Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Pediatrics Shelf Exam > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

APGAR

A 
Appearance
Pulse
Grimace
Activity
Respiration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Delivery Room Resuscitation

A

ABC

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

Infant with scaphoid abdomen, cyanosis, respiratory distress, heart sounds on right, breath sounds diminished on left =

A

diaphragmatic hernia (herniated bowel in chest) –> pulmonary hypoplasia

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

TX: diaphragmatic hernia

A

DON’T USE BVM (will cause accumulation of bowel gas); intubate!

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

Neonatal Resuscitation: If HR <60 and compressions aren’t working, give…

A

epinephrine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Infant has respiratory distress when she stops crying =

A

choanal atresia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

TX: choanal atresia

A

Intubate –> surgery

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

Maternal ingestion of phenobarbital during pregnancy can…

A

decrease the risk of neurologic damage in a jaundiced newborn

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

8-day-old jaundiced infant (noted on day 2 of life) with normal labs, Coombs, and smear…

A

Gilbert Syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

12-day-old infant with jaundice, above birth weight, exclusively breast-fed…

A

Breast Milk Jaundice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Physiologic jaundice in the first week of life in the majority of infants results from…

A
  1. higher bilirubin production rates

2. limited ability for excretion

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

R/F for neonatal sepsis (5)

A
  1. Young maternal age
  2. Small gestational size
  3. APGAR < 5
  4. > 18 hours ROM
  5. Young gestational age (premature)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

TX: early onset sepsis

A

amp + gent

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

TX: late onset sepsis

A

amp + cefotax

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

Most common neonatal sepsis pathogen from 0-3 months:

A

GBS

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

Organisms associated with EOS

A
  1. GBS
  2. E. Coli
  3. Listeria
  4. H. influenzae
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Late onset neonatal sepsis is caused by organisms found…

A

…in the environment.

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

DX: fever, irritability, erythema, blisters, epidermal shedding

A

Staphylococcal scalded skin syndrome (SSSS)

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

Pathophysiology of SSSS

A

Staph aureus strains that produce exfoliative toxins, which disrupt keritoncyte adhesion in the superficial epidermis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Blisters + honey colored crust

A

Bullous impetigo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Well demarcated, warm, tender area of erythema + constitutional sx

A

Erysipelas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Targetoid lesions; central bullae; Nikolsky sign is negative

A

Erythema multiforme

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Fine, pink, sandpaper-like rash following an episode of pharyngitis

A

Scarlet fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Extensive skin blistering and erosion; triggered by medication; Nikolsky sign is + with mucous membrane involvement

A

Toxic epidermal necrolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Pathogenesis: Croup
Parainfluenza viral infection of the larynx & trachea
26
Epidemiology: Croup
6 months - 3 years | Fall/Early Winter
27
Clinical Features: Croup
Inspiratory Stridor Barking Cough Hoarseness
28
Tx: Croup
Mild - humidified air +/- corticosteroids Moderate/Severe (stridor at rest) - corticosteroids + nebulized epinephrine
29
Another name for croup...
Laryngotracheitis
30
In croup, stridor will worsen with...
crying, laughter
31
Steeple sign =
Croup
32
Acute onset of high fever, stridor, significant respiratory distress; often unvaccinated --> tripod position
Epiglottitis
33
Lower respiratory tract illness most commonly caused by RSV
Bronchiolitis
34
Sudden-onset respiratory distress/stridor...
Foreign body aspiration
35
Collapse of supraglottic structures during inspiration; chronic inspiratory stridor that begins in neonatal period; worse in supine position
Laryngomalacia
36
Cyanosis within 24 hours of life + single S2 + egg on a string CXR =
Transposition of the great vessels
37
Immediate Tx for TGV
Prostaglandins (keeps PDA open!)
38
Chronic oligoarthritis + daily fever + rash =
Systemic-onset juvenile idiopathic arthritis
39
TX: sJIA
NSAIDs glucocorticoids biologic agents
40
Surge of this hormone leads to refeeding syndrome...
insulin
41
In refeeding syndrome, insulin stimulates cellular uptake of...
phosphorus potassium magnesium
42
Clinical manifestations of refeeding syndrome
arrhythmias | cardiopulmonary failure
43
4 anomalies of TOF
1. R ventricular outflow tract obstruction 2. R ventricular hypertrophy 3. Overriding aorta 4. Ventricular septal defect
44
Tet spell
Increase in PVR shunts deoxygenated blood from the right ventricle across the VSD into the aorta
45
Tx: tet spell
knee-chest positioning (kinks the femoral arteries, increases systemic vascular resistance, and reduces the degree of right-to-left shunting)
46
Pale stool + hepatomegaly + direct hyperbilirubinemia =
biliary atresia
47
Pathophysiology of biliary atresia
progressive obliteration of the extrahepatic biliary ducts connecting the liver to the small bowel
48
Tx: biliary atresia
Kasai procedure (hepatoportoenterostomy); all patients will require a liver transplant at some point
49
Jaundice in second week of life; unconjugated
Breast milk jaundice
50
Pathophysiology of Crigler-Najjar
Absent UDP; early symptoms, need liver transplant; unconjugated
51
Pathophysiology of Gilbert
Mild lack of UDP; mild symptoms; unconjugated
52
unconjugated hyperbilirubinemia + positive coombs =
alloimmune hemolytic disease (erythroblastosis fetalis)
53
Most common congenital heart defect in patients with Down syndrome
Complete atrioventricular septal defect
54
diminished or absent lower-extremity pulses and upper-extremity HTN; associated with Turner syndrome
coarctation of the aorta
55
triple or quadruple gallop (widely split s1 and s2 + loud s3 and/or s4) + holosystolic/early systolic murmur at LLSB
symptomatic Ebstein anomaly
56
continuous, machine like murmur
PDA
57
cyanosis + single s2 + harsh crescendo-decrescendo murmur
TOF
58
neonatal cyanosis + tachypnea + single s2 + associated with DiGeorge syndrome =
TGA
59
Pleural fluid analysis demonstrates milky-white fluid with elevated triglycerides
chylothorax/exudative
60
Exudative effusion due to disruption of lymphatic flow within thoracic duct...
chylothorax
61
In patients with apparent subcutaneous emphysema secondary to sever coughing paroxysms, ____ must be obtained to r/o _____.
CXR | pneumothorax
62
Allergic reaction to blood transfusion...
selective IgA deficiency
63
Lots of infections + GIARDIA
Common Variable Immunodeficiency (IgA, M, G low)
64
3-5 weeks old, nonbilious emesis...
