Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > random 1/16/17 > Flashcards

random 1/16/17 Flashcards

1
Q 
umbilical hernia 
vs
omphalocele
vs
gastroschisis
A

covered by skin
covered by peritoneum
not covered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q 
umbilical hernia
path
pres
dx
tx
A

incomplete closure of ab muscles around umbilical ring at birth
assoc w premie, af am, hypothyroid, ehlers danlo, beckwith wiedeman syndrome
soft nontender bulge covered by Skin protruding during crying coughing straining etc, may have small intestines omentum etc
easily reducible usually, little risk of incarceration or strangulation
clinical dx
spontaneous reduction by concentric fibrosis and scarring if small usually
if large (^1.5cm) or other medical issues may not reduce - surgery around age 5 if persisting or earlier if problematic

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

gastroschisis
define
tx

A

evisceration of bowel with no covering membrane, red, right of umbilical cord
surgical emergency

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

omphalocele
define
tx

A

protrusion of abdominal contents at base of umbilicus, covered by peritoneum without skin
immediate surgical repair for survival

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

umbilical granuloma
pres
tx

A

usually after umbilical cord cut, soft moist pink pedunculated friable
silver nitrate

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

tf

surgery usually required for umbilical hernia

A

f
usually reduces via concentric fibrosis wo incarceration or strangulation
-surg if not closed about age 5 (higher risk if large ^1.5cm or other medical issues) or earlier if problematic
-surg for omphalocele, gastroschisis
-silver nitrate for umbilical granuloma

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

how to know if aortic arch is widened on cxr

A

obscures left pulmonary artery/hilum

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

blunt aortic injury
path
pres
dx

A

mva or fall from height 10+ feet
not very specific htn tachyc anxiety
cxr mediastinal widening, maybe r trach dev, left mainstem bronchus depression
ct angio if cxr and hx equivocal

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

tf

mediastinal widening w myocardial contusion

A

f
tachyc
maybe see rib fractures

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

most common cxr finding after blunt chest injury

A

hemorrhagic lung opacities from pulmonary contusion

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

traumatic diaphragmatic rupture on cxr

A

herniation of abdominal contents into thorax

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

tf

any patient w blunt deceleration trauma (mva, fall 10 plus feet) gets cxr

A

t

mus ro aortic injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

anterior bursae of knee

A
  • suprapatellar bursa between quad tendon and distal femur, continuous w joint capsule
  • prepatellar bursa subcutaneously
  • deep infrapatellar bursa between patellar tendon amd proximal tibia
  • subcutaneous infrapatellar bursa
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

define bursa

A

synovial sac to alleviate friction at bony prominences and ligamentous attachments

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

pain w rom w inflamed bursa

A

active rom often painful

passive rom often not, less pressure on bursa

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

prepatellar bursitis aka

A

housemaid’s knee

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

pres
dx
tx
acute prepatellar bursitis

A

acute pain and tenderness anterieor knee in kneeling job
aspirate for cell count and gram stain (also crystals but less common) (acute prepatellar bursitis often infectious, staph aureus, from penetrating trauma, repeat friction, or extension of local cellulitis… other bursites usually not infectious…)
if cx positive drain and systemic abx
if cx neg activity mod, nsaids

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

patellar fx
path
pres

A

direct blow or sudden force under load (fall from height)

pain swelling tenderness inability to extend knee

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

patellofemoral pain gender preference

A

female

more valgus, maltracking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q 
extra axial 
well-circumscribed or round
enhancing
dural-based
mass on brain mri
think...
A

meningioma

may also calcify and appear hyperdense on non-con ct

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q 
meningioma
path
pres
dx
tx
A

benign primary tumor of meningiothelial cells
middleage elderly woman
if large enough for mass eddect - headache, focal weakness numbness, seizure
extra axial
well-circumscribed or round, enhancing, dural-based, mass on brain mri (may also calcify and appear hyperdense on noncon head ct)
confirm intraoperatively (surg resection for symptomatic pts)

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

when to consider chemo for brain cancer

A

combo w resection amd radiation for highly malignant brain tumors (glioblastoma multiforme, medulloastoma…) or highly sensitive mets (eg testicular germ cell tumor..)

