Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CP2 Child Health > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

CONSTIPATION: To be able to take a history to differentiate simple constipation from motility disorders such as Hirschprung’s disease.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

CONSTIPATION: To understand the management of simple constipation/stool withholding

A

Management

  • Lifestyle changes
    • Increase fibre intake: Fruit, veg, fruit juice
  • Addressing toilet habits
    • Encourage to go to toilet after meals for 5 minutes
    • Star chart as a reward
    • Step to enhance sitting position
  • Pharmacolgocial
    • 1st line: Stool softeners
    • 2nd line: Stimulant
    • Oral magnesium citrate/phosphate: Bowel ‘clear out’
  • Relief from distension or prolonged constipation if there is no response to above listed treatment
    • Enema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

CONSTIPATION: Be aware of features of history that differentiate soiling due to constipation and overflow and functional encopresis.

A

Soiling due to constipation

  • Faeces tend to be looser (types 6/7) as this is overflow diarrhoea
  • History of constipation: Difficulty passing stools, abdominal pain/distension,

Soiling due to functional encopresis (repeated (involuntary) faecal soiling)

  • May be ‘smears’ or more rarely whole stools
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

CONSTIPATION: Be aware of sources of support for children and families with soiling and encopresis.

A

ERIC - The childrens bowel and bladder charity

NHS Choices

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

CONSTIPATION: Understand aetiology, presenting features and management options of Hirschsprung’s disease.

A

Hirschprung’s disease

RARE but top differential in CONSTIPATION

Aetiology: Failed development of a portion of the myenteric plexus, of the large bowel or rectum. This causes a segment of the bowel to be ‘paralysed’ and narrowed and constricted, preventing the passage of stools (no peristaltic movement).

Associated with Down’s syndrome

Presenting features:

  • Delayed passage of meconium (> 24 hours)
  • Bilious vomiting
  • Explosive diarrhoea
  • Older children: Abdominal distension, faltering growth

Management:

  1. Bowel irrigation: Allows for faecal emptying. Only if NO enterocolitis
  2. Colostomy and biopsy
  3. ‘Pull through procedure’: Ganglionic bowel is connected to the rectum, restoring continuity of the bowel. The colostomy may then be reversed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

CONSTIPATION: Differentials for constipation

A
  • Idiopathic constipation
  • dehydration
  • low-fibre diet
  • medications: e.g. Opiates
  • anal fissure
  • over-enthusiastic potty training
  • hypothyroidism
  • Hirschsprung’s disease
  • hypercalcaemia
  • learning disabilities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

CONSTIPATION: Be aware of serious / life threatening complications and presenting features of Hirschprung’s disease.

A

Enterocolitis: Presents with abdominal pain, bloody watery diarrhoea, circulatory collapse and sepsis

Aetiology: Bowel ischaemia → necrosis → perforation → enterocolitis

Post-operative diarrhoea (following resection of bowel)

Duhamel-related rectal pouch (persistence of a section of the aganglionic bowel. Can grow overtime and allow for chronic faecal impaction)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

GASTROENTERITIS: To be aware of current NICE guidelines on management of gastroenteritis. This includes clinical examination relating to assessment of hydration.

A

Current NICE guidelines:

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

DIARRHOEA: Understand suggestive features in history and recommended management of infant with cow’s milk protein intolerance.

A

Features of history:

  • Vomiting (non-bilious)
  • Diarrhoea
    • Blood in stools (due to allergic colitis) in an otherwise healthy infant
  • Colicky-pain
  • Skin rash
  • FHx of ectopy
  • Faltering growth

Management:

  • Breast fed: Exclusion of cows milk from maternal diet
    • Prescribe maternal calcium and vitamin D supplementation
  • Specialised formula
    • Extensively hydrolysed
    • Amino acid: For those who cannot tolerate extensively hydrolysed
  • May reintroduce cows milk into the diet at a later stage of development (1 year)?
  • Do not use soya milk under 6 months of age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

DIARRHOEA: Understand the age range and clinical features of toddler diarrhoea.

