Hard Stuff/High Yield Flashcards

Question

Define impact seizure, and its potential clinical significance

Answer 1

- Brief self-resolving seizure after traumatic impact, w/ quick return to neurologic baseline - Occurrence may prolong recovery of concussion

Answer 2

Anterior Cord Hyperflexion or Ischemia Motor: Bilateral paralysis Sensory: Intact proprioception/vibration, Bilateral pain/temp loss Central Cord Hyperextension (lig. flavum buckles in) Motor: UE loss > LE loss Sensory: Intact proprioception/vibration, Pain/temp loss in distribution of one or several adjacent dermatomes at site of lesion Brown-Sequard Hemisection (penetrating trauma) Motor: Ipsilateral hemiparesis Sensory: Ipsilateral proprioception/vibration loss, Contralateral pain/temp loss

Answer 3

Sepsis & Bacteremia (gram pos & neg) Crush injury Complicated surgery Severe head injury Acute Leukemia Brain tumours Ovarian tumour Pancreatic cancer Amniotic fluid embolism Abruptio placentae HELLP syndrome Acute Fatty Liver of Pregnancy Eclampsia Septic abortion Amphetamine overdose Abdominal aortic aneurysm Peritoneovenous shunt Acute hemolytic transfusion reaction (ABO incompatibility) Severe Malaria Snake & Viper venoms Fulminant Hepatic Failure Reperfusion after Liver Transplant Catastrophic Antiphospholipid Syndrome Heat Stroke Burns Purpura Fulminans Protein C Deficiency Pulmonary Embolism ECMO

Answer 4

Treat underlying cause PLTs FFP Cryoprecipitate Supportive care +/- Heparin if thrombosis is primary issue TXA CONTRAINDICATED

Answer 5

Extremes of age Loss of consciousness

Answer 6

*Best if started w/in 6 hours of exposure COHb >25% w/out clinical findings COHb >15% in Children & Pregnancy (or signs of fetal distress) Unconsicousness at scene or Syncope reported Persistent Altered LoC Focal Neuro Deficits CV Instability (ischemia/arrhythmia) pH <7.25 Evidence of End-Organ Ischemia (Resp failure, ECG changes, High Trop) Prolonged CO exposure w/ minor clinical findings

Answer 7

Hyperglycemia >11 mmol/L Serum ketosis BHB ≥3 mmol/L) and/or Ketonuria (mod-large) Acidosis pH <7.3 or HCO3 <18 mmol/L w/ AG >12

Answer 8

- New-onset DM - Longer duration of symptoms - Young <5yrs - Lab evidence of severe dehydration (high Ur, HCT) - Severe acidosis (pH <7.1 or HCO3 <5) - Hypocapnia (pCO2 <21) - Insulin tx in 1st hr mgmt and/or insulin bolus - Rapid administration of Hypotonic IV fluids - Use of NaHCO3 - Failure of measured Na to rise during tx

Answer 9

- aLoC, especially after initial improvement - HA (severe, worsening, or starts after tx onset) - Irritability in young children - Vomiting - Urinary incontinence - HTN (may be diastolic) - Bradycardia (unrelated to sleep or improved vasc vol) - Respiratory depression or O2 desat - Cranial nerve palsies

Answer 10

Correct volume depletion Correct acidosis Stop ketogenesis Correct electrolyte imbalances Restore normal blood glucose Monitor for and prevent complications (CI, hypoglycemia, symptomatic electrolyte deficiencies, hyperchloremic acidosis) Manage coexistent illness or precipitating factors

Answer 11

- Minimizing movement & agitation - HOB >30 - Maintain head in midline position - Administering isotonic fluids (change to isotonic if using 0.45% NaCl) - Reduce rate to 75% of calculated hourly rate if sufficient to maintain adequate perfusion. - 3% NS @5 mL/kg over 10-15 mins (max 250mL) OR Mannitol 1g/kg (max 100g) over 15-20 mins - Urgent consultation w/ PICU

Answer 12

SADPERSONS Sex (Male) Age (Older) *Depression Previous attempts EtOH/Drugs *Rational thinking loss (Psychosis) Separated/Divorced *Organized attempt (Access to lethal weapon) No social supports *Suicidal ideation * = highest impact

