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PHAR 398: Minor Ailments > Cough/Colds/Fever > Flashcards

Cough/Colds/Fever Flashcards

1
Q

Describe the differential for respiratory infections and there subsequent prevalence

A

Common Cold > Bronchitis > Influenza > Covid = Strep Throat

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2
Q

What is the most common cause of an upper respiratory tract infection?

A

Common cold or Bronchitis

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3
Q

Describe how one can distingusih between the common cold and influenza

A

Common Cold - often just feel feverish

Influenza –> Fever in HOURS, dry cough and aches and pains

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4
Q

What are some concerns regarding respiratory infections in the elderly? Examples?

A

Example –> Influenza

fever and cough not always present in seniors

Encourage vaccionation

Risk of double sickening

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5
Q

Sx of RSV compared to flu, covid and cold

A

Wheezing is common

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6
Q

What are some characteristic sx of the flu, cold and allergies

A
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7
Q

Describe covid-19 sx in comaprison to tje flu and common cold

A

Fever - Common in flu and covid, rare in cold
Fatigue - Common in flu, sometimes in covid and cold
Cough - Common (usually dry) in flu and covid, mild in cold
Runny or Stuffy Nose - RAre in Covid-19, common in cold, sometimes in flu
Shortness nof breathe - sometimes in covid
Sore Throat –> Copvid-19 and Cold

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8
Q

What is becoming the dominant Covid Sympton now?

A

2/3 of people with sore throat

fever and loss of smell are rare now

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9
Q

Describe influenza in the elderly

A

65 and older with influenza –> MAy not necessarily have a fever or a cough

  • if require for diagnosis, miss more than half of people

Conditions such as asthma, COPD and HF often exacerbated or triggered by influenza

Only 31% had a diagnosable fever

Even when odler adults presented with fever amd influenza-like ilnness, they were still tested at lower rates

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10
Q

When as pharmacists are we concerned about ocation of sx? What is likely when in these areas with these sx?

A

Sx involving the head –> Head COld - less scary

Symptoms mainly in chest –> Chest cold –> More worrisome

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11
Q

Describe the difference between a productive and a non-productive cough

A
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12
Q

What are some causes of dry and wet coughs?

A
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13
Q

What is acute bronchitis? Sx? Sputum colour?

A

Cough starts as non-productive then becomes productive

Cough can last for up to 3 weeks –> Long (get it checked by MD if 3 weeks long)

Green Sputum (if known) can mean bacterial or viral

Does not necessarily warrant antibiotics

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14
Q

What is bronchitis sometimes referred to as? Severity of cough comapred to other conditions? Most common pathogen?

A

Sometimes referred to as a chest cold

Commonly viral in nature

Often described as being worse then the regular cold but not as bad as pneumonia

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15
Q

Describe where different chest infections occur? Which is a concern? Why?

A

Bronchitis –> Upper LUng
Bronchiolitis –> Deeper in lung
Pneumonia –> Deppest in the lung

RSV –> Hospital (kids)

Often commonly think bronchitis

If a fever is present with chest cold, refer –> Pneumonia potential

Pneumonia –> Likley present to the hospital as sicker

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16
Q

What is croup? Difference from Laryngitis? Severity?

A

Laryngitis is the same as croup (called this in older children)

Bark-like cough (‘croupy’) = very dry cough
–> Seal like

Viral in nature

Sounds worse than it actually is; benign in nature

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17
Q

Is croup a serious condition? When should it be better by?

A

Most cases, croup sounds worse than it actually is

Should clear up on its own within 5 to 7 days

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18
Q

Describe the therapy for croup

A

Humidity –> Soothing
Mist from a humidifier or sitting with the child in a bathroom

Allow child to breathe cool air during the night by opening window or door

Coughing can be treated with warm, clear fluid

No need for antibioptics as croup is caused by a virus and not by a bacteria

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19
Q

What is laryngitis? Duration?

A

Swellih and inflammation of the larynx

Acute or chronic

Often not serious and in most acses resolves without treatment in around 7 days

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20
Q

Describe laryngitis causes, children and tx

A

Viral infections such as colds are the most common cause of laryngitis

Children with laryngitis can develop a respiratory illness called croup

Acute laryngitis is best treated with self care measures and rest

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21
Q

Describ the symptoms of laryngitis in children

A

Symptoms of laryngitis in children can differ than in adults

COndition charceterized by hoarse barking caough –> Croup

Simple ilnnes to treat

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22
Q

What is epiglottis?

