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Physical Diagnosis > PD ENT > Flashcards

PD ENT Flashcards

1
Q

Inspection and otoscopy of ear

A

External ear
External auditory canal
Tympanic membrane

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2
Q

Palpation of ear

A

External structures

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3
Q

Hearing tests

A

Whisper test
Weber test
Rinne test

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4
Q

What questions do we ask about difficulty of hearing?

A

Onset of hearing loss

Unilateral or bilateral

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5
Q

What factors could contribute to hearing loss?

A

Medications (aminoglycosides)
Trauma
Vertigo
Family Hx of hearing loss

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6
Q

Inspection of external ear

A 
Mastoid process
Auricle
Tragus
Scaphoid fossa
Helix
Antihelix
Lobule
Auditory canal
Meatus
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7
Q

Assessment of ears

A

Position
Shape
Color
Lesions

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8
Q

Position of ears

A

Down syndrome

Outstanding ears

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9
Q

Shape of ears

A 
Microtia
Creased lobule
Elongation
Replcaition of lobes
Gouty tophus
Cauliflower ear
Darwin's tubercle
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10
Q

Color of ears

A

Inflammation
Infection
Hemangiomas

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11
Q

Lesions of ears

A 
Scars
Hematomas
Dermatitis
Trauma
Infectious processes
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12
Q

Area surrounding the ears

A 
Always look behind patient's pinna
Battle sign
Preauricular pits
Erythema
Edema
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13
Q

Hair distribution in ears

A

Hairy tragus

Hairy pinna

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14
Q

Microtia

A 
Gross hypoplasia of the pinna
Blind or absent auditory canal
Bilateral
Could have completely formed and functioning cochlea
Helped with hearing aides and surgery
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15
Q

Preauricular pits

A

Autosomal dominant, unilateral 75%
Can become infected
Surgical excision if repeated infections

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16
Q

Outstanding ears

A

Angle between auricle and side of head is greater than normal
Not pathologic
Easily surgically corrected

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17
Q

Darwin’s tubercle

A

Small cartilaginous protuberance, most commonly along concave edge of posterosuperior helix
Normal variation

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18
Q

Gouty tophi

A

Deposits of uric acid crystals

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19
Q

Hairy tragus/pinna

A

Most common in men, occurs with aging

Common in people of Indian descent

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20
Q

Creased lobe

A

May be associated with increased risk for CAD

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21
Q

Hematomas
Cause
Sequela

A

Accumulation of blood between skin and cartilage
Blunt trauma most common cause
Inspect for trauma and check hearing
Cauliflower ear is late sequela

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22
Q

Cauliflower ear

Cause

A

Caused by repeated trauma to auricle
Subperichondrial separation with focal generation of fibrous tissue and scar formation
Potential hearing loss, can be surgically corrected

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23
Q

Keloid

A

Abnormal wound healing
Excessive bulk produced at site of cutaneous injury (highly compacted bundles of hyalinized collagen)
Common in AA, and older than 20

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24
Q

Battle sign

A

Hematoma behind the ear

Indication of base of skull fracture

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25
Q

Palpation

A 
Nodules
Swelling
Tenderness
Warmth
Assessment of lesions
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26
Q

Otoscopy

A

Visualize auditory canal and TM

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27
Q

Otoscopy in adults versus children

A

Adults: pinna upward and outward
Children: pinna down and back

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28
Q

What does straightening of the canal allow for?

A

Better visualization of the tympanic membrane

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29
Q

Where does the auditory canal start and end?

A

External auditory meatus and medially TM

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30
Q

What joint makes up part of the posterior external auditory canal wall?

A

TMJ

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31
Q

Skin adheres to periosteum along the … and to cartilage and soft tissue along the …

A

Inner 2/3, outer 1/3

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32
Q

Skin of the outer 1/3 contains what structures?

A

Hairs and glands that secrete cerumen

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33
Q

Where is cerumen not produced?

A

Middle or inner canal

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34
Q

What is the average length of the auditory canal?

A

3.7 cm

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35
Q

Innervation of auditory canal

A

CN V, VII, X

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36
Q

What does the stimulation of a small branch of the vagus nerve (Arnold’s nerve) do to the patient?

A

Cough during exam

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37
Q

What is the blood supply to the auditory canal?