A

Age range: 6 months - 5 years

Clinical features:

  • Colicky intestinal pain
  • Increased flatulence
  • Abdominal distension
  • Loose stools with undigested food (‘peas and carrots’
  • Child is otherwise well and thriving
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

DIARRHOEA: Offer reassurance from more serious forms of diarrhoea

A

‘Commonly happens in children of this age..’

‘There are no risk factors/features in the history that suggest anything more serious/infection’

No sign of dehydration, no blood in stools

‘The examination has been completely normal, there is nothing concerning me’

‘If you’re still worried or things get worse then consult your GP or come back’

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

NUTRITION: To be aware of current NICE guidelines on infant feeding

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

NUTRITION: To be able to counsel parents on where to obtain advice / support with relation to breast feeding

A
  • Healthcare professionals: Midwife, health visitor, GP
  • Local support: Local children’s Centre or Family Information Service
  • Helplines: National Breastfeeding Helpline
  • Websites
  • Start4Life Breasting feeding

Should breast feed at least 8 times a day in the first few weeks

Cannot overfeed a breast fed baby

Babies stomach is small (size of walnut) hence, feeding must be little and often. This is why baby-led feeding is important

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

NUTRITION: To have a knowledge of specialist formulas and indications for their use i.e.: whole protein vs semi-hydrolysed vs hydrolysed feed

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

NUTRITION: To be able to take a history to determine a differential diagnosis in cases of failure to thrive/faltering growth.

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

NUTRITION: Understand importance of nutrition scoring (MUST tool and paediatric equivalents)

A

Nutritional scoring allows for the risk of malnutrition to be calculated and therefore avoid malnutrition in at risk individuals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

NUTRITION: Understand the concept and presenting features of protein / energy malnutrition (kwashiorkor).

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

NUTRITION: Recognise symptoms and signs of overfeeding

A

Signs:

  • Accelerated weight gain
  • Excessive nappy changes (8 or more heavily soiled)

Symptoms:

  • Abdominal distension
  • Diarrhoea (foul smelling)
  • Excessive flatulence and passing of wind
  • Refusal to feed

! Cannot overfeed a breast fed baby (NHS)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

GASTRO-OESOPHAGEAL REFLUX: Understand concept of gastro-oesophageal reflux, symptoms and the pathophysiology.

A

Concept: Retrograde passage of gastric contents into the oesophagus.

Classified as GORD when this process causes disturbance/distress to the patient.

Symptoms: Vomiting, chronic cough, irritability, reduced/distress feeding, difficulty feeding, faltering growth

Red flags/Must not miss: Epidodes of apnoea

Onset is normally seen at around 8 weeks with resolution by 12 months

Pathphysiology: Weakness of the lower oesophageal sphincter allows for gastric contents to pass into the oesophagus. Due to the acidic nature of the contents local irritation to the oesophagus may result (oesophagitis, bleeding) or metaplastic changes may occur.

Also, due to neonates/infants remaining in a supine position for the majority of time and they’re diet comprising of mainly fluids they are further predisposed to reflux.

20
Q

GASTRO-OESOPHAGEAL REFLUX: Outline non-medical, medical and surgical management strategies.

A

Non-medical:

  • Positioning of cot: Raise head
  • Smaller and more frequent feeds

Medical:

  • Thickened formula or thickeners for breast milk
  • Alginate (2 week trial, the continue if beneficial. Stop treatment at regular intervals to see if symptoms have improved)
  • PPI or Histamine 2 receptor antagonist if alginate therapy is unsuccessful

Surgical:

  • Nissen fundoplication: The fundus of the stomach is wrapped around the intraabdominal oesophagus
21
Q

GASTRO-OESOPHAGEAL REFLUX: Understand rare complications

A

NOTE: Reflux normally resolves/lessens by 12 months of age

SIDS: Reflux of gastric contents may lead to apnoea and subsequent death

Sandifer’s syndrome: Arching of the back and toricollis (abnormal neck posturing)

Aspiration: Stomach contents may pass into the lungs, leading to (recurrent) chest infections.

Oesophagitis: Inflammation of the oesophagus which may manifest as dysphagia, odynophagia, faltering growth, ?melaena

Barrett’s oesophagus: The squamous cells of the oesophagus undergo metaplastic change to columnar cells. Can predispose to neoplastic changes.

22
Q

JAUNDICE: Understand aetiology and pathogenesis of conjugated and unconjugated jaundice

A

Conjugated jaundice: The products of red blood cell breakdown have undergone conjugation in the liver but have been unable to travel to the small intestine, via the biliary tree, for excretion. Instead, bilirubin is reabsorbed into the blood stream. Indicates an obstruction has occured, leading to pale stools and dark urine.

Differentials: Gallstones (older children), biliary tree atresia, obstruction of the biliary tree

Uncojugated jaundice: The products of red blood cell breakdown have not been able to pass to/exceed the capacity of the liver. Resultantly, the breakdown products are unable to undergo conjugation.

Differentials: Physiological jaundice, breast milk jaundice, haemolytic disorders (rhesus or ABO incompatabilty), sepsis, metabolic disorders (galactosaemia, hereditary fructose intolerance, alpha-1 antitrypsin deficiency, hypothyroidism), liver enzyme problems (Gilbert’s syndrome and Crigler-Najjar syndrome), G6PD deficiency,

23
Q

JAUNDICE: Be aware of RCPCH / NICE guideline for investigation and management of jaundice.

A

Identify risk factors for development of significant hyperbilirubinaemia: Gestational age < 38 weeks, previous sibling with neonatal juandice requiring phototherapy, intention to exclusively breastfeed, visible jaundice in the first 24 hours of life

Examine at every opportunity - especially in the first 72 hours of life

Investigation

  • Visual inspection: Examine the gums and sclera. Check for jaundice on blanched skin
  • Urgent measurement of bilirubin level (within 6 hours) using a transcutaneous bilirubinometer or serum bilirubin if not available
    • If < 35 weeks gestation then serum bilirubin is indicated
  • Assessment of possible underlying disease:
    • Blood packed cell volume
    • Blood group (mother and baby)
    • Coombs’ test: Check for Rhesus status
    • G6PD levels (possibly)
    • Blood/urine/CSF microbiology (if infection is suspected)

Management

  • The level of hyperbilirubinaemia determines the management
  • Levels below phototherapy threshold but within 50 micromol/L of the phototherapy threshold:
    • Repeat bilirubin measurement
  • Phototherapy required:
    • Determined by gestational age vs bilirubin levels - see treatment threshold graph
      !NOTE - graphs are gestational age specific, check it is the correct one!
    • Intensive phototherapy should not be interrupted for feeding etc.
    • Complications include temporary rash, overheating, waterloss, diarrhoea, retinal damage (eye protection worn)
    • Acts to increase the ease of breakdown
  • Exchange transfusion indicated:
    • Determined by gestational age vs bilirubin levels
    • Requires admission to ICU. Performed alongside intensive phototherapy
    • Adverse effects:
  • Prolonged jaundice - gestational age of 37 weeks or more and jaundice lasting > 14 days OR gestational age < 37 weeks and jaundice lasting > 21 days
    • Check for signs of obstruction: Pale chalky stools and dark urine that stains the nappy
    • Measure conjugated bilirubin (elevated in obstructive jaundice)
    • Carry out FBC
    • Carry out blood grouping (mother and baby) and Coombs’ test
    • Urine culture
    • Ensure routine metabolic screening has been performed (Newborn spot test - congenital hypothyroidism, PKU, sickle cell disease, CF, MCADD, MSUD, IVA, GA1, homocystinuria)
    • Expert advice if conjugated bilirubin level is > 25 micromol/L - may indicate serious liver disease

Jaundice within the first 24 hours of life

  • Obvious jaundice in the first 24 hours of life requires urgent measurement of serum bilirubin level (within 2 hours)
  • Measurements should be repeated every 6 hours until the level is below the treatment threshold and stable/falling
  • Urgent medical review to exclude pathological causes

Kernicterus: Unconjugated bilirubin is able to cross the BBB and cause damage to the brain and spinal cord. Can result in cerebral palsy, hearing loss and intellectual disabilty.

24
Q

JAUNDICE: Understand the importance of stool colour in assessing a child with jaundice.

A

Pale stools and dark urine indicate an obstructive cause of jaundice (conjugated bilirubin).

Pale stools are resultant of absence of stercobilin within the faeces (as bilirubin cannot pass to the small intestine following conjugation within the liver). Urine is dark as the conjugated bilirubin can be reabsorbed from the blood by the kidneys and excreted in urine.

This is a red flag as it may be resultant of a deformitity of the GI tract, such as biliary tree atresia.

25
Q

JAUNDICE: Be aware of biliary atresia and know the features within history examination and investigation findings that would point you toward this diagnosis.

A

Features of history:

  • Jaundice (mild)
  • Onset of jaundice > 14 days and up to 2 monhs of age
  • Pale stools and dark urine
  • Faltering growth

Features of examination:

  • Hepatomegaly
  • Splenomegaly (2º to portal hypertension)

Features of investigation:

  • Elevated conjugated bilirubin
  • Deranged LFTs
  • Incomplete GI tract/gallbladder abnormalities on imaging - USS
  • ERCP reveals an unusual outline of the biliary tree
  • Liver biopsy shows neonatal hepatitis
26
Q

JAUNDICE: Be aware of the aetiology and presenting features of viral hepatitis.

A

Aetiology:

Hepatitis (A/B/C/D/E/) - chronic vs acute

EBV

CMV

HSV

VZV - a rare complication on chicken pox

Enterovirus

Rubella

Parvovirus (causes fifth disease)

Presenting features:

  • Fever and malaise (flu-like) with jaundice
  • Nausea and vomiting
  • Abdominal pain
  • Hepatomegaly with tenderness
  • LFTs - Elevated hepatic transaminases

Chronic hepatitis → coagulopathy, ascites 2º to reduced production of plasma proteins, immunodefieincy

27
Q

MALABSORPTION: Be aware of NICE guideline for diagnosis and management of coeliac disease.

A

Diagnosis:

History

  • Presentation between 8 - 24 months of age
  • Faltering growth (after introduction of solids/wheat products)
  • Symptoms: Abdominal bloating, diarrhoea/constipation, rice water stools, steatorrhoea, irritability/discomfort
    • In general, persistent and unexplained GI symptoms
  • Signs: Vitamin deficiencies (folate/B12/iron)
  • FHx/personal history of coeliac disease or other autoimmune conditions

Examination

  • Abdominal: Distension, ?tenderness
  • Other examinations normal
  • Normal vital signs
  • May be signs of dehydration: Mucus membranes, CRP, reduced urine output

Investigations

  • Elevated tTTG and EMA
  • Stool sample shows no infective cause

Management:

  • Introduce gluten diet
    • Dietician input
    • Advice for parents
  • Annual blood tests to check for the development of other autoimmune conditions or deficiencies (B12/folate/vitamin D/calcium) which may be resultant of the condition
  • Monitoring of height and weight via growth charts
28
Q

MALABSORPTION: Understand how to take a history to elicit symptoms of and risk factors for food intolerances.

A

Ddx: Coeliac disease, IBD, allergies, gastroenteritis

Symptoms of food intolerances:

  • GI symptoms: Abdominal pain, diarrhoea, constipation, bloating, nausea, vomiting, flatulence
  • Symptoms follow ingestion of certain foods/transient
  • ?Lack of systemic symptoms
  • Small amounts may be ingested without adverse effects whereas in allergy even small amounts cause a reaction to be mounted

Risk factors:

  • Family or personal Hx of intolerances
  • Asthma
  • Age - more common amongst younger age groups
29
Q

MALABSORPTION: Understand difference between type 1 and type 2 reactions and their management in food intolerance.

A

Type 1: Immediate allergic reactions. IgE triggers the release of pro-inflammatory chemical mediators from mast cells and eosinophils

! Causes an anaphylactic reaction! Requires administration of adrenaline, antihistamines and corticosteroids

Type 2: B cell mediated, require antibodies (IgM and IgG) to bind to the surface of antigens and activate the complement cascade. There is also antibody dependent T cell cytotoxicity.

Examples: Haemolytic disease of the newborn (Rhesus), autoimmune haemolysis anaemia, rheumatic fever (can follow group A strep. infection)

30
Q

MALABSORPTION: Understand what is meant by the term malabsorption.

A

Malabsorption:

Imperfect absorption of food material by the small intestine

Food material passes through the intestinal tract without the necessary/normal extraction of nutrients occurring, causing nutrients to instead to excreted in faeces.

Disorders affecting the digestion or absorption of nutrients manifest as abnormal stools, poor weight gain/faltering growth, specific nutrient deficiencies

31
Q

MALABSORPTION: Be able to take history / undertake examination to determine differential diagnosis in case of suspected malabsorption.

(THINK Ddx and features which may be present)

A
32
Q

MALABSORPTION: Be aware of first line investigations.

A

Bloods

FBC: Check for anaemia (if IBD has caused blood in stools), thrombocytosis and leucocytosis may also be seen in IBD

Coeliac testing: Anti-tTG and EMA

CRP/ESR: Check for infective caused, may be raised in IBD

Faecal calprotectin: Elevated levels indicate mucosal inflammation

U&Es: Chronic diarrhoea may lead to dehydration

LFTs: Check albumin levels.

Vitamin B12, vitamin D and folate: Vitamin deficiencies may be present

Stool microscopy and culture

Stools MS&C: Allows for infective causes to be identified e.g. C.difficile or pseudomembranous colitis1

Imaging

Endoscopy: Gold standard for diagnosis of IBD

AXR: Check for toxic megacolon or perforation

Barium meal and follow through: Check patency of the GI tract in Crohn’s

Biopsy

Biopsy: Gold standard for diagnosis of IBD

1: (Swelling of the large intestine due to overgrowth of C.difficile. A common cause of diarrhoea ater antibiotic use, especially clindamycin, cephalosporins (in particular second‑ and third‑generation cephalosporins), quinolones, co‑amoxiclav and aminopenicillins (for example, ampicillin and amoxicillin)))

33
Q

FUNCTIONAL ABDOMINAL PAIN: Understand concept of colic and sources of parental advice and support

A

Colic: A non-pathological syndrome that is thought to be abdominal is nature. Characterised by persistent/paroxysmal crying, excessive flatulence and drawing of the knees up to the chest.

Onset is usually within the first few weeks of life and resolution is normally seen by 3-12 months.

! Excessive and persistent crying increases the risk of NAI, such as from shaking of the infant

→ Parents require additional support

Sources of parental advice/support:

  • Cry-sis helpline
  • NHS choices
  • Health visitor
  • Family - ensure there is provision of alternative care for baby, allowing a break for parents
34
Q

FUNCTIONAL ABDOMINAL PAIN: Understand history, examination and investigation findings that would point to diagnosis of functional (recurrent) abdominal pain.

A

Recurrent/functional abdominal pain: Abdominal pain insufficient enough to disrupt normal activities but persisting for greater than 3 months. Characterised by periumbilical pain in an otherwise well child. The child may suffer from constipation which is likely to be stress related.

35
Q

DIARRHOEA: Understand suggestive features in history and recommended management of infant with cow’s milk protein intolerance.

A

Features of Hx:

  • Blood in stools (in an otherwise well child)
  • Diarrhoea
  • Abdominal pain/distension
  • Vomiting
  • Atopic dermatitis
  • Faltering growth
  • Irritability

Management

Breastfed babies: Exclusion of cows milk from maternal diet

Bottle fed babies: Semihydrolysed milk

Fully hydrolysed milk may be indicated if semihydrolysed is not tolerated

AVOID use of goat/sheep milk as an alternative - allergies to these are commonly also developed

AVOID use of soya milk substitutes < 6 months

Cows milk may be reintroduced into the diet at 1 year of age

36
Q

DIARRHOEA: Understand the age range and clinical features of toddler diarrhoea.

A

Age range: 6 months - 5 years of age

Clinical features:

  • Colicky-type abdominal pain
  • Increased flatulence
  • Abdominal distension
  • Diarrhoea with undigested food (‘peas and carrots’)
  • Otherwise well - normal growth on growth charts, normal intake
37
Q

CROHNS DISEASE/ULCERATIVE COLITIS: Be aware of presenting features

A
38
Q

CROHNS DISEASE/ULCERATIVE COLITIS: Understand differences in pathology and clinical signs/symptoms of Crohn’s and ulcerative colitis

A
39
Q

CROHNS DISEASE/ULCERATIVE COLITIS: Be aware of extra systemic manifestations.

(Begin by listing the affected systems)

A

Systems affected: Skin, eyes, joints, hepato-biliary

40
Q

CROHNS DISEASE/ULCERATIVE COLITIS: Be aware of main treatment options.

A

Mainstay of treatment is immunomodulatory medications and steroids

Treatment of Crohn’s disease

Induction of remission:

  • Nutritional therapy (normal diet is replaced by whole protein modular feeds for 6 – 8 weeks)
  • Systemic steroids may be used if the above is ineffective

Maintenance of remission:

  • Immunosuppressant medication: Azathiprine, mercaptopurine, methotrexate
  • Anti-tumour necrosis factor agents may be used when conventional treatments have failed

Surgery:

  • Necessary for complications of Crohn’s – obstruction, fistulae, abscess formation or severe localized disease unresponsive to medical treatment

Correction of growth failure:

  • Supplemental enteral nutrition – overnight nasogastric or gastrostomy

Treatment of Ulcerative Colitis

Induction and maintenance therapy

Mild disease – aminosalicylates

  • Acute exacerbation in aggressive or extensive disease
  • Systemic steroids
  • Immunomodulatory therapy

Treatment of resistant disease

  • Biological therapies – infliximab, ciclosporin

Ineffective treatment using pharmacological agents → surgery

  • Ileostomy or ileorectal pouch for severe fulminating disease
41
Q

GASTRITIS: Understand symptoms, signs and aetiologies of gastritis.

A

Symptoms:

  • Epigastric pain
  • Nausea/vomiting

Signs:

  • Melaena

Aetiologies: Medications, infection (H.pylori), allergies, autoimmune disease

42
Q

GASTRITIS: Be aware of role of helicobacter pylori in gastritis

A

Pathophysiology: H. Pylori causes increased secretion of gastric acid, increasing susceptibility to gastric irritation and ultimately ulceration.

Detection: 13C breath test to detect urease OR stool sample antigen

Causes nodular antral gastritis.

43
Q

GASTRITIS: Be aware of lifestyle factors in gastritis.

A
  • Smoking
  • Alcohol
  • Caffienated drinks
  • Medications: NSAIDs, SSRIs, steroids, contraceptives
  • Foods: Spicy, citrus
44
Q

GASTRITIS: Be aware of the causes and treatment of gastric duodenal ulcers.

A

Causes:

  • H. Pylori infection
  • Long term use of NSAIDs/aspirin

Treatment

Eradication therapy of H.Pylori

PPI

Signs/symptoms: Characteristic burning/knawing epigastric pain

45
Q

MESENTERIC ADENITIS: Understand concept and differential diagnosis

A

Concept: Abdominal pain that is resultant of inflammation of the lymph nodes of the mesentery of the GI tract

  • Commonly follows an URTI
  • Features: Diffuse tenderness, guarding in the absence of rigidity

Differential diagnosis:

  • Appendicitis: Epigastric pain initially with localisation to the RIF. Vomiting/nausea, severe pain
  • Intussception: Abdominal pain, bilious vomiting, red current jelly, RUQ sausage shaped mass
  • Meckel diverticulitis
  • Bowel obstruction
  • Gastroenteritis

CP2 Child Health (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions