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Hnp > Abdomen > Flashcards

Abdomen Flashcards

1
Q

What is the area of the abdomen called right below the xiphoid process?

A

Epigastric

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2
Q

What is the area of the abdomen called right below the epigastric region?

A

Umbilical

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3
Q

Whas is the area of the abdomen called right below the umbilical region?

A

Hypogastric or Suprapubic

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4
Q

Posteriorly, which ribs indicate where the kidneys are?

A

11th and 12th ribs

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5
Q

What is dyspepsia?

A

chronic or recurrent upper abdominal pain or discomfort in upper abdomen. Includes bloating, nausea, upper abdominal fullness and heartburn.

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6
Q

What is heartburn? When is it considered GERD?

A

Rising retrosternal pain occurring weekly or even more often. Aggravated by foods or positions/exercising. If accompanied by abdominal pain and occurring more than once per week it is considered GERD.

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7
Q

Other than abdominal pain and heartburn, what are some other symptoms of GERD?

A

GERD can also be present with respiratory symptoms such as cough and sore throat (pharyngitis).

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8
Q

What is retching?

A

involuntary spasm of stomach without vomitus

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9
Q

What is regurgitation?

A

Raising up of gastric contents without vomiting or retching, brine like taste

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10
Q

What is hematemesis?

A

vomiting up blood, brown or black contents in vomit, “coffee ground”

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11
Q

What is early satiety?

A

early fullness without eating a full meal

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12
Q

What is dysphagia?

A

“food doesn’t pass down right”, food that “sticks” or hesitates in passage.

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13
Q

What is odynophagia?

A

pain with swallowing

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14
Q

Clinically, what is diarrhea? What is chronic and acute diarrhea?

A

Diarrhea- increased water content of stool > 200g in 24 hours. Acute lasts < 2 weeks. Chronic is > 4 weeks.

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15
Q

What is tenesmus?

A

It’s the constant urge to poop!

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16
Q

What is steatorrhea?

A

Oily, fatty stools

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17
Q

Clinically, what is constipation?

A

constipation should be present for 12 weeks, < 3 stools per week

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18
Q

What is obstipation?

A

no passage of feces or gas

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19
Q

What is melena?

A

black, tarry stools

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20
Q

What is hematochezia?

A

red/maroon colored stools

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21
Q

What is intrahepatic jaundice?

A

from damage to liver cells themselves

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22
Q

When would you see extra hepatic jaundice?

A

from an obstruction of the bile duct

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23
Q

What is dysuria?

A

painful urination

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24
Q

What is incontinence?

A

involuntary loss of urine, can be caused by stress, urge, overflow

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25
Q

What is urinary hesitancy?

A

the straining to void or decrease in stream with voiding

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26
Q

What is polyuria?

A

voiding > 3 L of urine in a 24 hour period

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27
Q

What is nocturia? What is hematuria?

A

nocturia- increased voiding at night, hematuria-blood in urine

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28
Q

What is gross hematuria? Microscopic hematuria?

A

gross- blood in urine visible to the naked eye, microscopic-small amounts of blood in urine

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29
Q

What are alarm symptoms?

A

These are symptoms in which patients present which always require follow up and a work up. dysphagia, odynophagia, recurrent vomiting, GI bleeding, weight loss (unintentional), anemia, jaundice, and palpable mass.

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30
Q

What is visceral pain?

A

when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis). Ischemia causes stimulation of of visceral pain fibers.

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31
Q

What is parietal pain?

A

when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis). This pain is most severe than visceral. It is aggravated by movement, laughing, or coughing. Patients with this type of pain prefer to lie still.

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32
Q

What is referred pain?

A

originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder). Pain may also be referred TO abdomen from the chest, spine or pelvis which complicates the assessment of abdominal pain.

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33
Q

How do you differentiate kidney pain from ureteral pain?

A

Kidney pain is a visceral pain and is produced by distention of the renal capsule, it is dull, achy and steady. Kidney pain is higher in the abdomen than ureteral pain. Ureteral pain is sharp, colicky, severe and radiates down to lower abdomen.

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34
Q

What could epigastric pain indicate?

A

stomach, duodenum, pancreas

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35
Q

What could RUQ pain/epigastric pain indicate?

