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A2 > FM Cases > Flashcards

FM Cases Flashcards

1
Q

What is the single risk factor that is responsible for the most death?

A

Smoking

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2
Q

What are grades 1-5 of the diabetic foot ulcer grading system?

A
  • Grade 1: Diabetic ulcer (superficial)
  • Grade 2: Ulcer extension (involving ligament, tendon, joint capsule or fascia)
  • Grade 3: Deep ulcer with abscess or osteomyelitis
  • Grade 4: Gangrene forefoot (partial)
  • Grade 5: Extensive gangrene of foot
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3
Q

What criteria must be met to treat a pt with a DVT as an outpatient? (3)

A
  • Hemodynamically stable
  • Good kidney function
  • Low risk for bleeding
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4
Q

True or false: rivaroxaban alone is sufficient to treat a pt with a DVT

A

True

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5
Q

What are the five major advantages of LMWH over unfractionated heparin?

A
  • Longer half life
  • No monitoring needed
  • Lower risk of HITT
  • Fixed dosing
  • May be used in outpatient setting
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6
Q

How long are pts with an unprovoked or provoked DVT anticoagulated for after resolution?

A

3 months unless 2/2 CA. Then no set stopping date

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7
Q

True or false: it is appropriate to screen all pts with a h/o DVT for a thrombophilia

A

False–not all, but those with obvious risk factors, or unprovoked

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8
Q

What is the half-life or warfarin?

A

40 hours

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9
Q

How long does dabigatran need to overlap with LMWH?

A

5 days

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10
Q

How can anemia lead to palpitations?

A

Loss of blood = tachycardia

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11
Q

True or false: menopause can cause palpitations

A

True

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12
Q

A systolic murmur at the left sternal border that increases with Valsalva maneuver would suggests what?

A

HOCM

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13
Q

True or false: pulsating chest pain is more concerning for ACS

A

False–less concerning

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14
Q

When does age become a risk factor for heart disease?

A

Over 55 for women and over 45 for men

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15
Q

Does ASA decrease the risk of ischemic stroke

A

No

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16
Q

True or false: ASA decreases the risk of MI in men

A

True

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17
Q

Difficulty with heel walk is associated with (___) disc herniation

A

Difficulty with heel walk is associated with L5 disc herniation

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18
Q

Difficulty with toe walk is associated with (___) disc herniation

A

Difficulty with toe walk is associated with S1 disc herniation

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19
Q

What etiology of LBP classically improves with squatting?

A

spinal stenosis

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20
Q

LBP that worsens with flexion is suspicious for what etiology?

A

Herniation
OA
Muscle spasm

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21
Q

LBP that worsens with extension is suspicious for what etiology?

A

DJD

Spinal stenosis

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22
Q

What indicates a positive SLR?

A

The test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc.

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23
Q

At what degree of leg movement during the SLR is indicative of malingering?

A
  • True pain will most likely occur between 40 and 70 degrees.
  • Pain earlier than 30 degrees is suggestive of malingering.
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24
Q

What does the crossed SLR do?

A

If disc is herniated, will compress on the nerve roots of the contralateral side. Very specific test, but not sensitive.

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25
Q

What are the s/sx of a disc herniation, besides back pain?

A

Pain worse with sitting
Pain worse with coughing/sneezing
Drop foot

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26
Q

What is the usual prognosis for disc herniation?

A

Self limited most of the time–resolves in two weeks

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27
Q

True or false: leg numbness with LBP is a red flag symptom

A

False–can be seen with simple disc herniations

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28
Q

What are the indications for obtaining an x-ray for LBP in a pt, besides obvious trauma?

A

Strenuous lifting in patient with osteoporosis
Prolonged steroid use
Osteoporosis
Age <20 and >70
History of cancer
Fever/chills/weight loss
Pain worse when supine or severe at night

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29
Q

What is the timeframe for which LBP merits an MRI?

A

More than six weeks of conservative care

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30
Q

What is the recurrence rate of LBP?

A

35-75%

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31
Q

Patients older than what age take longer to recover from episodes of LBP?

A

45

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32
Q

What is the usual presentation of chondromalacia patellae?

A

Anterior knee pain worsens with sitting for long periods

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33
Q

What is the first choice medicine for the treatment of OA?

