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Year 4 Family and Children ANNA > Paeds > Flashcards

Paeds Flashcards

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1
Q

What ages are the following classes of children?

  1. Neonate
  2. Infant
  3. Young Child
  4. Child
  5. Adolescent
A

​

  1. Neonate – birth to 1 month
  2. Infant – 1 month to 2 years
  3. Young Child – 2 -6 years
  4. Child – 6-12 years
  5. Adolescent – 12-18 years
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2
Q

Name some differentials for

  • looks unwell
  • Inspiratory expiratory Stridor at rest
  • A dry barking cough is observed
  • RR 48/min, nasal flaring, moderate tracheal tug, intercostal and subcostal recession.
  • She appears pink in air
A

Croup (parainfluenza)

Epiglottitis (Haemophilus influenzae)

Bacterial tracheitis

Foreign body

Laryngomalacia

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3
Q

What are the signs of anaphylaxis?

A
  1. Hypotension - Pale and sweaty
  2. Bronchoconstriction - Wheeze
  3. Airway compromise - Stridor
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4
Q

What questions should you ask with a Hx of allergic reaction/ anaphylaxis?

A
  1. Does your child have Asthma?
  2. If they have Asthma what treatment do they take?
  3. Do they take a regular preventer inhaler?
  4. When they had the initial reaction how much of the foodstuff or allergen had they been in contact with?
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5
Q

Allergy - How does sensitisation occur and what are the underlying physiological mechanisms involved?

A

Following exposure to an antigen the protein causes cross binding of two bound IgE molecules on the Mast Cell or Basophil surface. This process results in degranulation of the Mast Cell.

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6
Q

What are the 4 effects of histamine?

A
  1. Endothelial Cell Separation
  2. Localised irritation
  3. Vasodilatation
  4. Bronchoconstriction
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7
Q

When would you prescribe an EpiPen?

What would you prescribe instead if none of these are present?

A
  1. History of Anaphylaxis
  2. Previous cardiovascular / Respiratory involvement
  3. Evidence of airway obstruction
  4. Poorly controlled Asthma requiring regular inhaled corticosteroids
  5. Reaction to a small amount of allergen
  6. Ease of allergen avoidance

In the absence of these risk factors anti-histamine

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8
Q

what kind of course does croup follow?

A

Viral croup often follows an undulating course with symptoms flaring at night.

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9
Q

Up to a month of age the minimum milk requirement to provide enough calories to grow is what?

A

150mls/kg/day.

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10
Q

what are the 3 areas of history always relavent in paediatric history? (BIG)

A
  1. Birth history; or example prematurity
  2. Immunisation history; risk for specific infections
  3. Growth and wellbeing;
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11
Q

What patterns of bruising would be suspicious for NAI?

A
  1. Face, back, buttock, TEN (Torso, Ears, Neck)
  2. Bruise outlines a particular object e.g. hand, belt
  3. Pattern of bruising e.g. fingertips
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12
Q

What fractures would be suspicious of NAI?

A
  1. Metaphyseal fractures (twisting force)
  2. Rib fractures (ribcage = v complient at young age)
  3. Fractures of different ages
  4. Complex skull fractures
  5. Long bone shaft fractures in non-mobile child
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13
Q

What history would be suspicious for NAI?

A
  1. No mechanism offered / mechanism not consistent with the injury
  2. Delay in reporting the injury / seeking medical attention
  3. Inconsistent histories from parents
  4. Inappropriate reaction of parents e.g. vague, elusive, unconcerned, excessively distressed, aggressive
  5. Recurrent injuries
  6. Injuries inconsistent with the child’s age, development, mobility e.g. bruising in non mobile babies
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14
Q

What burn pattern would be suspicious for NAI?

A
  1. Uniform shape e.g. cigarette burn
  2. Glove-stocking distribution
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15
Q

Consider what clinical features a baby with non-accidental head injury may show.

A
  • Irritability
  • Poor Feeding
  • Increasing head circumference
  • Seizures
  • Reduced GCS
  • Full fontanelle
  • Anaemia
  • Retinal Haemorrhages
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16
Q

What is abusive head trauma?

What is one of the most useful diagnostic signs?

A

Head injury may follow severe shaking, especially in children under 6 months. This may cause rupture to the small vessels crossing the subdural space, causing a subdural haemorrhage.

