skin abscess
- Lymphadenopathy
- Tumour (SCC or sarcoma)
- Lipoma
- Goitre or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma
- Thyroglossal cysts
- Branchial cysts
- Young children cystic hygromas, dermoid cysts, haemangiomas, venous malformation
107
Red flags of neck lumps
- Unexplained neck lump in someone aged 45+
- Persistent unexplained neck lump at any age
108
Lymph node red flags
- Unexplained
- Persistently enlarged (>3cm)
- Abnormal shape
- Hard or rubbery
- Non-tender
- Tethered or fixed to skin or underlying tissues
- Associated Sx night sweats, weight loss, fatigue, fevers
109
Investigations of Red Flags
- Urgent US in patients with lump growing in size
o Within 2wks if 25+ or within 48 hrs if <25
- FBC and blood film leukaemia and infection
- HIV test
- Monospot test or EBV infectious mononucleosis
- TFTs goitre or thyroid nodules
- ANA SLE
- Lactate dehydrogenase Hodgkin’s lymphoma
- CT/MRI
- Nuclear medicine scan
- Biopsy
o Fine needle aspiration cytology
o Core biopsy
o Incision biopsy
o Removal of lump
110
Head and neck cancer includes:
1. Oral cavity cancers
2. Cancers of pharynx (oropharynx, hypopharynx, nasopharynx)
3. Cancer of larynx
111
Risk factors for head and neck cancer
- Smoking
- Chewing tobacco
- Chewing betel quid
- Alcohol
- HPV (esp 16)
- EBV infection
112
Features of head and neck cancer
- Neck lump
- Hoarseness
- Persistent sore throat
- Persistent mouth ulcer
113
Red flags for head and neck cancer
- Lump in mouth or on lip
- Unexplained ulceration in mouth lasting >3wks
- Erythroplakia or erythroleukoplakia
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
114
Referral criteria for head and neck cancer
- Laryngeal cancer
o People aged >45 with persistent unexplained hoarseness or unexplained lump in neck
- Oral cancer
o Unexplained ulceration in oral cavity lasting more than 3 weeks
o Persistent and unexplained lump in neck
o Lump on lip or in oral cavity
o Red/ red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia
- Thyroid cancer
o Unexplained thyroid lump
115
Management of head and neck cancer
- MDT
- Options chemo, radiotherapy, surgery, targeted cancer drugs, palliative care
116
Risk factors for parotitis
Dehydration
Immunosuppressed
117
Management of parotitis
- Metronidazole, flucloxacillin
- Hydrate
- Sialogogues (fresh pineapple)
- Analgesia
Finals
flashcards
Decks in class (23)
# Cards
-
Breast33
-
Cardiology120
-
Dermatology93
-
Emergency Medicine89
-
Endocrinology88
-
ENT117
-
Gastroenterology107
-
Geriatrics and palliative care74
-
Haematology86
-
Neurology133
-
Obstetrics201
-
Gynaecology149
-
Ophthalmology112
-
Paediatrics202
-
Renal143
-
Respiratory98
-
Sexual health109
-
Liver53
-
Infectious diseases87
-
Rheumatology104
-
Orthopaedics79
-
General Surgery101
-
Psychiatry171
