1
Q
What are the features of hypokalaemia?
A
U waves
Small or absent T waves (occasionally inversion)
Prolonged PR interval
ST depression
Long QT interval
In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT!
2
Q
What drugs can cause SIADH?
A
Drugs causing SIADH: ABCD
A nalgesics: opioids, NSAIDs
B arbiturates
C yclophosphamide/ Chlorpromazine/ Carbamazepine
D iuretic (thiazides)
3
Q
Which type of polyp has the greatest risk of malignant transformation?
A
Villous adenoma
4
Q
What are the macroscopic features of chronic inflammation?
A
Ulcers
Fibrosis
Granulomatous process
5
Q
What cells are involved in acute vs chronic inflammation?
A
Acute- neutrophils
Chronic- Macrophages, plasma cells and lymphocytes predominate
6
Q
What is the MOA of Tranexamic acid?
A
Tranexamic acid inhibits plasmin and this prevents fibrin degradation.
7
Q
What is normal ICP?
A
<15mmHg
8
Q
What are the features of Cushing’s reflex?
A
Wide pulse pressure
HTN
Bradycardia
9
Q
What do Absent a waves in JVP represent?
A
Atrial fibrillation
10
Q
What do large a waves in JVP represent?
A
Any cause of right ventricular hypertrophy, tricuspid stenosis
11
Q
What do cannon waves in JVP represent?
A
(extra large a waves) = Complete heart block
12
Q
What do prominent v waves in JVP represent?
A
Tricuspid regurgitation
13
Q
What does a slow y descent in JVP represent?
A
Tricuspid stenosis, right atrial myxoma
14
Q
What does a steep y descent in JVP represent?
A
Right ventricular failure, constrictive pericarditis, tricuspid regurgitation
15
Q
What gland is responsible for the release and synthesis of calcitonin?
A
Thyroid gland (c- cells)
16
Q
What is the role of calcitonin in calcium homeostasis ?
A
Inhibits intestinal calcium absorption
Inhibits osteoclast activity
Inhibits renal tubular absorption of calcium
17
Q
In haemophilia what time is prolonged?
A
APTT
18
Q
Which disorders is characterized by a PTEN mutation and intestinal hamartomas?
A
Cowdens disease
19
Q
Where is osteosarcoma lesions most likely to metastasise to?
A
Lung
20
Q
List the causes of hypercalcaemia?
A
CHIMPANZEES
C alcium supplementation
H yperparathyroidism
I atrogentic (Drugs: Thiazides)
M ilk Alkali syndrome
P aget disease of the bone
A cromegaly and Addison’s Disease
N eoplasia
Z olinger-Ellison Syndrome (MEN Type I)
E xcessive Vitamin D
E xcessive Vitamin A
S arcoidosis
21
Q
List the risk factors for developing active TB?
A
silicosis
chronic renal failure
HIV positive
solid organ transplantation with immunosuppression
intravenous drug use
haematological malignancy
anti-TNF treatment
previous gastrectomy
22
Q
What factors increase production of gastric acid?
A
Parasympathetic Vagal nerve stimulation
Gastrin release
Histamine release (indirectly following gastrin release) from enterchromaffin like cells
calcium
23
Q
What factors decrease production of gastric acid?
A
Somatostatin (inhibits histamine release)
Cholecystokinin
Secretin
Nausea
24
Q
Where is majority of iron absorbed?
A
Duodenum and upper jejunum
25
List the pathways of CSF flow?
Choroid plexus > Lateral ventricles > Foramen of Monro > Third Ventricle > Slyvian aqueduct > Fourth ventricle > Foramen of lushcka and magendie > Subarachnoid space > Reabsorbed into the venous system via arachnoid granulations into superior sagittal sinus
26
List the electrolyte abnormalities in re-feeding syndrome?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Abnormal fluid balance
27
What is the prescription for re-feeding syndrome?
Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days
Start immediately before and during feeding: oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium (0.2-0.4 mmol/kg/day)
28
What is Takayasu arteritis?
a large vessel vasculitis.
It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse.
It is more common in females and Asian people
mx- steroids
29
What are the typical features of a lipoma?