Retinal haemorrhage

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17
Q

What investigations should be done for NAIs?

A

CT head

Skeletal Survey

FBC

Coagulation studies incl. von Willebrand disease

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18
Q

What are toddler bruises like?

A
  1. anterior shins
  2. bony prominences
  3. Single circular bruises
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19
Q

What is the toxic trio?

A
  1. Domestic violence
  2. substance abuse
  3. Mental illness
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20
Q

What is pyloric stenosis?

How does it present?

A
  • 2-8 weeks, more male than female, presents with projectile vomiting, dehydration and olive-shaped mass in RUQ
  • Thickening of the pylorus of the stomach → obstruction
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21
Q

How does pyloric stenosis lead to electrolyte / blood gas changes?

A
  1. Thickening of the pylorus of the stomach → obstruction
  2. → vomiting
  3. →→ projectile vomiting
  4. →dehydration
  5. →→ ↓K+, ↓Cl- (loss of HCl)
  6. →→→ exchange of intracellular K+ for extracellular H+ → metabolic alkalosis
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22
Q

How do you test for pyloric stenosis?

How do you treat it? C-M-S

A

Test feed + USS

C - fluids and correct electrolytes

S - pyloromyotomy

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23
Q

What are some differentials of bile-stained vomit?

A

Potential emergency!

Intestinal obstruction:

intussusception, malrotation, strangulated inguinal hernia

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24
Q

What investigations might you need for severe GORD in a child?

A
  1. 24hr oesphageal pH study
  2. endoscopy
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25
Q

How do you manage GORD? C, M, S

A

Conservative - thicken feed

Medical - omeprazole / ppi or H receptor antagonist e.g. ranitidine

Surgical - RARE - fundoplication

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26
Q

How does intussusception present?

A
  1. Acute abdominal pain in 6-18 month year old
  2. Pain = guarding (!-peritonitis), worse with peristalsis, paroxysmal, colicky pain
  3. Pallor
  4. Vomiting - bile-stained (obstruction)
  5. Mass in abdomen - sausage or large mass (→volvulus)
  6. Red jelly stool
  7. Sy of sepis / shock!!
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27
Q

What are the 3 causes of intussusception?

A
  1. Infection (e.g. gastroenteritis) → increased size of peyer’s patches (lymph nodes) → act as leap point
  2. Meckel’s diverticulum inverts into ileum and acts as leap point
  3. Idiopathic (we no know)
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28
Q

What is the classic investigation finding for intususseption?

A

target sign on USS

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29
Q

What are the risk factors for intusussception?

A
  1. Malrotation
  2. Sibling with intusussception
  3. Past Hx of intusussception
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30
Q

Management of intusussception?

A

C: Fluid resuscitation

M: Barium or air enema, rectal air insufflation

S: Surgery to reverse it and remove obstruction

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31
Q

Name some red flags for abdominal pain in children

A
  • Blood in the stools
  • Symptoms regularly waking child from sleeep
  • Poor growth
  • Age <5 years
  • Weight loss
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32
Q

What are the common causes of melena in children?

A
  1. Infective – bacterial diarrhea eg campylobacter, salmonella
  2. Inflammatory bowel disease
  3. Tearing from anal vein
  4. Polyp
  5. Intussusception – acutely unwell
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33
Q

Name 7 symptoms of coeliac disease

A
  1. Chronic or intermittent diarrhoea
  2. Failure to thrive or faltering growth (in children)
  3. Persistent or unexplained gastrointestinal symptoms including nausea and vomiting
  4. Prolonged fatigue (‘tired all the time’)
  5. Recurrent abdominal pain, cramping or distension
  6. Sudden or unexpected weight loss
  7. Unexplained iron-deficiency anaemia, or other unspecified anaemia
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34
Q

What kind of gastroenteritis is most likely with children?

A

Viral

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35
Q

Classically seen in young children, what is the trio found in children with HUS (haemolytic uraemic syndrome)?

What is it caused by on 90% of cases?

A
  1. acute kidney injury
  2. microangiopathic haemolytic anaemia
  3. thrombocytopenia

classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7

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36
Q

List important features in the history for assessment of a child presenting with diarrhoea and vomiting:

A
  • Duration, frequency/number, volume and colour of the vomitus
  • Duration, frequency/number, volume of loose stools and any passage of blood in stools
  • Current oral intake and usual feeding pattern
  • Ask about passage of urine- number of wet nappies, if the nappies are as heavy as before and how long ago did the child have a wet nappy?
  • History of fever and other red flag symptoms
  • Recent contact with someone with diarrhoea and vomiting, ingestion of contaminated food or water and recent travel abroad
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37
Q

What are the signs of dehydration in an infant?

A
  1. reduced capillary refill time
  2. reduced skin turgor
  3. tachycardia
  4. hypotension
  5. tachypnoea
  6. dry mucous membrane
  7. Sunken anterior fontanelle
  8. oliguria
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38
Q

What are the common gastroenteritis-causing viruses in children?

A
  1. Rotavirus (most will develop immunity by 5yrs)
  2. Adenovirus
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39
Q

What is the most common bacterial cause of gastroenteritis?

A

Camplyobacter jejuni

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40
Q

What kind of fluid is used in acute fluid resus?

A

0.9 % saline

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41
Q

What is the normal age for the anterior fontanelle to close?

A

18-24 months

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42
Q

What are some concerning signs in C of ABCDE?

A
  1. Tachycardia
  2. Pallor
  3. Cool Peripheries
  4. Reduced urine output
43
Q

What tests would you request on CSF samples?

A

Protein

Glucose (get BM beforehand too for comparison)

Microscopy and gram stain

Culture and sensitivity

PCR for virology, pneumococcus and meningococcus

44
Q

What are the contraindications to lumbar puncture?

A
  1. Cardioresp. instability
  2. Focal neurological signs
  3. Signs of Raised ICP
    1. coma
    2. low HR
    3. high BP
    4. papilloedema
  4. Coagulopathy
  5. Thrombocytopenia
  6. Local infection at LP site
  7. If it causes undue delay in starting abx
45
Q

A child over 3 months with suspected Meningitis should be treated with Intravenous ?

A

ceftriaxone

46
Q

What are the most common bacterial causes of meningitis in

  1. neonates (<3mo)
  2. Young children (3 mo-5yrs)
  3. Children (5yrs+)
A
  1. Birth canal bugs:
    1. Group B strep
    2. E coli
    3. Listeria
  2. Niesseria mengitides, Strep pneumoniae, Haem influenza group B
  3. Niesseria mengitides, Strep pneumoniae
47
Q

describe CSF changes in bacterial / viral / tb / fungal meningitis

A

Bacterial: Turbid, Lots of polymorphs/neutrophils, Low glucose, Raised protein

Viral: Clear, Lots of lymphocytes (initially could be polymorphs), normal protein / glucose

TB: Like bacterial but with lymphocytes instead of polymorphs

48
Q

What virus group commonly cause meningitis?

A

enteroviruses (85%, especially coxsackie and echovirus)

49
Q

When should you not give corticosteroids for meningitis?

What is the dose?

A
  1. If it is TB
  2. Below 3 months
  3. If it is mengococcal septicaemia
  4. More than 12 hours after starting antibiotics.

0.15 mg/kg to a maximum dose of 10 mg, four times daily for 4 days (high dose 0.6)

50
Q

What are the indications for Dexamethasone in suspected/confirmed Meningitis?

A
  • Frankly purulent pus
  • CSF wcc > 1000/microlitre
  • Raised CSF wcc with CSF Protein > 1g/l
  • Bacteria on Gram stain
51
Q

What are the layers of the meninges called?

A

DAP:

Dura mater

Arachnoid

Pia mater

52
Q

Name some long term complications of meningitis

A
  1. Hearing impairment
  2. Local vasculitis - CN palsies, focal neurological lesions
  3. Local cerebral infarction → seizures, may → epilepsy
  4. Neuro impairment
  5. Learning difficulties
  6. Requiring surgery:
    1. Subdural effusion
    2. Hydrocephalus
    3. Cerebral abscess
53
Q

What should happen after diagnosis and successful treatment of meningitis?

A

Rapid (2 week) hearing assessment (before calcification of the cochlea)

54
Q

In Renal disease, what are the significant levels of proteinuria?

A

>20 mmol/ml - This may be significant, and may indicate tubular disease

>200 mmol/mg - This is nephrotic range

55
Q

What is the most common nephrotic syndrome in children?

A

Minimal change nephrotic syndrome

56
Q

What is the treatment for minimal change nephrotic syndrome

A

High dose steroids

Abx to prevent infection (strep, pnumococcal) → penicillin

57
Q

What is the clinical triad for nephrotic syndrome?

A
  1. Massive proteinuria (>200g/L)
  2. ↓circulating albumin (<25g/L)
  3. oedema
58
Q

What are risk factors for UTI in children?

A

↓ Flow:

  • poor urine flow
  • dysfunctional voiding
  • ↑ bladder size
  • constipation
  • abdominal mass

Health:

  • Prev UTI
  • ↑ BP
  • ↓growth
  • recurrent fever of unknown origin

Renal:

  • renal abnormality
  • FHx of
    • renal disease
    • vesicoureteric reflux
59
Q

What is the Definition of atypical UTI; increased risk of renal screening?

A
  • Seriously ill
  • Poor urine flow
  • Abdominal or bladder mass
  • Raised creatinine
  • Septicaemia
  • Failure to respond within 48 hours
  • Non E coli
60
Q

What is the definition of recurrent UTI?

requires investigations for an underlying cause

A
  1. 2 or more upper UTI
  2. 1 upper and 1 or more lower UTI
  3. 3 or more lower UTI
61
Q

What clinical signs make an Upper UTI likely in kids?

A
  • Bacteriuria and fever of 38*C or higher +/- loin tenderness
  • Bacteriuria, loin pain/tenderness and fever of less than 38*C
  • Age less than 3 months
62
Q

What follow-up is required after UTI?

A

Renal US within 6 weeks

63
Q

What scans should a child under 1 year have with atypical UTI to assess kidneys?

A

US scan

DMSA

MCUG (micturating cystourethrogram)

64
Q

What is vesicoureteric reflux?

A

A developmental anomaly of the vesicoureteric junctions. The ureters enter directly into the bladder rather than at an angle → urine can reflux back into ureter.

Severe disease can lead to backflow of urine into renal pelvis → scarring risk if UTIs occur.

65
Q

What is an MCUG?

A

Micturating cystogram

to identify any vesicoureteric reflux (VUR), bladder abnormalities and posterior urethral valves within a few weeks after treatment of UTI.

The technique consists of catheterizing the child in order to fill the bladder with a radio-contrast agent then taking x-rays as the infant voids urine..

66
Q

When would you consider a MCUG?

A
  • Infants younger than 6 months with atypical or recurrent UTI
  • Consider in children older than 6 months if dilatation on ultrasound, poor urine flow, non-E coli infection or family history VUR
67
Q

What is a DMSA and when would you do it?

A

DMSA in 4-6 months (after UTI). This is a radionucleotide scan used to assess renal function and identify any scarring of the kidneys due to the UTI. Healthy renal tissue takes up the isotope. Unhealthy or scarred tissue doesn’t take up the isotope and appears as a filing defect on DMSA scan.

DMSA may be inaccurate if performed shortly after an infection.

Indications:

All children with recurrent UTI

Children under 3 years with atypical UTI

68
Q

You are asked to see a boy on the postnatal ward aged 1 day. The antenatal scan showed bilateral dilated kidneys. The child appears well and examination is normal. Nappies are wet.

What should you do?

A

Arrange ultrasound of kidneys within 24 hours

Need to exclude posterior urethral valves – this is a very serious condition which if untreated can cause renal failure due to obstruction.

If was just one side then outpatients is ok

69
Q

What extra questions are important in fever or diarrhoea histories?

A

Contact - With other ill people - home or nursery, or with animals e.g. petting zoo

Travel - at risk areas, vaccination, contact with mosqitos, anyone ill on the plane?

70
Q

When would you send a sample of stool for microscopy and culture?

A

NICE recommend sending stool for microbiology if you :

  • suspect septicaemia,
  • there is blood or mucus in the stool or
  • the child is immunocompromised,

and to consider sending stool if

  • there is a history of travel,
  • the diarrhoea has persisted more than 7 days,
  • or you are uncertain about the diagnosis of gastroenteritis.
71
Q

What is the name for the classic red, expanding lesion with bright red outer spreading edge found in Lyme disease?

What is the infecting organism?

A

erythema migrans

caused by the spirochete b.burgdorferi

72
Q

What are the 3 stages of Lyme disease?

A
  1. Early - skin lesion + fever-like symptoms: fever, malaise, myalgia, arthralgia, lymphadenopathy
  2. Dissemination (rare) - meningitis, cranial nerve palsies, arthritis, carditis
  3. Late - after weeks / months: neuro, cardio and joint manifestations:
    1. Neuro: meningoencephalitis, cranial (facial nerve normally) and peripheral neuropathies
    2. Cardiac: myocarditis, heart block
    3. Joint: arthralgia, oligoarthritis etc
73
Q

How do you test for Lyme disease?

A

Testing early in the disease may not be useful, as seroconversion generally happens after the early stage.

→ Blood tests are indicated if symptoms persist and there is uncertainty about the diagnosis:

  1. enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test
  2. if this test is positive or equivocal then an immunoblot test for Lyme disease should be done
74
Q

How do you treat Lyme disease?

A

> 12 yrs doxycycline

<12 yrs amoxicillin

75
Q

What disease do reptiles sometimes carry?

A

Salmonella

76
Q

What are the features of Kawasaki disease? x6

A

CRASH and BURN

  1. Burn = High temperature >5 days +4/5
  2. Conjunctivitis
  3. Rash- pleomorphic
  4. Adenopathy - Cervical lymphadenopathy
  5. Swollen red lips, tongue (strawberry)
  6. Hands - Peeling of skin of hands and feet
77
Q

What is the most common cause of infective diarrhoea in children in the UK?

A

Rotavirus

78
Q

How do you treat Kawasaki?

What is the main complication?

A

Aspirin (prevents clots) - the only time you prescribe aspirin in children due to risk of Reye’s syndrome

intravenous immunoglobulin

echocardiogram (rather than angiography) is used as the initial screening test for coronary artery aneurysms

79
Q

What is the sequence of acute Seizure medications?

A
  1. No vascular access: 0.5mg / kg
    1. Rectal diazapam
    2. Buccal midazolam
  2. OR Vascular access 0.1 mh/kg lorazepam
  3. Still fitting: 0.1 mh/kg lorazepam
  4. Optional - give paraldehyde
  5. Confirm it’s still a fit!
  6. Sr Help, get anaethetics / ICU help
  7. Give 20mg/kg phenytoin or phenobarbitone over 20 mins (if already on phenytoin)
80
Q

When is a child hypoglycaemic?

A

Glucose <2.6

Re-Check if between 2.6 and 3.5

81
Q

What should you ask about in suspected seizure

  1. Pre-seizure
  2. During
  3. After
  4. Recent illness?
A
82
Q

What is a complex febrile seizure?

A
  1. A focal, or generalized and prolonged seizure,
  2. of a duration of greater than 15min,
  3. recurring more than once in 24h,
  4. and/or associated with postictal neurologic abnormalities, more frequently a postictal palsy (Todd’s palsy),
  5. or with previous neurologic deficits
83
Q

What are the indications for brain imaging in seizures?

A

Indications for urgent head CT or MRI:

  • Encephalopathic or coma
  • Suspected raised intracranial pressure
  • Progressive neurological deficit

Indications for elective head MRI:

  • In a child under 2 year of age at onset
  • hard focal neurological signs
  • a focal epilepsy
  • associated significant learning difficulties
  • an epilepsy resistant to full doses of 2 appropriate drugs
84
Q

What points should you cover when reassuring a patient about febrile seizures?

A
  1. Counselling on recurrence risk of fever related seizures and risk of epilepsy.
  2. Parents need first aid training and what not to do in a convulsive seizure (especially not to put something into the child’s mouth or do chest compressions)
  3. They maybe considered for training to administer rescue medication, buccal midazolam for example, at 5 minutes.
  4. They need to be aware of when to call an ambulance (e.g. after 5 minutes of a convulsive seizure, or if rescue medication was ineffective after 5 minutes)
  5. Follow up arrangements, by either their Consultant, or a referral to an epilepsy specialist
85
Q

What is the GMFCS?

A

Gross motor function classification system

  1. no limitations
  2. some limitations
  3. uses handheld assisting device
  4. self-mobility with limitations, may use powered mobility
  5. transported in a manual wheelchair
86
Q

What are the causes of cerebral palsy?

A
  1. 80% antenatal:
    1. cerebral vascular damage / ischaemia
    2. ↓ development of brain in utero
    3. cortical migration disorders
    4. infection
  2. 10% hypoxic ischaemic injury
87
Q

What is Periventricular leukomalacia (PVL)?

A

is a condition of underdeveloped white matter in the brain surrounding the ventricles.

It is the leading cause of CP in preterm infants.

88
Q

Premature babies brains are at risk of what 2 pathologies?

A

The premature neonatal brain is susceptible to two main pathologies: intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL).

89
Q

What is the definition of global developmental delay?

A

A child has global developmental delay if they have a significant delay in milestones in two or more areas (2 or more standard deviations below the mean).

90
Q

What is the definition of Cerebral Palsy?

A

A disorder of tone, posture and movement, caused by a non-progressive brain lesion in a developing brain

91
Q

What are the types of CP?

A

Spastic - ↑↑tone - clasp knife

Dyskinetic - involuntary movements

Ataxic - shaky movements, low tone, balance and spatial awareness ↓

92
Q

What do the terms hemiplegia, diplegia, quadriplegia mean?

A

Hemiplegia – unilateral arm and leg involvement

Diplegia – symmetrical paralysis (may be of the legs, arms, face or combined thereof)

Quadriplegia – all four limbs involved.

93
Q

What medications may help manage increased tone in CP?

A

Baclofen - antispasmodic

Diazepam - relaxant

Botulinum toxin - botox injections (Mr B)

94
Q

What is Duchenne muscular dystrophy?

what is the test for DMD?

A

X-linked condition

characterised by progressive muscle weakness commencing in the legs and pelvis, then extending to other muscles of the body.

DMD should be considered in all boys who have delayed motor milestones and speech delay

Test creatinine phosphokinase ↑↑↑ (CK) level is nearly always at least five times as high as the maximum for unaffected people

95
Q

How do you diagnose DKA?

Do blood glucose levels have to be high?

A

Diagnose DKA in children and young people who have

  • acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre)

and

  • ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre)

Blood glucose levels are generally high (above 11 mmol/l) but children and young people with known diabetes may develop DKA with normal blood glucose levels.

96
Q

How do you classify DKA?

A

Children and young people with a pH of 7.1 or above have MILD or MODERATE DKA

Children and young people with a pH of less then 7.1 have SEVERE DKA

97
Q

What is Hyperosmolar Hyperglycaemic State?

A

If a child is hyperosmolar with a very high bloog glucose level (>30 mmol/l), with little or no acidosis or ketones

98
Q

How do you work out how much fluid a child in DKA needs?

A

Requirement = Deficit + Maintenance

Deficit:

  • Mild DKA = 5%
  • Severe DKA = 10%

Maintenance:

  • if they weigh less than 10 kg, give 2 ml/kg/hour
  • if they weigh between 10 and 40 kg, give 1 ml/kg/hour
  • if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.
99
Q

What is kussmaul breathing?

A

Deep and Laboured breathing as a result of diabetic ketoacidosis - trying to blow off CO2

100
Q

What is the worry with ↑fluids in DKA?

A

↑risk of cerebral oedema

The morbidity and mortality in childhood DKA is from cerebral oedema. The aim of therapy is very gentle and slow correction to avoid cerebral oedema

101
Q

What is the rule for maintenance fluids outside of DKA?

A

1st 10kg = 100ml/kg/day

2nd 10 kg = 50ml/kg/day

Subsequent = 20ml/kg/day

102
Q

What are the signs that a baby may have a congenital heart defect?

A

(top to bottom)

  1. Poor feeding
    1. Pale
    2. Breathless
  2. Failure to thrive
  3. Recurrent LRTIs
  4. Congestive heart failure symptoms
  5. ?cyanosis
103
Q

How do you manage croup?

A
  1. Do not examine throat!
  2. Steroids - oral dexamethasone 0.15 mg/ kg as a single dose (can be repeated 12 hours later).
  3. Nebulised Adrenaline 5mls 1:1000

Year 4 Family and Children ANNA (23 decks)

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