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Family Medicine > Pulm > Flashcards

Pulm Flashcards

1
Q

Tx acute bronchitis

A

Sx: cough

Usually viral so no abx
Cough suppressants for sx
Bronchodilators for sx

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2
Q

Tx common cold

A

Sx: sore throat, malaise, rhinorrhea

Water
rest
analgesics
cough sppressants
oral 1st gen anti-histamine
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3
Q

Tx sinusitus

A

Analgesics as most are viral

consider acute bacterial if cold > 8-10 d

  • saline nasal spray
  • decongestant
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4
Q

Tx laryngitis

A

Usually viral

Rest voice

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5
Q

Sore throat Ddx

A

Viral infection (Rhino, adeno, corona, EBV)

Bacterial (strep, Hib, gonococcal)

Tonsilitis

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6
Q

Tx strep throat

A

penicillin

erythromycin

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7
Q

Tx acute exacerbation of COPD

A

Abx
Oxygen
Bronchodilators (b2-agonists, ipratropium)
Systemic steroids –> shorten course of exacerbation and can reduce risk of relapse

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8
Q

Dx chronic bronchitis

A

Cough + sputum production on most days for at least 3 months during at least 2 consecutive years

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9
Q

Pathophys of COPD

A

Disease of inflammation of airways, lung tissue, vasculature

Mucous gland hypertrophy + hypersecretion
ciliary dysfunction
destruction of lung parenchyma
airway remodeling

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10
Q

Progression of tx for COPD

A

All should quit smoking, get pneumococcal + annual flu vaccine

In order of increasing stage of dz, txs are:
Short acting bronchodilators (albuterol, ipratroprium) —>
+ Long acting bronchodilators (salmeterop, tiotropium, theophylline) –>
Inhaled steroids, short term –>
O2

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11
Q

Causes of chronic cough in adults

A

Smoking
Postnasal drip
GERD
Asthma

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12
Q

When do CXR for cough ?

A

If pulm cause suspected
Hemoptysis
Chronic cough
Long term smoker

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13
Q

. Pneumonia should be suspected in any child with

A

fever, cyanosis, and any abnormal respiratory finding in the history or physical examination

Tx w/ high dose amoxicillin

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14
Q

first-line therapy for Bordetella pertussis infection

second line?

A

1st - macrolides (azithromycin), or clarithromycin

2nd - TMP/SMX

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15
Q

Health care-associated pneumonia is more likely to involve

Tx?

A

severe pathogens such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter species.

Tx: Ceftazidime sodium (Fortaz) and gentamicin

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16
Q

A small spontaneous pneumothorax involving less than 15%-20% of lung volume can be managed by

A

administering oxygen and observing the patient.

The pneumothorax will usually resorb in about 10 days if no ongoing air leak is present.

Oxygen lowers the pressure gradient for nitrogen and favors transfer of gas from the pleural space to the capillaries.

Decompression with anterior placement of an intravenous catheter is usually reserved for tension pneumothorax.

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17
Q

Lights criteria

A

Pleural fluid/serum ratios greater than 0.6 for LDH

0.5 for protein are indicative of exudates.

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18
Q

Causes of transudative pleural effusions

A

Heart failure

Cirrrhosis

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19
Q

Causes of exudative pleural effusions

A

Pulmonary embolism
Tuberculous pleurisy
Malignancy
Bacterial pneumonia

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20
Q

When consider bacterial rhino sinusitis?

A

URI sx
>7 d for adults
>10 d for kids

Suggested with purulent nasal d/c, maxillary tooth pain, worsening of sx

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21
Q

Tx acute sinusitus

A

1st line:

  • amoxicillin
  • TMP SMX
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22
Q

Group A strep throat sx

A

abrupt onset sore throat
fever
tonsillar and/or palatal petechiae
tender cervical adenopathy

NO COUGH

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23
Q

Group a strep vs mono - how best to tell difference?

A

Mono will have retrocervical lymphadenopathy or hepatosplenomegaly or atypical lymphocytes on periph blood smear

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24
Q

swelling of peritonsillar region
associated tonsil pushed toward midline
contralateral deviation of uvula

what could this be?

A

peritonsilar abscess

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25
Q

Gold std to dx group A strep infections

A

throat cx

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26
Q

Tx group A strep

A

PCN

Cephalosporins
Macrolides

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27
Q

Tx otitis media initial therapy

A

Amoxicillin

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28
Q

drugs known to cause pleural disease include

A

amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin

Lupus-like pleurisy:
Hydralazine
INH
Procainamide
Minocycline
Quinidine
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29
Q

Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for

A

methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa

Ceftazidime, levofloxacin, and vancomycin

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30
Q

Not ok for monotherapy in asthma

A

Long acting beta agonists

Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved and accepted for both monotherapy and combination therapy in the management of asthma

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31
Q

Which one of the following has been shown to be most effective for smokeless tobacco cessation? (check one)
A. Behavioral interventions
B. Mint snuff as a smokeless tobacco substitute
C. Bupropion (Wellbutrin)
D. The nicotine patch
E. Nicotine gum

A

Behavioral interventions

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32
Q

Tx Child w/ influenza A for 24 hrs

A

Oseltamivir

Zanamivir is not recommended for treatment of children under the age of 7

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33
Q

recommended for the treatment of cough and cold symptoms in children younger than 2 years of age?

A

nasal saline, bulb suction, humidified air, and good hydration

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34
Q

What happens next if spirometry shows restrictive pattern? Obstructive?

A

restrictive = undergo full pulmonary function testing for static lung volume measurements and diffusing capacity of the lung for carbon monoxide.

obstructive = should repeat spirometry after administering an inhaled bronchodilator.

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35
Q

S/E varenicline

A

Suicidal ideation

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36
Q

Sx diarrhea and PNA?

A

legionella

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37
Q

Common cause of post-influenza PNA

A

Staph aureus

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38
Q

Suspect PNA - next step?

A

CXR

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39
Q

B/l ground glass appearing lung infiltrate

A

P jirovecei

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40
Q

Direct fluorescent AB testing on sputum can ID…

A

Mycoplasma

Legionella

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41
Q

Empiric tx for community acquired PNA

A

Clarithromycin
Azithromycin
Doxy
Levofloxacin, moxifloxacin

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42
Q

Empirin Tx comunity acq PNA for hospitalized pt?

A

IV cefuroxine, ceftriaxone, amp-sulbactam
+
IV erythromycin/azithromycin

Can also use IV fluoroquin that hurts S pneumo

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43
Q

How long f/u PNA to assess response?

A

3-4 d later

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44
Q

When do f/u CXR for PNA?

A

If doesn’t improve in 5-7 ady b/c bronchiogenic carcinoma can p/w picture of typical pneumonitis

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45
Q

Hospital acquired PNA tx

A

B-lactam + fluoroquin or aminoglycoside

46
Q

How long Tx PNA?

A

Until afebrile for 72 hrs

2 wks tx for S. aureus, P. aeruginosa, Klebs, M. pneumo, C. pneumo, legionella

47
Q

Tx PNA w/ erythromycin?

A

Legionella

Staph

48
Q

Tx PNA w/ cefuroxime

A

HiB

49
Q

Tx PNA w/ PCN

A

Strep Pneumo

50
Q

Sx diarrhea and PNA?

A

legionella

51
Q

Common cause of post-influenza PNA

A

Staph aureus

52
Q

Suspect PNA - next step?

A

CXR

53
Q

B/l ground glass appearing lung infiltrate

A

P jirovecei

54
Q

Direct fluorescent AB testing on sputum can ID…

A

Mycoplasma

Legionella

55
Q

Empiric tx for community acquired PNA

A

Clarithromycin
Azithromycin
Doxy
Levofloxacin, moxifloxacin

56
Q

Empirin Tx comunity acq PNA for hospitalized pt?

A

IV cefuroxine, ceftriaxone, amp-sulbactam
+
IV erythromycin/azithromycin

Can also use IV fluoroquin that hurts S pneumo

57
Q

How long f/u PNA to assess response?

A

3-4 d later

58
Q

When do f/u CXR for PNA?

A

If doesn’t improve in 5-7 ady b/c bronchiogenic carcinoma can p/w picture of typical pneumonitis

59
Q

Hospital acquired PNA tx

A

B-lactam + fluoroquin or aminoglycoside

60
Q

Vocal cord dysfunction

A

vocal cords partially collapse or close on inspiration.
It mimics, and is commonly mistaken for, asthma.

Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing.

Sx are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma.

Pulmonary function tests (PFTs) are normal,
- with the exception of flattening of the INSPIRATORY loop, which is diagnostic of extra-thoracic airway compression.

Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).

61
Q

Severe COPD dz and already on ipatroprium. What should be added for tx?

A

Inhaled steroids

62
Q

When is supplemental O2 recommended for COPD?/

A

Continuous oxygen has been shown to improve overall mortality and endurance in patients with an oxygen saturation of 88% or less,

has not been shown to improve quality of life in those with mild hypoxemia or if used only at night.

63
Q

Barking cough and stridor…what do you suspect?

A

Croup

64
Q

croup

  • info
  • tx
A

Usually 2/2 viruses

Bacteria can be laryngotracheobronchitis (LTB), laryngotracheobroncheopneumonia (LTBP)

+ steeple sign

Tx:
- Steroids (IM dexamethasone + nebulized budesonide)

  • if bacterial:
    Antibiotics are indicated in LTB and LTBP, which can be diagnosed on the basis of crackles and wheezing on examination, or by an abnormal chest radiograph

The following medications should be avoided: sedatives, opiates, expecto- rants, bronchodilators, and antihistamines.

65
Q

Pleuritic chest pain…how do you evaluate?

A

EKG
CXR
are recommended in the evaluation of acute/subacute pleuritic chest pain.

CXR will r/o pneumothorax, pleural effusion, or pneumonia.

66
Q

Tx acute exacerbation of asthma

A
  • inhaled short-acting bronchodilators

- Systemic corticosteroids are recommended for all patients admitted to the hospital.

67
Q

The chest radiograph of a child with meconium aspiration syndrome will show

A

patchy atelectasis or consolidation

68
Q

hyaline membrane disease in newborn will show what on CXR?

A

Homogeneous opaque infiltrates with air bronchograms

69
Q

Transient tachypnea of newborn

A

benign condition due to residual pulmonary fluid remaining in the lungs after delivery

70
Q

Tx RSV

A

Sx: cough, wheezing, hypoxia, A chest radiograph shows peribronchiolar edema

Supportive

Supplemental oxygen should be administered if functional oxygen saturation (SpO2) persistently falls below 90% and can be discontinued when an adequate level returns

71
Q

What is Palivizumab?

A

Ppx for RSV

Not used for acute dz

72
Q

The most common cause of nasal obstruction in all age groups is

A

the common cold, which is classified as mucosal disease.

73
Q

most frequent cause of constant unilateral nasal obstruction

A

Anatomic abnormalities (septal deviation is #1)

74
Q

Tx pertussis

A

Erythromycin
Azithromycin
Clarithromycin

75
Q

Two doses of influenza vaccine are recommended for

A

children under the age of 9 years unless they have been vaccinated previously.

76
Q

key factors in diagnosing streptococcal pharyngitis are

A

a fever over 100.4 degrees F,
tonsillar exudates,
anterior cervical lymphadenopathy,
absence of cough.

Age plays a role also, with those <15 years of age more likely to have streptococcal infection, and those 10–25 years of age more likely to have mononucleosis

77
Q

Tx spontaneous PTX

A

Studies have found that an average of 30% of patients will have a recurrence within 6 months to 2 years.

An initial pneumothorax of <20% may be monitored if the patient has few symptoms.
Follow-up should include a chest radiograph to assess stability at 24–48 hours.

Indications for treatment include progression, delayed expansion, or the development of symptoms.

78
Q

the treatment of choice for acute Pneumocystis pneumonia.

A

Trimethoprim/sulfamethoxazole

Adjunctive corticosteroids should also be started in any patient whose initial pO2 on room air is <70 mm Hg.

79
Q

Mild to moderate allergic rhinitis (clear rhinorrhea, nasal congestion, and watery, itchy eyes for several months) - tx?

A

Intranasal corticosteroids

80
Q

A 23-month-old child is brought to your office with a 2-day history of a fever to 102°F (39°C), cough, wheezing, and mildly labored breathing. He has no prior history of similar episodes and there is no improvement with administration of an aerosolized bronchodilator.

Which one of the following is now indicated? (check one)
A. Bronchodilator aerosol treatment every 6 hours
B. Corticosteroids
C. An antibiotic
D. A decongestant
E. Supportive care only

A

This child has typical findings of bronchiolitis.

The initial infection usually occurs by the age of 2 years.

It is caused by respiratory syncytial virus (RSV).

Bronchodilator treatment may be tried once and discontinued if there is no improvement.

Treatment usually consists of supportive care only, including oxygen and intravenous fluids if indicated

81
Q

A 50-year-old Hispanic male has a solitary 5-mm pulmonary nodule on a chest radiograph. His only medical problem is severe osteoarthritis. He quit smoking 10 years ago.

Which one of the following would be the most appropriate follow-up for the pulmonary nodule? (check one)
A. Positron emission tomography (PET)
B. Chest CT
C. A repeat chest radiograph in 6 weeks
D. A repeat chest radiograph in 6 months
E. Referral for a biopsy

A

Solitary pulmonary nodules are common radiologic findings, and the differential diagnosis includes both benign and malignant causes. The American College of Chest Physicians guidelines for evaluation of pulmonary nodules are based on size and patient risk factors for cancer. Lesions ≥8 mm in diameter with a “ground-glass” appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should also be evaluated, especially in a patient with a history of smoking.

CT is the imaging modality of choice to reevaluate pulmonary nodules seen on a radiograph (SOR C). PET is an appropriate next step when the cancer pretest probability and imaging results are discordant (SOR C). Patients with notable nodule growth during follow-up should undergo a biopsy

82
Q

Tx aspiration pna

A

Gram-negative coverage is required for aspiration pneumonia

piperacillin/tazobactam or
ticarcillin/clavulanate

83
Q

Bronchiolitis

A

Most common cause of acute wheezing in kids < 2

Respiratory syncytial virus (RSV) accounts for 70% of cases;
the rest are caused by parainfluenza, adenovirus, Mycoplasma, and metapneumovirus.

84
Q

Epiglottitis

A

is a bacterial infection of the supraglottic tissue and surrounding areas that causes rapidly progressive airway obstruction.

+ thumb sign

Haemophilus influenzae, H parainfluenzae, Streptococcus pneumoniae, Staphylococcus aureus, and b-hemolytic streptococcus A, B, and C

Med emergency!

85
Q

Tx epiglotitis

A

Treatment consists of appropriate antibiotics (oxacillin or nafcillin; cefazolin; clindamycin and ceftriaxone or cefotaxime)

airway management, usually in an ICU setting with a team ready to respond for intubation or tracheostomy.

86
Q

In patients with severe pneumonia, the urine should be tested for antigens to

A

Legionella and pneumococcus

87
Q

Assessment of asthma control

A

< 12 yo, asthma is NOT well-controlled if

  • —-had sx or used a β-agonist for sx relief >2x / wk
  • —- >=2 nocturnal awakenings 2/2 asthma / month
  • —- >=2 exacerbations requiring systemic corticosteroids in the past year.

> 12 yo, not well controlled if:
—– > 2 nocturnal awakenings / month to classify their asthma as not well controlled.

Exercise-induced asthma is considered separately. A β-agonist used as premedication before exercise is not a factor when assessing asthma control.

88
Q

For patients with a pulmonary embolus, what is tx rec?

A

Warfarin +
low molecular weight heparin (LMWH), unfractionated heparin, or fondaparinux for at least 5 days,

and then can be stopped if the INR has been ≥2.0 for at least 24 hours

89
Q

In vitro interferon-gamma release assays (IGRAs)

A

are a new way of screening for latent tuberculosis infection. One of the advantages of IGRA is that it targets antigens specific to Mycobacterium tuberculosis. These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results of IGRA are objective. It is unnecessary for IGRA to be done in tandem with skin testing, and it eliminates the need for two-step testing in high-risk patients. IGRAs are labor intensive, however, and the blood sample must be received by a qualified laboratory and incubated with the test antigens within 8-16 hours of the time it was drawn,depending upon the brand of cuurently available IGRAs

90
Q

PPD interpretation

A

≥5 mm = + if:
Highest risk and/or immunocompromised, including HIV-positive patients, transplant patients, and household contacts of a tuberculosis patient,

≥10 mm + if:
children; 
employees or residents of nursing homes, correctional facilities, or homeless shelters; 
recent immigrants; 
intravenous drug users; 
hospital workers; 
those with chronic illnesses

≥15 mm = + if:
Low risk of exposure
Usually do not do screening test for low risk!

Increase in ≥10 mm in 2 yr period = + if have repeated testing (eg healthcare workers)

91
Q

Tx pulmonary A HTN

A

Sildenafil and nifedipine are utilized in pulmonary arterial hypertension,

but evidence is lacking for their use in pulmonary hypertension associated with chronic lung disease and/or hypoxemia

92
Q

Radiograph findings of benign vs malignant pulmonary nodules

A

benign nodules:
diameter 10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year

93
Q

In patients with a pulmonary embolism, what is the blood gas disturbance?

A

pO2 and pCO2 are decreased,

pH is elevated,

94
Q

Tx influenza

A

Oseltamivir and Zanamivir

Zanamivir should not be used in patients with COPD, asthma, or respiratory distress.

Antiviral treatment of influenza is recommended for all persons with clinical deterioration requiring hospitalization, even if the illness started more than 48 hours before admission.

95
Q

An 80-year-old male nursing-home resident is brought to the emergency department because of a severe, productive cough associated with a high fever, hypoxia, and hypotension. The patient is found to have a left lower lobe pneumonia, and admission to the intensive-care unit is advised.
Which one of the following is the most appropriate antibiotic therapy for this patient? (check one)
A. Moxifloxacin (Avelox)
B. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
C. Doxycycline
D. Ceftriaxone and metronidazole (Flagyl)
E. Ceftazidime (Fortaz), imipenem/cilastatin (Primaxin), and vancomycin (Vancocin)

A

Empiric coverage for methicillin-resistant Staphylococcus aureus and double coverage for pseudomonal pneumonia should be prescribed in patients with nursing home–acquired pneumonia requiring intensive-care unit admission

96
Q

What is almost universally present with peritonsillar abscess?

A

Trismus

voice changes, otalgia, and odynophagia may or may not be present.

97
Q

Any child 12 years or younger who presents with nasal polyps should be suspected of having

A

cystic fibrosis until proven otherwise.

A sweat chloride test, along with a history and clinical examination, is necessary to evaluate this possibility

98
Q

the most efficacious medications for the treatment of allergic rhinitis

A

Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis.

Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms

99
Q

Tx acute laryngotracheitis (croup)

A

Treatment with corticosteroids is now routinely recommended for acute laryngotracheitis (croup).

A single dose of dexamethasone, either orally or intramuscularly, is appropriate.

100
Q

The treatment of choice for occasional acute symptoms of asthma is an inhaled β2-adrenergic agonist such as albuterol, terbutaline, or pirbuterol. If symptoms do not respond to β-agonists, they should be treated with

A

a short course of systemic corticosteroids.

101
Q

Patients who have a low or moderate pretest probability of pulmonary embolism should have

A

d-dimer testing as the next step in establishing a diagnosis.

102
Q

When need chest tube for PTX?

A

Practice guidelines state that a patient without apparent lung disease who develops a spontaneous “small” pneumothorax (15% of lung volume.

103
Q

Tx COPD

A

Stage 1-4:
- Short-acting bronchodilators such as albuterol and ipratropium

Stage 2-4
- Long-acting bronchodilators such as salmeterol or tiotropium a

Stage 3-4

  • Inhaled corticosteroids
  • Mucolytics
104
Q

a young adult with community-acquired pneumonia who is not sick enough to be hospitalized, the current recommendation is to empirically treat with

A

a macrolide antibiotic such as azithromycin.

This covers the atypical organism Mycoplasma pneumoniae, which is one of the most common causes of community-acquired pneumonia.

105
Q

rhinosinusitis in adults

A

initiating antibiotic treatment in patients with symptoms persisting for 7–10 days that are not improving or worsening

1st line: Amoxicillin
- azithromycin or TMP/SMX for PCN allergy

106
Q

Tx nursing home acquired PNA

A

Levofloxacin

empiric therapy must cover Streptococcus pneumoniae, Staphylococcus aureus,Haemophilus influenzae, and gram-negative bacteria.

107
Q

Sarcoidosis,

A

About one-third of cases will present with fever, malaise, weight loss, cough, and dyspnea.

The pulmonary system is the main organ system affected, and findings may include bilateral hilar lymphadenopathy and discrete, noncaseating epithelial granulomas.

Facial nerve palsy is seen in <5% of patients, and usually occurs late in the process.

108
Q

A positive result on the second, but the not the first, step of a two-step Mantoux tuberculin skin test indicates

A

long-standing, latent infection.

109
Q

A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking cough and hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and expiratory stridor, noticeable intercostal retractions, and good color.
Which one of the following is indicated?
(check one)
A. Albuterol syrup and the use of a humidifier
B. Inhaled albuterol (Proventil, Ventolin)
C. Aerosolized epinephrine and intramuscular dexamethasone
D. Visualization of the epiglottis, and ceftriaxone (Rocephin)

A

This child has a history and physical findings typical of viral laryngotracheobronchitis, or croup. In rare instances, this illness can be complicated by critical upper airway obstruction. The symptoms of cough, respiratory stridor, and distress result from edema of the subglottic portion of the upper airway. Humidification of inspired air is sometimes beneficial, but the child should not be sent home until improvement is demonstrated. Because this child has stridor and intercostal retractions, aerosolized epinephrine is indicated, along with intramuscular dexamethasone, and hospitalization may be required for observation and continued treatment. Antibiotics do not have a role in the treatment of viral croup, and attempted visualization of the epiglottis is not indicated since it will increase the child’s anxiety and worsen the symptoms.

110
Q

Intranasal decongestants such as phenylephrine should not be used for more than how many days? Why?

A

3 days

cause rebound congestion on drug withdrawal.

Can cause rhinitis medicamentosa if use for months

111
Q 
Three members of the same family present with a high fever and cough that began abruptly yesterday. All three report having fevers over 40° C (104° F), painful coughs, moderate sore throats, and prostration. They have loss of appetite, but no vomiting or diarrhea. Two other family members have similar symptoms. On examination the patients appear ill and flushed. There is no cervical adenopathy, no visible pharyngeal inflammation, and no significant findings on examination of the chest. Which one of the following is the most likely diagnosis?  (check one)
 A. Mycoplasma pneumonia 
 B. Influenza-like illness 
 C. Bacterial bronchitis 
 D. Upper respiratory infection 
 E. Legionnaires disease
A

Influenza has a very abrupt onset, and a fever with a nonproductive cough is almost always present. Unconfirmed cases are referred to as influenza-like illness (ILI) or suspected influenza. Patients with confirmed cases tend to say they have never been so ill. Mycoplasma pneumonia can spread among family members, but it is milder and has a more indolent onset and a longer incubation period. Bacterial bronchitis is an overdiagnosed, supposed complication of upper respiratory infections, and is not contagious. While the phrase cold and flu is often used, upper respiratory infections are not so febrile or prostrating, and coryza is the dominant syndrome sooner or later. Legionella can have point-source epidemics, but the incubation period is longer, symptoms vary from mild illness to life-threatening pneumonia, and diarrhea is prominent in many cases

Family Medicine (11 decks)

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