Located in superficial tissues
Presence of multiple similar lesions at other anatomical sites
Increased mobility of lesion
Lobulated appearance during surgical excision
30
What is the medical management of hypercalcaemia?
Nacl 0.9%
Calcitonin
IV pamidronate or IV zoledronate (IF MALIGANCY ASSOCIATED)
31
What ECG changes are seen in hypercalcamia?
Shortening of QTc
32
What % of blood flow will the kidney receive from resting CO?
25%
33
What is the guidance for surveillance of AAA?
< 3 cm- Normal > No further action
3 - 4.4 cm- Small aneurysm> Rescan every 12 months
4.5 - 5.4 cm- Medium aneurysm> Rescan every 3 months
≥ 5.5cm- Large aneurysm> Refer within 2 weeks to vascular surgery for probable intervention
34
Who is eligible for AAA screening?
single abdominal ultrasound for males aged 65.
35
Where is a AAA rupture most likely?
80% rupture posteriorly into the retroperitoneal space
These patients will tend to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg.
36
What are the indications for surgery for a AAA?
Symptomatic aneurysms (80% annual mortality if untreated)
Increasing size above 5.5cm if asymptomatic
Rupture (100% mortality without surgery)
37
What morphology of AAA would be suitable for EVAR?
Long neck
Straight iliac vessels
Healthy groin vessels
38
Where are the arterial baroreceptors located?
Carotid sinus and aortic arch
39
What are Hydatid cysts?
Hydatid cysts are endemic in Mediterranean and Middle Eastern countries. They are caused by the tapeworm parasite Echinococcus granulosus.
40
List the clinical features of a hydatid cyst?
Up to 90% cysts occur in the liver and lungs
Can be asymptomatic, or symptomatic if cysts > 5cm in diameter
Morbidity caused by cyst bursting, infection and organ dysfunction (biliary, bronchial, renal and cerebrospinal fluid outflow obstruction)
In biliary rupture there may be the classical triad of; biliary colic, jaundice, and urticaria
41
What is the Ix and Mx of choice for Hydatid cysts?
CT is the best investigation to differentiate hydatid cysts from amoebic and pyogenic cysts.
Surgery is the mainstay of treatment (the cyst walls must not be ruptured during removal and the contents sterilised first).
42
What is seen on histology in hashimotos thyroiditis?
Lymphocytic infiltrates +/- acinar destruction and fibrosis
42
What is responsible for the rapid depolarisation phase of the myocardial action potential?
Rapid sodium influx
43
What is responsible for the early repolarisation phase of the myocardial action potential?
Efflux of potassium
44
What is responsible for the final repolarisation phase of the myocardial action potential?
Efflux of potassium
45
How do you calculate cerebral perfusion pressure?
Cerebral perfusion pressure= Mean arterial pressure - intra cranial pressure
MAP= Diastolic pressure+ 0.333(Systolic pressure- Diastolic pressure)
46
When a diagnosis of lymphoma is suspected what is the correct ix to confirm diagnosis?
Excision biopsy of lymph node
47
What is the cell of origin for GIST (Gastro-intestinal Stromal tumour)?
Interstitial cells of cajal
48
List the causes of hyperkalaemia?
Machine' - Causes of Increased Serum K+
M - Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism, haemolysis
I - Intake - Excessive
N - Nephrons, renal failure
E - Excretion - Impaired
49
What is the most common childhood brain tumour?
Astrocytoma
50
What hormone is released form the alpha cells of the islets of langerhans?
Glucagon
51
What hormone is released form the beta cells of the islets of langerhans?
Insulin
52
What hormone is released form the delta cells of the islets of langerhans?
somatostatin
53
What hormone is released form the F cells of the islets of langerhans?
Pancreatic polypeptide
54
Where is secretin released from?
Secretin is released from mucosal cells in the duodenum and jejunum.
55
What viral agents is most commonly implicated in the development of nasopharyngeal carcinoma?
EBV
56
What is trotters triad?
Trotter's triad (diagnosis of nasopharyngeal carcinoma)
Unilateral conductive hearing loss
Ipsilateral facial & ear pain
Ipsilateral paralysis of soft palate
57
What cells are seen in a Blood film in hyposplenism?