A

Inflamamed epiglottis

Affectes breathing

RAre - Kids are now vaccinated for it (Hib)

Can be very danageriys

Docs will consider sx and then look down the throat with a scope

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23
Q

What are the classic signs of epiglottis?

A

Dysphoria
Dysphagia
Drooling
Distressed repiration

Leaning forward –> Protects the airway and maximizes ventilation

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24
Q

What is often the cause of epiglottis?

A

Haemophilus Influenzae

Now vaccinated against so less of. acause

Mainly due to syrep now

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25
Q

Describe the symptoms of asthma

A

Persistent cough
No cold-like sx
Wheezing/shortness of breath

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26
Q

What are some trigegrs of asthma?

A

Exercise
Allergens
COLDS

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27
Q

What are some symptoms that would help discern asthma from the common cold?

A

Asthma does not cause a fever, chills, muscle aches or a sore throat

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28
Q

What is a trigger for asthma?

A

Colds are often a trigger for asthma attacks

So can have both at once occuring and sx of both conditions

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29
Q

Describe how a cold initially presents

A

Sore throat/throat discomfort

Followed by clear, watery nasal discharge

Sneezing, fatigue, feverish

Post nasal drip from nose and sinuses can cause one to have a cough

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30
Q

Describe the onset of asthma

A

42% of adults with active asthma reported an onset occuring before the age of 16

Mean age of onset - 7 years old

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31
Q

What is more worrisome in children than in adults? Is it able to distinguish the cause?

A

Sore throats are more worrisome in kids

Often difficult to discern whether bacetrial or viral

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32
Q

Describe the anatomy of the throat? Pharmacist role here?

A

Glands cans well up during an infection

Pharamcists are getting involved in strep throat testing

However, looking into the throat suggests you know what you are doing

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33
Q

Describe the different conditions of sore throats

A
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34
Q

What is strep throat? Sx? Common age? Pathogen?

A

Incraesed fever and incraesed pain

Cough is less common

Exudate/swollen glands/rash

More common in kids 5-15 years old

Strep Pyogenese (Group A strep)

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35
Q

What is the more common pathogen for a sore throat: Bacteria or Virus

A

Viral is still the most common

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36
Q

Describe the likelihood of strep throat? Bacteria?

A

Bacteria: Group A Beta-Hemolytic Streptococcal

Patients with a sore throat, likelihood of GABHS is highest in children five to fifteen years of age (37%) and lower in younger children (24%) and adults (5-15%)

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37
Q

What are some of the common causes of tonsillitis?

A

15-30% of tonsilitis cases are due to baceteria

Most often strep bacteria

Viruses are the most common cause of tonsilitis –> Epstein BArr Virus can casue tonsilitis and can also cause mononucleosis

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38
Q

What is a critical factor to cosnider in the treatment of strep throat?

A

If strep throat is left untreated and caused by streptococcus bacteria, it can lead to serious complications

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39
Q

How long does tonsilitis usually last?

A

Symptoms usually go away within 7-10 days

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40
Q

Describe the signs and symptoms of strep throat? What doe sit typically not include?

A
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41
Q

What is the practice relaity for strep throat regarding pharamcists?

A

1) Exudate
2) Swollen Glands
3) Pain
4) Fever

If all 4 –> 50% chance of strep throat

Still requires testing to confirm diagnosis

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42
Q

Can strep throat simply be diagnosed by looking at an individuals throat?

A

Strep throat cannot be diagnosed by a doctor simply looking at the childs throat

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43
Q

Describe why antibiotics are used in strep throat?

A
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44
Q

What can be used to determine if strep throat is likely?

A

Centro Score

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45
Q

Are antibiotics needed for strep throat?

A

Doctors sually treat strep throat with antibiotics

Antibiotics are not prescribed to treat the strep itself, but to prevent serious complications

ANtibiotics are often needed

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46
Q

What are antibiotics used to prevent after strep throat? Or is it to treat the strep throat?

A

Rheumatic fever

Rheumatic Heart Disease

Strep throat is self-limkting; however, downstream effects are the worry here

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47
Q

What is rheumatic fevere? Rate?