A

biliary tree and liver

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36
Q

What could periumbilical pain indicate?

A

small intestine, appendix, proximal colon problems

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37
Q

What could suprapubic or sacral pain indicate?

A

rectum problems

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38
Q

What could hypogastric pain indicate?

A

colon, bladder, uterus, colonic pain may be more diffuse than illustrated

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39
Q

What could white or gray stools indicate?

A

liver or gall bladder disease

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40
Q

Difficulty starting to urinate happens more in women or men?

A

Men

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41
Q

Incontinence happens more in women or men?

A

Women

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42
Q

If someone has back pain at the costovertebral angle, this could indicate problems with..?

A

the kidneys

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43
Q

In men, lower back pain could indicate problems with…?

A

referred pain from the prostate

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44
Q

When pts come in for an abdominal complaint, have risk factors for theyl should be screened for are…

A

alcohol abuse, hepatitis (A, B and C), and colon cancer

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45
Q

Do an alcohol abuse screening if the patient has what?

A

a hx of hepatitis, pancreatitis, alochol abuse, alcohol overindulgence, ascites, hepatosplenomegaly, or a suspicion for an alcohol problem. Use your CAGE questions.

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46
Q

What are the CAGE questions?

A

Have you ever felt like you needed to cut down on your drinking? Have you ever felt annoyed at others who have been concerned about your drinking? Have you ever felt guilty about your drinking? Have you ever had a drink in the morning (eye opener)?

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47
Q

What are the standard drink equivalents for beer, wine and liquor?

A

12 oz for beer or wine cooler, 8 oz. of malt liquor, 5 oz of wine, 1.5 oz of 80 proof spirits

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48
Q

What is the initial screening question for alcohol intake?

A

How many times in the past year have you have you had 4 or more drinks a day (women), or 5 or more drinks a day (men)?

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49
Q

What is considered moderate, maximum or binge drinking for women?

A

Moderate- < or equal to 1 per day, Maximum- < or equal to 3 drinks per day, Binge- > or equal to 4 drinks per day

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50
Q

What is considered moderate, maximum or binge drinking for men?

A

Moderate- < or equal to 2 drinks per day, Maximum- < or equal to 4 drinks per day (if < or equal to 14 drinks in a week), < or equal to 3 drinks per day (if >65 y/o, and < or equal to 7 drinks in a week), Binge- > or equal to 5 drinks per day.

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51
Q

How do you get hep A?

A

fecal oral transmission- undercooked food or if they have traveled recently

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52
Q

Is there a vaccine for hep A?

A

Yes

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53
Q

In hep A, how does the virus leave the body?

A

virus leaves through feces, hand washing is very important

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54
Q

How do you get hep B?

A

blood transmission

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55
Q

Is there a vaccine for hep B?

A

Yes, vaccine is recommended especially for high risk populations

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56
Q

How do you get hep C?

A

blood transmission

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57
Q

Is there a vaccine for hep C?

A

No, it is the most common blood borne pathogen in the United States

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58
Q

Who are the in the high risk populations for hep B?

A

men having sex with men, people with multiple partners (more than one partner in the past 6 months), people with STDs, people who have been exposed to blood (mucosal or percutaneous exposure), (IV drug users, dialysis patients, residents and staff for the developmentally disabled), Travelers to endemic areas, people with chronic liver disease/HIV infected, correctional facilities, drug abuse programs

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59
Q

What are the common high risk conditions for colorectal cancer?

A

25% of colorectal cancers- personal hx of colorectal cancer, first degree relative w/ colorectal cancer or adenomatous polyps, personal hx of breast, ovarian, or endometrial cancer, personal hx of ulcerative or crohn’s colitis

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60
Q

When do you start screening for colorectal cancer?

A

20 years old, if high risk, refer for more complex management. If average risk at age 50 (high risk conditioned absent),offer more screening options

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61
Q

What are the hereditary high risk conditions for colorectal cancer?

A

6% of colorectal cancers-familial adenomatous polyps, hereditary nonpolyposis colorectal cancer

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62
Q

What are the screening recommendations for adults 50-75 years old for colorectal cancer?

A

High sensitivity fecal occult blood testing (FOBT) annually, sigmoidoscopy every 5 years with FOBT every 3 years, screening colonoscopy every 10 years

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63
Q

What are the screening recommendations for adults 76-85 years old for colorectal cancer?

A

Do not screen routinely, as gain in life years is small compared to colonoscopy risks, and screening benefits not seen for 7 years; use individual decision making if screening for the first time

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64
Q

What are the screening recommendations for adults 85+ years old for colorectal cancer?

A

Do not screen, as “competing causes for mortality preclude a mortality benefit that outweighs harms”

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65
Q

You always auscultate before percussing or palpating the abdomen, T or F?

A

True!

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66
Q

What is borborygmi?

A

Bowel Sounds- long gurgles

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67
Q

What is the normal frequency of borborygmi?

A

5-34 sounds per minute

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68
Q

On the abdomen, where do you listen for bruits?

A

aorta, iliac, renal and femoral arteries

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69
Q

Why do you auscultate the liver and spleen?

A

checking for friction rub

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70
Q

Where do you percuss the abdomen? What is tympany? What is dullness?

A

Percuss in all 4 quadrants, percuss over the midclavicular line and the midsternal line. Tympany is heard in hollow areas and dullness is heard when there is a mass or large stool

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71
Q

How much should midclavicular percussion be for the liver?

A

6-12 cm, larger than this indicates an enlarged liver

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72
Q

How much should midsternal percussion be for the liver?

A

4-8 cm, shorter than this indicates a small, hard, cirrhotic liver

73
Q

What is traube’s space?

A

Left lower anterior chest wall between lung resonance above the costal margin. Percuss here for the spleen.

74
Q

What does dullness in traube’s space mean?

A

enlarged spleen, when tympany is present, splenomegaly is not likely

75
Q

What is a splenic percussion sign?

A

Percuss the lowest interspace in the left anterior axillary line. This area is usually tympanitic. Then have the patient take a deep breath and percuss again. If the spleen is a normal size the percussion remains tympanitic. Shifting from tympany to dullness with inspiration suggests an enlarged spleen. This is a positive splenic percussion sign.

76
Q

What are the two techniques you can use to percuss the spleen?

A

Check for splenic percussion sign and percuss in traube’s space

77
Q

What relaxation techniques can you use to assess for voluntary guarding?

A

Tell the patient to breathe out deeply, or tell the patient to breathe out of their mouth with their jaw dropped open. You assess for guarding during light palpation.

78
Q

What is rebound tenderness during deep palpation?

A

Rebound tenderness occurs if pain increases when the examiner decreases the pressure against the abdomen.

79
Q

Why should you ask the patient to take a deep breath while palpating the liver?

A

This can illicit pain in liver or gallbladder disease and also makes it easier to find the inferior border of the liver (the diaphragm lowering during deep inspiration forces the liver downward).

80
Q

When do you use the “hooking technique” during palpation?

A

This technique is useful when a patient is obese. Place both hands, side by side, on the right abdomen below the border of liver dullness.
Press in with the fingers and go up toward the costal margin. Ask the patient to take a deep breath. The liver edge should be palpable under the finger pads of both hands.

81
Q

Can the spleen be palpated using the “hooking technique”?

A

Generally the spleen cannot be palpated this way even with deep inspiration. It should be done because palpating a splenic tip may indicate splenomegaly.

82
Q

Palpation of the aorta should be no more than _____cm wide

A

3

83
Q

Palpate the costovertebral angle on each side of the back for ________ tenderness

A

kidney

84
Q

A protuberant abdomen with bulging flanks is suspicious for ____________

A

ascites- fluid in the abdomen for diseases such as cancer

85
Q

Due to gravity, dullness should be located along the _______ sides of the abdomen, while the ______ portion should be tympanitic.

A

lateral; anterior

86
Q

How do you test for shifting dullness? (test for ascites)

A

After mapping out the areas of tympany and dullness on the abdomen, have the patient roll to one side. Remap the areas of tympany and dullness. In ascites, there should be
a shift due to free fluid moving with gravity.

87
Q

How do you test for a fluid wave?

A

Have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. Now tap on one flank sharply and feel with your own hand if the wave transmits to the other side of the flank.

88
Q

How can you assess for appendicitis?

A

check for rebound tenderness and involuntary guarding in the RLQ

89
Q

What is Rovsing’s sign?

A

Palpating the LLQ and rebound tenderness is found in the RLQ, this is a sign of acute appendicitis

90
Q

What is the Psoa’s sign?

A

The patient flexes his thigh against the examiner’s hand; pain indicates a positive sign, or turns on left side and extends the leg at the hip; the pain indicates acute appendicitis.

91
Q

What is the obturator sign?

A

Flex the patient’s leg at the hip and knee, and then internally rotate the hip. This stretches the internal obturator muscle. Pain indicates appendicitis.

92
Q

Where is Mcburney’s point?

A

2 cm from right anterior superior illiaic spine towards umbilicus, pain here indicates appendicitis.

93
Q

What is Murphy’s sign?

A

Deep palpation in RUQ with inspiration, if pt. ceases respiration with deep palpation this is a positive Murphy’s sign. This tests for acute cholecystitis.

94
Q

How can you see a ventral wall hernia in a patient?

A

Ventral wall hernias cannot be seen with the patient lying down, ask the pt. to elevate themselves off the table by raising head and shoulders this should show a ventral hernia if present

95
Q

Where is GERD felt?

A

chest or epigastric

96
Q

What does GERD feel like?

A

burning (heart burn) and regurgitation

97
Q

Why does GERD occur?

A

Prolonged exposure of esophagus to gastric acid, due to impaired esophageal motility, or lower esophageal sphincter action.

98
Q

Which bacteria may be present in GERD?

A

H. pylori

99
Q

Where do you feel a peptic ulcer and dyspepsia? What does it feel like?

A

epigastric, may radiate to the back- pain is variable-gnawing, burning, aching, pressing or hungerlike

100
Q

What and where is the peptic ulcer?

A

ulcer is present in duodenum or stomach, dyspepsia causes similar symptoms but not ulcer, h. pylori is often present

101
Q

Where is stomach cancer usually present?

A

cardia and GE junction; also in distal stomach

102
Q

What type of cancer is stomach cancer usually?

A

adenocarcinoma (90-95%)

103
Q

What is acute appendicitis and where is it felt?

A

acute inflammation of the appendix with distension or obstruction- it is poorly localized in the periumbilical region, followed usually by RLQ pain- pain worsens as time passes

104
Q

Steady, aching pain in the RUQ or upper abdominal, may radiate to the right scapular area

A

acute cholecystitis

105
Q

Acute cholecystitisis is inflammation of the….

A

gall bladder, usually obstruction of the cystic duct from a gall stone

106
Q

Steady, aching, NON-colicky pain in the epigastric or RUQ- may radiate to the right scapula and shoulder

A

biliary colic

107
Q

What is biliary colic?

A

sudden obstruction of the cystic duct or common bile duct by a gall stone

108
Q

Steady pain in the epigastric, it radiates to the back or other parts of the abdomen and is poorly localized…

A

acute pancreatitis

109
Q

Steady, deep pain in the epigastric, radiating to the back…

A

chronic pancreatitis

110
Q

What happens in chronic pancreatitis?

A

fibrosis of the pancreas secondary to recurrent inflammation

111
Q

Steady, deep pain that occurs in the epigastric and in either upper quadrant, radiates to the back

A

Cancer of the pancreas

112
Q

What type of cancer usually presents in pancreatic cancer?

A

predominately adenocarcinoma (95%)

113
Q

Initial cramping that that becomes steady in the LLQ

A

Acute diverticulitis

114
Q

What is acute diverticulitis?

A

acute inflammation of a colonic diverticulum, a saclike mucosal outpouching through the colonic muscle

115
Q

Cramping in the periumbilical or upper abdominal (small bowel) or lower abdominal or generalized (colon)

A

acute bowel obstruction

116
Q

Acute bowel obstructions are most commonly causes by ….

A

adhesions or hernias (small bowel) or cancer or diverticulitis (colon)

117
Q

Initial cramping then steady, may be periumbilical at first, then diffuse…

A

mesenteric ischemia- blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion) or reduced from hypoperfusion

118
Q

Motor disorder affecting the pharyngeal muscles-

A

oropharyngeal dysphagia

119
Q

What aggravates oropharyngeal dysphagia?

A

attempts to start the swallowing process-

120
Q

What are some associate symptoms of oropharyngeal dysphagia?

A

aspiration into the lungs or regurg into the nose with attempts to swallow. From stroke, bulbar palsy, or other neuromuscular conditions.

121
Q

What are some forms of esophageal dysphagia?

A

mucosal rings and webs, esophageal stricture, esophageal cancer

122
Q

What happens with mucosal rings and webs?

A

food irritates the esophagus and food is regurgitated

123
Q

Food irritates the esophagus, food is regurgitated, long history of heart burn and regurg, this may become slowly progressive

A

esophageal stricture

124
Q

Solid foods with a progression to liquids aggravate the esophagus, food is regurgitated, pain in the back and chest, weight loss, gets worse as time goes on

A

esophageal cancer

125
Q

chest pain that mimics angina or MI, lasts minutes to hours, heartburn, intermittent trouble swallowing foods and liquids

A

diffuse esophageal spasm

126
Q

How can you relieve diffuse esophageal spasm?

A

nitroglycerin, valsalva maneuver, straightening the back, raising the arms

127
Q

intermittent and progresses slowly, trouble swallowing solids or liquids, heartburn

A

scleroderma

128
Q

how do you relieve scleroderma?

A

valsalva maneuver, straightening the back, raising the arms

129
Q

intermittent and progresses slowly, trouble swallowing solids or liquids, heartburn, regurg at night, nocturnal cough, chest pain after eating

A

achalasia

130
Q

Reasons for constinpation?

A

diet deficient in fiber, not in the right setting to poop, false expectations for bowel movements

131
Q

change in frequency or form of bowel movement without known pathology, possibly from change in intestinal bacteria

A

irritable bowel syndrom

132
Q

What are the three patterns of irritable bowel syndrome?

A

diarrhea-predominant, constipation-predominant, or mixed.

133
Q

What is the diagnostic criteria for irritable bowel syndrome?

A

symptoms present > or equal to 6 months, ab pain > or equal to 3 months, plus at least 2 of 3 features (improvement with defecation, onset with change in stool frequency, onset with change in stool form and appearance)

134
Q

weight loss, change in bowel habits, diarrhea, abdominal pain, bleeding, occult blood in stool, tenesumus and pencil shaped stools

A

progressive narrowing of the bowel lumen from adenocarcinoma- cancer of the rectum or sigmoid colon

135
Q

rectal fullness, ab pain, diarrhea, common in debilitated, bedridden and elderly patients

A

immovable fecal mass, most often in the rectum

136
Q

colicky abdominal pain, abdominal distension

A

narrowing or complete obstruction of the bowel- in intussusception- currant jelly stools are present (red blood and mucus)

137
Q

What are some other reasons for constipation?

A

painful anal lesions (hemorroids, anal fissures), drugs (opiates, anticholinergics), depression, neurologic disorders, metabolic conditions (hypothyroidism, pregnancy, hypercalcemia)

138
Q

What can cause acute diarrhea? (< or equal to 14 days is acute)

A

colonization or invasion of intestinal mucosa (inflammatory) preformed bacteria, viruses, (secretory infections- non-inflammatory)

139
Q

watery diarrhea, without blood, pus or mucous

A

preformed bacteria, viruses, (secretory infections- non-inflammatory)

140
Q

loose to watery diarrhea, often with blood, pus or mucous

A

colonizations or invasion of intestinal mucosa (inflammatory)

141
Q

Which drugs can cause diarrhea?

A

antibiotics, magnesium containing antacids, antineoplastic agents, laxatives- these all can cause loose or watery stool

142
Q

What causes chronic diarrhea? (> or equal to 30 days is chronic)

A

irritable bowel syndrome, cancer of the sigmoid colon, inflammatory bowel disease,

143
Q

stool- 50% with mucus, small to moderate volume, small, hard stools with constipation, may be mixed pattern

A

irritable bowel syndrome

144
Q

cancer of the sigmoid colon, partial obstruction by a malignant neoplasm- what does poop look like?

A

may be blood streaked

145
Q

What are some inflammatory bowel diseases?

A

ulcerative colitis, crohn’s disease of the small bowel or colon

146
Q

soft to watery stool, often containing blood, inflammation of the mucosa and submucosa of the rectum and colon with ulceration, typically extends proximally from the rectum

A

ulcerative colitis

147
Q

small, soft to loose or watery, usually free from gross blood, chronic transmural inflammation of the bowel wall, in a skip pattern typically involving the terminal ileum, and/or proximal colon

A

crohn’s disease

148
Q

What are the different kinds of voluminous diarrhea?

A

malabsorption syndrome, osmotic diarrhea (lactose intolerance or abuse of osmotic purgatives), secretory diarrhea

149
Q

typically poop is bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy, particularly foul smelling, usually floats in toliet

A

malabsorption syndrome

150
Q

deficiency in intestinal lactase- watery diarrhea of large volume

A

lactose intolerance- osmotic diarrhea

151
Q

What are osmotic purgatives?

A

laxatives- cause watery diarrhea of large volume

152
Q

When do you see melena?

A

gastritis, GERD, peptic ulcer, stress ulcers, esophageal or gastric varices, reflux esophagitis mallory weiss tear in esophagus

153
Q

What is melena?

A

black, tarry, sticky and shiny stool- occult blood tests are positive

154
Q

Involves loss of at least 60 mL of blood in GI tract (less in children, usually from esophagus, stomach, or duodenum, transit time of 7-14 hours

A

melena

155
Q

What is a pannus?

A

apron of fatty tissue, may extend below the inguinal ligaments

156
Q

What is an adynamic (paralytic) ileus?

A

obstructed intestine

157
Q

Does gaseous distention become more marked in the colon or the small bowel?

A

colon

158
Q

What does a hepatic bruit indicate?

A

carcinoma of the liver or alcoholic hepatitis

159
Q

How do you treat GERD?

A

Proton pump inhibitor

160
Q

What should you think of if a smoker has painless hematuria?

A

Bladder cancer (until proven otherwise)

161
Q

Onset of anemia in elderly? What would you do to diagnose them?

A

Colon cancer, do a rectal exam, guiaic them

162
Q

Causes for pancreatitis?

A

Tryglycerides and alcohol abuse

163
Q

Procedure to push a large hernia back in?

A

Ice packs, morphine, elevate legs, push hernia back in, surgery

164
Q

Supraclavicular LDN, early satiety, h. Pylori (which can lead to gastric cancer), melena, LUQ pain can radiate to the back, pain worse on empty stomach

A

Peptic ulcer

165
Q

Overweight female in her 40’s has pain in the RUQ after eating a fatty meal (post prandial pain), pain radiates to shoulder

A

Gall bladder is sludgey- gall stones, acute cholecystitis, biliary colic

166
Q

Silent cancer, pt is yellow, has weight loss

A

Pancreatic cancer

167
Q

Most common cause of bowel obstruction in the elderly

A

Cancer

168
Q

Painful vomiting, poop and gas is not coming out

A

Acute bowel obstruction

169
Q

How do you treat diffuse esophageal spasm?

A

Ativan

170
Q

What is the hepato jugular reflex?

A

Press on liver, JVD becomes present, sign of right sided heart failure

171
Q

What is Wilson’s disease?

A

Copper in liver, kayser fleicher ring in eye

172
Q

How do you diagnose and treat cholecystitis?

A

CBC, CMP, elevated white count, ultrasound you’ll see inflamed gall bladder and stones, sonographic Murphy’s sign, febrile- refer them to surgery, give antibiotics (4 g unison) when infection improves they’ll go to surgery

173
Q

Epigastric pain, radiates to back- high triglycerides-abnormal CBC, amylase and lipase elevation

A

Pancreatitis

174
Q

Rebound pain is common in?

A

Peritonitis

175
Q

Acute, sharp, colicky uretal pain?

A

Kidney stone

176
Q

Spider angiomas on stomach could mean?

A

Liver failure

177
Q

Alcoholic vomiting bright RED blood could mean?

A

Esophageal varies, excessive bleeding occurs so lower their pressure and give them octreotide

178
Q

Most common cause of Upper GI bleed and melena is?

A

Peptic ulcer disease

179
Q

Bright red blood in rectum, post prandial pain, seen most common in elderly, abdominal pain

A

Mesenteric ischemia

Hnp (9 decks)

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