Howell-Jolly bodies
Pappenheimer bodies
Poikilocytes (Target cells)
Erythrocyte containing siderotic granules
Heinz bodies
58
In a biopsy taken from the gastro intestinal tract, where is a Paneth cell most likely to be identified
Crypt of Lieberkuhn
they are an important contributor to the gut microbiome and have roles in host defence and immunity.
59
What tumour markers is most helpful in identifying an individual with hepatocellular carcinoma
Serum AFP
60
Which changes are most likely to be identified in the aortic wall of a 38 year old lady with a Marfans syndrome and a dissecting aortic aneurysm?
cystic medial necrosis
61
62
What is **Li-Fraumeni Syndrome**?
A genetic condition associated with a high incidence of malignancies, particularly sarcomas and leukaemias
## Footnote
It is characterized by germline mutations to the p53 tumour suppressor gene.
63
What gene is primarily affected in **Li-Fraumeni Syndrome**?
p53 tumour suppressor gene
## Footnote
Mutations in this gene lead to an increased risk of various cancers.
64
List the types of malignancies associated with **Li-Fraumeni Syndrome**.
* Sarcomas
* Leukaemias
## Footnote
Individuals with this syndrome have a notably high incidence of these malignancies.
65
What are the criteria for diagnosing **Li-Fraumeni Syndrome** related to family history?
* First degree relative diagnosed with any cancer below age 45
* Another family member develops malignancy under 45 or sarcoma at any age
## Footnote
These criteria highlight the hereditary nature of the syndrome.
66
What is **Lynch Syndrome**?
A genetic condition associated with a high risk of developing certain cancers
## Footnote
Specifically, it increases the risk of **colonic** and **endometrial cancer**.
67
High risk individuals for **Lynch Syndrome** may be identified using the _______.
Amsterdam criteria
## Footnote
The Amsterdam criteria are specific guidelines used to identify families at risk for Lynch Syndrome.
68
What is the **genetic defect** associated with **Familial adenomatous polyposis**?
Mutation of APC gene (80% cases), dominant
## Footnote
This mutation is responsible for the development of the condition.
69
What are the typical **features** of **Familial adenomatous polyposis**?
Typically over 100 colonic adenomas
Cancer risk of 100%
20% are new mutations
## Footnote
The presence of numerous adenomas significantly increases cancer risk.
70
What is the recommended **screening** for individuals at risk of **Familial adenomatous polyposis**?
* Predictive genetic testing as teenager
* Annual flexible sigmoidoscopy from 15 years
* If no polyps found, then 5 yearly colonoscopy started at age 20
* Polyps found = resectional surgery
## Footnote
Early detection and management are crucial to prevent cancer.
71
What are the **management** options for **Familial adenomatous polyposis** if polyps are found?
* Resectional surgery (resection and pouch)
* Sub total colectomy and IRA
## Footnote
Surgical options depend on the extent of polyp development.
72
What are the associated **disorders** with **Familial adenomatous polyposis**?
* Gastric fundal polyps (50%)
* Duodenal polyps (90%)
* Abdominal desmoid tumours
## Footnote
Duodenal polyposis carries a cancer risk of 30% at 10 years if severe.
73
What is the **mutation** associated with **Peutz-Jeghers syndrome**?
STK11 (LKB1) mutation on chromosome 19
## Footnote
This mutation is present in some (but not all) cases of the syndrome.
74
What type of **tumors** are associated with **Peutz-Jeghers syndrome**?
Multiple benign intestinal hamartomas
## Footnote
These hamartomas can lead to episodic obstruction and intussusception.
75
List the types of **cancers** that individuals with **Peutz-Jeghers syndrome** are at increased risk for.
* Breast cancer
* Ovarian cancer
* Cervical cancer
* Pancreatic cancer
* Testicular cancer
## Footnote
These cancers are in addition to the gastrointestinal cancers.
76
How often should **pan intestinal endoscopy** be performed for individuals with **Peutz-Jeghers syndrome**?
Every 2-3 years
## Footnote
This procedure helps in monitoring for intestinal hamartomas and other complications.
77
What is **Cowden disease** associated with?
Mutation of **PTEN gene** on chromosome **10q22**
## Footnote
Cowden disease is a genetic disorder characterized by multiple growths and an increased risk of certain cancers.
78
List three **characteristic features** of Cowden disease.
* Macrocephaly
* Multiple intestinal hamartomas
* Multiple trichilemmomas
## Footnote
These features are part of the clinical presentation of Cowden disease.
79
What is the **risk percentage** for breast cancer in individuals with Cowden disease?
81% risk
## Footnote
Breast cancer is one of the most significant risks for individuals with Cowden disease.
80
Name two other types of cancer associated with Cowden disease.
* Thyroid cancer
* Uterine cancer
## Footnote
These cancers are also part of the increased risk profile for individuals with Cowden disease.
81
What is the process of acute inflammation?
Process may resolve with:
Suppuration
Complete resolution
Abscess formation
Progression to chronic inflammation
Healing by fibrosis
82
What are the typical cellular components of an abscess cavity?
Polymorphonuclear leucocytes, cellular debris and fibrin
83
What are the typical cellular components of a granuloma?
Altered/fused macrophages
Epithelioid cells
Mixture of chronic inflammatory cells
84
What cytoplasmic inclusions may be seen after **splenectomy**?
* Howell-Jolly bodies
## Footnote
These inclusions indicate the inability to remove abnormal red blood cells.
85
What types of cells appear in circulation in the first few days after **splenectomy**?
* Target cells
* Siderocytes
* Reticulocytes
## Footnote
These cells indicate changes in the blood film following splenectomy.
86
What type of white blood cell increase is seen immediately following **splenectomy**?
Granulocytosis (mainly composed of neutrophils)
## Footnote
This is a temporary response that changes over time.
87
What follows granulocytosis in the weeks after **splenectomy**?
* Lymphocytosis
* Monocytosis
## Footnote
These changes reflect the body's adjustment in white blood cell composition.
88
What happens to the **platelet count** after splenectomy?
Usually increased
## Footnote
This increase may be persistent, and some patients may require oral antiplatelet agents.
89
Tx of carcinoid syndrome?
Octreotide
Surgical removal
90
What does the **Nottingham Prognostic Index (NPI)** indicate?
Survival following breast cancer surgery
## Footnote
The NPI provides a way to assess prognosis based on various parameters.
91
What is the formula for calculating the **Nottingham Prognostic Index (NPI)**?
Tumour Size x 0.2 + Lymph node score + Grade score
## Footnote
The calculation incorporates multiple factors to assess prognosis.
92
What NPI score indicates an **excellent prognosis**?
<2.4
## Footnote
Scores below this threshold suggest a favorable outcome.
93
What NPI score indicates a **worse prognosis**?
<5.4
## Footnote
Scores above this threshold suggest a less favorable outcome.
94
What type of thyroid cancer is a recognised cause of **bone metastasis**?
Follicular carcinomas
## Footnote
Follicular carcinomas are known for their ability to spread to bones.
95
How do **papillary lesions** typically spread?
Via the lymphatics
## Footnote
Papillary thyroid cancer commonly spreads through the lymphatic system.
96
What is the general term for a virus associated with **cancer**?
Oncovirus
## Footnote
Oncoviruses are known to contribute to the development of various types of cancer.
97
Which virus is associated with **Burkitt's lymphoma**?
Epstein-Barr virus
## Footnote
Epstein-Barr virus is linked to several lymphomas, including Burkitt's lymphoma.
98
Name a type of lymphoma associated with **Epstein-Barr virus**.
* Hodgkin's lymphoma
* Post transplant lymphoma
* Burkitt's lymphoma
## Footnote
These lymphomas can be influenced by the Epstein-Barr virus.
99
What cancer is associated with **Human papillomavirus 16/18**?
* Cervical cancer
* Anal cancer
* Penile cancer
* Vulval cancer
* Oropharyngeal cancer
## Footnote
HPV 16 and 18 are high-risk types linked to several cancers.
100
Which virus is linked to **Kaposi's sarcoma**?
Human herpes virus 8
## Footnote
This virus is primarily associated with Kaposi's sarcoma, especially in immunocompromised individuals.
101
What type of cancer is associated with **Hepatitis B virus**?
Hepatocellular carcinoma
## Footnote
Hepatitis B virus is a significant risk factor for liver cancer.