A

Acetominophen

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34
Q

HOw often and how frequently can steroid injections be given for OA?

A

No more than once per month, and no more than three per year

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35
Q

What is the relative sensitivity and specificity of tinel’s and phalen’s maneuver for carpal tunnel?

A

Somewhat useful with lower sensitivities and higher specificities

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36
Q

What is the first line treatment for carpal tunnel?

A

Nightly wrist splint

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37
Q

What is the most common side effect of opioids?

A

Constipation

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38
Q

Which opioids have a higher risk of tolerance: short or long acting

A

Short

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39
Q

What is a major issue with using carbamazepine for neuropathic pain?

A

p450 inducer

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40
Q

When does colorectal screening stop?

A

age 75

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41
Q

When does breast CA screening stop?

A

age 75

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42
Q

When does cervical CA screening stop?

A

age 65 if they have had normal paps up until this point

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43
Q

When is the pneumovax indicated?

A

Age 65 or those with DM or COPD

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44
Q

When is the 13 valent pneumo vaccine indicated?

A

one year after pneumo 23

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45
Q

When is the varicella vaccine indicated?

A

If over 60 years

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46
Q

What is the major side effect of tramadol?

A

Seizures

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47
Q

What is the normal synovial fluid color?

A

Straw colored

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48
Q

Which comes first in the case of a suspected septic arthritis: PCR or culture?

A

PCR

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49
Q

True or false: warfarin is a contraindication to NSAID use for OA

A

True–have anticoagulant effects

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50
Q

What are the classic CXR features of silicosis?

A

Calcifications of the hilar lymph nodes

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51
Q

What is POEMS syndrome?

A 
Polyneuropathy
Organomegaly
Endocrinopathy
Monoclonal protein
Skin changes
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52
Q

What are the s/sx of POEMS syndrome, besides the POEMS symptoms?

A

Sclerotic bone lesions
Anemia
hyperuricemia

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53
Q

What is the diagnostic test for POEMS syndrome? What does this show?

A

Urine and serum electrophoresis

Shows a monoclonal M spike

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54
Q

Is the rash in pityriasis rosea pruritic?

A

Yes

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55
Q

What is the prognosis for pityriasis rosea?

A

Self limiting within a few months

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56
Q

What are the two major sulfonylureas?

A

Glipizide

Glyburide

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57
Q

What are the electroscopic findings of carcinoid tumors?

A

Dense core granules

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58
Q

Pleural plaques on CXR = ?

A

Asbestosis

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59
Q

What are the auscultatory findings of asbestosis?

A

Fine end inspiratory crackles

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60
Q

How can NSAIDs worsen dilated cardiomyopathy?

A

increase afterload and affect cardiac output by inhibiting prostaglandin synthesis (eliminated their effects on vasodilation) and by counteracting the benefits of ACEIs

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61
Q

What is the pathophysiology of the restrictive lung disease caused by coal pneumoconiosis?

A

Macrophages eat up the coal, and fibrosis in response

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62
Q

What are the cardiac manifestations of silicosis?

A

cor pulmonale

RVH

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63
Q

What are the components of the HEEADSSS mnemonic for preparticipation exams in adolescents?

A 
Home
Education / Employment
Eating
Activities
Drugs
Sexuality
Suicide / Depression
Safety / Violence
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64
Q

Who should be screened for chlamydia? (2)

A

Women over 25 years who are at high risk, and all sexually active women under 25.

NOT:

  • prego
  • men
  • low risk women
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65
Q

What supplement should all sexually active women take in case of pregnancy?

A

Folic acid

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66
Q

What environmental situations should prego pts avoid?

A

Hot tubs or hot areas

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67
Q

What is the caffeine intake recommendation for pregos?

A

No more than two cups / day

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68
Q

What is chadwick’s sign?

A

Bluish/purple hue to the vagina with pregnancy

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69
Q

What is Goodell’s sign?

A

Softening of the cervix with prego

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70
Q

What is Hegar’s sign?

A

Softening of the uterus

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71
Q

When are fetal heart tones first heard?

A

10-12 weeks

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72
Q

What are fetal movement first felt?

A

18-20 weeks

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73
Q

What is a common cause of bleeding early in pregnancy?

A

When trophoblasts attaches to the uterine wall (“implantation bleed”)

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74
Q

Up to how many weeks is an abortion legal?

A

22 weeks

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75
Q

How accurate is the estimated gestational age based on the LMP?

A

Usually actual age is two weeks less than EGA

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76
Q

What is Naegele’s rule for determining the due date of a prego?

A

LMP, Add 1 year
Subtract three months
add 1 week

(or, more concisely, add 9 months and a week from LMP)

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77
Q

When is rhogam indicated in vaginal bleeding episodes?

A

Always, regardless of gestational age

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78
Q

What percent of prego women experience vaginal bleeding in their first trimester? What are the chances of miscarriage?

A

1/4 experience bleeding

25-50% chance of miscarriage

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79
Q

What is a cervical ectropion? What is its significance?

A

When the central part of the cervix appears red from the mucous-producing endocervical epithelium protruding through the cervical os, onto the face of the cervix. It has no clinical significance and is common in women who are taking oral contraceptive pills.

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80
Q

What is the role of progesterone in a threatened miscarriage?

A

If the result is >25, it is highly associated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage or ectopic pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic pregnancy

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81
Q

What is the normal progress of bHCG in pregnancy?

A

Doubles every 48 hours in the first 6-7 weeks.

82
Q

What hCG level indicates that a fetus will be detectable by a transvaginal US? Transabdominal?

A 
Transvaginal = 1500-1800
Transabdominal = over 5000
83
Q

What happens to beta-hCG levels in an ectopic pregnancy?

A

Rise slower than usual

84
Q

What is the measure that is used to determine EGA by US in the first trimester?

A

Crown-rump length

85
Q

What are the four measures that are used to determine EGA by US in the second trimester?

A
  1. biparietal diameter
  2. head circumference
  3. abdominal circumference
  4. femur length
86
Q

When is US gestational age preferred over LMP dating?

A

If the EGA & EDD from the ultrasound measurements are within one week of the EGA / EDD estimated from the LNMP, today’s gestational age and the due date (EGA & EDD) should not change to reflect the ultrasound calculations, as in this case.

If, however, the ultrasound measurements suggest an EGA & EDD that is greater than seven days from the EGA & EDD calculated from the LNMP (or, in some cases, if the LNMP is historically inaccurate), then the estimated gestational age today, as well as the estimated due date, should be changed to reflect the ultrasound measurements and estimates.

87
Q

What happens to dating a pregnancy as it progresses? Why?

A

Less and less accurate

This is because of the response of the fetus to internal and external insults. During the 1st and 2nd trimester, many problems that develop result in pregnancy loss and/or teratogenensis. However, during the third trimester, many of fetal and maternal challenges manifest themselves in fetal growth.

88
Q

What is the definition of threatened abortion?

A

Bleeding before 20 weeks gestation

89
Q

What is an inevitable abortion?

A

dilated cervical os

90
Q

What is an incomplete abortion?

A

some but not all of the intrauterine contents have been expelled

91
Q

What is a missed abortion?

A

fetal demise without cervical dilitation and/or uterine activity (often found incidentally on ultrasound without a presentation of bleeding).

92
Q

What is a septic abortion?

A

with intrauterine infection (abdominal tenderness and fever usually present).

93
Q

What is a complete abortion?

A

The products of conception have been completely expelled from the uterus.

94
Q

What is the medical therapy for an inevitable abortion?

A

Vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this method is generally around 95%, and the time to completion is generally 3-4 days (but may take up to 2 weeks), as opposed to 2-6 weeks with expectant management.

95
Q

True or false: most women who have a miscarriage will not have another

A

True, but biggest risk factor for miscarriages is h/o them

96
Q

True or false: physical and emotional stress can cause miscarriages

A

false

97
Q

What is the amount of folate that a women with DM or epilepsy should take prior to getting pregnant? What about a woman with a h/o delivering a baby with a NTD?

A

1 mg for the diabetic
4 mg for the NTD history
400-800 mcg for all others

98
Q

True or false: a PE can cause wheezing

A

True

99
Q

True or false: pneumonia can cause wheezing

A

False

100
Q

True or false: OSA can cause wheezing

A

False

101
Q

True or false: CHF can cause wheezing

A

True

102
Q

True or false: epiglottitis can cause wheezing

A

False

103
Q

True or false: upper airway cough syndrome (post nasal drip) can cause wheezing

A

True

104
Q

True or false: persistent bronchitis can cause wheezing

A

True

105
Q

How long can acute sinusitis last for, prior to becoming chronic?

A

12 weeks

106
Q

True or false: clear drainage is associated with acute sinusitis

A

False

107
Q

What are the four criteria to diagnose chronic sinusitis? How many are needed to dx?

A

Two of the following:

  • nasal obstruction or congestion
  • mucopurulent drainage (anterior, posterior or both)
  • facial pain, pressure or fullness
  • decreased sense of smell
108
Q

What conditions classically worsen sinusitis? (4)

A

Obesity
OSA
Depression
GERD

109
Q

What is the indication for a methacholine challenge?

A

Normal PFTs, but continued s/sx

110
Q

What are the mainstays of treatment for sinusitis? (2)

A

Oral antihistamines

Inhaled nasal corticosteroids

111
Q

What are the diagnostic criteria for asthma?

A

FEV1 increased by at least 12% after bronchodilator therapy

112
Q

What is the diagnostic test for eosinophilic bronchitis?

A

Eosinophils in the sputum

113
Q

What are the symptoms, FEV1, and medications for mild, intermittent asthma?

A

Up to 2 days/week
Up to 2 nights /month

Over 80% FEV1

PRN albuterol

114
Q

What are the symptoms, FEV1, and medications for mild, persistent asthma?

A

More than 2 times/week or 2 nights / month but less than once a day

FEV1 over 80%

Daily low dose corticosteroids
PRN albuterol

115
Q

What are the symptoms, FEV1, and medications for moderate, persistent asthma?

A

Daily s/sx
More than 1 night a week

FEV1 60-80%

Corticosteroids, long acting b2 agonist, and PRN inhaler

116
Q

What are the symptoms, FEV1, and medications for severe, persistent asthma?

A

Continual, frequent symptoms

FEV1 less than 60%

High dose steroids + long acting beta agonist
PRN albuterol

117
Q

What is the most effective treatment for allergic rhinitis?

A

Nasal corticosteroids

118
Q

Is asthma an indication for the pneumonia vaccine?

A

Yes, but only the 23 variant

119
Q

Who should get the pneumovax-13?

A

Elderly, young, or those with COPD/DM

120
Q

What is an indication of a severe asthma attack in terms of peak flows?

A

Less than 50% of peak flow–80% is good control

121
Q

What are the number of symptoms that qualify for mild, moderate, and severe alcohol use disorder?

A

Mild: Two to three symptoms.
Moderate: Four to five symptoms.
Severe: Six or more symptoms.

122
Q

What is the definition of heavy drinking?

A

Consuming five or more alcoholic drinks on a single occasion, five or more days in a 30-day period.

123
Q

What hCG concentrations are home pregnancy tests positive? Serum hCG?

A 
Home = 25 mlU/mL
Serum = 5
124
Q

When can the gestational sac be visualized with a transvaginal US?

A

4-5 weeks

125
Q

When should the first transvaginal US be performed?

A

ASAP, but not later than 20 weeks

126
Q

Most clinicians will use dates determined by ultrasound for any discrepancy in what three situations?

A

more than one week between the ultrasound and another method in the first trimester
more than two weeks in the second trimester
more than three weeks third trimester

127
Q

True or false: in the third trimester, fundal height measurements have the same accuracy as US

A

True

128
Q

Is intimate partner violence more or less common in pregnancy?

A

More

129
Q

What is the test for Hep B in pregnancy?

A

Surface antigen–core etc will be done if this is positive

130
Q

How often should a UA be obtained in pregnancy?

A

At every prenatal visit

131
Q

When should a pap smear be obtained in pregnant women?

A

12-16 weeks gestation

132
Q

When should a hep C test be performed in pregnancy?

A

Only if high risk for

133
Q

When should varicella testing be performed in pregnancy?

A

Women should be asked about a history of chicken pox; women with no history can have serologic testing for varicella zoster IgG. Non-immune women should be offered preconception or postpartum varicella vaccination. Varicella vaccination is contraindicated in pregnancy.

134
Q

When should herpes testing be performed in pregnancy?

A

All pts should be asked and counseled

Women with a history of recurrent HSV should be counseled about the use of antiviral medicine (such as acyclovir) to reduce risk of cesarean delivery due to active lesions at the time of delivery (the presence of active lesions during labor is a contraindication for vaginal delivery).

135
Q

When should screening for BV be done in pregnancy?

A

Not recommended unless symptomatic

136
Q

When should toxoplasmosis screening be performed in pregnant women

A

Not recommended

137
Q

When should CMV screening be performed in pregnant women

A

Not recommended

138
Q

When should parvovirus screening be performed in pregnant women

A

Not recommended

139
Q

How often should pregnant women be seen for prenatal visits?

A

every 4 weeks until 28 weeks gestation.

Then, q2 weeks from 28-36 weeks

Finally, weekly 36 weeks on

140
Q

When does the neural tube close?

A

4 weeks

141
Q

When does the heart begin to beat in pregnancy?

A

8 weeks

142
Q

When do the heart, spine, arms, legs, and other organs begin to take shape in pregnancy?

A

1-12 weeks

143
Q

True or false: prolonged standing is good for pregnant women

A

false–linked to complications

144
Q

What is the recommendation for exercise in pregnant women?

A

30 minutes on most days of the week

145
Q

What are the risks of hot tubs and sauna use in pregnancy?

A

NTDs

miscarriages

146
Q

What is the recommendation regarding fish eating in pregnancy?

A

Don’t eat–Hg

147
Q

What is recommendation for the use of aspartame in pregnancy?

A

Fine in moderate amounts if mom does not have PKU

148
Q

What is the recommendation regarding saccharin use in pregnancy?

A

Do not use.

149
Q

For expecting mothers whose BMI is between 18.5-25, what is the expected amount of weight gain?

A

25-35 lbs

150
Q

For expecting mothers whose BMI is between 25-30, what is the expected amount of weight gain?

A

15-25 lbs

151
Q

For expecting mothers whose BMI is 30 and above, what is the expected amount of weight gain?

A

10-20 pounds

152
Q

When does the fundal height correspond to the weeks gestation?

A

20 weeks +

153
Q

When does the fundus become palpable in prego?

A

10 weeks ish

154
Q

When does serum screening for chromosomal abnormalities begin?

A

15-21 weeks

155
Q

When is Rhogam given to pregnant women?

A

At 28 week and 72 hours prior to delivery

156
Q

IS the flu vaccine recommended for pregnant women?

A

Yes, but only the injection

157
Q

What are the components of the triple screen?

A

AFP
hCG
Unconjugated estriol

158
Q

What are the components of the quad screen?

A

AFP
hCG
Unconjugated estriol
dimeric inhibin A

159
Q

What is the screen for NTDs, and when is it performed?

A

10-14 weeks

Nuchal translucency + biomaker

160
Q

When is chorionic villus sampling performed in pregnancy?

A

First trimester

161
Q

When is amniocentesis performed in pregnancy?

A

second trimester

162
Q

Routine US screening for fetal anomalies is recommended starting when?

A

18-20 weeks

163
Q

What are the dietary measurements for n/v in early pregnancy?

A
  • frequent, small meals
  • Solid foods should be bland
  • Salty food in morning, sour/tart liquids better than water
164
Q

When does the n/v in pregnancy usually occur?

A

4-20th week

165
Q

When can sex be determined by US for fetuses?

A

18 ish weeks

166
Q

What is the sensitivity of a quad screen for fetal anomalies?

A

80%

167
Q

What is the sensitivity of the triple screen?

A

70%

168
Q

What is the rate of spontaneous abortion 2/2 amniocentesis?

A

1/300 - 1/500

169
Q

What is the prognosis for placental previa early on in the pregnancy (21 weeks or under)?

A

Spontaneously resolve

170
Q

What are the risk factors for placenta previa? (5)

A
  • have had a prior pregnancy
  • are older (>35)
  • smoke
  • have had twins or a higher multiple pregnancy
  • have had previous uterine surgery, including prior cesarean section
171
Q

True or false: partial or marginal placenta previas are less likely to resolve on their own compared to complete placenta previas

A

False–more likely to resolve

172
Q

What is the management for placenta previa after found with US?

A
  • US surveillance, and monitoring for bleeding

- If not resolved by delivery time, then c-section

173
Q

What are the components of anticipatory guidance at 23 weeks? (3)

A

Breastfeeding talk
Car seats
Contraception s/p delivery

174
Q

When should screening for gestational DM be performed?

A

24-28 weeks

175
Q

What is the definition of chronic HTN in pregnancy defined as?

A

Blood pressure elevation first detected before the 20th week of pregnancy that persists beyond 12 weeks postpartum.

176
Q

What is the definition of gestational HTN in pregnancy defined as?

A

The presence of persistent systolic blood pressure of ≥140 mmHg and/or a diastolic blood pressure of ≥90 mmHg, without proteinuria, in a previously normotensive pregnant woman at or after 20 weeks of gestation.

177
Q

What is the definition of preeclampsia defined as?

A

The presence of persistent systolic blood pressure of ≥ 140 mmHg and/or a diastolic blood pressure of ≥ 90 mmHg, with proteinuria of 0.3 grams or greater in a 24-hour urine specimen.

178
Q

What are the risk factors for eclampsia?

A

White, nulliparous women from lower socioeconomic backgrounds are at higher risk, and the incidence appears to be higher in younger (teenage and low twenties) and older (> 35 years) women.

179
Q

What is the risk of developing eclampsia in women with mild and severe preeclampsia respectively?

A

Eclampsia occurs in about 0.5% of women with mild preeclampsia and in about 2-3% of women with severe preeclampsia.

180
Q

What are the s/sx of severe preeclampsia?

A
  • Visual disturbances
  • HAs
  • N/v
  • RUQ pain
  • Decreased urine output
181
Q

When does the fetus begin to breathe and open eyes?

A

27-ish weeks

182
Q

What are the criteria for the fasting glucose tolerance test in pregnancy?

A

Need two or more of the following:

  • Fasting serum glucose concentration ≥ 95 mg/dL
  • One-hour serum glucose concentration ≥ 180 mg/dL
  • Two-hour serum glucose concentration ≥ 155 mg/dL
  • Three-hour serum glucose concentration ≥140 mg/dL
183
Q

When is screening for gestational DM done?

A

27 weeks

184
Q

When does GBS screening start?

A

35-37 weeks

185
Q

True or false: it is standard practice to perform urine screening for GBS

A

False

186
Q

What are the first and second line choices for GBS in pregnancy?

A

PCN

Ampicillin

187
Q

What is PUPPP? What are the s/sx? When does it occur? treatment?

A

-pruritic urticarial papules and plaques of pregnancy
-Trunk and extremity lesions that are treated with low dose steroid and topical lotions
-

188
Q

What are the components of the birth plan for pregnant women?

A
  • who will be present
  • strategies for pain management
  • Comfort measures
189
Q

What is the usual presentation of placenta previa?

A

Bright red, painless vaginal bleeding after 20 weeks w/o contractions (usually)

190
Q

What is the management for placenta previa?

A

Stop sexy time

191
Q

What is the presentation of placental abruption?

A

Vaginal bleeding with associated abdominal pain, contractions, and non-reassuring FHTs

192
Q

What is the treatment for placental abruption?

A

some are self limited if small, but sometimes c-section if fetus oxygen/nutrient supply significantly disrupted

193
Q

What is the definition of preterm labor?

A

Labor beginning before 37 weeks

194
Q

What is the usual presentation of uterine rupture?

A

Bleeding
Fetal distress
expulsion of the uterine wall and overlying serosa

195
Q

What is the treatment for uterine rupture?

A

C-section with uterine repair or hysterectomy

196
Q

What is the treatment for BV in pregnancy?

A

Metronidazole 500 mg BID x 7 days

197
Q

What is the treatment for a UTI?

A

Cipro 500 mg BID x 7 days

198
Q

What is the treatment for vaginal candidiasis?

A

Clotrimazole cream, 1 vaginal applicator full per vagina BID x 7 days

199
Q

What is the Moro reflex? What happens to this reflex with Down syndrome?

A

Air grabbing reflex when head is let down suddenly

Decreased reflex with downs

200
Q

What type of contraception is contraindicated in the recent postpartum woman?

A

Estrogen containing since it interferes with breast milk

201
Q

How long do postpartum blues typically last?

A

2 weeks

202
Q

What is the post natl depression scale used to screen for postpartum depression?

A

Edinburgh

A2 (26 decks)

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