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6030 Primary Care Test 3 COMPLETE ☑️ > Module 8: GU > Flashcards

Module 8: GU Flashcards

1
Q

Barriers to Men’s Health

A
  1. Men often feel embarrassed and un-masculine to have an exam
  2. Many providers also feel embarrassed and may avoid testicular and prostate exams
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2
Q

Adolescent Injury Statistics

A
  1. Males 2.5x more likely to die of unintentional injury
  2. Males 5x more likely to die of homicide or suicide
  3. Largest proportion of injuries d/t MOTOR VEHICLES**
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3
Q

Function of Testicle

A
  1. Produce Sperm

2. Produce Testosterone hormone

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4
Q

Testicular Cancer

-Risk Factors

A
  1. Most common CA in ages 15-35 yrs
  2. Fam hx of testicular CA or mother/sister w/ breast CA
  3. White > black
  4. Undescended testicles — 10% higher risk
  5. Hx of HIV infection
  6. Higher social status and unmarried

EARLY DIAGNOSIS is almost always curable**

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5
Q

Testicular Cancer

-Clinical Presentation

A
  1. Small, hard, PAINLESS lump, size of pea, which may grow
  2. Mass will NOT trans-illuminate
  3. Feeling of heaviness in testicle w/ enlargement
  4. Change in feel of testicle to touch
  5. Sudden accumulation of fluid in scrotum
  6. May present concurrently w/ gynecomastia
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6
Q

Testicular Torsion

-Definition & info

A
  1. Obstruction of blood flow to testes b/c of a twisting of arteries and veins in spermatic cord inside scrotum
  2. Testicle can die w/in 4-8 hrs if not treated IMMEDIATELY
  3. MEDICAL EMERGENCY**
  4. Described as “TENDER, High-riding testicle”
  5. Most common in newborns and ages 10-25 yrs
  6. Diagnosed w/ Ultrasound and clinical presentation
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7
Q

Testicular Torsion

-Presentation

A
  1. Sudden and SEVERE pain
  2. Most often LEFT testicle d/t longer spermatic cord on right side
  3. Adults present after vigorous work-out or RUNNING
  4. Adolescents often AWAKE w/ scrotal pain
  5. Cremasteric reflex absent (MOST COMMON sign)**
  6. Elevation of testis does not relieve testicular pain (Phren’s sign doesn’t work)
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8
Q

Testicular Torsion

-Differentials

A
  1. Hydrocele
  2. Orchitis
  3. Strangulated inguinal hernia
  4. Epididymitis
  5. Varicocele
  6. Scrotal abscess
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9
Q

Hydrocele

-Definition

A
  1. Fluid accumulation around testicle
  2. Usually superior & anterior to testicle
  3. Typically painless
  4. Treatable
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10
Q

Hydrocele

-Presentation

A
  1. Testicle will transilluminate
  2. Benign but may mask testicular cancer
  3. Range from un-palpable to grapefruit size
  4. Diagnosed w/ Ultrasound
  5. NO Treatment
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11
Q

Varicocele

-Definition & Info

A
  1. Increased venous dilation above testes — increases w/ valsalva maneuver
  2. Usually on left side or bilaterally
  3. “Bag of worms”
  4. Usually painful described as “DULL, Achy”
  5. May decrease fertility
  6. Treatment — watch & wait; support briefs; or surgery
  7. Does NOT transilluminate
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12
Q

Varicocele

-Differential Dx.

A
  1. Hydrocele
  2. Spermatocele
  3. Testicular tumor
  4. Epididmytis
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13
Q

Varicocele

-Management

A
  1. Conservative Treatment — NSAIDS and Scrotal support - boxer briefs
  2. Refer to Surgeon — Ligation of spermatic vein or embolization w/ coils
  3. Tx has NOT consistently improved sperm count or fertility in controlled trials
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14
Q

Spermatocele

-Definition & Info

A
  1. Cystic lesions in head of epididymitis — superior and posterior to testes
  2. Painless and does Transilluminate
  3. Most COMMON cyst in scrotum
  4. Diagnosed by PALPATION of cyst outside testicle
    —Ultrasound if still unsure
  5. Treatment — Leave it alone; surgery is discouraged
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15
Q

Spermatocele

-Differentials

A
  1. Epididymitis
  2. Orchitis
  3. Strangulated inguinal hernia
  4. Hydrocele
  5. varicocele
  6. Scrotal abscess
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16
Q

Epididmytis

-Definition and Info

A
  1. Infection of the epididymis
  2. Most COMMON cause of scrotal pain and swelling in men 18 and up
  3. Can be viral, bacterial, parasitic or trauma related
  4. Most common reason in YOUNGER MEN is — Gonorrhea & Chlamydia**
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17
Q

Epididmytis

-Causes

A
  1. Hx of unprotected intercourse & new sexual parter
  2. Hx of UTI w/ dysuria
  3. Heavy lifting, straining — sitting a lot
  4. If Younger than 35 yrs — STD’s: Chlamydia & Gonorrhea
  5. If 35 yrs or Older — E. Coli bacteria most common — also P. Aeruginosa or S. Aureus
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18
Q

Orchitis

-Definition and Info?

A
  1. A systemic, blood-borne infection that results in inflammation of one or both testicles
  2. 20-25% of young men with MUMPS will develop orchitis
  3. Most commonly VIRAL (MUMPS) — Can also be caused by STD’s: syphilis, gonorrhea, chlamydia
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19
Q

Epididymitis & Orchitis

-Clinical Presentation

A
  1. Scrotum is red, enlarged, and extremely tender
  2. CREMATERIC reflex is PRESENT
  3. Painful intercourse and/or ejaculation
  4. Possible penile discharge (blood in semen) — testicular pain, dysuria, flank pain
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20
Q

Epididymitis & Orchitis

-Treatment

A
  1. Non-Pharmacologic — Ice & Scrotal elevation (Phren’s sign)
  2. Pharmacologic —NSAIDS & Antibiotics
    —Treat sexual partners as well
  3. Antibiotics
    —Younger men — Ceftriaxone + Doxycicline 10 days
    —Pt participates in Anal Sex — Ceftriaxone + Levofloxacin 10 days
    —Enteric Organism — (Usually Older men) — Levofloxacin (Risk of tenden rupture) 10 days
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21
Q

Hematocele

-Definition & Info

A
  1. Collection of blood in tunica vaginalis around testicle
  2. Testicular trauma — kick, strike, saddle injury
  3. Painful
  4. NO transillumination
  5. DX by ultrasound confirmation
  6. Treatment — Watch & Wait; surgery if severe
  7. Positive Phren’s sign
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22
Q

Prostate

-What does it do?

A
  1. Positioned along path from bladder to penis
  2. Produces prostatic/seminal fluid — secreted at time of ejaculation
  3. Gland propels seminal fluid into urethra during ejaculation
  4. Fluid helps neutralize acidic environment of vagina, increase mobility of sperm & acts as energy source for sperm
    - Helps sperm survive after ejaculation
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23
Q

BPH

-Definition & info

A
  1. Non cancerous enlargement of prostate gland
  2. Evident in 50% of men by age 50 yrs
  3. Hyperplasia of prostate narrows the urethral lumen
  4. BOTH enlargement of gland and increased smooth muscle tone cause lower urinary tract symptoms
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24
Q

BPH

-Symptoms

A
  1. Weakness of urinary stream (FIRST SIGN)
  2. Nocturia
  3. Intermittent urinary stream (Dribbling)
  4. Feeling of incomplete bladder emptying
  5. LUTS (Lower urinary tract symptoms)
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25
Q

BPH

-Diagnosis

A
  1. UA to exclude UTI — painless hematuria is common
  2. DRE will reveal “firm, smooth, symmetrically enlarged” prostate**
  3. Measurement of PSA in men w/ life expectancy more than 10 years
  4. PSA is measurement of protein produced by prostate when it is “BUSY”*** (I.e Making additional tissue)
  5. DRE & PSA is most sensitive diagnostic test
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26
Q

BPH

-Treatment

A
  1. Mild — Observe and reassure
  2. Moderate — Alpha blocker; Laser or microwave (minimally invasive); TURP
  3. Severe — Alpha blocker + 5 alpha-Reductase inhibitor; laser or microwave; TURP; Open Surgery
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27
Q

BPH

-Current Available Medications?

A
  1. Alpha Blockers — Flomax (Tamsulosin)
  2. 5 alpha-Reductase inhibitors — Proscar
  3. Combination Therapy — alpha blocker + 5 alpha-Reductase inhibitor; Tx for moderate to severe symptoms

Take med at bedtime d/t BP effect of med

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28
Q

Prostate Cancer

-Info

A
  1. MOST COMMON neoplasm in men other than skin cancer
  2. 2nd leading cause of death of men >55 yrs
  3. 1 in 6 males in US will be diagnosed in lifetime
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29
Q

Prostate Cancer

-Clinical Presentation

A
  1. Asymptomatic in early stages
  2. Symptoms increase QUICKLY in first 1 to 2 months (BPH is SLOW progression)
  3. New Onset & rapid erectile dysfunction
  4. Urinary hesitancy, urgency, Nocturia & frequency
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30
Q

Prostate Cancer

-Risk Factors

A
  1. Advancing age
  2. African American and Jamaican American — mortality of black is twice that of white men
  3. Positive Fam Hx
  4. High fat diet
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31
Q

Prostate Cancer

-Physical Exam

A
  1. Firm nodule on rectal examination — indication, or stony asymmetric prostate on exam
  2. Differential Dx:
    - Bladder output obstruction
    - UTI
    - BPH
    - Prostatitis
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32
Q

Prostate Cancer Screening

-Recommendations

A
  1. Screening in average-risk men — 50 yrs w/ average life expectancy >10 yrs
  2. Screening in high-risk men — 40-45 yrs OR 10 yrs before 1st degree relative
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33
Q

Prostatitis

-Definition and Info

A
  1. Non cancerous enlargement of the prostate gland — inflammation
  2. Often Chronic
  3. 50% of men will experience in lifetime
  4. Treatment has low predictability of success
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34
Q

4 Types of Prostatitis

-Classifications

A
  1. Acute bacterial prostatitis — Look sick — fever, pain, etc. — Sexually active men 30-50 yrs —associated w/ UTI & has abrupt onset
  2. Chronic bacterial prostatitis (3-6 months) — Pt’s >50 yrs old — major cause of bacteriemia
  3. Acute or chronic non-bacterial prostatitis OR pelvic pain syndrome (CPPS)
  4. Prostatodynia — saddle pain
  5. Most Common bacteria is — E. Coli (55-88%)

RISK Factor
-Athletes who run long distances and have vigorous exercise regimens predisposed to prostatitis**

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35
Q

Acute Bacterial Prostatitis

-Clinical Presentation

A
  1. Abrupt onset — Fever, chills, malaise, myalgia’s
  2. Hesitancy, frequency, urgency, dribble
  3. Low back pain & suprapubic pain
  4. Elevated PSA
  5. Scrotal pain, inguinal pain, prostatic pain
  6. Painful ejaculation
36
Q

Diagnosing Prostatitis?

A
  1. Hx, PE, UA and urine culture for all chronic cases
  2. Bacterial Prostatitis — dx based on symptoms and presence of bacteria (5 day culture)
  3. DRE — enlarged, boggy, tender prostate
  4. AVOID prostatic massage or vigorous palpation if ACUTE bacterial prostatitis suspected
  5. CBC will show Leukocytosis and LEFT shift w/ acute bacterial prostatitis
  6. CT or US if malignancy or abscess suspected
  7. Urology may biopsy mass or aspirate abscess for culture
37
Q

Prostatitis

-Differentials

A
  1. Cystitis
  2. Urethritis
  3. Pyelonephritis
  4. Epididymitis
  5. Prostatic abscess
  6. Malignancy
  7. Obstructive calculi
  8. Foreign bodies
  9. Acute urinary retention
38
Q

Acute Prostatitis

-Treatment

A
  1. If Severe — Hospital admission for IV antibiotics
  2. If not severe
    —Fluoroquinolone’s — Cipro, Levo, OR Bactrim x 6 weeks
    —NSAIDS
39
Q

Non-Bacterial Prostatitis

-Treatment

A
  1. May benefit from — Erythromycin, Bactrim (TMP-SMX), OR combination w/ fluroquinolone
  2. Some Pt’s respond to — Nitrofurantoin
40
Q

Chronic Bacterial Prostatitis

-Treatment

A
  1. BEST MED — Bactrim (TMP-SMX) 12-15 wks
41
Q

Prostatitis

-Clinical Pearls

A
  1. Normal Prostate — Feels like tip of the nose
  2. Boggy Prostate — Feels like puffed out cheek
  3. Nodular Prostate — Feels hard like your forehead (often r/t tumor
  4. Enlarged prostate = Painful bowel movement
    —No painful BM with BPH
42
Q

UTI in men

-Clinical Features?

A
  1. Dysuria, frequency, urgency, suprapubic pain, hematuria
  2. Fever >100.4
  3. Flank pain, costovertebral angle tenderness
  4. N/V suggestive of upper tract infection
43
Q

UTI in Men

-Risks?

A
  1. Relatively rare in men under 35 yrs
  2. RISKS include
    —Older men w/ prostatic dz, Insertive anal intercourse, partner colonized w/ uropathogens
44
Q

UTI in Men

-Common Pathogens

A
  1. E. Coli MOST COMMON
45
Q

UTI in Men

-Treatment

A
  1. Uncomplicated — TMP/SMX (Bactrim) 7-14 days

2. Complicated (DM, fever, chills, flank pain) — Levofloxacin 7-14 days

46
Q

STD’s

-Common STD’s (6)

A
  1. Gonorrhea
  2. Chlamydia
  3. Syphilis
  4. HIV
  5. Trichomonas
  6. Herpes
47
Q

Genital Ulcer Diseases

-Differentials

A
  1. HSV-1 & HSV-2 — MOST common in US
  2. Syphilis (primary)
  3. Chancroid — rare
48
Q

Genital Ulcer Diseases

-Herpes Simplex Virus

A
  1. Recurrent incurable viral disease
    —Most HSV-2 infections UNDIAGNOSED — most transmission is from undiagnosed or Asymptomatic pt’s
  2. Diagnosed w/ — clinical suspicion + viral swab is standard BUT PCR assay is most sensitive
49
Q

HSV

-Likelihood of transmission

A
  1. Infected male and Unaffected female — Risk 10% per year (7-31%)
  2. Infected Female and unaffected male — Risk 4 % per year

Female has greater risk of transmission

50
Q

HSV

-Treatment

A
  1. 1st clinical episode — Acyclovir 5-10 days
  2. HSV-2 SIGNIFICANTLY more likely to RECUR
    —Episodic recurrent treatment — Acyclovir 5-10 days
  3. HSV Suppression — Pt has >6 episodes per year
    - Reduces frequency of “flares” by 70-80%
    - Acyclovir
51
Q

Penile (Genital) Warts

A
  1. Contagious — appear 1-8 months following exposure
  2. Caused by HPV
  3. Treatable
  4. Test w/ acetic acid — If positive, wart turns white
  5. Usually spread when symptoms are present
52
Q

Penile (Genital Wart)

-Treatment

A
  1. 1/3 of cases resolve w/out treatment after approx 4 months
  2. Topical
    —Imiquimod or Podophyllotoxin
  3. Cryotherapy, electrocautery, surgery, lasted treatment
53
Q

Syphilis

-Info

A
  1. Systemic disease caused by T. Pallidum
  2. Stages of infection
    —Primary
    —Secondary
    —Tertiary
    —Latent —Early, latent, neurosyphilis
54
Q

Primary Syphilis

-Presentation

A
  1. PAINLESS ** (Looks painful)
  2. Sexual contact — 30-90 days after exposure (average 21 days)
  3. Usually 1 chancre
  4. Common on Penis in heterosexual men
  5. Common rectally or anally in MSM
  6. May last 3-6 wks w/out treatment
55
Q

Secondary Syphilis

-Presentation

A
  1. If PRIMARY is left UNTREATED it progresses to
    - Skin rash
    - Muco-cutaneous lesions — reddish-pink rash, non-itching, on trunk, extremities, palms, soles of feet — may become painful and pustular
    - Regional lymphadenopathy
  2. Secondary syphilis is — MOST contagious stage
    - 4-10 wks after primary
56
Q

Tertiary Syphilis

-Presentation

A
  1. Cardiac, neurologic, dementia, ophthalmic, auditory, organ lesions
  2. Occurs 3-15 years after initial untreated infection
57
Q

Latent Syphilis

-Presentation

A
  1. Latent — active infection dx by serology w/out clinical signs of infection
  • Early latent — Infection acquired w/in preceding year
  • Late Latent — Infection acquired >1 yr
  • Syphilis of Unknown Duration — self explanatory
58
Q

Syphilis Diagnostic Testing

A
  1. Nontreponemal Test must come back positive — can have false positive w/ pregnancy, IV drugs, rickets, hepatitis and endocarditis
    FOLLOW-UP POSITIVE TEST W/
  2. Treponemal test

BOTH tests must be POSITIVE to confirm diagnosis**

59
Q

Syphilis

-Nontreponemal Tests?

A
  1. 4 fold change in titer considered clinically significant
  2. Should become undetectable w/ treatment
  3. Multiple etiologias can cause false positive — Lupus, pregnancy, mono, etc..
60
Q

Syphilis

-Treponemal Tests

A
  1. FTA-ABS — CSF FTA-ABS highly sensitive for neurosyphilis (Useful 3-4 wks after exposure) Negative test excludes neurosyphilis
  2. MHA-TP
    - Another confirmatory test
    - NOT used often d/t being poor marker of disease activity
61
Q

Syphilis Treatment?

A
  1. Penicillin G 2.4 MU IM X1 — Treats primary, secondary, early latent TB w/ one injection of penicillin
  2. If PCN Allergy — Doxycycline x14 days
  3. If pt is Late Latent, unknown duration, or Tertiary?
    —Penicillin IM
  4. Think failure if titer FAILS to fall FOURFOLD or if titer rises — from 1:16 to 1:4 is success**
    —Think failure or re-infection
62
Q

Chancroid Ulcers

-Diagnosis

A
  1. PAINFUL
  2. Diagnosed by culture for H. ducreyi
  3. Negative test for syphilis
  4. Suggestive Clinical Picture — endemic area, exposure, regional lymphadenopathy; risk such as HIV
63
Q

Chancroid Ulcers

-Treatment

A 
1. Azithromycin 1gm x1 AKA “THE BOMB”
OR
2. Ceftriaxone IM
OR
3. Cipro x3 days
64
Q

Urethritis/Cervicitis Diseases

-3 types

A
  1. Chlamydia (C)
  2. Gonorrhea (G)
  3. Non-gonoccoccal Urethritis (NGU)
65
Q

Urethritis/Cervicitis Diseases

-Chlamydia

A
  1. Caused by C. Trachomatis (Gram negative) — MOST commonly reported STI in US
  2. White discharge from penis
  3. Burning sensation w/ urination
  4. Tenderness around testicles
66
Q

Urethritis/Cervicitis Diseases

-Chlamydia Diagnosis

A
  1. Nucleic acid amplification testing (NAAT)
    - Via Gavin also swab or urine clean catch
    - Urine is MOST common test used
  2. Rarely use rapid tests or cultures as
67
Q

Urethritis/Cervicitis Diseases

-Chlamydia Treatment

A
  1. Azithromycin 1gm x1 — BEST if pregnant
  2. Doxycycline x 7 days

ALT Treatment
—Ofloxacin, Levofloxacin, Erythromycin

  1. Treat sexual partners and screen for other STD’s
  2. Abstain from sex for 7 days after patient and partner treated
68
Q

Urethritis/Cervicitis Diseases

-Chlamydia follow-up

A
  1. Test of cure — recommended especially if Azithromycin/doxy not used
  2. Test for REINFECTION — 3-4 months later; definitely 12 months after diagnosis
  3. Urine chlamydia testing IDEAL
69
Q

Urethritis/Cervicitis Diseases

-Gonorrhea

A
  1. White dripping discharge aka “the drip”
  2. Burning with urination
  3. Women often asymptomatic

Complications
4. Epididymitis, PID, infertility, ectopic pregnancy

70
Q

Urethritis/Cervicitis Diseases

-Gonorrhea Risk Factors?

A
  1. African-American males
  2. <25 yrs
  3. Hx of prior STD’s
  4. Multiple sexual partners
  5. MSM
  6. Often found in conjunction w/ chlamydia
71
Q

Urethritis/Cervicitis Diseases

-GC Treatment

A
  1. NEW GUIDELINE — Ceftriaxone 1G IM + Zithromax 1G PO single dose
  2. Can sub Doxy for Zithromax
  3. Can sub 2G Zithromax for penicillin or ceph allergies — Can cause GI upset and resistance
72
Q

Urethritis/Cervicitis Diseases

-Non-Gonoccoccal Urethritis

A
  1. Inflammation/infection of urethra w/ chlamydia
  2. Dx w/ Urethral smell — Treat symptomatically
  3. MOST common pathogen — Chlamydia trachomatis
  4. Treatment — 1G Zithromax or Doxycycline 100 BID x7 days
73
Q

Reportable STD’s to Health Department?

A
  1. Syphilis -YES nationally
  2. Gonorrhea -YES
  3. Chlamydia -YES nationally
  4. Chancroid -State specific
  5. Herpes -NO reporting

MOST labs report for you.

74
Q

Men’s Health Emergencies

-(4)

A
  1. Priapism
  2. Testicular torsion
  3. Paraphimosis
  4. Acute prostatitis
75
Q

Men’s Health Emergencies

-Priaprism

A
  1. Persistent, painful erection lasting longer than 3-4 hrs; unrelated to sexual desire
    —MEDICAL EMERGENCY
  2. Related to Sickle Cell Anemia
76
Q

Men’s Health Emergencies

-Priaprism Treatment

A
  1. Ice packs
  2. Surgical ligation
  3. Intracavernous injection
  4. Surgical shunt
  5. Aspiration
77
Q

Men’s Health Emergencies

-Phimosis & Paraphimosis

A
  1. Phimosis — Inability to retract the foreskin covering glans of penis — ONLY uncircumcised
  2. Paraphimosis — Foreskin becomes trapped BEHIND the glans and cannot be reduced
    - Usually caused by well-meaning med professionals not retracting foreskin after foley or procedure
  3. Circumcision is treatment
78
Q 
Erectile Dysfunction (ED)
-What is it?
A
  1. Inability to achieve or maintain edition adequate for intercourse to mutual satisfaction
    - Both partners in relationship are affected
    - Symptoms will progress slowly over time
79
Q

Cause of ED

-Organic Causes (50%)

A
  1. CVD
  2. DM
  3. Surgery on colon, bladder, prostate
  4. Neurologic causes (Lumbar disc, MS, CVA)
  5. Priaprism
  6. Low testosterone

Test for nocturnal erections to differentiate between organic and psychogenic causes

80
Q

Cause of ED

-Psychogenic Causes (50%)

A
  1. Anxiety, Depression
  2. Medication (Thiazide diuretics)
  3. Fatigue
  4. Guilt or stress
  5. marital discord
  6. Excessive ETOH consumption
81
Q

ED Treatment

A
  1. PDE-5 Inhibitor (Viagra, Cialis) — enables and sustains smooth muscle relaxation by enhancing nitric oxide (Widens blood vessels)
    —These are 1st LINE meds w/ no contraindications
  2. Contraindications to PDE-5 Inhibitors
    —If pt is taking Nitrates (Nitroglycerin)** OR Severe Cardiac Disease*
82
Q

ED Medication

-How do they work?

A
  1. Viagra — Peaks in 1 hr & Excreted in 8-12 hrs
  2. Levitar —Peaks in 42-54 minutes & Excreted in 8-12 hrs
  3. Cialis — Peaks in 2 hrs & excreted in 36 hrs.

S/E

  • HA, Flushing, Nasal congestion, Hearing Loss
  • Abnormal vision
  • Syspepsia
83
Q

Kidney Stones

-Risk Factors

A
  1. Men 2x risk — 20-40 yrs
  2. White men > AA men
  3. Diet rich in protein, carbs and sodium
  4. Peak incidence in summer d/t dehydration
  5. Higher in obese men & Family Hx
  6. Southeastern US has highest prevalence
84
Q

Kidney Stones

-Diagnostis

A
  1. UA
  2. Abdominal X-ray to ID location & number of stones
  3. Renal US will show hydronephrosis — swelling of a kidney d/t build-up of urine
  4. CT SCAN non-contrast is BEST DIAGNOSTIC TOOL
85
Q

Kidney Stones

-Differentials

A
  1. Gastroenteritis
  2. Ovarian Cyst (Women)
  3. Peptic Ulcer Dz
  4. AAA
  5. Ectopic pregnancy
  6. Biliary stones
  7. Back strain
  8. Bowel obstruction
86
Q

Kidney Stone Treatment

A
  1. Many pass w/out intervention
  2. Alpha blocker (Flomax) to dilate GU OR CCB (Procardia)
  3. Strain urine to monitor stone passage
  4. High dose NSAID or narcotics

6030 Primary Care Test 3 COMPLETE ☑️ (7 decks)

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