102
What diseases are associated with **Human T-lymphotropic virus 1**?
* Tropical spastic paraparesis
* Adult T cell leukaemia
## Footnote
HTLV-1 is known to cause these conditions, particularly in endemic regions.
103
What does the presence of **amyloid** within a thyroid tumor indicate?
A big red flag for **medullary thyroid carcinoma**
## Footnote
The detection of amyloid is a significant indicator that may suggest the presence of this type of cancer.
104
What can **falsely elevate 5-HIAA** and potentially lead to incorrect diagnosis of carcinoid syndrome?
* Food: spinach
* Food: cheese
* Food: wine
* Food: caffeine
* Food: tomatoes
* Drugs: Naproxen
* Drugs: Monoamine oxidase inhibitors
* Recent surgery
## Footnote
Awareness of these factors is crucial for accurate diagnosis.
105
**Stipple cells** are found in which conditions?
* Lead poisoning
* Haemoglobinopathies
## Footnote
Stipple cells are indicative of certain blood disorders.
106
What are the **blood film findings** in **hyposplenism**?
* Howell-Jolly bodies
* Pappenheimer bodies
* Poikilocytes (Target cells)
* Erythrocyte containing siderotic granules
* Heinz bodies
## Footnote
These findings are associated with the absence of splenic function.
107
What type of necrosis is seen in the **arterioles** of patients with **malignant hypertension**?
ibrinoid necrosis
## Footnote
Ibrinoid necrosis is characterized by the deposition of fibrin-like protein in the vessel walls.
108
What is **coagulative necrosis**?
The commonest type of necrosis, occurs in most organs
## Footnote
Tissue is initially firm, later becomes soft as tissue is digested by macrophages. In the early phases, histological appearances may demonstrate little change.
109
What is **liquefactive necrosis** also known as?
Colliquative necrosis
## Footnote
Occurs in tissues with no supporting stroma and is the dominant necrosis pattern in the CNS.
110
What is a characteristic of **caseous necrosis**?
No definable structure seen in the necrotic tissue
## Footnote
Amorphous eosinophilic tissue may be seen histologically and is classically seen in tuberculosis.
111
What does **gangrene** involve?
Necrosis with putrefaction of tissue
## Footnote
May complicate ischaemia and results in the deposition of iron sulphide, causing black tissue.
112
What are the two types of **gangrene**?
* Wet gangrene
* Dry gangrene
## Footnote
In wet gangrene, there is often a liquefactive component and super-added infection.
113
What is **fibrinoid necrosis** classically seen in?
Arterioles in patients with hypertension (malignant type)
## Footnote
Necrosis of the smooth muscle wall occurs and plasma may extravasate into the media with fibrin deposition.
114
What can cause **fat necrosis**?
Direct trauma to fat
## Footnote
This can result in rupture of adipocytes and incite a local inflammatory reaction.
115
What is **apoptosis** also known as?
Programmed cell death
## Footnote
Energy dependent pathways are activated via intracellular signalling mechanisms.
116
What triggers the activation of **caspases** in apoptosis?
Bcl-2 family or the binding of the FAS ligand to its receptor
## Footnote
This leads to DNA fragmentation, mitochondrial function ceasing, and cellular shrinkage.
117
In apoptosis, what happens to the cell after it degenerates?
It degenerates into apoptotic bodies
## Footnote
Phagocytosis of the cell does not occur.
118
What is highly suggestive of **Actinomycosis**?
The presence of chronic sinuses together with gram positive organisms and sulphur granules
## Footnote
Actinomycosis is a bacterial infection that can cause chronic abscesses and sinus tracts.
119
120
What is a **classical feature** of invasive lobular carcinoma?
Risk of metastasis to the contralateral breast
## Footnote
This characteristic distinguishes invasive lobular carcinoma from other types of breast cancer.
121
122
When malignancy occurs in patients with achalasia, it is most likely to be of what type?
Squamous cell type
## Footnote
This type of cancer is associated with the esophagus.
123
What histological feature is most likely to be identified in a **lymph node** in **sarcoidosis** is present?
Asteroid bodies → star-shaped inclusions within multinucleated giant cells
## Footnote
This feature is classic for sarcoidosis.
124
Where do ependymomas commonly arise?
4th ventricle
## Footnote
This location is significant as it is part of the ventricular system in the brain.
125
Ependymomas can grow through which foramina?
* foramina of Luschka
* foramina of Magendie
## Footnote
These foramina are openings that allow cerebrospinal fluid to flow between the ventricles and the subarachnoid space.
126
What are **liver cell adenomas** linked to?
OCP use
## Footnote
90% of patients with liver cell adenomas have used the OCP.
127
Describe the typical **echoity** and texture of lesions in liver cell adenomas.
Mixed echoity and heterogeneous texture
## Footnote
These characteristics can help in the imaging diagnosis of liver cell adenomas.
128
A large **hyperechoic lesion** in the presence of normal **AFP** is likely to be a _______.
haemangioma
## Footnote
This suggests that the lesion is benign, as haemangiomas are common vascular tumors.
129
What is **acute intermittent porphyria (AIP)**?
A rare autosomal dominant condition caused by a defect in porphobilinogen deaminase
## Footnote
This enzyme is involved in the biosynthesis of haem.
130
What are the **toxic accumulations** in acute intermittent porphyria?
* Delta aminolaevulinic acid
* Porphobilinogen
## Footnote
These substances accumulate due to the enzyme defect.
131
What age group is most commonly affected by **acute intermittent porphyria**?
20-40 years old
## Footnote
AIP is more common in females with a ratio of 5:1.
132
List the **abdominal symptoms** associated with acute intermittent porphyria.
* Abdominal pain
* Vomiting
## Footnote
These symptoms are characteristic of AIP.
133
What are the **neurological symptoms** of acute intermittent porphyria?
* Motor neuropathy
## Footnote
Neurological symptoms can vary in severity.
134
What are some **psychiatric symptoms** associated with acute intermittent porphyria?
* Depression
## Footnote
Psychiatric symptoms can also include anxiety and confusion.
135
What cardiovascular symptoms are common in acute intermittent porphyria?
* Hypertension
* Tachycardia
## Footnote
These symptoms may occur during acute attacks.
136
What is the classic **urine test result** for diagnosing acute intermittent porphyria?
Urine turns deep red on standing
## Footnote
This is a key diagnostic feature.
137
What is **raised urinary porphobilinogen** indicative of in acute intermittent porphyria?
Elevated between attacks and to a greater extent during acute attacks
## Footnote
This is crucial for diagnosis.
138
What laboratory test can confirm the diagnosis of acute intermittent porphyria?
Assay of red cells for porphobilinogen deaminase
## Footnote
This test measures the enzyme activity.
139
What are the **serum levels** that are raised in acute intermittent porphyria?
* Delta aminolaevulinic acid
* Porphobilinogen
## Footnote
Elevated levels are significant during acute attacks.
140
What are the indications for a cardiopulmonary bypass surgery?
Indications for surgery
Left main stem stenosis or equivalent (proximal LAD and proximal circumflex)
Triple vessel disease
Diffuse disease unsuitable for PCI
141
What conduits are used for a CABG?
> Internal mammary artery is best. Use of both is associated with increased risk of sternal wound dehiscence. However, many surgeons will use both especially for redo surgery.
> Radial artery harvested from forearm. Ensure ulnar collateral working first!
> Reversed long saphenous vein grafts
Typically anastamosed using 7/0-8/0 prolene sutures (distally) and 6/0 prolene for top end.
142
Complications of a CABG?
Post perfusion syndrome: transient cognitive impairment
Non union of the sternum; due to loss of the internal thoracic artery
Myocardial infarction
Late graft stenosis
Acute renal failure
Stroke
Gastrointestinal
143
144
In surgical patients that may need a rapid return to theatre, which type of **heparin** is preferred?
unfractionated heparin
## Footnote
Unfractionated heparin is preferred because it can be reversed more easily.
145
Why are **low molecular weight heparins** not preferred for surgical patients needing rapid return to theatre?
They have a longer duration of action and are harder to reverse
## Footnote
This makes them less suitable for situations requiring quick surgical intervention.
146
EMRCS Notes
flashcards
Decks in class (7)
# Cards