Answer 13

*Any point means NOT low risk, cannot r/o, need other risk score "HAD CLOTS" Hormone use Age >50 DVT/PE hx Coughing blood Leg swelling U/L O2 <95% Tachycardia HR >100 Surgery/Trauma <4wk

Answer 14

* basically anything that would reasonably require a pt to be admitted, or cause concern for their safety at home * like PERC, having 1pt means have to stay in hospital Hemodynamically unstable (HR >100, SBP <100, need ICU) Thrombolysis or Embolectomy needed Active bleeding or high risk for bleeding (recent CVA, GIB, Sx, PLT<75, uncontrolled HTN) >24hr on suppO2 req'd for SaO2 >90% PE dx'd while on AC >24hr severe pain needing IV analgesia Medical or Social reason for admission >24 hr (infxn, cancer, no support) Cr clearance <30 mL/min Severe liver impairment Pregnant Documented Hx of HIT

Answer 15

* validated in pregnancy * if pregnant w/ signs of DVT, get U/S first. If abnormal = tx w/ AC. If U/S normal, move to usual 3 Q's 3 Q's: 1. PE most likely dx? 2. Clinical signs of DVT? 3. Hemoptysis? Score = 0, use D-Dimer cutoff of 1000 FEU Score 1+, use D-Dimer cutoff of 500 FEU >500 or >1000 gets CTPA <500 or <1000 gets R/O PE

Answer 16

Valvular Afib NVAF <12hr & recent TIA/CVA NVAF 12-48hr & CHADS2 2+ NVAF >48hr

Answer 17

Hypertensive heart disease Cardiomyopathy Ischemic heart disease Valvular disease (especially mitral) Congestive heart failure Pericarditis Hyperthyroidism Sick sinus syndrome Myocardial contusion Acute ethanol intoxication (holiday heart syndrome) Idiopathic Cardiac surgery Catecholamine excess Pulmonary embolism Sepsis Cardiac tamponade Accessory pathway (Wolff-Parkinson-White) syndrome

Answer 18

Measles Ebola Rubella Strep TSS RMSF VZV EBV West Nile Zika Chikungunya African sleeping sickness Serum sickness Parvovirus B19 Roseola (HHV6) HIV Scarlet fever Mycoplasma pneumoniae Juevenile idiopathic arthritis Still's disease Acute cutaneous lupus erythematosus SJS/TEN Fixed drug eruption DRESS Drug eruption Kawasaki Enterovirus (Coxsackie HFM)

Answer 19

Type I: Minimal or no displacement *splint/cast for comfort Type II: Displacement of the fracture but with the posterior cortex intact --> IIA: No rotational component --> IIB: Some rotational component *reduction, casting, monitor for compartment syndrome *percutaneous pinning Type III: Displaced, no cortical contact, periosteal contact --> IIIA: No rotation of the fracture --> IIIB: Rotation present *sedation+reduction *posterior splint *percutaneous pinning Type IV: Complete disruption/displacement *operative mgmt

Answer 20

Functional dependence or disability Poor physical health Cognitive impairment/dementia Poor mental health Low income/SES Social isolation/low social support Hx of family violence Previous traumatic event exposure Substance abuse

Answer 21

Mental illness Substance abuse Caregiver stress Hx of family violence Financial dependence on older adult

Answer 22

Poor living conditions according to paramedics or others Unexplained injuries Hx of frequent injuries Delay between onset of medical illness or injury and seeking of medical attention Recurrent visits to ED for similar injuries Using multiple physicians and EDs for care rather than one primary care physician (“doctor hopping or shopping”) Noncompliance w/ medications, appointments, or physician directions Patient or caregiver reluctant to answer questions Strained patient/caregiver interaction Inconsistent history of injury mechanism between the patient and caregiver Elderly patient referred to as “accident prone” Caregiver not able to give details of the patient’s medical history or routine medications Caregiver answers the questions regarding the patient Abandonment of the patient in the ED by the caregiver

Answer 23

- Acute MI - Acute pericarditis - LVH - LV aneurysm - Ventricular paced rhythm - Benign early repolarization - Normal variant - Osborn J wave of hypothermia - Hyperkalemia - Brugada syndrome - PE - Acute cerebral hemorrhage - Prinzmetal angina - Takotsubo cardiomyopathy - Postelectrical cardioversion

Answer 24

Bleeding: - Major vascular injury - Coagulation disorder - Anticoagulant therapy Reperfusion: - Arterial bypass grafting - Embolectomy - Ergotamine ingestion - Cardiac catheterization - Lying on limb Trauma: - Fracture - Seizure convulsions Intensive muscle use: - Exercise - Seizures - Eclampsia - Tetany - Muscle hypertrophy Burns: - Thermal - Electrical Intraarterial drug injection Interstitial infiltration Leaky dialysis cannula Venous obstructions: - Phlegmasia cerulea dolens - Ill-fitting leg brace - Tight cast - Venous ligation Procedures/Surgery: - ORIFs - Excessive traction on fractured limbs - Closed fascial defects Nephrotic syndrome Popliteal cyst

Answer 25

ANTERIOR Muscles: - tibialis anterior - long toe extensors Vessels: - anterior tibial artery Nerve: - deep peroneal nerve = sensation to first web space of foot LATERAL Muscles: - peroneus longus - peroneus brevis Nerve: - superficial peroneal nerve = sensation to dorsum of foot SUPERFICIAL POSTERIOR Muscles: - gastrocnemius - plantaris - soleus Nerve: - sural nerve = sensation lateral side of foot & distal calf DEEP POSTERIOR Muscle: - tibialis posterior - long toe flexors Vessels: - posterior tibial artery - peroneal artery Nerve: - tibial nerve = sensation to plantar aspect of foot

Answer 26

1) Positive BCx = 2 sets (+) with typical pathogens: - Staphylococcus aureus - Viridans streptococci species of Streptococcus bovis - Enterococcus species - HACEK group OR = Persistent (+) BCx with typical organism for IE OR = 1x BCx (+) or Serology (+) for Coxielli burnetii 2) Echo evidence of Endocardial Involvement - Pendulum-like vegetation on valve endocardium - Paravalvular abscess - Prosthetic valve dehiscence - New valvular regurgitation

Answer 27

1) Predisposition = predisposing heart condition or IVDU 2) Fever >38°C 3) Vascular phenomena - arterial emboli - septic pulmonary infarcts - mycotic aneurysm - conjunctival hemorrhages - Janeway lesions 4) Immunologic phenomena - glomerulonephritis - Osler’s nodes - Roth’s spots - (+) Rheumatoid Factor 5) Microbiologic evidence = (+) BCx not meeting Major Criteria 6) Echo findings = consistent w/ IE but do not meet Major Criteria

Answer 28

Type A: --> Stable, posterior arch intact - Avulsion fractures - Isolated iliac wing fracture - Pubic rami fractures - Minimally displaced ring fracture - Transverse fractures of the sacrum or coccyx Type B: --> Partially stable, incomplete disruption of the posterior arch - Rotationally unstable - Vertically stable - 2/2 AP injuries = open-book fractures - 2/2 Lateral compression injuries - Unilateral or Bilateral Type C: --> Unstable, complete disruption of the posterior arch - Rotationally & Vertically unstable - Iliac, Sacroiliac, and Vertical sacral injuries - 2/2 Vertical shearing forces - Unilateral or Bilateral

Answer 29

AP Compression: I. Symphysis diastasis <2.5 cm II. Symphysis diastasis >2.5 cm = Rotational instability - Sacrospinous + Anterior sacroiliac ligament disruption III. Symphysis diastasis >2.5 cm = Complete Rotational & Vertical instability - Complete disruption of Anterior + Posterior sacroiliac ligament Lateral Compression w Pubic Rami #s: I. Sacral crush injury on ipsilateral side II. Sacral crush injury with disruption of Posterior sacroiliac ligaments = Rotational instability - Iliac wing fracture may be present (crescent fracture) III. Severe internal rotation of ipsilateral hemipelvis with external rotation of contralateral side = Rotational instability - "Windswept" pelvis Vertical Shear: - Vertical displacement of symphysis and sacroiliac joints = Complete Rotational & Vertical instability Combined Mechanisms: Any combination of above

Answer 30

CONJUGATED: Obstructive * Biliary atresia * Bile duct stricture * Choledochal cyst Infectious * Sepsis * TORCH infection Metabolic/Genetic * Cystic fibrosis * Galactosemia * Alpha-1 antitrypsin deficiency UNCONJUGATED: Hemolysis * G6PD * Spherocytosis * Sickle Cell * ABO incompatibility * Cephalohematoma Infectious * Sepsis * TORCH infection Obstructive * Duodenal atresia * Pyloric stenosis Metabolic/Genetic * Galactosemia * Crigler-Nejar syndrome * Gilbert syndrome

Answer 31

- Prematurity - Cephalohematomas - Dehydration - Asphyxia - Significant lethargy - Temperature instability - Sepsis - Acidosis - Hypoalbuminemia <30 - G6PD deficiency - ABO incompatibility - Hereditary spherocytosis

Answer 32

TRANSUDATIVE - CHF - Cirrhosis with ascites - Nephrotic syndrome - Hypoalbuminemia - Myxedema - Peritoneal dialysis - Glomerulonephritis - SVC obstruction - PE EXUDATIVE - Bacterial PNA - Bronchiectasis - Lung abscess - TB - Viral illness - Primary lung cancer - Mesothelioma - Pulmonary or pleural metastases - Lymphoma - RA - SLE - Pancreatitis - Subphrenic abscess - Esophageal rupture - Abdominal surgery - Pulmonary infarction - Uremia - Drug reactions - Postpartum - Chylothorax

Answer 33

* 1-Year risk of major bleeding * Score =/>3 is HIGH RISK HYPERTENSION =1 - uncontrolled, SBP >160 ABNORMAL Renal & Liver Fnc = 1 each - Dialysis, transplant, Cr >200 - Cirrhosis - Bili >2x normal - AST/ALT/ALP >3x normal STROKE = 1 - any hx BLEEDING = 1 - hx major bleed or predisposition to bleed LABILE INR = 1 - unstable or high INR ELDERLY = 1 - age >65yr DRINKS & DRUGS = 1 each - >8 drinks/wk - bleeding meds (anti-PLT, NSAIDs)

Answer 34

EARLY: Infection Bleeding PTX Obstruction Dislodgement/Displacement LATE: Tracheal stenosis Stoma stenosis Fistulization with artery or esophagus Aspiration chronic PNA Dislodgement/Displacement

Answer 35

- Overinflate the tracheostomy cuff - Apply pressure to the suprasternal notch - Intubate from above, with cuff below the stoma, and hyerinflate the cuff - Place finger in stoma and compress the artery along the anterior wall - Pack around the wound with thrombogenic agents - TXA IV

Answer 36

- LeFort 2 or 3 - Complex skull fracture/basilar skull fracture/occipital condyle fracture - Severe TBI (GCS <6) - C-spine fracture, subluxation or ligamentous injury at any level - Near hanging with anoxic brain injury - Seat belt abrasion w/ significant swelling, pain, or altered mental status - TBI w/ thoracic injury - Scalp degloving - Thoracic vascular injury - Blunt cardiac rupture - Upper rib fracture (ribs 1–6)

Answer 37

1) High Risk Mandating Radiography - Age > 65 - Sensory deficit in extremities - Dangerous mechanism of injury: * Fall from ≥ 1 meter or five stairs * Axial load * MVA ≥ 100 km/hr, rollover or ejection * MVC involving recreational vehicle * Bicycle collision 2) Low Risk Factors Allowing for Range of Motion Assessment: - Simple rear-end MVC - Sitting position in ED - Ambulatory at scene - Delayed onset of neck pain - Absence of midline cervical spine tenderness 3) Able to rotate neck 45 degrees to L+R?

Answer 38

Heat stroke/Environmental Bundling Leukemia Lymphoma Neuroblastoma Wilm's tumour Juvenile rhematoid arthritis Post-Vaccination Epilepsy-induced Drug fever IBD HSP SLE Diabetes insipidus Serum sickness Pancreatitis Sarcoiditis Thyrotoxicosis

Answer 39

SSSS TSS TEN/SJS Kawasaki Pemphigus vulgaris Burns Bullous impetigo Scarlet fever

Answer 40

Dull eye ache Chemosis/Conjunctival injection Hypopyon Hazy view of retina Decreased visual acuity

Answer 41

Periorbital (Pre-septal) - Normal VA, non-painful EOM, white sclera - Staph, Strep, H. flu - Amox-Clav x14d Orbital (Post-Septal) - Fever - Ill toxic appearance - Decreased VA, painful limited EOM, red sclera - Proptosis, maybe RAPD - Staph, Strep, H. flu - CT orbit - Pip-Tazo + Vanco IV

Answer 42

--> Benzathine Penicillin 1.2mill units IM x1 (600k units if <28kg) OR --> Penicillin V 500mg PO q8h x 10 days (250mg if <28kg) OR --> Amoxicillin 500mg PO q12h x 10 days OR --> Clarithromycin 250mg PO q12h x 10 days (for pen allergy) For Arthritis: --> ASA 50-100mg/kg/day PO divided q6h (no effect on cardiac) OR --> Hydrocortisone 1-2mg/kg/day PO slowly taper over 2-4 weeks (better for cardiac involvement) Ongoing PPX: --> Penicillin PO or IM qMonthly x 5 years or until adulthood (recurrence rate 8-10% w/in 5 yrs)

Answer 43

Real-time interaction with the prehospital providers via face-to-face or radio/telephone communications

Answer 44

Off-line processes such as: - protocol development - quality improvement - personnel education - prospective + retrospective patient care review

Answer 45

Boyle's Law = volume of a unit of gas is inversely proportional to its pressure - hypoxia at altitude due to fewer molecules of oxygen present per volume of inhaled gas. Dalton's Law = total barometric pressure at any given altitude equals the sum of the partial pressures of gases in the mixture - A decrease in arterial oxygen tension with increasing altitude, resulting in hypoxia.

Answer 46

ADVANTAGE: Transport time <75% ground time Larger service area Avoid common traffic delays and ground obstacles Access usually inaccessible rural & remote locations DISADVANTAGE: Helicopter landing zone requirement more difficult than ground Noise & Vibration Weather limits availability Confined space for transporting pts and equipment, and performing procedures

Answer 47

ADVANTAGES: Increased range & speed Greater patient, crew, and equipment capacity Decreased cabin noise & turbulence Pressurized cabin DISADVANTAGES: Limited to areas w/ airports & runways, & refuelling stations Pts require multiple vehicles for each length of trip to hospital

Answer 48

Distance to closest appropriate facility is too great for safe & timely transport by ground Patient’s clinical condition requires that time spent in transport be as short as possible Patient’s condition is time critical, requiring specific or timely treatment not available at referring hospital Potential for transport delay associated w/ ground transport is likely to worsen patient’s clinical condition. Patient requires critical care life support during transport that was not available from local ground ambulance service Patient is located in area inaccessible to regular ground traffic Local ground units are not available for long-distance transport. Use of local ground transport services would leave local area without adequate EMS coverage. For interfacility medical transport, requesting physician determines need for AMT. For scene medical transport, the requesting authorized out-of-hospital provider determines need for AMT

Answer 49

BLS: 1) Arrest unwitnessed by providers 2) No ROSC in field 3) No AED shocks delivered ALS: 1) Arrest unwitnessed by bystander 2) No bystander CPR 3) Arrest unwitnessed by providers 4) No ROSC in field 5) No AED shocks delivered If ANY of the above absent, transport to ED

Answer 50

FIXED: PROS: - Longer distance - Pressurized - More space - More equipment - Quieter CONS: - Airport - Requires ground crew - No scene landing - Slower - Can’t get remote ROTARY: PROS: - Faster - Scene landing - Remote locations - No need for ground transport CONS: - Loud - Not pressurized - Shorter distances - Less space - Less equipment - Weather restrictions

Answer 51

Yawning Piloerection Pupil dilation Sweating Anxiety or Irritability GI Upset Myalgia or Arthralgia Tremor Pulse Rate Restlessness Runny nose or Tearing

Answer 52

In Hr 1 - max reduction of MAP by 20-25% In Hrs 2-6 - goal BP 160/100 * to prevent acute changes in cerebral blood flow

Answer 53

PERIPHERAL - BPPV - Labyrinthitis - Vestibular neuritis - Meniere’s - AOM - Acoustic neuroma - Perilymph fistula - FB in ear canal - Motion sickness - Ramsay-Hunt syndrome (Herpes zoster oticus) CENTRAL: - Cerebellar Stroke - Tumour - Vestibular migraine - MS - Meningitis - Toxin (EtOH, Ketamine) - Vertebral basilar artery insufficiency - Posttraumatic injury (temporal bone fracture, postconcussive syndrome) - Encephalitis - Brain abscess - Temporal lobe epilepsy - Subclavian steal syndrome - Chiari malformation

Answer 54

Carotid/Femoral pulse not palpable Coronary perfusion pressure <15 mmHg Arterial relaxation (diastolic) pressure <20–25 mm Hg PET CO2 <10mmHg ScvO2 <40%

Answer 55

Infection Management: 1) ABX w/in 1hr for septic shock or high likelihood sepsis 2) Obtain BCx before ABX 3) Use broad-spectrum ABX initially Resuscitation: 4) 30 mL/kg crystalloid bolus w/in 1st 3hr for sepsis-induced hypoperfusion 5) Crystalloids over colloids as 1st-line IVF 6) Vasopressors to maintain MAP ≥65

Answer 56

1. Be at least 18 years old and mentally competent 2. Have a grievous and irremediable medical condition 3. Make a voluntary request for medical assistance in dying, without outside pressure or influence 4. Give informed consent to receive medical assistance in dying

Answer 57

CRITOE = Capitellum = 1 Radial head = 3 Internal (medial) epicondyle = 5 Trochlea = 7 Olecranon = 9 External (lateral) epicondyle = 11

Answer 58

*All types involve pterygoid plate - Injuries can be U/L, B/L or both Type I = horizontal fracture - transverse fracture through maxilla above roots of teeth - maxilla may be mobile when gripping upper teeth Type II = pyramidal fracture - fractures of nasal bridge, maxilla, lacrimal bones, orbital floor, and rim Type III = craniofacial dysjunction - fractures thru nasal bones, medial, inferior & lateral walls of orbit, and zygomatic arches

Answer 59

Malnutrition AUD Chronic Liver Dz Hyperemesis Gravidarum HypoK HypoPO4 Rapid correction of hypoNa

Answer 60

1) Fever >38.9°C 2) Diffuse macular erythroderma 3) Desquamation 1-2wk after illness onset , of palms + soles 4) Hypotension: - SBP <90 (adults) - < 5th%ile by age for children <16 yrs old - orthostatic drop in DBP >15 from lying to sitting - orthostatic syncope - orthostatic dizziness 5) Multisystem involvement +3 of following: - GI: Vomiting or diarrhea at illness onset - MSK: Severe myalgia or CK >2x ULN - Mucous membrane: Vaginal, oropharyngeal, or conjunctival hyperemia - Renal: BUN or Cr >2x ULN, or urinary sediment with pyuria >5 WBC/hpf in absence of UTI - Hepatic: Total bilirubin, AST, and ALT >2x ULN - Heme: PLT <100 - CNS: Disorientation or aLoC w/out focal neurologic signs when fever + hTN are absent

Answer 61

(-) Results of: - BCx, Throat Cx, CSF Cx - Rise in titer to RMSF, leptospirosis, or rubeola

Answer 62

Probable: - 4/5 clinical findings + lab criteria met Confirmed: - 5/5 clinical findings + lab criteria met - unless pt dies before desquamation occurs

Answer 63

1) Hypotension: - SBP <90 (adults) - < 5th%ile by age for children <16 yrs old 2) Multisystem involvement +2 of following: - Renal: Cr >177 for adults, or >2x ULN for age, or >2x above baseline for preexisting CKD pts - Heme: PLT <100, or DIC - Hepatic: Total bilirubin, AST, and ALT >2x ULN, or >2x above baseline for preexisting liver dz pts - ARDS: acute onset of pulmonary infiltrates + hypoxemia in absence of cardiac failure, or by evidence of diffuse capillary leak manifested by acute onset of generalized edema, or pleural or peritoneal effusions w/ hypoalbuminemia - Generalized erythematous maculopapular rash that may desquamate - Soft tissue necrosis, including necrotizing fasciitis, myositis, or gangrene

Answer 64

(+) Isolation of Group A Streptococcus

Answer 65

Probable: - meets clinical findings in absence of another identified cause of illness + (+)Cx of GAS from nonsterile site Confirmed: - meets clinical findings + (+)Cx of GAS from normally sterile site (CSF, joint, pleural, pericardial)

Answer 66

Non-linear skull fractures Long bone in a non-ambulatory child Posterior rib CML Vertebral body Fractures at different stages of healing Multiple fractures Any fracture <1-year-old

Hard Stuff/High Yield Flashcards

(93 cards)