pyloric stenosis
65
Mild mental delay, eunuchoid habitus, gynecomastia, long arms, long legs, hypogonadism...
Klinefelter (XXY)
66
Explosive anger, weakness with fine motor control, accelerated growth, large teeth, asymmetrical ears, severe acne...
XYY Syndrome
67
Girls with short stature, amenorrhea, excessive nuchal skin, low posterior hairline, broad chest, coarctation of the aorta...
Turner's (45, XO)
68
Primarily in boys; ID, macroencephaly, long face, high arched palate, large ears, macroorchidism...
Fragile X (fragile site at X gene)
69
Beta thalassemia blood findings...
microcytic, nonimmune, hemolytic anemia (normocytic w/ high reticulocytes) MCHC = decreased presents >6 months
70
Hereditary spherocytosis blood findings...
hemolytic anemia (normocytic w/ high reticulocytes) MCHC = elevated
71
Young patient in distress, sitting in tripod position with chin thrust forward...
epiglottitis
72
Pathogen: epiglottitis
H. influenzae B
73
R/F for epiglottitis
no vaccinations
74
XR findings for epiglottitis:
thumb sign
75
Tx: epiglottitis
intubation | antibiotics
76
McCune-Albright Syndrome (3)
irregular cafe-au-lait precocious puberty fibrous dysplasia of bones
77
McCune-Albright Syndrome Gene
GNAS
78
Peutz-Jeghers Syndrome (2)
GI tract hamartomatous polyposis; skin lesions (small, perioral, mucocutaneous pigmented macules)
79
Sturge-Weber (4)
ID seizures visual impairment Port Wine Stain (trigeminal nerve)
80
Tuberous Sclerosis (2)
Ash-leaf spots | Shagreen patches
81
Hand, Foot, Mouth (virus, sx)
Coxsackievirus | Sx: fever, oral sores, rash on palms/soles
82
Measles (sx, rash distribution)
sx: cough, coryza, conjunctivitis rash: cephalocaudal
83
Scarlet Fever (sx)
sx: fever, strawberry tongue, sandpaper rash, exudative pharyngitis
84
Complications of Kawasaki Disease (2)
1. Coronary Artery Aneurysms | 2. Myocardial Infarction & Ischemia
85
Severe Combined Immunodeficiency (Etiology)
Gene defect leading to failure of T cell development, B cell dysfunction due to absent T cells
86
SCID (inheritance)
x-linked recessive | autosomal recessive
87
SCID (tx)
Stem Cell transplant
88
CD19 =
B Cells
89
CD3 =
T Cells
90
Down Syndrome Features
``` epicanthic folds upslanting palpebral fissues low set, small ears flat facial profile short neck w/ excess skin furrowed tongue brushfield spots single, transverse palmar crease sandal-toe deformity ```
91
Beckwith-Wiedemann Syndrome
Macrosomia Hemihyperplasia Omphalocele Macroglossia
92
Prader-Willi Syndrome
Hypogonadism | Almond-shaped eyes
93
Complications of Eczema (4)
1. Impetigo (staph aureus, strep pyogenes); painful pustules with honey-crusted adherent coating 2. Eczema herpeticum (herpes simplex type I); painful vesicular rash with punched-out erosions and hemorrhagic crusting 3. Molluscum contagiosum (poxvirus); flesh colored papules with central umbilication 4. tinea corporis/ring worm(trichophyton rubrum); pruritic circular patch with central clearing and raised, scaly border
94
Croup (virus, age, sx)
Virus: parainfluenza Age: 6 mo - 3 y/o Sx: inspiratory stridor, barking cough, hoarseneess
95
Croup (tx)
mild - humidified air, +/- steroids severe - steroids + nebulized epi
96
Croup (pathophys)
edema and narrowing of proximal trachea, aka subglottis; steeple sign
97
Recurrent sinopulmonary and GI infections , absence of lymphoid tissue (little tonsils), beginning after 6 y/o...
x-linked agammaglobulinemia, AKA Bruton's
98
X-linked agammaglobulinemia (Dx)
decreased immunoglobulins and b cells; normal t cells; no response to vaccinations
99
Adenosine deaminase deficiency =
SCID
100
Impaired oxidative burst =
CGD (reccurent skin and pulm infections)
101
Osgood-Schlatter Disease
``` unilateral, knee pain progressive young adolescents pain over tibial tubercle clinical dx tx: supportive ```
102
Patellar tendinitis
overuse injury due to repetitive jumping; point tenderness at inferior pole of the patella
103
Patellofemoral pain
overuse injury presenting as progressive knee pain; pain localized to patella, associated with instability and buckling of knee
104
Prepatellar bursitis
direct, chronic trauma of anterior knee; pain with direct pressure, superficial swelling over patella
105
Nephrotic syndrome in kids...
minimal change disease
106
Nephrotic syndrome in adolescents/adults...
focal segmental glomerulosclerosis (FSGS) and membranous nephropathy
107
R/F for membranous nephropathy
Hep B +
108
Herpangina
``` Coxsackie virus Posterior Oral Ulcers Fever Pharyngitis Tx: supportive ```
109
Hand-Foot-Mouth
Similar to herpangina + rash on hands/feets; also caused by coxsackie virus
110
Herpetic gingivostomatitis
``` HSV1 Anterior/Lip Ulcers Fever Pharyngitis Erythematous gingiva Tx: oral acyclovir ```
111
Tonsillitis pathogen
adenovirus
112
Vitamin K Deficiency
elevated PT & INR | normal platelets
113
Options for foreign body ingestion (2)
1. If no severe r/f exist = serial XR | 2. If severe r/f = endoscopic removal
114
Tx: mild to moderate dehydration
Oral rehydration
115
Tx: severe dehydration
IVF - isotonic saline
116
Pinworm (worm, sx, dx)
Enterobius vermicularis Sx: nightly perianal pruitis Dx: eggs on tape test
117
Pinworm (tx)
albendazole OR pyrantel pamoate
118
Candida albicans (diaper rash)
beefy red rash within skin folds, satellite lesions; tx = clotrimazole
119
Strongyloidiasis
helminth | sx: urticaria, abdominal pain, respiratory problems
120
Strongyloidiasis (tx)
ivermectin
121
Scabies
sx: intense pruritis (worse at night); affects extremities; associated papules and burrows
122
Scabies (tx)
permethrin
123
Schistosomiasis
caused by flatworms | sx: rash on lower legs, several weeks later -- diarrhea, weight loss, RUQ pain
124
Schistosomiasis (tx)
Praziquantel
125
Respiratory Distress Syndrome (pahtophys.)
common in premature neonates with very low birth weight; immature alveoli are unable to produce sufficient surfactant to reduce alveolar surface tension, results in alveoli collapse and diffuse atelectasis
126
RDS (sx)
present within minutes to hours of birth; tachypnea, grunting, nasal flaring, retractions, hypoxia, cyanosis
127
RDS (XR findings)
ground glass opacities perihilar linear opacities diffuse, fine, reicular granularity
128
RDS (tx)
continuous positive air pressure ventilation; can consider surfactant therapy
129
Burkitt lymphoma
neoplasm of mature B cells; mass in the mandible or abdominal viscera; "starry sky appearance"
130
Hodgkin lymphoma
fever, lymphadenopathy; mediastinal mass on CXR
131
Microcytic anemia think...
iron deficiency, thalassemia
132
Distinguishing laborartory findings for IDA include...
decreased erythrocytes, elevated red cell distribution, reactive thrombocytosis (>400)
133
Premature infants should receive vaccines...
according to their chronological age. Do NOT delay!
134
Live attenuated vaccines are withheld in this population...
immunocompromised patients
135
Most common GI anomaly associated with Down Syndrome
duodenal atresia
136
XR finding for duodenal atresia
double bubble sign
137
Management for duodenal atresia
d/c enteral feeds, NG tube decompression, surgical repair
138
Immediate routine neonatal resuscitation includes...
drying, stimulating, warming
139
The only absolute infant contraindication of breastfeeding is...
galactosemia
140
ambigious genitalia + 46,xx, elevated 17-hydroxyprogesterone =
congenital adrenal hyperplasia
141
Most common cause of CAH is...
21-hydroxylase deficiency
142
CAH (tx)
glucocorticoid and mineralcorticoid therapy