A

Branches of auricle temporal branch of the inferior maxillary artery

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38
Q

The canal … from the pinna to the TM

A

Conducts sound waves

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39
Q

Cerumen impaction

A

Painful depending on extent of cerumen
Conductive hearing loss
Common in elderly and children

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40
Q

Tx for cerumen impaction

A

Debrox drops, irrigation, curette/otoloop

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41
Q

Otitis externa

A 
Swimmer's ear, common in summer
Painful infection of skin
Swelling erythema or canal
Pinna edematous and red
Narrowed lumen with purulent drainage
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42
Q

Bacterial causes of otitis externa

A

Pseudomonas, Staph aureus

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43
Q

Tx of otitis externa

A

Otic drops, oral abx

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44
Q

Common foreign body in the ear

A

Q tip, beans, peas, jewelry

Common in kids and psych

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45
Q

Result from foreign body

A

Complete conductive hearing loss

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46
Q

Caution with foreign body

A

Don’t irrigate if organic material suspected or insects

Carefl not to cause TM perforation

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47
Q

Exostosis

A

Small boney growths of canal
Benign
Multiple and bilateral
Aris more commonly near TM

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48
Q

Exostosis Tx

A

Usually no tx necessary unless recurrent cerumen impactions

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49
Q

Cholesteatoma

A

Overgrowth of epidermal tissue, usually in pts with hx of chronic otitis media
Canal or middle ear
Painful, erode into bone
Conductive or sensorineural hearing loss

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50
Q

Middle ear

A

Small air filled cavity within temporal bone

Lined with squamous epithelium

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51
Q

Boundaries of middle ear

A

TM oval window and round window

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52
Q

What is the opening in the posterior wall in the middle ear?

A

Opening to mastoid sinus

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53
Q

Where does infection of epithelial lining of the middle ear come from?

A

Nasopharynx via the eustacian tube

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54
Q

What structure transmits sound waves through the middle ear?

A

TM vibrates, transmitting sound waves from the canal into mechanical motion, setting the ossicles into motion

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55
Q

Ossicles

A

Malleus, incus, stapes

Augment vibrations and distribute mechanical energy to cochlea

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56
Q

Eustachain tube

A

Connects middle ear to posterior portion of nasopharynx

Neutralizes internal and external air pressures

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57
Q

Why do children have more otitis media infections?

A

Eustachian tube is much smaller and more horizontal, so pathogens are more easily introduced to the middle ear

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58
Q

Otitis media

A

Hx of recent URI
Bacterial or viral
More common in infants and children
Unilateral

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59
Q

Complications of otitis media

A 
Mastoiditis
Meningitits
Osteomyelitis
Sigmoid sinus thrombosis
Facial nerve involvement
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60
Q

Common pathogens causing otitis media

A

Strep pneumoniae
Haemophilus influenzae
M. cattarhalis

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61
Q

S&S of otitis media

A 
Pain
Fever
Erythematous, building TM
Decreased TM mobility
TM may rupture and cause purulent drainage in external auditory canal
Decreased hearing
Effusion behind TM
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62
Q

Serous otitis media

Pts

A

Can procede AOM
May be due to poor Eustachian tube function
May be concurrent with URI
Common in people with allergies
Look for fluid, bubbles behind TM, TM not inflamed

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63
Q

Bullous myringitits

A

Otalgia
Erythematous TM
Blisters
Accompanies URI symptoms

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64
Q

Pathogens of bullous myringitits

A

Mycoplasma pneumoniae

Virus

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65
Q

Cause of TM perforations

A

Trauma
Infection
Barotrauma (divers, airplane)

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66
Q

Results of TM perforation

A

Conductive hearing loss

Increased risk of infection

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67
Q

Cuase of TM scarring

A

Previous infections
Trauma
Perforations

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68
Q

Results of TM scarring

A

Decreased hearing over time due to decreased mobility of TM

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69
Q

Otosclerosis

A

Progressive hearing loss

Due to deposition of bone in cochlea/stapes foot

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70
Q

S&S of otosclerosis

A

No pain
Tinnitus
Normal TM
Patent Eustachian tube

Common in females, 30-40, familial tendency

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71
Q

Tx otosclerosis

A

Stapedectomy

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72
Q

Hemotympanum

A

blood in middle ear behind TM
Result of head trauma or severe barotrauma
Could be painful

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73
Q

Tx hemotympanum

A

Spontaneous resolution over several weeks is normal

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74
Q

Result of hemotympanum

A

Could result in conductive hearing loss

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75
Q

Pneumatic otoscopy

A

Done if loss of mobility of TM is suspected
Puff of air from otoscope gulf creates a positive pressure, and the TM should move inward, then return to normal position quickly

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76
Q

No movement or decreased movement during pneumatic otoscopy

A

Increased pressure within middle ear is suspected

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77
Q

Cause of no movement

A

Porr functioning Eustachian tube

Fluid within middle ear

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78
Q

Is pneumatic otoscopy part of the normal physical exam?

A

No

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79
Q

What are the three hearing tests?

A

Whisper
Rinne
Weber

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80
Q

Whisper test

A

Occlude opposite ear, stand behind patient and whisper words for patient to repeat, or ask a simple question and ask for an answer

Patient should be able to hear your whisper from 1-2 feet away from their ear

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81
Q

What does the whisper test test?

A

Grossly defines hearing

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82
Q

What does the Weber test test?

A

If hearing loss is noted in history or detected on exam

83
Q

Weber test

A

Bottom of vibrating tuning fork is placed on midline of patient’s head
Ask patient if sound is heard equally in both ears, or better in one ear (lateralization of sound)

Should be heard equally

84
Q

2 abnormal results of Weber test

A

Conductive hearing loss in the lateralizing ear

Sensorineural loss in the ear opposite of the lateralizing ear

85
Q

What test is used as a follow up after the Weber test?

A

Rinne test

86
Q

Rinne test

A

Placing the base of vibrating tuning fork against patients mastoid process
Ask when patient no longer hears the sound
Quickly position vibrating fork 1-2 cm from auditory canal and ask when sound is no longer heard
Count the time sound is heard

87
Q

What is a normal Rinne test?

A

Air conduction is twice as long as bone conduction

88
Q

Conductive loss in Rinne test?

A

Bone conduction is longer than air conduction in affected ear

89
Q

Sensorineural loss in Rinne test

A

Air conduction is longer or equal to bone conduction in affected ear

90
Q

Functions of the nose

A 
Airway
Warms air
Filtration of dust particles, pathogens
Humidification of air
Receives secretions from sinuses and eyes
Peripheral organ of smell
91
Q

CN for smell

A

CN I Olfactory

92
Q

History complaints relating to the nose

A 
Nasal obstruction
Discharge
Epistaxis
Change in sense of smell
Trauma
Itching nose
Olfactory hallucinations
93
Q

Inspection of nose

A 
Shape
Size
Color
Patent nares
Columnella, septum midline
Ala flaring
Discharge
Lesions
94
Q

External/middle/inner ear - conductive/sensorineural

A

External middle ear - conductive hearing loss

Inner ear - sensorineural hearing loss

95
Q

Rhinophyma

A

Bulbous enlargement of the distal 2/3 of nose from multiple sebaceous adenomas
Follows long standing rosacea

96
Q

Saddle nose

Causes

A

Sunken bridge
Loss of cartilage from septal hematoma or abscess
Congenital or acquired syphilis

97
Q

Internal inspection

A

Stabilize head, tilt head back
Gently introduce speculum
Avoid touching septum

98
Q

Observation of internal inspection

A 
Anterior nares
Mucosa
Septum
Turbinates
Posterior nares
99
Q

Inspection of mucosa

A 
Edematous
Pale
Erythematous
Moist/dry
Discharge
100
Q

Inspection of septum

A

Deviation

Perforation

101
Q

Posterior nares

A

Open to the nasopharynx

102
Q

Watery clear discharge

A

Allergies
Vial rhinitis/URI
Rhinitis medicamentosa
CSF leak

103
Q

Purulent discharge

A

Viral URI
Bacterial sinusitis
Foreign body

104
Q

Serosanginous discharge

A

Trauma

Neoplasm

105
Q

Bloody (sanginous) discharge

A 
Trauma
Coagulopathies
Carcinoma
Vasculitis
HTN
Ulceration
Drug use
106
Q

Nasal polyps

Examples

A

soft protrusions of mucosa
Pale, edematous, non tender
Chronic allergic rhinitis
Positive relationship with asthma

107
Q

What do you need to determine with epistaxis?

A

Anterior or posterior bleed

108
Q

Which is more common, anterior or posterior bleeds? Which is more serious?

A

Anterior is most common 90%

Posterior has greatest risk to hemorrhage

109
Q

Anterior bleed
Causes
Risk factors

A

Digital trauma to Kiesselbach’s plexus

Trauma, dry/cold weather, dehydration, blood thinners

110
Q

Anterior bleed tx

A

Small - cauterize with silver nitrate sticks

Extensive - nasal packing

111
Q

Posterior bleed

Risk factors

A

Acute blood loss anemia

HTN, coagulopathies, blood thinners, carcinoma

112
Q

Posterior bleed tx

A

Posterior packing
Transfusion
Hospitalization*

113
Q

What is the most common malformation of the nasal airway?

A

Choanal atresia

114
Q

Choanal atresia

Who present with it?

A

Congenitally closed orifice
Usually infants have difficulties breathing with first URI
If bilateral, respiratory distress at birth

115
Q

Hyperosmia causes

A

Addison’s disease
Allergies
Hunger
Nausea

116
Q

Cacosmia

Causes

A

Perception of four odor when one doesn’t exist

Sinusitis
Psych DO
Tumor
Tetracyclines

117
Q

Anosmia causes

A 
Infection
Allergies
Septal deviation
Pregnancy
Tumor
Trauma to head or nose
Sjogren's syndrome
Diabetes
Polyps
Zinc deficiency
Vitamin A deficiency
Schizophrenia
118
Q

Paranasal sinus tenderness

A

Palpate over frontal and maxillary sinuses looking for swelling or tenderness
Percuss sinuses

119
Q

Causes of sinus tenderness

A

Swelling, tenderness, and pain may indicate infection or obstruction

120
Q

Functions of oropharynx

A

Emission of air for vocalization and respiration
Passageway for food, liquid, saliva, vomitus
Initiation of digestion - mastication and salivary enzymes
Identification of taste

121
Q

History of complaints for oropharynx

A 
Pain
Lesions
Difficulty swallowing/chewing
Dry mouth
Excess salivation 
Decreased taste, bad taste
Halitosis
122
Q

Inspection of lips and mouth

A 
Symmetry
Color
Swelling/edema
Moisture
Lesions
123
Q

Pallor in lips causes

A

Anemia
Vitamin deficiencies
Scarlet fever

124
Q

Cyanosis in lips causes

A

Hypoxia

Cardiac and respiratory DO

125
Q

Erythema in lips causes

A

CO poisoning
Infection
Allergy

126
Q

Swelling edema in lips causes

A

Allergies
Trauma
Infections

127
Q

Dry lips and mouth causes

A

Dehydration
Mouth breathing
Sjogren’s syndrome

128
Q

Lesions in lips in mouth causes

A

Neoplasm
Infection
Irritations

129
Q

Cheilosis

A

Fissures/cracks at angles of lips

130
Q

Causes of cheilosis

A 
Dehydration
Ill fitting dentures
Nervous habit
Riboflavin deficiency
Medications (chemo)
Malignancy
131
Q

Angioedema

Causes

A

Swelling of one or both lips
Develops rapidly
Usually not pruritic

Allergic reaction, anaphylaxis, infection

132
Q

SCC

A 
Non painful
Lesions grow slowly, often bleed
Non healing
Most common oral tumor
Hx of sun exposure
133
Q

Herpes Simplex Virus

A

HS1, could be HS2
Groups of vesicles with clear fluid on erythematous base
May be painful, burn

Develop in times of illness or stress

134
Q

Petz Jehger’s syndrome

Associated with…

A

Blue or black patches of pigmentation in skin or mucosa (buccal, fingers, hands, face)

Associated with FAP, internal bleeding, anemia

135
Q

Chancre

A

Primary lesion of syphilis
Painless, raised border
Button like
Can become crusted or ulcerated

136
Q

Inspection of teeth

A 
Number
Missing or loose
Dental hygiene
Color, staining
Shape
Caries
Malocclusion
Abscesses
Dental appliances
137
Q

Malocclusion

A

Crowding of teeth

Upper molars should rest directly on lower molars and upper incisors should override lower incisors slights

138
Q

Causes of malocclusion

A

Congenital
Trauma
Jaw pain
Thumb sucking

139
Q

Hutchinson teeth

Cause

A

Notching of the permanent upper central incisors
Small than normal, tips resemble a cone

Congenital syphilis

140
Q

Tetracycline staining

A

Mother took tetracycline while in utero, or tetracycline was given as a child

Before 1980

141
Q

Inspection of gingiva

A 
Color
Bleeding
Swelling
Hyperplasia
Masses/lesions
142
Q

Gingivitis

A

Inflammation of the gums

Erythematous, swollen, bleeds easily

143
Q

Causes of gingivitis

A 
Poor hygiene
Systemic infection
Leukemia
Vitamin deficiencies
Pregnancy
OCP
DM
144
Q

Gingival hypertrophy

A

Insidious onset
Non painful
Non pathologic

145
Q

Causes of gingival hypertrophy

A 
Dilatin
Cyclosporin
Leukemia
Pregnancy
OCP
Genetic disorders
Crohn's
Sarcoidosis
146
Q

Peridontitis (pyorrhea)

A 
Receding and bleeding gums
Often painful
Halitosis
Pus pockets form between gums and teeth
Anaerobes
147
Q

Cause and result of peridontitis

A

Caused by untreated gingivitis

Common cause of tooth loss

148
Q

Periapical abscess

A

Tender swelling in adjacent gum
Sinus tract may form draining pus
Common cause of toothache
Pain accentuated by tapping tooth

149
Q

Scurvy

A

Vitamin C deficiency
Deep red/purple, swollen gums
Tender, bleed easily

150
Q

Vincent stomatitis

A

Trench mouth, acute necrotizing ulcerative gingivitis
Abrupt onset, painful, increased salivation
Punched out ulcers covered in gray yellow membrane
Halitotis is horrible
Systemically ill

151
Q

Cause of vincent stomatitis

A

Anaerobes (Fusobacterium)

152
Q

Kaposi sarcoma

A

Malignancy of vascular origin
Red/blue plaques and nodules
Commonly found on skin
Seen in advanced AIDS

153
Q

Inspection of buccal mucosa

A 
Color
Moisture
Exudates
Masses, lesions
Ulcers
Stensen's duct
154
Q

Apthous ulcers

A

Canker sores
Painful ulcers with white floor and yellow margins on erythematous base
Anteriorly in mouth on tip or sides of tongue and labial/buccal mucosa

155
Q

Cause of apthous ulcers

A

Virus
Malnutrition
Stress

156
Q

Oral candidiasis

A

White, raised exudates on buccal mucosa, palate, pharynx, or tongue
Can interfere with taste and eating
Scrapable
Not painful

157
Q

Risk factors for oral candidiasis

A 
Antibiotics
Steroids
Immunosuppression
HIV/AIDS
Cancer, chemo
DM
158
Q

Leukoplakia

A

Appears anywhere in oral cavity
Painless white plaque adherent to mucous membrane
Not scrapable
Premalignant lesions

159
Q

Risk factors for leukoplakia

A

Smoker
HIV/AIDS
Autoimmune DO
Alcohol abuse

160
Q

Fordyce spots

A

Mucosal sebaceous cysts
Small white or yellow spots on mucosa of lips, cheeks, tongue
Painless, non pathologic

161
Q

Inspection of palate

A

Continuity of palate (clefts)
Lesions
Masses
Color

162
Q

Cleft palate

A

Midline opening in hard palate due to congenital failure of fusion of the maxillary process
Usually associated with cleft lip
Severity varies

163
Q

Complications of cleft palate

A 
Breathing and speech difficulty
Hearing deficits
Chronic otitis media
Degluttination deficits
Improper teeth development/feeding problems
164
Q

Torus palatinus

A 
Bony outgrowth of the palate
Non painful
Benign
Arises in puberty
25% women, 15% men
165
Q

What is the bony outgrowth of the mandible?

A

Torus mandibularis

166
Q

Inspection of the uvula

A 
Color
Size
Lesions
Masses
Deviation
167
Q

Bifid uvula

A

May indicate underlying cleft palate

Need to palpate palate to assure bony closure

168
Q

Uvular deviation causes

A

Peritonsillar abscess

Lesion/defect of CN X

169
Q

Which way will the uvula deviate with a lesion?

A

Have patient say ahh
Uvula will deviate away from side that has lesion/defect
Soft palate on affected side will not rise

170
Q

Inspection of the tongue

A 
Size
Papillae
Deviation
Moisture
Masses/lesions
Dorsal and ventral surfaces
171
Q

Tongue deviation

A

Due to lesion/abnormality of CN XII or muscle weakness of tongue muscles

172
Q

Which way will the tongue deviate?

A

Towards side of the lesion or weakness

173
Q

Fissured tongue

A

Median sulcus is deepened
Dorsal surface interrupted with transverse furrow
Harmless, inherited

174
Q

What would longitudinal furrowing indicate?

A

Syphilitic glossitis

175
Q

Geographic tongue

A

Migratory glossitis
Irregular patches of bright red denuded epithelium - no papillae
Patches heal in a few days, only to develop new ones in other areas
Harmless, idiopathic

176
Q

Varicose veins

A

Normal, more common in elderly

177
Q

Hairy tongue

A

Overgrowth of filiform papillae
Yellow, brown, green, black
Bacterial or fungal overgrowth may play a role
Non pathologic

178
Q

Risk factors for hairy tongue

A

Poor oral hygiene
Antibiotics
Smokers
Coffee drinker

179
Q

Glossitis

A

Sore, painful, tnder, erythematous tongue

180
Q

Causes of glossitis

A 
Nutritional deficiencies
Autoimmune
Medications
Smoking, alcohol
Infection
Trauma
Dehydration
181
Q

Atrophic glossitis

A 
Atrophy of papillae
Dryness
Intermittent burning
Paresthesia of taste
Tongue becomes smaller
Slick and glistening surface
Small, punctate red dots
182
Q

Cause of atrophic glossitis

A

Poor nutrition

Alcoholic with vitamin deficiencies - folic acid, B vitamins

183
Q

Inspection of pharynx

A 
Presence of tonsils
Size of tonsils
Swelling
Exudate
Post nasal drip
Masses, lesions
184
Q

Grading tonsillar size

A

1 - visible
2 - halfway between tonsillar pillars and uvula
3 - touching uvula
4 - touching each other (kissing tonsils)

185
Q

Pharyngitis accounts for 20% of … and 50% of …

A

Outpatient sick visits

Outpatient antibiotics

186
Q

Bacterial causes of pharyngitis

A

Group A Strep
Neisseria gonorrhea
Corneybacterium diptheriae

187
Q

Viral causes of pharyngitis

A 
Rhinovirus
HSV
CMV
Adenovirus
Echovirus
EBV
Parainfluenza
Coxsackie virus
188
Q

Other causes of pharyngitis

A 
Allergies
Sinusitis
GERD
Peritonsilar abscess
Carcinoma
Fungal infections
189
Q

Incubation of Group A strep

A

2-5 days

190
Q

Symptoms of Group A strep

A 
Sore throat
Fever/chills
Malaise
Headache
Nausea
Vomiting
Abdominal pain
191
Q

PE with Group A strep

A

Erythema of pharynx and uvula
Enlarged tonsils, patchy white exudates
Enlarged, tender anterior cervical LN

192
Q

Diagnosis for Group A strep

A

Rapid strep test

If negative, culture for 24 hours

193
Q

Tx for Group A strep

A

Pen VK
Amoxicillin
Erythromycin

194
Q

Viral pharyngitis tx

A

NO ABX
Motrin, tylenol
Warm salt water gargles
Lots of fluids and rest

195
Q

Diphtheria S&S

A 
Sore throat
Hoarseness
Malaise
Fever
Nasal discharge
Tenacious gray membrane on pharynx, tonsil, palate, or uvula
196
Q

Diphtheria cause

A

Corneybacterium diphtheriae

197
Q

Complications of diphtheria

A

Myocarditis

Neuropathies

198
Q

Infectious mononucleosis

A 
Fatigue
Malaise
Fever
Lymphadenopathy
Pharyngitis
Headache
Hepatosplenomegaly
199
Q

Cause of mono

A

EBV

CMV

200
Q

Tx for mono

A 
Rest
Fluids
Proper nutrition
Time
Avoid contact sports and heavy lifting
NO ABX
201
Q

Peritonsillar abscess S&S

A 
PAIN
Deviation of uvula
Fever
Odynophagia
Hot potato voice
LAD
202
Q

Tx for peritonsillar abscess

A

I&D often required

Abx, usually IV to start

203
Q

Oral HIV/AIDS manifestations

A 
Hairy leukoplakia
Oral candidiasis
Herpes simplex
Kaposi's sarcoma
Apthous ulcers
Peridontal disease

Physical Diagnosis (10 decks)

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