A

Fewer than 0.3% of people who have had strep get rheumatic fever

Most common among children aged 5-15, but adults can also get it

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48
Q

Symtoms of rheumatic fever

A

Fever

Non-itchy rash

Narrowed mitral valve cauisng heart murmur

Painful joints

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49
Q

What is rheumatic heart disease?

A

Damaged valves

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50
Q

What is fifth and sixth disease?

A

Skin conditions that occur in kids after cold symptoms

Will come across as typical cold until rash starts

Common after URTi’s

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51
Q

What is a common occurrence in children with an URTi?

A

A very common cause of HIves in children is URT infections (within the last 6 weeks)

Viral URTIs cause about 40% of hive rashed

These outbreaks resolve as the infection resolves

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52
Q

What are some main symptoms of mononucelosis?

A
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53
Q

Describe the diagnosis of mononucelosis

A

Will likely present like the flu or strep throat initially

Sore Throat (slower onset)
Fatigue
Fever
Swollen Neck Glands

Test after 3 or 4 tries (bronchitis, common cold, etc.)

NONO test finds it

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54
Q

Describe the differential algorithm for colds

A
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55
Q

Describe how pharamcists can play the odds?

A
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56
Q

What is another condition that will likely be brought up if the patient has it? Describe this situation?

A

Heart FAilure:

Cough
Shortness of Breath (not in bronchitis)
Hx of HF

Comes to mind when patient says they have had a cold that has lasted for months and mentions SOB

Patie nt should inform us of HF diagnopsis when ask about health status in the consult

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57
Q

How long does a cold last? How long does a cough last?

A

A cold typically wraps up around day 10

Some people experience a post-infectious cough shich is a nagging cough can last an average of 18 days after the cold subsides

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58
Q

When should a child be seen by a doctor for a cough?

A

1) Frequent persistent cough for 3-4 days (recall 18 days is normal)

2) Short, fast cough with whooping sound (whooping cough)

3) Loud, wet cough with faster breathing than normal

4) Wheezing cough (sounds like asthma)

5) Barky Cough (croup - oless worried)

6) Productive cough with persistent mucous, sneezing and nose-blowing

59
Q

Describe how to rule in and rule out certain respiratory disorders?

A
60
Q

Describe the distribution of acute cough amoung children in phaermacies?

A

Common Cold - 59%
Brochitis - 9%
Asthma - 9%
Influenza - 8%

61
Q

When should a child see a physician for a cough?

A

If a child has a cough for greater than one month

OR

It’s a relapse

62
Q

What is commonly seen for immunity boosting now a days?

A

Zinc is now commonly seen for immunity/colds

In cough and cold products for children for immunity

Not effective

63
Q

Is there preventative therapies for a cold? If so, use and effectiveness?

A

VICK’s - Early Defence

Cold virus blocker - not useful and low chance of sucess here

Pump 2-3 times in the nostri;l

Allow 4 hours between administrations (max of 4/day)

Would need more like Q2H

64
Q

What are the treatment options for a common cold? Efficacy?

A

Cough suppressants - Not that great
1) DM - Have low expectations
- best agent we have oTC but low effeicacy

2) Expectorant (gaufenisen)
- Not that great of an agent
- Some efficacy

3) ANtihistamines - Not indicated (except for sneezing, runny nose)
- Often added for nightime sedation

4) Decongestants are often helpful

65
Q

Describe the role and efficacy of guaifenesin in the management of chronic brnchitis and URTi’s?

A

Considered a safe and effective expectorant for the treatment of mucus-related symptoms in acute URTi’s and stable chronic bronchitis

Clinical efficacy has been demonstrated most widely in chronic respiratory conditions, where excess mucous production and cough are more stable sx

66
Q

How does gaufenisen work aws an expectorant?

A

Incraeses airway hydration

Increases volume of bronchial secretions

Decraeses mucuous viscosity

67
Q

What is the dose of guafensisen?

A

200-400 mg Q4H up to 6x daily

68
Q

Does honey have a role in cough and cold management? Efficacy? Dose?

A

CAn help diminish a cough and the discomfort experienced by children and parents

Safe to use but low efficacy

Single dose of 2.5 mL HS for children over the age of 1

Children under 1 years old - Risk of botulism

69
Q

Describe the difference in efficacy between honey and DM?

A

DM and Honey had a similar efficacy to no treatment in regards to cough severity

70
Q

Describe the meta-analysis and systematic review of the effectiveness of honey in URTi’s?

A

Honey was superior to usual care for the improvement of symptoms of a URTI

  • Safe agent, but not great efficacy (similar to DM)

Improvement of sx refers ro:
- Combined Symptom Scores
- Cough frequency
- Cough severity
- 1-2 days shorter

The honey was delievered in different ways

71
Q

What is the most common way that a parent will give honey to their child?

A

DIY Cough Syrups with Honey

Vast majority are going to get honey within a standard syrup formulation

72
Q

Role of anti-histamines in the treatment of cough

A

Not indicated (except for sneezing, runny nose)

Added to products for nightime sedation

DayQuil Vs NyQuil

Dayquil –> Cough
NyQuil –> Sedation

73
Q

Describe the role of decongestants in the common cold

A

Helpful agents; except phenylephrine

Best agents we have for symptom relief

74
Q

Describe the SUDAFED agents and their efficacy

A

Sudafed - pseudoephedrine
- Great agent
- Can be used to make crystal meth

Sudafed PE - phenylephrine

  • Formulated to prevent crytsal meth synthesis
  • Does not work well due to variable metabolism
75
Q

What are the different types of available decongestants?

A

Oral and Topical

76
Q

How can one decide between oral and topical decongestants?

A
77
Q

What are some concerns with topical decongestants?

A

Rebound congestion

Local irritation

78
Q

Describe the available OTC topical decongestants

A
79
Q

Describ ethe duration of usage of Otrivin? Concern and in who?

A

Xylometazoline

7 days of usage

Max of one month of usage

Head Cold - Use for 3-4 days

Big Worry here is in allergy users

80
Q

What are some warnings for xylometazoline? Is this factual?

A

Xylometazoline should not be used for self-care for more than 3-5 days due to risk of rebound congestion

Wrong 7 days of use

81
Q

What is rebound congestion with topical decongestants?

A

Persistent nasal congestion despite frequent use of a topical decongestant or when the medication is abruptly disocntinued

82
Q

What topical decongestant agents are more concerning for rebound congestion?

A

Rebound congestion occurs more frequently with shorter actingd econgestants (phenylephrine) than with longer actinga gents such as xylometazoline

83
Q

Is there a debate regarding topical decongestants?

A

A literature review by a medical panel

Analysis conducted by the task force tends to refute the concepts of rebound congestion and rhinitis medica-mentosa

Nasal decongestants must nevertheless be use din a controlled setting

84
Q

What is rhinitis medicamentosa?

A

Rebpoung COngestion

Inflammation of the nsal mucosa caused by the overuse of nasal decongestants

85
Q

When does rebound congestion occur?

A

After prolonged use

Sitiuation found to develop as early as 3 days and up to 4-6 weeks of use

Modern vasconstrictors such as imidazoline derivatives, the risk of developping RM is considered to be small

Still ma xout at 7 datys if use

86
Q

Is the recommended days of use for oxymetazoline and phenylephrine the same?

A

Oxyymetazoline - 7 days of use

Phenylephrine - No more than 3-4 days pof use in a row

87
Q

What are some concerns regarding oral decongestants?

A

CNS effects (like a cup of coffee)

CV effects (bp, hr) for 3 days max with HTN
- Do not recommend in HTN

Incraese in blood glucose (already incraesed due to virus)

Angle closure glaucoma
Urinary Retention/prostatet ***

Hyperthryoidism

88
Q

Describe th CV risk of oral decongestants. Recommendation?

A

Can incraese blood pressure - do not use in individuals with HTN

The incraese is minimal in people with controlled high BP

Slight increase if anything, legal over clinical here

89
Q

Evidence of CV risk with oral decongestants

A

Numerous case reports suggest that oral decongestants can raise BP to dangerous levels whereas other reviews suggest that the danger is exagerrated

Pseudoephedrine causes a small increase in SBP (1 mm Hg) and HR (2.8 beats/min). T

he effect in patients with controlled hypertension demonstrated an SBP increase of similar magnitude (1.2 mm Hg).

Higher doses were associated with greater increases.

Shorter duration of use was associated with greater increases in SBP and DBP.

90
Q

Describe the risk to the prostate with oral decongestants

A

Decongestants are alpha-agonists and act to shrink blood vessels

Lots of alpha receptors in the prostate gland

Decongestant gets to prostate and cr5eates more tone leading to es speing and urinary retention

Topicals –> No effect

91
Q

What medications can be used for urinaray retenion due to. en,arged prostate? MOA? Decongestant effect?

A

Proscar (finasteride) –> Decreases 5 α reductase –> Relaxes prostate

Flomax (tamsulosin) –> α adrenergic antagonist –> Blocks alpha receptrs and takes tension off prostate

If giev decongestant –> cancels each other out

92
Q

What are some drug interactions with deocngestants?

A

TCA’s
MAOI’s (MAIN ONE HERE)
SSRI’s/SNRI’s (okay to use; monitor)

MonoAmine Oxidase breaks the neurotransmitters down to inactive cpds

MAOI’s and Decongestants –> Drug induced hypertensive crisis –> Extra noradrenaline flishes out into blood system and hits the heart

93
Q

Concerns with the eyes regarding decongestant usage

A

Galucoma Eye Drops (oipen angle) - Decraeses pressure at the back of the eye

Narrow Angle –> Dilating the iris blocks fluid drainage

Decongetsnats do not interfere here

Statement on package for narrow angle; unlikely - can use in normal galucoma

94
Q

What is narrow angle glaucoma?

A

As pupil dilates, block drainage process, acute spike in intra ocular pressure

Anything that dilates the pupil can cause this

Least common type of glaucoma

95
Q

What can be used for nasal mucous in children?

A

Running Nose - May not need saline

Thick Mucous –> Likely needs saline first
–> let saline sit to soften mucous before suctioning

Vacuum
- Colear tip so parent can see what comes out
-The saline goes into the nose, not into the bulb
- Just for suctioning it out

Close other nostril while suctioning

96
Q

Examples of Saline NAsal Sprays

A

Salinex
Rhinaris
Generic Brands

97
Q

Describe the role of saline nasal mists

A

Plain saline applied into a congested nose, where the mucous has become dry, will be soothing and perhaps ‘moisturizing’.

But this effect will not last long; saline does not ‘soothe’ nor ‘moisturize’ beyond a minute or two.

That is where added lubricants come in, they will be soothing for a longer time and do better on irritated nasal tissue.

But, it is hard to tell which products have actually added lubricants, unless you see something like this on the pkg. (e.g. Rhinaris)

98
Q

Describe the avilable benylin agents

A

Nonproductibve Cough; non-congested - DM

Non-productive; congested - Rather not supress; want to become productive –> Gaufenisen

Productive cough; congested - Nothing

DM + gaufenisen does not make sense

99
Q

Describe the flu decision chart

A
100
Q

Describe a difference between the flu and Covid-19 regarding residual side effects

A

A major difference between influenza and covid-19 is the expectation, that with influenza, once the illness has subsided, the impact of the infectious agent is over

Covid-19 can have lingering effects

101
Q

Treatment of Influenza

A

Pharamcists can prescribe oral anti-viral agents only during an epidemic or pandemic declared by the chief medical officer of SK

102
Q

What are some causes of a fever? WHich are the common ones?

A

Play the Odds Here

103
Q

What are some sx of a fever?

A

Depending on the cause of the fever, additional feer signs and sx include:

104
Q

Fever in head cold and stomach flu?

A

Head cold =
congestion,sneezing,
fever-ish

Stomach flu =
diarrhea, nausea,
fever-ish

105
Q

Describe the best ways to measure a fever

A

Method of choice –> Rectal up to 5 yeaers of age

Armpit = Meh «&laquo_space;Oral

Pharamcy: Most do not take the temp

106
Q

What are the recommended methods to measure temperatur and the temperatures for fever?

A
107
Q

What is the best way to describe how to use a specific thermomemter?

A

Showing the parent a video of this is FAR better than describing it in words !!

108
Q

How to measure a temperature rectally?

A

Most reliable way to measure temperature is rectally

109
Q

nTaking an ear temperature: Age and technqiue

A

5 year Old Patient –> Pull the ear up and back to help position the probe

For babies under 12 months, pull the lobe down and back

110
Q

When do we treat a fever?

A

Is the child:

1) Showing a sick demeanor
2) Attentive
3) lethargic
4) Playing with something

111
Q

When is fever a red flag?

A

A fever on its own with no other sx is a red flag

112
Q

Describe when to treat a fever and its associated temp and duration?