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

when to consider ct cap for brain cancer

A

when visceral primary suspected cause of brain mets (multiple ring-enhancing lesions at gray-white junction (intraaxial))

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

typical appearance of brain mets on… mri? ct?

A

multiple ring-enhancing lesions at gray-white junction (intraaxial)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

multiple ring-enhancing lesions at gray-white junction (intraaxial)

think…

A

metastasis to brain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

indication for whole brain radiation

A

widely metastatic brain disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

ddx for anterior mediastinal mass

A 
4 Ts
thymoma
thyroid neoplasm
teratoma (and other germ cell tumors)
terrible lymphoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

serum hormone levels in germ cell tumors

A

seminoma - 1/3 have ele b-hcg but usually normal afp

non-seminoma (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

anterior mediastinal mass
w elevated afp amd b-hcg
think…

A

non-seminoma germ cell tumor (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg

(seminoma - 1/3 have ele b-hcg but usually normal afp)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

how long can surgery for femoral neck fracture be delayed to stabilize acute comorbid medical problems

A

72hrs

longer risks further medical complication and less likely return to previous functional status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

the 2 lobes of the parotid gland are separated by…

A

the facial nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

hoarseness can result from surgery on…

A

thyroid or parathyroid glands

if recurrent laryngeal branches of vagus injured

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

tic doloroux
distribution
etiology

A

2nd and 3rd trigeminal branches (V2 V3)

external compression of trigeminal probably

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

tongue palsy can be caused by surgery…

A

in the submandibular region

if hypoglossal XII injured

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

jaw assymmetry can result from unilateral injury to

A

V3 which innervates muscles of mastication

exits foramen ovale and follows deep course to mastication muscles, so deep dissection needed to injure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

strabismus results from what nerve injury

A

lr6so4ao3
extraocular muscles

abducens trochlear occulomotor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

winged scapula a complication of this surg…

A

axillary lymphadenectomy for breast cancer if long thoracic nerve injured

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

2 most important exam findings for compartment syndrome

A

pain w pasilsive stretch
paresthesias
(and swollen, tense, inc pressure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

are paresthesias an early or late compartment syndrome symptom?

A

early

from sensory nerve ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q 
tf
dec sensation
motor weakness
paralysis
dec distal pulses

are common findings in compartment syndrome

A

f
uncommon findings

pain out of proportion, pain w passive stretch, paresthesias, tense swelling

are earlier more common findings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

causes of compartment syndrome

A

direct trauma
prolongued compression
reperfusion after ischemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

tf

compartment syndrome responds well to narcotics

A

f

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

tf

paresthesias count as neurologic deficit in context of compartment syndrome

A

f
paresthesias early from sensory nerve ischemia

but neurologic deficits (dec sensation, motor weakness) arise later

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

tf

pallor is required to dx compartment syndrome

A

f

uncommon, not required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

what does pallor signify in compartment syndrome and is it required for diagnosis

A

arterial occlusion

not required, uncommon, late finding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

tf most compartment syndrome pts have dec distal pulses

A

f
most intact pulses
uncommon
not required for dx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

most critical prognostic factor for compartment syndrome amd what does it mean for disgnostic method

A

time to fasciotomy

so in high risk pt (eg limb revascularization) don’t wait to measure compartment pressures - go straight to fasciotomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

tf

elevation and ice recommended for compartment syndrome

A

f
for inflammation
just keep cs at level of torso

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

differentiate compartment syndrome from dvt

A

cs more acute, severe, paresthesias, pallor rare but pallor if vascular component

dvt more insidious onset, no neuro sx, red and hot because vein occluded

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

diverticulitis on ct

A

inflammatory soft tissue stranding and colonic wall thickening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

proportion of uncomplicated vs complicated diverticulitis

A

75%

25%

52
Q

manage uncomplicated diverticulitis

A

bowel rest
oral abx
observation

but for elderly immunosuppressed significant fever or leukocytosis or significant comorbidities - admit amd iv abx

53
Q

define complicated diverticulitis

and manage

A

abscess
perf
obstruction
fistula

fluid collection v3cm iv abx and obs
w surg if sx worsen
fluid collection ^3cm ct guided percutaneous drainage, if sx not controlled in 5 days surgical drainage and debridement, sigmoid resection for fistulas perfs w peritonitis obstruction recurrent diverticulitis

54
Q

define
initial
total
terminal hematuria

A

at start if void
throughout void
at end of void

55
Q

ddx for terminal hematuria

A

lower collecting system (bladder, prostate)

  • urothelial cancer
  • cystitis (infection vs radiation)
  • urolithiasis
  • bph
  • prostate cancer
56
Q

6 indications for cystoscopy

A
  • gross hematuria w no evidence of glomerular disease or infection
  • microscopic hematuria w no ev kf glom dz or inf but inc risk of cancer (^40 male smoker…)
  • recurrent uti
  • obstructive sx w signs of stone or stricture
  • irritative sx wo infection
  • abnorm urine cytology or imaging
57
Q

tf

clots in urine think glomerular

A

f
clots rare w glomerular (diff from casts)

an get clots w bleeding from ureters or bladder…

58
Q

initial hematuria (at start of void) think…

A

urethritis or trauma (catheter)

59
Q

total hematuria (throughout void) think…

A

upper collecting system (kidneys, ureters)

  • renal mass
  • glomerulonephritis
  • urolithiasis
  • polycystic kidney disease
  • pyelonephritis
  • urothelial cancer
  • trauma
60
Q

tf

urinary clots are typically seen in renal causes of hematuria

A

f
clots not the same as casts

can get clots w urethral or bladder cause of hematuria

61
Q 
chronic nsaids
episodic post prandial epigastric pain
followed by acute severe constant pain
think...
tx
A

perforated peptic ulcer
expect pneumoperitoneum on upright xr between liver diaphragm

ng suction
ivf
iv abx
iv ppi
definitive mgmt w urgent exploratory laparotomy
62
Q

q waves on ecg indicate…

A

old mi

63
Q

pneumoperitoneum on upright xr

next step is ct w oral con?

A

no

already thinking per from xr, no need to repeat dx w ct

64
Q

indications for upper gi endoscopy

A

upper gi bleed (hematemesis, melena)

weeks after resolved perfed peptic ulcer to eval for cancer h pylori infection or healing

65
Q

what does viscus refer to

A

an internal organ

singular of viscera

66
Q

what causes the classic coloration of venous stasis dermatitis

A

erythrocyte extravisation thru post-capillary venules and hemosiderin deposition

67
Q

pathogenesis of venous stasis dermatitis

A

venous valvular incompetence, venous htn, fluid protein blood extravisation thru postcapillary venules
inflammation fibrin deposition platelet aggregation
microvascular dz, ulceration

68
Q

xerosis

define

A

dry skin

69
Q

vocabulary of venous stasis signs and sc

A

xerosis (dry skin) early

lipodermatosclerosis (inflammation of subq fat
ulcers
late)

70
Q

stasis dermatitis most commonly involved what specific part of the body

A

medial leg between knee and inferior maleolus

71
Q

raynaud disease /phenomenon
path
feared complication

A

arterial spasm in response to cold or emotional stress causing discoloration amd discomfort of distal digits

distal gangrene if severe

72
Q

limb complications of neurosyphilis

A

tabes dorsalis - posterior spinal cord lesion causing dec sensation and proprioception of lowe extremities - paresthesias and ataxia

73
Q

rivaroxaban
apixaban
fondaparinux

moa’s

A

rivaroXaBAN
apiXaBAN
direct factor Xa inhibitors

fondaparinuX
indirect factor Xa inhibitor

74
Q

argatroban
bivalirudin
dabigatran

moa’s

A

argaTroBAN
bivalirudin
dabigaTran (oral)

thrombin (factor II) inhibitors

75
Q

preferred long term oral anticoagulant in end stage renal dz

and moa

A

warfarin

vit k antag
(factors II VII IX X, proteins C and S

76
Q

what clotting factors does heparin inhibit

A

XII XI IX
VII
X
II

(all a)

77
Q

duration of anticoagulation after provoked dvt by surger

A

likely 3 mos

78
Q

when to bridge to warfarin w ufh vs lmwh

A

ufh if end stage renal (lmwh ci - renally excreted)

79
Q

how to bridge heparin to warfarin

A

4-5 days till inr 2-3 (start warfarin usually evening same day as heparin)

80
Q

aspirin’s role in dvt

A

none

it’s a platelet inhibitor, not involved w clotting cascade

81
Q

when to start anticoagulation therapy postop in a hemodynamically stable pt

and does it inc risk of bleeding

A

48-72 hours

does not significantly inc risk of bleeding

82
Q

why bridge ufh to warfarin - why not just keep heparin goimg

A

heparin is iv only

so want to get to oral warfarin for discharge

83
Q

mechanism of diaphragmatic rupture in blunt trauma

special presentation in kids

A

high intraabdominal pressures
or avulsion
-left more common because left posterolat diaphragm congenitally weak and lover protects right

some pts, kods especially, may have no s or s initially but delayed presentation mos yrs later w expansion of defect and herniation risk strangulation and high risk death

84
Q

looks like diaphragm hernia on cxr, next diagnostic step?

A

ct to confirm

85
Q

diaphragmatic hernia on cxr

A

left lower lung opacity
(usually left because weaker there and liver protects right)
left elevated hemidiaphragm
mediastinal shift right

86
Q

what about severe burns provides good substrate for infection

A

avascular
immunilogically poor
protein-rich

87
Q

bugs in burns

A

staph a (g+) immidiately, from sweat glands and hair follicles

pseudomonas and candida (g- and fungi) 5 days out

88
Q

systemic signs of burn wound sepsis

A 
temp v36.5 (97.7)
          ^39.   (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90
89
Q

s and s of burn wound sepsis

A

oliguria, unexplained hyperglycemia, thrombocytopenia, ams

temp v36.5 (97.7)
          ^39.   (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90
90
Q 
burn wound sepsis
pres
dx
expected bugs
tx
A

large area (^20% bsa high risk)
wound changing for worse eg getting deeper or failing skin graft
oliguria, hyperglycemia, thrombocytopenia, ams
t v36.5 97.7 ^39 102.2, tachyc tachyp hypot
wound cx ^10^5/g tissue
bx for histopath depth
staph a from sweat glands and follicles immediately
5 days out pseudomonas candida
broad abx piptazo carbapenem
vanc maybe for mrsa
aminoglycoside maybe for mdr pseudo
local wound care and debridement

91
Q

tf

CO exposure can cause a delayed neuropsych syndrome / ams

A

t

sometimes it can

92
Q

temp inc w drastic metabolic rate inc eg w large burn

A

up to 38.5 101.3

93
Q

typically first signs of burn wound infection

A

change in appearance (getting deeper, necrotic)

failed skin graft

94
Q

pts of primary vs secondary pmeumothorax

A

prim - thin young men no hx

sec - copders / lung dz

95
Q

s and s

tension pneumo vs spontaneous pneumo

A

hemodynamic instability and trachial deviation away

in addition to usual cp sob dec chest wall movement hyperresonance

96
Q

tf

spontaneous pneumothorax most often occurs at rest

A

t
spontaneous rupture of subpleural blebs
(thin male in 20’s, marfan, smoker, thoracic endometriosis… all risks)

97
Q

manage small primary spontaneous pneumothorax in medically stable pt

A

obs

and supplemental o2 (speeds resorption of pneumo… how..?)

98
Q

manage primary spontaneous pneumothorax

A
  • obs and supplemental o2 to speed resorption if small pneumo clinically stable
  • large bore needle (14 or 18 gage) decompression via 2nd or 3rd mid-axillary intercostal (sup border of rib) or 5th intercostal mid or ant axillary if large pneumo clinically stable
  • emergent tube thoracostomy if possible otherwise needle decompression if hemodynamically unstable
99
Q

when to get cct after cxr for suspected pneumothorax

A

don’t usually
can if dx uncertain
or loculated pneumo suspected
or thoracostomy concern

100
Q

when to consider VATS for pneumothorax

A

video assisted thorascopic surgery

for failure to reexpand ^90%
or recurrence

can patch or pleurodese

101
Q

how might recent fever and sore throat in young athlete predispose to splenic laceration

A

could have been mono
splenomegaly
higher risk of laceration with blunt abdominal trauma

102
Q

epidermal hematoma typically from trauma to this bone

A

sphenoid
(mma)
middle meningeal artery

103
Q

epidural hematoma most common in what age group

A

children and adolescents

from trauma

104
Q

level of the diaphragm

A

up to 4th (nipple) thoracic dermatome on right and 5th (just below pec) on left w expiration

down to 12th thoracic dermatome w inspiration (posteriorly?)

105
Q

must consider both chest and abdominal trauma w gunshot wound at what level

A

anywhere nipples or below (t4 dermatome or lower) - diaphragm can get up there with expiration

106
Q

possible abdominal trauama after gunshot wound, pt hemodynamically unstable, best procedural next step?

what if stable?

A

fast focused assessment w sonography for trauma
(for hemoperitonium, peritoneal effusion, pericardial effusion)
if pos
exploratory laparotomy for any gsw hemodynamically unstable, peritonitis, or organ evisceration
if equivocal
dpl diagnostic peritoneal lavage
if neg
look for other reasons for hemorrhage - pelvic… long bone fx… - and stabilize
-ct when stable

if stable w neg us or diagnostic peritoneal lavage, ct to determine need for exploratory laparotomy

107
Q

dpl diagnostic peritoneal lavage done in hemodynamically ____ pts w ____ abdominal trauma w inconclusive ____

A

unstable
blunt abdominal trauma
inconclusive fast focused assessment w sonography for trauma

108
Q

reverse warfarin for emergent laparotmomy

A

ffp

vit k not fast enough… relies on synth of new vit k dependent clotting factors ii vii ix x by liver

109
Q

treat acute bowel perf from afib thrown clot infarct perf

A 
ng tube decompression
ivf
iv abx
ffp to reverse warfarin
emergency laparotomy
110
Q

tf

preop transfusion is often required for pt w chronic anemia

A

f
usually not
generally, tissue oxygen delivery not deficient till hb v7
consider risk factors for ischemia and anticipated operative blood loss

111
Q

when is desmopressin ddavp given preoperatively

A

pt had hemophilia a

(ddavp indirectly inc factor viii by releasing vwf from endothelial cells

112
Q

penile fracture is a fx of the…

A

corpus cabernosum

w tear in tunica albuginea which envelopes it

113
Q

detumescence

A

subsiding of swelling, tension, or sexual arousal

114
Q

presentation of penile fracture

A

audible snap when erect
detumescence
pain ranging w severity of fx
hematoma bends shaft

115
Q

manage penile fracture

A

emergent urologic surgery

too many complications with medical mgmt… erectile dysfunction, painful erections, etc

116
Q

when to get retrograde urethrogram for penile fracture

A

urethral injury suspected

blood at meatus, hematuria, dysuria, urinary retention

117
Q

normal serum calcium

A

8.4-10.2

118
Q

normal serum phosphorus

A

3.0-4.5

119
Q

describe neuromuscular irritability from hypocalcemia

A 
perioral tingling and numbness
muscle cramps
tetany
carpopedal spasms
seizures
qt prolongation
120
Q

which is symptomatically worse, acute or chronic hypocalcemia

A

acute
can be very symptomatic even with small decrease if fast enough

chronic may be asymptomatic at a quite low number

121
Q

causes of primary hypoparathyroidism

A 
post surgical
autoimmune
congenital (digeorge eg)
defective ca receptors on pt gland
infiltrative dz eg hemochromatosis wilson's neck irradiation
122
Q

what is subtotal parathyroidectomy moat commonly done for

A

eg removal of 3.5/4 parathyroid glands for parathyroid hyperplasia

123
Q

3 drugs that cause vitamin D deficiency

A

phenytoin
carbamazepine
rifampin

by inducing cytp450 in liver, breaking vit d into imactive metabolites

124
Q

kidney function in vit d metab

A

1a-hydroxylase converts 25hydroxy to 1,25dihydroxyvitamin d

ca resorb
phos excrete

failure gives hypocalcemia hyperphosphatemia and seconday hyperparathyroidism

125
Q

Treat AFib after CABG

A

BB or Amio
Usually resolves v24 hours

If persists, then start thinking about cardioversion and anticoagulation

126
Q

Eval bunt genitouronary trauma

A

UA – for hematuria basically

CT AP if hemodynamically stable

IV Pyelogram before Surgery if hemodynamically unstable

Surgery (22 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions