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IPAP > Peds Block 3 Cram > Flashcards

Peds Block 3 Cram Flashcards

1
Q

What is the MC nutritional d/o in the world?

What are the risk factors?

A

Fe deficient anemia

Cows milk intake @ 9-24mon
Under nutrition
Blood loss
Celiac/Giardiasis/H Pylori

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2
Q

Breast fed infants need to have iron supplementation starting @ ?

At what age can Fe foods be introduced to infant diets?

When can they start drinking cows milk?

A

4mon

6mon

12mon; <24oz/day

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3
Q

Microcytic anemia DDx

What is the MC congenital bleeding d/o

A 
FLATS
Fe deficiency anemia
Lead poisoning
Anemia of chronic Dz
Thalassemia
Sideroblastic anemia

Von Willebrand Dz

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4
Q

Functions of vWF?

How is it Dx?

How is it Tx?

A

Joins platelets and collagen
Protect Factor 8 from rapid clearance

Measured vWF quantity
Function measured w/ Ristocetin

Desmopressin for Type 1,2
vWF concentrate for Type 3

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5
Q

What Sx combo is a medical emergency for PTs w/ Sickle Cell?

By ? age they are functinoally asplenic leaving them vulnerable to ? microbes

If Sickle PT has osteomyelitis, consider ? microbes?

A

Fever + Sickle Cell anemia

5y/o
Encapsulated: HiB, Strep Pneumo, N Meningitidis

Salmonella
Staph A

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6
Q

What is the most common type of vasooclusive event?

What is the other form of this occlusive crisis?

A

Pain crisis
2-7 days of leg/arm pain w/ possible femoral head necrosis
Tx w/ Fluids, Pain, O2

Acute Chest Syndrome
CXR w/ new infiltrates
1st Sx= chest pain-> respiratory distress
Tx: Fluid Pain Transfusion O2 ABX Dilators

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7
Q

What meds are used for Sickle Cell management?

A

Hydroxyurea @ 9mon old- inc Hgb F and dec occlusive severity/frequency
Daily PO PCN
Vaccines: HIB, HBV Influenza
Folate

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8
Q

What is the most common childhood systemic vasculitis?

What adverse outcome can occur but usually in adults?

A

HSP after URIs

Inflammation of small blood vessels w/ Hemorrhage Ischemia and Leukocyte infiltration

IgA deposition= glomerulonephritis

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9
Q

How does HSP present?

What other outcomes can be seen?

A

Palpable purpura
Arthralgia
Renal involvement
Abdominal pain

Orchitis Pancreatitis
Edema Encephalopathy

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10
Q

What are the 3 phases od Kawasakis

A

Acute:
Fever Conjunctival erythema Cracked lips Strawberry tongue
Cervical lymphadenopathy

Subacute: desquamation, coronary aneurysms (Inc ESR, <1yr, >6yrs)

Convelescent: from Sx resolution until ESR normalizes

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11
Q

When are f/u Echos done for Kawasaki PTs?

How is it Tx?

A

2wks
6-8wks

IVIG- reduces aneurysm risk
High dose ASA

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12
Q

What are the “B-Sxs” of Hodgkins?

What 3 Sxs are less likely to be seen?

What will be seen on PE?

A

Fever x 3 days
Weight loss +10% in 6mon
Drenching night sweats

Fatigue Anorexia Pruritus

Cervical/Supraclavicular lymphadenopathy
Pleural effusion

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13
Q

What is seen on tissue biopsies in Hodgkin results?

Why are CXR and CTs ordered for these PTs?

What info do marrow aspirations provide?

A

Reed-Sternberg cells (owl eyes)

CXR- mediastinal mass eval
CT- Dz staging

Dz staging
+25% blasts= acute leukemia

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14
Q

What is the MC primary malignant tumor of childhood?

This type of tumor is #2 of?

A

Wilms Nephroblastoma tumor

2nd MC malignant abdominal tumor of childhood (#1= neuroblastoma)

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15
Q

What other abnormalities is Wilms tumors associated w?

Why are there so many issues w/ these PTs?

A

WAGR: Wilms tumor Aniridia GU malformation Retardation

Germline deletion Chrom #11p

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16
Q

Wilm tumors make PTs more susceptible for ? syndrome

What are the 3 common sites for these tumors to show?

A

Beckwith-Wiedemann- macroglossia, umbilical hernia, omphalocele

Lungs
Lymph nodes
Liver

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17
Q

What are the 2 MC presenting Sxs of a nephroblastoma?

What labs are drawn and what test is Dx?

What images are ordered?

A

Abdominal mass
Abdominal pain

CBC UA Liver/Renal function
Histology exam= Dx

Abd CT/US: renal or adrenal mass
CXR: pulmonary metastases
CT of chest, abdomen, pelvis

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18
Q

What are oncological emergencies in Peds?

A 
Sepsis- chemo causes severe neutropenia
TLS- common in leukemia/lymphoma Txs
Anemia/Thrombocytopenia
Inc ICP
Airway obstruction
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19
Q

What is the MC childhood CA?

What are the 3 subtypes of this kind of CA?

A

Leukemia

ALL: males
AML: neonates, adolescence
CML
JMML

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20
Q

What will be seen on lab results of PTs w/ leukemia?

What type of analysis is done for Dx?

A

Peripheral smear w/ blast cells
Anemia
Thrombocytopenia
WBC >50K

Cytogenetic

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21
Q

Osteosarcomas are assoicated w/ ? hereditary issue

What syndrome is susceptible to this CA?

A

Retinoblastoma

Li-Fraueni Syndrome

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22
Q

What can trigger osteosarcoma and what would be seen on lab results?

What bones are MC affected?

A

Radiation
Osteoid substance

Distal femus
Proximal tibia and humerus

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23
Q

How does Ewing Sarcoma appear under microscopy?

What Sxs does it present w/ that causes it to be mis-Dx as osteomyelitis

A

Small Round Blue cell tumors

Pain and Fever

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24
Q

Although it can occur anywhere, where does Ewings occur MC?

What is the MC childhood solid neoplasm outside of the CNS?

A

Femur and Pelvis

Neuroblastoma

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25
Q

What is the MC infant malignancy

What tissues does this grow from?

A

Neuroblastoma

Neural crest cells that form adrenal medulla and SNS
Half- adrenal glands
Half- paraspinal ganglia

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26
Q

What are the MC presenting Sxs of Neuroblastomas?

What paraneoplastic syndromes can it present w/?

A

Abdominal mass and pain

Sweating Diarrhea Clonus
Horners

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27
Q

Where are neuroblastomas likely to metastasis to?

How is this Dx?

A 
Lymph nodes
Long bones
Liver
Skull
Marrow
Skin

24hr UA catecholamine

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28
Q

What type of infections do CA PTs tend to get?

What is the MC if only presenting Sx of a CA PT w/ an infection

A 
Catheter/Port infections
Crypto meningitis
HSV
Aspergillus
P jiroveci

Fever

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29
Q

CA PTs w/ what 2 Sxs are immediately admitted?

When do parasomnias tend to occur and MC in ? PTs?

A

Fever + Neutropenia

NREM
In association w/ REM
Preschool kids

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30
Q

Parasomnias are linked w/ ? FamHx?

What are the different types?

A

Sleep walking
Night terrors

Sleep walking
Terrors if first 1/3 of night
Mares if last 1/3 of night
Confused arousal- less dramatic and more gradual than terrors

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31
Q

What type of seizure is MC between 6mon and 5yrs

What part of the PT Hx has to be present for a Dx of febrile seizure to be given?

A

Febrile

+100.4 before, during or after the seizure

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32
Q

What are the two types of febrile seizures

Febrile status epilepticus can last for how long?

A

Simple: <15min and only one in 24hrs

Complex/Atypical: >15min, repeats in 24hrs or Hx of neuor issues

> 30min

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33
Q

What meds can be given during a febrile seizure

What two meds are not used?

What lab result needs to be checked?

A

Rectal diazepam

Antconvulsant
Antipyretics

Fe deficiency

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34
Q

What are the cardinal Sxs of NF Type 1

What imaging is needed during Dx?

A

Cafe au lait spots
Lisch nodules
Axilla/Inguinal freckles
Neurofribromas, cutaneous

Cranial imaging to r/o neoplasms

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35
Q

What is the first Sx of botulism poisoning?

How are these poisonings Tx?

A

Constipation
Poor feeding

IVIG
Respiratory/supportive care

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36
Q

What type of HA is most recurrent and MC

What Sxs are/not seen?

What is the etiology of these types of HA?

A

Tension

Squeezing pressure
No N/V/phobias

Stress/Psych illness

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37
Q

How do PTs w/ migraines describe the pain?

What Sxs will they complain of?

What will be seen in their Hx 90% of the time?

A

Pounding/throbbing

N/V/Phobia

1* or 2* relative w/ recurrent HA

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38
Q

What part of the head is measured for circumference?

What does accelerated/decelerated patterns mean?

What is the criteria for macro/micro cephalus?

A

Occipitofrontal

Accelerated= hydrocephalus
Decelerated= brain injury, degenerative d/o
Macro= 2 SD above mean
Micro= 2 SD below mean
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39
Q

When does the anterior fontanelle become tense/bulging?

Define craniosynostosis

A

Crying Inc ICP Febrile

Premature closure of 1 or more sutures causing unusual/ridge feeling head

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40
Q

Who is more likely to have a UTI <1yr and over 1yr

What type of microbes are MC cause?

What are the 2 forms of UTIs?

A

Under: uncircumcised male
Over: healthy female

Colonic: E Coli Klebsiella Proteus Enterococcus Pseudomonas Sapro GBS

Pyelonephritis
Cystitis

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41
Q

How are UTIs Dx

How are these samples recommended to be collected?

A

UA

Cath if 2-24mon
Clean catch if toilet trained
NO perineal bags

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42
Q

What lab results are Dx for UTIs

What finding is concerning for contaminated samples

A

Pyuria >10
Pos LE/Nitrite
Pos LE/bacteria

3-5 epithelial cells

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43
Q

What is the gold standard for Dx UTIs and these are needed for ?

What results are Dx or indicative of repeat testing

A

UA culture: confirmation and appropriate therapy

> 50K CFU + pyuria
100K if older/adolescent
1-50K= repeat UC

44
Q

When is imaging warranted for UTIs in Peds?

When is a VCUG study warranted?

A

Renal/bladder if 1st UTI in infant or non-toilet trained

1st UTI in 2-24mon w/ abnormal US or recurrent/febrile UTI

45
Q

Define Enuresis

Define Diurnal

Define Nocturnal

A

Incontinence in child who is mature enough to have achieved continence

Daytime enuresis

Night time enuresis

46
Q

Define Primary/Secondary Enuresis

What are the etiological factors behind enuresis

A

Primary: incontinence in child who has never achieved dryness
Secondary: child who has been dry x 6mon

Psych distress
Organic illness
Developmental difference

47
Q

What type of enuresis often has a FamHx and least likely to have an identifiable cause?

What type is more likely to be due to organic etiology?

What labs are done for these PTs?

A

Primary nocturnal

Secondary diurnal/nocturnal

UA clean catch and culture

48
Q

How are non-organic causes of enuresis Tx?

What meds can be used?

A

Fluid intake restriction
Bedtime void
Snoring= adenoidectomy

Desmopressin, 90% relapse when d/c
Rare- Imipramine, TCA

49
Q

What lab results are Dx for Nephrotic Syndromes?

A 
Proteinuria: 3-4+
Hematuria
Spot urine protein: creatinine ratio >2
Serum albumin <2.5g/dL
Serum cholesterol/TG elevation
Complement levels normal
50
Q

Minimal change nephrotic syndrome

How do these PTs present?

A

No progression to renal failure
Inc BUN
Normal complement
Remission after 8wks of steroids in 90% of PTs

Sudden dependent pitting edema/ascites
Anorexia Malaise Abdominal pain
HTN

51
Q

What finding on PE of a nephrotic syndrome is indicative of tubular necrosis and significant HOTN?

What deformity makes PTs are risk for testicular torsion?

A

Sudden decline of serum albumin and volume depletion

Bell-clapper

52
Q

What PE findings are indicative of testicular torsion?

Define Hydrocele

A

High/tender testicle
Absent cremaster
Negative Prehn’s sign

Fluid collection in tunic vaginalis

53
Q

What are the two types of hydroceles

How are these Tx?

A

Communicate- w/ peritoneal space
Non-communicating- MC; processus vaginalis obliterated

Non-Comm: self resolve by 12mon, refer by 18mon
Comm: smallest in AM, refer for surgery

54
Q

Communicating hydroceles are associated w/ ? injury/issue

What is the MC cause of intestinal obstruction before 3mon old

A

Inguinal hernias

Pyloric stenosis: m>f and more in first born

55
Q

What type of issue is a pyloric stenosis

What is the classic presentation of this issue?

What will be seen on lab results?

A

Muscle hypertrophy and spasm= outlet obstruction

Non-bilious projectile vomit w/ FTT

Hypochloremic, Hypokalemic, Metabolic alkalosis
Inc BUN

56
Q

What PE finding is indicative of a pyloric stenosis?

What finding is seen on imaging?

A

Olive sign

String sign on barium upper GI seris

57
Q

What is the Rule of 2s for Meckels?

How do these PTs present?

A 
2% of population
2 ectopic mucosae: gastric/pancreatic
Presents by 2yrs
W/in 2ft of cecum
2" long

Massive, painless GI bleed

58
Q

What type of scan is ordered for suspected Meckels?

What complications can occur even after surgery?

Umbilical hernias ? size are less likely to close on their own?

A

Technetium scan- labels acid producing mucosa

Perforation Obstruction Diverticulitis Bleeds

> 2cm

59
Q

What are the predisposing risk factors for umbilical hernias?

What two tissues can be contained w/in the hernia?

A

Low birth weight
African American

Omentum
Small intestine

60
Q

When are umbilical hernias referred for surgical repair?

Define Intussusception and the origin they’re associated w/

A

After 5y/o
Sxs / Strangulated
Grows after 1-2yrs

Telescoping of proximal bowel into downstream bowel
Rotavirus infection/vaccine

61
Q

What are the two lead points of intussusception?

How do these PTs present?

A

Lymphoid hyperplasia- Peyers patches
Abnormal anatomy- ileocecal valve, Meckels

Paroxysmal cramping abdominal pain
Currant jelly stools- mucous and blood mixture

62
Q

What is the MC surgical emergency of kids

What are the MC causes of the obstruction

What emergency occurs after 48hrs of Sx onset?

A

Appendicitis

Fecalith
Lymphoid hyperplasia after viral infection
Neoplasm

Rupture

63
Q

Hirschsprung is AKA ?

What is the pathological reason for this issue

Where does the dilation occur in the PT

A

Congenital Aganglionic Megacolon- absent motility and functional obstruction

Failure of ganglion cell precursors to migrate to distal bowel

Proximal to aganglionic segment

64
Q

How do PTs w/ Hirschsprung’s present?

What causes polyhydramnios

A

95% don’t pass stool in first 24hrs
Distal obstruction w/ distension
Bilious vomit

Fetus w/ esophageal atresia can’t swallow amniotic fluid, prevents transfer for fetus wastes to maternal blood

65
Q

How do PTs w/ tracheoesophageal fistulas present

What type of Peds Fx is and is not conerning

A

Drooling
Mucus/saliva bubbling from nose/mouth
Single umbilical artery

Is: metaphyseal bucket handle
Not: spiral

66
Q

What bones in Peds are not likely to be Fx accidentally

What type of images are taken when investigating?

A 
Scapula
Posterior ribs
Spinous process/vertebrae
Skull
Sternum

Skeletal surveys if child is <3y/o

67
Q

What type of head traumas are seen in abuse?

What is the Shaken Baby triad?

Rape kit can be performed it assault occurred within how many hrs?

A

Shaking
Blunt impact/force trauma

Retinal hemorrhage
Brain swelling
Subdural hematoma

72hrs

68
Q

What are the top causes of death in PTs <1yr, 1-4yr, 5-14yr and 15-24yrs old?

What are the top 5 unintentional injuries in kids 9-18y/o

A

<1: development/genetic issues/SIDS
1-4: accidental injuries
5-14: accidental injuries
15-24: accidental injuries

MVC Drown Burn Falls Toxins

69
Q

What organ is the MC injured in kids?

What type PE finding is indicative of damage to this organ?

A

Spleen

Kehr sign- LUQ pressure causes L shoulder pain

70
Q

If PT has spleen removed due to trauma, what management meds are they put on?

Define Nurse Maid elbow

A

PCN
Pneumococcal/H Influenza vaccine

Radial head subluxation
Annular ligament passing around radial head partiall slips off w/ elbow traction

71
Q

How is Nurse Maid elbow Tx

When are images needed for this injury?

A

Supinate hand w/ pressure on radial head and flex elbow to 90*

Unable to reduce
Concern for Fx- swelling/bruising

72
Q

PTs that are ? old w/ SCFE need an endocrine work up

What is the earliest sign of this issue?

A

<10yrs
>16yrs

Preslip condition

73
Q

How are SCFEs classified

What complications can develop?

A

1: 0-33% slip
2: 34-50% slip
3: >50% slip

Chondrolysis
Avascular necrosis

74
Q

What is the MC foreign body ingestion object

When do Peds w/ burns need to be referred?

A

Coins

> 10% of body and under 10y/o
20% and older than 10
Face, Hands, Feet, Genital, Perineum burns
Electrical Chemical Inhalation burns

75
Q

What is 1st line Tx of anaphylaxis

These PTs must be monitored for how long due to likelihood of relapse?

A 
Epinephrine, 0.3mg max dose
NS for hypovolemia
Nebulized B-agonists for bronchospasms
Diphenhydramine/steroids
20% relapse w/in 4-6hrs
76
Q

What parent is more likely to to be reported as a perpetrator or as the infliction of serious injury?

What is the MC types of child abuse and the 3 types?

A

Mother- perp
Father/maternal boyfriend- injury

Neglect, hardest to prove

77
Q

What 4 types of Fxs are highly specific for abuse?

What type of trauma injury is most common in infant/toddlers?

A

Rib Metaphyseal/Bucket handle Vertebral Scapular

Blunt trauma

78
Q

What medicinal practice is common in Vietnam/SE Asia

Define Quat Sha

Define Moxabustion

A

Shaved wind, coining

Spoon rubbing

Burning of moxa (mugwort) on accupuncture point

79
Q

What color are bruises at specific days of healing?

What are the names of visible blood types during the healing phases?

A 
Red: 0-2
Blue/purple: 2-5
Green: 5-7
Yellow: 7-10
Brown: 10-14
Gone: 2-4wks

Hbg- red/blue
Biliverdin- green
Bilirubin- yellow

80
Q

How are Fxs healing stages estimated?

What is the leading cause of morbidity and mortality in abused minors?

A

7-14 days: new periosteal bone, callus
14-21: loss of Fx line, trabecular formation
3-6: callus inc w/ density
+6wks: sclerotic thickening

Shaken baby: retinal hemorrhage, brain swelling, subdural hematoma

81
Q

What 3 STDs in Peds are almost always due to abuse?

What can be seen on PE due to the MC form of abuse?

A

GC/C
Syphilis

Neglect- Type 1 growth deficiency= normal head/length, low weight

82
Q

What are the legal ramifications for not reporting child abuse in TX?

What are neonatal surgical red flags?

A

Class A midemeanor

Delayed meconium passage
Abdominal distention
Maternal polyhydramnios- can’t swallow amniotic fluid
Perinatal vomiting

83
Q

Why do tracheoesophageal fistulas occur

What is the MC type

A

Both tissue develop between 4-6wks of gestation
Fistula= dysgenesis

Esophageal atresia w/ distal TEF

84
Q

What is the VACTERL association w/ T/E fisulations?

A 
Vertebral anomalies
Anal atresia
Cardiac anomalies
TEFistula
Renal anomaly
Limb anomaly
85
Q

How are E/T fistulas Dx?

How are difficult cases Dx?

A

OG catheter won’t pass
CXR showing catheter curled in esophagus

Gastrografin swallow
Methylene blue challenge

86
Q

How are PTs w/ pyloric stenosis managed?

What is the name of the Tx procedure?

A

NS bolus
D5 w/ K+
Surgery won’t take them until alkalosis is fixed

Pyloromyotomy

87
Q

Congenital diaphragmatic hernia usually occurs on ? side

What developmental issue causes this deformity

Where is the herniation MC?

A

Left

Defective fusion of pleuroperitoneal membranes
Leaves large opening in posterolateral diaphragm

Bochdalek foramen: bowel herniation through diaphragm impeding lung development

88
Q

What will be found on PE if child has congenital diaphragmatic hernia

How is it Dx

A

Respiratory distress
Scaphoid abdomen w/ bowel sounds in L chest

CXR

89
Q

What is a common type of ventral hernia

Intestinal malrotation/midgut leaves PT predisposed for ?

A

Umbilical hernia- protruding contents covered by subcutaneous tissue/skin

Midgut volvulus- intestines twist on themselves causing obstruction/artery occlusion

90
Q

How does an intestinal malrotation/volvulus present

If there’s no rotation, what else can cause the PT to vomit?

A

Bilious vomit in 1st mon of life

Ladd’s bands- duodenal constrictors

91
Q

What will be seen on barium imaging of intestinal malrotation/volvulus

What sign is seen?

How is it Tx?

A

Cecum in RUQ

Corkscrew effect due to volvulus in upper GI

Fluid, OG decompression, Laparotomy

92
Q

If Peds PT has atresis, what Dz needs to be screened?

What deformities is this associated w/?

A

CF

Trisomy, Malrotation, Annular pancreas, Meconium ilieu w/ CF

93
Q

What is the classic x-ray finding of an intestinal atresia?

Define Gastroschisis

A

Double bubble sign

Split/open stomach, usually on R side, w/out involving umbilicus

94
Q

Gastroschisis is thought to be due to the absence of ? artery

Define Omphalocele

A

Omphalomesenteric

Impaired mesodermal/ectodermal (muscle/skin) growth of abdominal wall
Intestines remain out and covered by peritoneum and amniotic membrane
Herniation of bowel contents through umbilical ring

95
Q

PTs w/ omphalocele are more likely to have ? d/o?

Meckel’s develop due to lack of obliteration of ?

A

Bechwith-Wiedemann syndrome

Omphalomesenteric duct

96
Q

? is a true diverticulum on anti-mesenteric border of ileum

All infants/ w/ imperforate anus require ? and commonly have ? dysfunction

What causes necrotizing enterocolitis

A

Meckels

MRI of lumbosacral spinal cord
Urologic

Ischemia secondary to immature GI system
MC premature births <34wks

97
Q

What is the Alvarado/MANTRELS rule for appendicitis?

A

1 Pt:
Fever Rebound pain Anorexia Migration to RLQ N/V
WBC >75% neutrophils
2Pts: RLQ tenderness, Leukocytosis >10K

<4pts: unlikely
>7pts: likely

98
Q

What Peds issues cause non-bilious vomit?

Which ones cause bilious vomit?

A

Non: Pyloric stenosis

Bilious: Malrotation/Volvulus, Atresia, Hirschsprung, NEC, Intussusception

99
Q

Which Peds issues present w/ pain?

Which ones present as painless issues?

A

Pain: intussusception, Appendicitis

Painless: Meckels

100
Q

What GI Tx can be curative for enuresis?

Define Hypospadias

10% of these PTs will also have ? issue

A

Chronic constipation

Failure of ventral urethral folds to fuse

Undescended testes
Inguinal hernias

101
Q

When are hypospadias’ Tx

If baby is born w/ this, this automatically means no ? procedure

A

Ideal 6-12mon
Before 18mon

No circumcision

102
Q

Cryptorchidism usually don’t spontaneously descend after ? age

Orchidopexy presentation under 2y/o is uncommon presentation for ? issue

A

4-6mon

Testicle CA

103
Q

What are the 3 DDx for testicular torsions?

A

Epidiymo-orchitis: abnormal UA, no scrotal edema/erythema, + Prehns sign

Appendiceal torsion- blue dot on top of scrotum, swelling on upper pole of testicle

Incarerated inguinal hernia: hernia felt w/ valsalva, difficult exam due to pain

104
Q

What PT population has renal agenesis presentations the most?

Uni/bilateral renal agenesis is often associated w/ ? other issues?

A

Diabetic mother
Black races

Unilateral: VUR Vacterl Turner syndrome
Lateral: Potter syndrome

105
Q

Define characteristics of Potter Syndrome

Why does this issue cause fetal malformations?

A

Flat face
Club foot
Pulmonary hypoplasia

Reduced fetal urine excretion= oligohydramnios leading to compression

106
Q

Hemolytic uremic syndrome is characterized by what 3 things

What is the MC type?

A

Microangiopathic hemolytic anemia
Thrombocytopenia
Renal injury

Prodromal diarrheal illness from E Coli O157:H7 in food/water

107
Q

How does HUS present in clinic

Since Tx is supportive, what two meds are avoided?

A

CNS/Seizure involvement
Pancreatitis
Cardiac dysfuntion
Colonic perforation

ABX, Anti-diarrheals

IPAP (212 decks)

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