143
Rett Syndrome
females, regression of milestones, hand-wringing, hyper/hypoventilation, seizures; MECP2 gene
144
Krabbe disease
peripheral neuropathy, optic atrophy, spasticity, microcephaly
145
Landau-Kleffner Syndrome
language skills deteriorate secondary to severe epileptic attacks
146
Lennox-Gastaut Syndrome
severe seizures of multiple types + ID
147
Wiskott-Aldrich syndrome
eczema microthrombocytopenia recurrent infections
148
WAS (genetics)
WAS gene x-linked recessive cytoskeleton problem
149
WAS (tx)
stem cell transplant
150
Shigella gastroenteritis
``` high fever abdominal pain profuse diarrhea (+ mucus, blood) +/- seizures (kiddos) ```
151
Methemoglobinemia
excessive exposure to oxidizing agent; presents with O2 sat of 85% when it is actually normal (PaO2); presents with cyanosis and dark chocolate blood
152
Methemoglobinemia (tx)
Methylene blue
153
Transient proteinuria
isolated proteinuria in u/a; normal, make sure to check again on two separate occasions to ensure that it isn't chronic
154
Rubella
low-grade fever maculopapular rash w/ cephalocaudal spread posterior auricular suboccipital lymphadenopathy
155
Cystinuria (triad)
recurrent kidney stones + family history + hexagonal crystals
156
Cystinuria (pathophys.)
impaired transport of cystine and the dibasic amino acids ornithine, lysine, and arginine = cystine stones!
157
Cystinuria (dx)
cyanide-nitroprusside test
158
Dx test for hereditary spherocytosis
1. 5-eosin-malimide binding test | 2. osmotic fragility on acidified glycerol lysis test
159
CXR: fluid in interlobar fissures
TTN
160
Sickle Cell Trait - Gross hematuria
Renal papillary necrosis
161
Factor 8 replacement therapy can cause...
inhibitor development
162
Contraindications for Rotavirus Vaccine
Intussesception Meckel's Diverticulum SCID
163
SCD: Progressive Anemia
Folate Deficiency
164
SCD: Sudden Anemia
Aplastic Crisis
165
Medication that can trigger hemolysis in G6PD deficiency
nitrofurantoin
166
Trendelenberg gait
pelvic shift downward | weakness of gluteus maximus
167
Babies born to mothers who are + for Hep B should receive...
vaccine AND immune globulin
168
Beckwith-Wiedemann Syndrome
``` macrosomia macroglossia umbilical hernia/omphalocele hemihyperplasia hypoglycemia ``` get abdominal u/s and afp q 3mo higher risk for Wilm's tumor and hepatoblastoma
169
Central Precocious Puberty
Advanced Bone Age | High LH, FSH
170
Peripheral Precocious Puberty
Advanced Bone Age | Low LH, FSH
171
Common cause of peripheral precocious puberty
Nonclassic congenital adrenal hyperplasia
172
Topical erythromycin is used in neonates to prevent...
gonorrhea
173
Microcytic anemia in kids (2)
iron deficiency | thalassemia
174
Acute rheumatic fever
``` Jones criteria: fever migratory polyarthritis erythema marginatum elevated acute-phase reactants (ESR,CRP) ```
175
Serum Sickness Reaction
Beta lactams, sulfa drugs; sx - fever, urticarial rash, arthralgia, lymphadenopathy
176
Phenytoin Use During Pregnancy...
microcephaly wide open fontanelle cleft lip/palate distal phalange hypoplasia
177
One week old boy who has poor feeding, vomiting, signs of dehydration, low Na, and virilization...
21-hydroxylase deficiency; aka CAH
178
Dx for CGD (2)
Nitroblue tetrazolium test; dihydrorhodamine
179
Biphasic stridor that improves with neck extension but NOT with prone positioning
Vascular Ring
180
Inspiratory stridor that worsens with feeding or crying; gets better when baby is prone
Laryngomalacia
181
Waterhouse-Friderichsen Syndrome
patients w/ meningococcemia; sudden vasomotor collapse and skin rash = adrenal hemorrhage
182
5 Cyanotic Heart Lesions
``` 5 T's Truncus arteriosis Transposition of Great Vessels Tricuspid Atresia Tetrology of Fallot Total anomalous pulmonary venous return ```