A
113
Q

Describe when an MD should be called for a fever in a child (age and temp)

A

Younger than 3 months –> Rectal temp > 38 C

Ages 3-6 months –> rectal > 39 C and seems unsually iriitable, lethargic or uncomfortab;le

Between the ages of 6 months and 2 years old –> Recral 39 C for longer than one day

114
Q

Children and MD Rferall of Fever

A
115
Q

Does a fever lead to brain damage?

A

Most healthy children and adults can tolerate a fever to 40C for short periods of time without problems

Can handle high temperatures without brain damage

116
Q

Describe the 39C 1,2,3 rule in relation to MD thoughts about fevers

A

Doctors do not start worrying until a fever has lasted for 5 or more days

117
Q

Non-Otc Management of a fever

A

Only treat regarding childs overall state

ANti-pyretic last option –> No value in alterating between acet and Ibu

118
Q

When do we treat kids for a fever?

A

Child in distress - Tx
Help find a product

119
Q

Which anti-pyertic to use?

A

Either Acet or IBu is fine

Advil –> Ibu
- less dosing frequency
- Ok for NSAID-induced asthma exacerbation (adulthood condition)

120
Q

Descriobe acetaminophen dosing

A

Do not need to aaken child to give a dose

121
Q

Publ;ic thoughts on a fever

A

Do not need to wake child up

122
Q

Describe Tylenol fever and Sore Throat: USe?

A

Often in cough ane cold section

Does nothing for main cold sx

123
Q

What is Ibuprofen used for?How long of releief of fever?

A
124
Q

What does Ibuprofen do?

A
125
Q

How fast is releief from pain expected with Ibuprofen?

A

relief from pain may be excpected in 0.5 hour

Slower with food

126
Q

Ibuprofen dosinf

A
127
Q

Strength of Avilable CHildren Advil

A
128
Q

Acet or Ibu for fever

A

Either one is fine for majority of cases

129
Q

Naproxen for fever n

A

Not for fever in Canada

130
Q

Does a fever reeally need to be treated?

A

You only need to treat a fever if the child is miserable or distressed

often give before this

131
Q

What is fever phobia?

A

Unrealistic and exagerrated misconceptions of parents whose children have a fever

132
Q

Can Ibu and Acet be used for fever and Pain simultaneously?

A

Yes

Can give Q4H
Ok as long as you stay below limit of each med

Explain schedule on paper

RArarely wake child up for nightime doses

Combo can have greater efficcayb than individual for management –> Not necessary, just do one well

133
Q

CFP stance on aceta and ibu alternation

A

Monotx has failed, a short trial of alternating regimen could be implemented

Optimal single therapeutic regimen is better than alternating plan

Studies of children with fever report no incraese ina dverse effects

134
Q

Risk of alternating acet and Ibu alternation

A

Do not alternate between using acet and ibu as this can lead to dosing errors

135
Q

What vaccinations can lead to a fever in children?

A

Diptheria, tetanus and acellular pertrususiis or pneumonoccal vaccine

136
Q

How long does a fever following vaccination last for?

A

Fever with most vaccines begins within 24 hours and lasts 1-2 days

137
Q

Overall, evidence about NSAID/ACet usage for vaccines

A

Short-term use of analagesics/antipyretics at non-prescription doses is unlikely to affect vaccine induced immunity

138
Q

How common are febrile seizures?

A

Rare

139
Q

Describe febrile seizures. Is it severe?

A

Usually last for a few minutes (less than 1-2 kins)

Occurs during first few hours of fever

Usually caised by a viral infx

A child will lose conciosuness and both arms and legs will shake

Very scar, they are harmless to the child

3-4% chance

Not caused by the drug (if given), caused by the fever

Child outgrows it as age

140
Q

febrile seizure: Main management

A

Place child on his or her side to prevent chokung

Cool wascloths to forehead and neck

Sponge body with luke warm water
–> Cold water and alcohol may make shivers and make fevr worse

Give acet or Ibu once awake

141
Q

Do anti-pyretics prevent febrile seizures?

A

No evidence that anti-pyretics reduce the risk of subsequent febrile seizure

142
Q

fevers in the elderly

A

Attenuated

Number on theramorer tends to decraese with age

143
Q

Which of the following has a more severe cough: influenza or the common cold

A

Influenza

PHAR 398: Minor Ailments (9 decks)

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