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[2b] A- step 2 CK > PEDS > Flashcards

PEDS Flashcards

1
Q

Identify possible causes of this rash - 3

A

THE STRAWBERRY TONGUE!

  1. GASP +/- mononucleosis
  2. Kawasaki disease
  3. Toxic Shock Syndrome
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2
Q

Dx Criteria for Kawasaki Disease

A

[Burning HIGH Fever x ≥ 5 days] PLUS 4/5 of CRASH:

  • Conjunctivitis
  • Rash
  • Adenopathy unilaterally in cervical region (least likely)
  • Strawberry tongue/oral mucosa changes
  • Hand/Feet redness or swelling
  • THIS IS DX OF EXCLUSION! THERE CAN NOT BE ANOTHER OBVIOUS CAUSE OF PRESENTATION*
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3
Q

There are 5 major complications of Kawasaki Disease

In order of greatest to least, list them

A

[Burning HIGH Fever x ≥ 5 days] PLUS 4/5 of CRASH:

CNS ∆(irritability/aseptic meningitis) > CORONARY ARTERY ANEURYSM (within 1-4 wks!) > Liver dysfxn > Arthritis > GallBladder Hydrops

THIS IS DX OF EXCLUSION! THERE CAN NOT BE ANOTHER OBVIOUS CAUSE OF PRESENTATION

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4
Q

Tx for Kawasaki disease-2 ; when should this be given?

A

[Burning HIGH Fever x ≥ 5 days] PLUS 4/5 of CRASH:

  1. [ASA 80-100 mg/kg/day divided into 4 doses] –> [3-5 mg/kg/day as one dose after defervescence] –> DC after 6 wks if no coronary involvement. Cont indefinitely if so.
  2. [IVIG 2g/kg given over 12 hours]

within 10 days of Burning HIGH FEver

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5
Q

Which diseases in kids involve rash involving palms and soles - 4

A
  1. Kawasaki
  2. Enteroviruses
  3. Syphilis
  4. Rocky Mountain Spotted Fever
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6
Q

CBC findings for Kawasaki - 6

A

[Burning HIGH Fever x ≥ 5 days] PLUS 4/5 of CRASH:

  1. ⬆︎WBC w/neutrophil predominance
  2. Normocytic Anemia
  3. ⬆︎⬆︎⬆︎⬆︎ Platelets during 2nd wk of illness–>clots–>coronary artery aneurysm
  4. +/- ⬆︎LFTs
  5. low albumin
  6. ⬆︎ESR that persist after fever subsides

THIS IS DX OF EXCLUSION! THERE CAN NOT BE ANOTHER OBVIOUS CAUSE OF PRESENTATION

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7
Q

Which tx for Kawsaki is effective in preventing coronary artery aneurysms?-2 ; when is f/u echo recommended?

A

[Burning HIGH Fever x ≥ 5 days] PLUS 4/5 of CRASH:

[IVIG 2g/kg given over 12 hours] AND [low dose ASA] ; 1-2 weeks since coronary aneursyms develop within 4 wks

HIGH dose ASA is for fever control only

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8
Q

3 classic Clinical Manifestations of [Tetralogy of Fallot]

A

A:

  1. [Systolic Ejection HARSH Murmur @ L Sternal 2/3 ICS] from [RVOO -R Vt Outflow Obstruction]
  2. Squatting relieves sx (INC afterload–> [DEC amount of R to L shunt]
  3. [Cyanotic lethal Tet Spells] (tx: Knee chest positioning and inhaled O2)

“VOIR is to have See + Sight & Cry”

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9
Q

What is a BRUE ?

A

Brief Resolved Unexplained Event

when there is an IDIOPATHIC sudden, brief and now resolved episode occuring in an infant < 1 yo that included at least:

  1. cyanosis
  2. breathing ∆ (absent, ⬇︎, irregular)
  3. Hyper/hypotonia
  4. altered LOC

this is a dx of exclusion

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10
Q

Violent Infant Shaking —> ________. This is characterized by what 3 things?

B: How is this differentiated from similar conditions?

A

Violent Infant Shaking –> [AHT- Abusive Head Trauma]! =

  1. Subdural Hemorrhage (from tearing bridging veins between Dura and Arachnoid)
  2. Retinal Hemorrhages Bilaterally (from congested retinal vein ruptures)
  3. POSTERIOR rib fractures

B: Usually Accidental Fall is not sufficient for Subdural Hemorrhage OR [BL Retinal Hemorrhage]

AHT is formely known as Shaken Baby Syndrome

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11
Q

What’s used to keep the PDA Patent?

A

Prostaglandin E1

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12
Q

What should you always suspect in a pediatric pt who recently had a viral illness, now p/w SOB and cardiomegaly?

A

Viral myocarditis (coxsackie B vs adenovirus)

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13
Q

2 main sx of Bronchiolitis ; cause?

A
  1. Wheezing w/respiratory distress
  2. Fever

RSV

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14
Q

Laryngomalacia etx

A

As a neonate, collapse of supraglottic structures during inspiration –> chronic inspiratory stridor worst when supine

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15
Q

[T or F] LAD is actually normal in kids and young adults

A

TRUE - AS LONG AS THEY’RE SOFT AND MOBILE

tx = observation

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16
Q

Why is cessation of breast feeding in a jaundiced 20 day old pt who is lethargic not necessary?

A

Galactosemia (Conjugated Hyperbilirubenima) is unlikely considering pt is 20 days old. Sepsis should be r/o first with blood cx and px abx

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17
Q

What are the 2 major complications of Mumps

A
  1. Orchitis
  2. Aseptic Meningitis
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18
Q

A child comes in with neonatal conjunctivitis

DDx?-3 ; How do you differentiate each?

A
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19
Q

Tx for Neonatal Chlamydia Conjunctivitis?

Tx for Neonatal Gonococcal Conjunctivitis?

A

Topical macrolides are only PX for Gonococcal conjunctivitis

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20
Q

What is the most common cause of Chronic renal failure (and urinary tract obstruction) in pediatrics?

A

Posterior Urethral valves (THIS ONLY AFFECTS BOYS-including newborns)

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21
Q

All kids with a febrile UTI at age 2mo-2yo should undergo ___ to evaluate for ______

A

Renal US–>[cystourethrogram if recurrent] ; Vesicoureteral reflux

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22
Q

Oligohydramnios –> ___ sequence.

Describe this clinical presentation for this Sequence ; Name the 3 most common causes of Oligohydramnios

A

Oligohydraminos –> POTTER Sequence

Pulmonary hypOplasia

Oligohydraminos from renal agenesis/damage (cause)

[Twisted Face & Extremities]

Twisted Skin

Ears set low

Renal Failure

POSTERIOR URETHRAL VALVES are the most common cause of obstruction in newborn boys (which causes renal damage –> oligohydramnios during utero)

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23
Q

Minimal change disease is most common cause of nephrOtic syndrome in kids

Tx?

A

Prednisone

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24
Q

Minimal change disease is most common cause of nephrOtic syndrome in kids

When is renal biopsy indicated?-2

A
  1. >10 yo
  2. Child has NOT responded well to CTS
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25
Q

What dx should be suspected in a neonate with painless bloody stools ; mngmt?

A

Milk/Soy protein proctocolitis ; dairy/soy cessation –> bleeding stops in 2 wks

these pts usually also have eczema and regurgitation from Milk/Soy

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26
Q

DDx for neonatal rectal bleeding - 4

A
  1. **Milk/Soy Proctocolitis** = PAINLESS
  2. Meckel Diverticulum = PAINLESS
  3. Volvulus (bloody stool from intestinal ischemia)
  4. Intussuception (dx= AIR contrast enema)
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27
Q

cp for neonatal Lactose Intolerance - 3

A
  1. crampy abd pain
  2. bloating/flatulence
  3. Nonbloddy diarrhea
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28
Q

etx for Choanal atresia in kids ; cp

A

Congenital falure of posterior nasal passage to canalize –> bony obstruction instead; cyanotic infant whose cyanosis worsens with feeding and relieves by crying

Dx = inability to pass catheter thorugh nares

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29
Q

Demographic for Hypertrophic pyloric stenosis

A

First Born boys age 3-5 wks

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30
Q

Pts with Beckwith-Wiedemann syndrome should be monitored for what 2 CA?

A
  1. Hepatoblastoma
  2. Wilms tumor
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31
Q

cp for Reye syndrome - 3

A
  1. encephalopathy from ⬆︎ICP –> seizure & lethargy –>eventually DEATH
  2. liver dysfunction
  3. vomiting
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32
Q

Dx? ; Mngmt?

A

Congenital Diaphragmatic Hernia ; Intubation without any preceding bag mask ventilation

Image = Scaphoid concave abdomen with Barrel Chest

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33
Q

Why do pts with this condition often have polyhydramnios?

A

Hernia of Diaphragm compresses esophagus –> polyhydramnios

Congenital Diaphragmatic Hernia

Image = Scaphoid concave abdomen with Barrel Chest

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34
Q

Constipation is common in Toddlers

Why? - 3

A
  1. Transition to solid food and cow’s milk
  2. toilet training
  3. school entry

Tx = PO Laxatives

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35
Q

When should ingested batteries be emergently and endoscopically removed?

A

ONLY when the battery is still IN the esophagus and not distal to it. If distal –> obs

this also includes sharp objects, or multiple magnets

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36
Q

[T or F] Gastroesophageal reflux is common in infants

Why or why not? ;

A

TRUE

  1. More time spent supine
  2. Shorter esophagus
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37
Q

Physiological Gastroesophageal reflux is common in infants

What is the mngmt for this?-2 ; When should you be concerned for GER Disease in infants?-2

A

Physiologic reflux = REASSURANCE, hold infant upright after feeds

GERD =failure to thrive, opisthotonic posturing after feeds. Tx = add oatmeal to thicken feeds + PPI

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38
Q

What is the mngmt for an ingested coin? - 3

A
  1. Obs for up to 1 day after ingestion UNLESS
  2. Pt is symptomatic = flexible endoscopy
  3. Pt has no recollection of ingestion time = flexible endoscopy
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39
Q

Zollinger Ellison etx ; cp-2

A

gastrin producing tumor in pancreas or duodenum –> ⬆︎⬆︎gastric acid > 1000 –>

  1. multiple duodenal/jejunal ulcers REFRACTORY to PPI
  2. steatorrhea from pancreatic enzyme inactivation

Be sure to screen Zollinger Ellison pts for MEN1 using PTH, Ca+ and Prolactin studies

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40
Q

What is Hepatic Hydrothorax

A

Liver Disease pts cause damage to R diaphragm –> small defects that allows R pleural effusions to form

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41
Q

[T or F] UNILATERAL cervical lymphadenitis in kids from __(bacteria)__ is uncommon and should be worked further

A

FALSE! uL cervical lymphadenitis is common

Usually from Staph ( > GASP)!

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42
Q

cp for Bronchiolitis in neonates - 3 ; px for this?

A
  1. Wheezing and/or Crackles
  2. URI sx
  3. Respiratory distress eventually –> APNEA

Px = Palivizumab for kids<2 yo

43
Q

What does APGAR stand for? ; How is it done? ; How is it used?

A

Appearance, Pulse, Grimace(reflex irritability), Activity(tone), Respiration

Performed at 1 and 5 min postpartum, All scaled from 0 to 2 and then added together

[< 3 = Critical] / [4-6 = fair: PPV] / [7-10 = normal: No intervention]

44
Q

APGAR is used to assess newborn status immediately postpartum

Describe the grading system for Respiration?

A

APGAR

0 = not breathing

1 = breathing slow/irregular

2 = crying

45
Q

APGAR is used to assess newborn status immediately postpartum

Describe the grading system for Pulse?

A

APGAR

0 = No HR

1 = < 100 bpm

2 = > 100 bpm

46
Q

APGAR is used to assess newborn status immediately postpartum

Describe the grading system for Activity & tone?

A

APGAR

0 = no motion

1 = arms & legs flexed but not active

2 = Active Motion of extremities

47
Q

APGAR is used to assess newborn status immediately postpartum

Describe the grading system for Grimace & reflex irritability?

A

APGAR

Test response to stimulation (i.e. pinch)

0 = no rxn

1 = grimace

2 = grimace AND cough/cry/sneeze

48
Q

APGAR is used to assess newborn status immediately postpartum

Describe the grading system for Appearance?

A

APGAR

0 = entirely blue

1 = pink with blue extremities

2 = entriely pink

49
Q

In a neonate, when should compressions be started?

A

HR <60

50
Q

Neonatal Respiratory Distress Syndrome is caused by _____

What are the major risk factors?-2

A

Surfactant Deficiency

  1. Prematurity
  2. Maternal DM
51
Q

Enuresis (nocturnal urinary incontinence/bed wetting) tx - 3

Dx criteria: occurs ≥2/week AFTER 5 yo

A
  1. LIfestyle change (no fluids at bedtime/void before bedtime/reward system)
  2. Enuresis alarm
  3. Rx: DESMOPRESSIN –> add Oxybutynin if minimal change
52
Q

Any neonate who presents with Bilious emesis should be worked up for _____

A

Bowel Obstruction!

AbdXray (r/o perf bowel) –> water-soluble contrast enema

53
Q

A Contrast enema demonstrating microcolon is indicative of what condition? ; etx?

A

Meconium iLeus 2/2 Cystic Fibrosis

viscous meconium accumulation obstructs terminal iLeum –> underused colon –> contracted microcolon

54
Q

In regards to timing, what is the difference between Breastfeeding Failure jaundice and Breast Milk jaundice?

A
55
Q

In terms of physical exam, what is a difference between Breastfeeding Failure jaundice and Breast Milk jaundice?

A

In BreastFeeding Failure jaundice there will be clinical signs of Failure to thrive/dehydration

these dehydrated neonates may have brick red urate crystals in their diapers from dehydration

56
Q

In terms of etiology, what is a difference between Breastfeeding Failure jaundice and Breast Milk jaundice?

A

BFF jaundice within the First week of life: inadequate feeding –> inadequate stooling –> ⬇︎bilirubin elimination –> ⬆︎Unconjugated bilirbuin recycling with Failure to thrive/dehydration

57
Q

Tx for BreastFeeding Failure jaudice - 3

A
  1. Optimize lactation
  2. ⬆︎BreastFeeding frequnecy
  3. Supplement with Cow’s formula ONLY if mom’s milk is inadequate
58
Q

Why is human milk better absorbed than formula?

A

Protein Whey in human milk is more easily digested than casein which –> ⬆︎absorption and ⬆︎gastric emptying

59
Q

cp for Physiological Jaundice ; etx?-2

A

Unconjugated hyperbilirubinemia that appears the first 24 hours of life and resolves by the end of that week ; comes from ⬇︎hepatic UGT activity and ⬆︎bilirubin production

60
Q

Describe Metatarsus Adductus

A

Most common congenital foot deformity in which there is BL medial deviation of the forefoot usually in 1st born infants

Tx = this corrects spontaneously

61
Q

Atlantoaxial Instability MOD ; Which demographic are at most risk for this?

A

excessive laxity in the Posterior transverse ligament –> ⬆︎mobility between C1 atlas and C2 axis –> spinal cord compression and UMN signs

Down Syndrome (remember pts with down syndrome are usually hypOtonic but not with Atlantoaxial instability!)

62
Q

What is Osgood Schlatter Disease

A

Traction apophysitis of the tibial tubercle from Self-limited irritation of the growth plate at the tibial tuberosity (front of tibia) possibly –> hard nodule, relieved with rest/growth spurt

xray: lifting of tubercle from the shaft

63
Q

Osgood Schlatter Disease tx -3

A
  1. NSAIDs
  2. Ice
  3. self-limited (stops with end of growth spurt)

xray: lifting of the tibial tubercle from the shaft

64
Q

Tx for Croup-2

A
  1. Mild = Humidified air +/- CTS
  2. > Mild = CTS +/- Racemic Epi nebulized

Croup = paraflu that –> subglottic edema and narrowing

65
Q

Dx for Intussuception

A

AIR contrast enema ultrasound guided

Intussuception age = 3-36 mo

Look for the Target Sign on US!

66
Q

Diagnostic Criteria for Colic - 4 ; tx

A

Colic = the 3’s

excessive crying during first 3 weeks of life that’s

≥3hrs/day (usually evenings) for

≥3days / week for

≥3weeks in a healthy infant

Tx = Soothing and feeding techniques

67
Q

Necrotizing Enterocolitis cp - 3 ; X ray finding?

A
  1. Bloody stools
  2. feeding intolerance
  3. abd distension

X-ray = Pneumotosis Intestinalis

Risk factors= prematurity, congenital heart disease, hypotension

68
Q

Dx

A

X-ray = Psuemoatosis Intestinalis

Necrotizing Enterocolitis

69
Q

What are the risk factors for Necrotizing Enterocolitis cp - 3

A
  1. Congenital heart disease
  2. Prematurity
  3. hypotension

X-ray = Psuemoatosis Intestinalis

70
Q

Why should a pediatric pt with fever and rash who received MMR 1 week prior only receive reassurance

A

small fraction of pts who receive MMR may develop fever and mild rash that are self-limited

71
Q

What Mothers are at high risk of having Neonates with [TGA - Transposition of Great Arteries]?

A

Diabetic Mothers

72
Q

What is the most common congenital cyanotic heart defect in the neonatal period?

A

Transposition of Great Vessels

Look for the single Loud second heart sound!

73
Q

A: Clinical Manifestations of DiGeorge Syndrome (5)

B: Genetic Cause

A

“CATCH 22 & Pa3”

Cardiac (Aortic Arch abnormalitites, Tetralogy of Fallot)

Abnormal face (Bifid Uvula/low set ears)

Thymus Aplasia

Cleft Palate

[HypOcalcemia from PTH deficiency] may–> Carpopedal Spasms

22q.11.2 deletion

Pharyngeal arch - 3rd/4th both fail to develop

74
Q

What does Constitutional Short Stature refer to

A

“late bloomer” but will attain normal adult height later

pts have normal birth wt and ht but ht velocity slows between 6 mo-3 yo, picks back up after and slows again at adolescence. bone radiographs will show delayed bone age

75
Q

What is the most common cause of hip pain in kids? ; Dx?

A

Transient Synovitis; Clinical but obtain Xray to r/o Legg Calve Perthes

Tx = NSAID and rest

may have ⬆︎inflammatory markers but xrays will be normal

76
Q

Transient Synovitis is the most common cause of hip pain in kids

Tx for Transient Synovitis - 2

A

obtain Xray to r/o Legg Calve Perthes

Tx = NSAID and rest

77
Q

Cerebral Palsy is a group of clinical syndromes generally characterized as ______

How does it present? - 3

A

Nonprogressive motor dysfunction (Prematurity>EtOH = RF) ;

Cerebral Palsy is SAD

  1. BL equinovarus club feet (image)
  2. UMN signs LE >UE
  3. Mental Retardation

Greatest RF = prematurity ( < 32 wks gestation)

78
Q

Mangement for Clubfoot - 3

A

START THIS MNGMT IMMEDIATELY!

1st: Stretch and Manipulate foot –>
2nd: serial plaster cast, malleable splits or taping
3rd: Surgery beween ages 3-6 mo if refractory to #1-2

79
Q

Langerhans cell histiocytosis cp - 3

A
  1. solitary painful lytic bone lesion in child
  2. overlying swelling
  3. hypercalcemia
80
Q

Craniopharyngiomas and Pituitary adenomas both can cause bitemporal hemianopsia

How can you differentiate the two? - 2

A
  1. Craniopharyngiomas are calcified (show up white on CT)
  2. Craniopharyngiomas results in pituitary hormonal deficiency (adenomas result in pituitary hormone ⬆︎)

Craniophyarngiomas are calcified epithelial remnants of Rathke’s pouch that reside in the SUPRAsellar region

81
Q

Craniopharyngioma etx

A

Calcified low grade malignancy dervied from epithelial remnants of Rathke pouch within the pituitary stalk and reside in the SUPRAsellar region

82
Q

What is Erythema Toxicum Neonatorum ; tx?

A

benign neonatal rash with blanching erythematous papules and/or pustules ; self limited to 2 weeks after birth

83
Q

Malrotation and Volvulus are both diagnosed with ______

Describe how both would look on this diagnostic?

A

barium swallow Upper GI Series

Malrotation = Ligament of Treitz on the R side of the abd in a gasless abd

Volvulus = corkscrew image on barium swallow Upper GI series

84
Q

Malrotation and Volvulus are both diagnosed with ______

What would a Volvulus look like?

A

barium swallow Upper GI Series

corkscrew pattern

Try not to use CT scans in kids

85
Q

cp for Meckel’s Diverticulum ; dx

A

PAINLESS hematochezia ; technetium 99 pertechnetate scan

86
Q

Describe general characteristics of intentional child scald burns - 3

A
  1. uniform depth
  2. sparing of flexor surfaces
  3. sharp lines of demarcation
87
Q

Strabismus (ocular misalignment) after the age of ____ is abnormal and requires intervention to prevent _____

Which intervention is employed for this? - 3

A

4 mo ; Amblyopia(vision loss from disuse of the deviated eye)

  1. CTL eye patch to strengthen deviated eye OR
  2. CTL cycloplegic eye drops (blurs normal eye to strengthen deviated eye)
  3. Corrective lens

Dx = asymmetric corneal light reflex

88
Q

What is Legg Calve Perthes Disease? ; Demographic? ; mngmt-2?

A

Avascular necrosis of the Capital Femoral Epiphysis ; [Boys 4-10 yo) ;

  1. Self limited but can –>deformity/degeneration
  2. contain femoral head within acetabulum during encounter
89
Q

Slipped Capital Femoral Epiphysis is a complication of childhood obesity

When does this present?; How does this present? ; dx?

A

puberty (most common hip disorder in fat teens!) ; Months of vague hip/knee pain without acute onsets ; plain pelvis XRay

posterior displaement of capital femoral epiphysis thru cartilage growth plate

90
Q

Risk factors for Developmental Dysplasia of Hip - 3 ; when should you stop screening for this?

A
  1. Breech Delivery - GET HIP IMAGING IF FEMALE AND BREECHED
  2. Female - GET HIP IMAGING IF FEMALE AND BREECHED
  3. Fam hx

12 months old

91
Q

pediatric pt presents with apparent leg length discrepancy and is diagnosed with ______

What is the work up for this?-2

A

Developmental Dysplasia of Hip

hip ultrasound < 4 mo < hip xray

92
Q

What is the treatment for Developmental Dysplasia of Hip?

A

Pavlik Harness tat holds hip in flexion and ABduction

93
Q

Infants with congenital hypothyroidism appear normal because _______

What are s/s of hypothyroidism in peds later on? - 10

A

protected by maternal thyroid hormone for 6 wks;

  1. G: ⬇︎Feeding
  2. G: ⬇︎Activity
  3. P: Mental retardation (check for Down Syndrome)
  4. H: Large Fontannel
  5. H: Macroglossia
  6. H: Puffy Face
  7. A: Umbilical Hernia
  8. A: Constipation
  9. S: Jaundice
  10. S: Skin Mottling

EARLY DETECTION IS KEY, AS NORMALIZING TSH BY 1-2 MONTHS OLD PREVENTS NEURO DAMAGE!

94
Q

Common characteristics of Down Syndrome pts - 7

A

the SHEEPPS of genetics

  1. Skin excessive at the nape of the neck = nuchal skin
  2. HypOtonia w/ ⬇︎ Startle Moro reflex
  3. Epicanthal folds
  4. Ears that are small
  5. Protruding tongue w/flat face
  6. Palpebral fissures are upslanted
  7. Single palmar crease

these pts also have ⬆︎risk for hypothyroidism

95
Q

cp for Laryngomalacia ; dx? ; tx?

A

inspiratory stridor that improves when prone ; Direct laryngoscopy ; self limited to 18 mo ;

96
Q

tx for Physiological Jaundice

A

Phototherapy

Unconjugated hyperbilirubinemia that appears the first 24 hours of life and resolves by the end of that week

97
Q

What is the most common pediatirc renal cancer?

A

Wilms tumor

unilateral abd mass with hematuria

98
Q

Which pediatric renal tumor crosses the midline and presents in the ____ year of life

A

Neuroblastoma ; first

99
Q

What is the major (and contraindicating) side effect of the Rotareovirus vaccine?

A

Intussuception

Live attenuated vaccine

100
Q

Both Croup Laryngotracheitis and Epiglottitis can cause inspiratory stridor

How do you discern the two?

A

Epiglotitis causes Drooling!

101
Q

What finding is indicated by the appearance of Pink Stains or Brick Dust in neonatal diapers?

A

Uric Acid Crystals

102
Q

At what age does Bedwetting start to become pathological for kids?

A

5

103
Q

Infants that are Small for Gestational Age (SGA) are at risk for developing what complications? - 5

A

“I’m small, GOT Calcium?”

  1. low Oxygen (hypoxia) (which –> polycythemia)
  2. low Glucose hypoglycemia
  3. low Temperature hypothermia
  4. low Calcium hypocalcemia
  5. HIGH RBC COUNT POLYCYTHEMIA

[2b] A- step 2 CK (16 decks)

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