183
Most common complication of near drowning =
acute respiratory distress syndrome
184
Radio-opaque tablets =
iron
185
Tx for iron OD
deferoxamine
186
XR findings for Ewing Sarcoma
1. central lytic lesion 2. onion skinning 3. moth eaten appearance 4. codman triangle
187
XR Findings for Giant Cell Tumor
Soap Bubble
188
XR Findings for Osteoid osteoma
small, round lucency
189
Duhenne Muscular Dystrophy would show ____ dystrophin on dx.
ABSENT
190
Neonate with exposure to VZV give...
VZV IVIG
191
Fanconi anemia
most common cause of congenital aplastic anemia; DNA repair defect; sx - short stature, hypo/hyperpigmented macules, abnormal thumbs, GU malformations
192
Niacin Deficiency
Diarrhea Dermatitis Dementia Death **enlarged, smooth, red tongue
193
See honey, think...
infant botulism
194
Craniopharyngiomas
+ calcifications | present like mom's tumor
195
Pituitary Adenoma
- calcifications | present with more hormone based sx
196
Androgen Insensitivity Syndrome
Genotypically Male Phenotypically Female Elective Gonadectomy (b/c undescended testes can lead to testicular cancer)
197
Diamond-Blackfan Anemia
Craniofacial abnormalities Triphalangeal thumbs Increased risk of malignancy
198
Diamond-Blackfan Anemia
Corticosteroids | RBC Transfusions
199
APSGN (pathophys)
mesangial immune complex deposits
200
Gaucher Disease
``` Glucocerebrosidase Deficiency hepatosplenomegaly anemia, thrombocytopenia bony pain FTT, delayed puberty ```
201
Atlantoaxial Instability
Down Syndrome | sx - UMN findings, urinary/fecal incontinence, gait changes, weakness
202
Congenital Lymphedema
Turners Syndrome | Pathophys = lymphatic network dysgenesis
203
Langerhans cell hsitiocytosis
Lytic bone lesions Skin lesions (rash) Diabetes insipidus Lymphadenopathy
204
Primary Amenorrhea
U/S | FSH - low = TSH/prolactin; high - karyotype
205
ABG findings for pyloric stenosis
pH, PaCO2, HCO3 = high | K, Cl = low
206
Patients with beta-thalessemia major need...
transfusions and chelation therapy for LIFE
207
Jervell & Lange-Nielsen Syndrome
congenital deafness death at young age (+ fhx) elongated QT interval
208
Trisomy 18
``` IUGR microcephaly VSD closed fists with overlapping fingers micrognathia rocker-bottom feet ```
209
Most common cause of neonatal hypothyroidism
thyroid dysgenesis
210
Primary Ciliary Dyskinesia
situs inversus recurrent sinusitis bronchiectasis
211
Gene in Marfans...
fibrillin 1
212
Gene in Homocystinuria...
Cystathionine Synthase
213
Patients with SCD on hydroxyurea will have a hemoglobin electrophoresis that resembles...
``` high S (80%) mildly elevated F (17%) ```
214
Aplastic anemia does NOT have...
bone pain | hepatomegaly
215
Henoch-Schonlein Purpura
palpable purpura arthritis/arthralgia abdominal pain renal disease
216
In patients with SCD, lab findings during a splenic sequestration are:
increased reticulocytes | decreased platelents
217
In patients with SCD, lab findings during an aplastic crisis are:
decreased reticulocytes
218
Aspirin during influenza/varicella think...
Reye's Syndrome
219
Reye's Syndrome
Acute Liver Failure Encephalopathy Excess Ammonia
220
Pathophys for Reye's Syndrome
Microvascular Steatosis
221
Tanner Stage 3/4 boy w/ tender, nipple breast tissue....
reassure and observe --> probably gynocomastia
222
Vitamin supplementation for Measles Patients
A
223
Tx for neonate clavicular fx
Nothing (annoyed)
224
Thrill, 4/6 murmur at LLSB
VSD
225
Maternal diabetes is a R/F for RDS b/c...
it delays surfactant production
226
Wiscott-Aldrich - Water
Wa - WASP T - thrombocytopenia E - eczema R - recurrent sinopulm infections
227
Umbilical hernia + macroglossia =
Congenital Hypothyroidism

Pediatrics Shelf Exam (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions