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MUSCULOSKELETAL > Test#2 Study Guide (Dz/Disorder, Tx, Meds) > Flashcards

Test#2 Study Guide (Dz/Disorder, Tx, Meds) Flashcards

1
Q

What does a Greenstick Fracture look like and who is prone to getting them?

A
  • FX occurs on one side, other side of bone is BENT

- common in CHILDREN

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2
Q

What does a Spiral Fracture look like and who is prone to getting them?

A
  • FX that occurs from a TWISTING motion

- commonly ASSOCIATED WITH ABUSE

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3
Q

What does a Comminuted Fracture look like and what is a probable cause?

A

-the bone is in FRAGMENTS/multiple pieces.

  • commonly associated with HIGH IMPACT INJURIES
    • MVA -FALLS -TRAUMA
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4
Q

What is an open/compound fracture? What is a possible complication?

A

-bone protrudes through the skin DISRUPTING SKIN INTEGRITY, causing an OPEN WOUND, and tissue injury.

RISK FOR INFECTION!!!

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5
Q

What bones are at greater risk for emboli?

A

LONG BONES (femur, etc.), pelvis, and ribs are at highest risk for having FAT EMBOLISM.

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6
Q

Describe pallor

A

Pallor - paleness; lack of normal skintone.

one of the 7 P’s to assess for neurovascularity

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7
Q

What is a priority assessment post-op cast placement?

A
  • CMST
  • 7 P’s (Pallor, Pain, Pulselessness, Polar Temp., Paralysis, Paresthesia, Pufffiness)
  • Drainage (s/s infection)
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8
Q

What foods help promote healing in pts with fractured bones?

A

PROTEIN
+
VITAMIN C

(increase fiber and fluids

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9
Q

OSTEOPOROSIS

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A

OSTEOPOROSIS: bone breakdown faster than building
AFFECTS–> *
-CAUSE
-advanced AGE -long-term corticosteroid use
-low calcium -sedentary
-S/S
-progressive deformities (spinal, etc.)
-pain worse with activity
-PATHOLOGICAL FXs
-brittle bones/limited movement
-DIAGNOSTICS
-DEXA SCAN: scans for bone mass
-CT SCAN: scans for spinal bone loss
-LABS –> Serum Ca+, Phos, Parathyroid, Parathyroid

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10
Q

OSTEOARTHRITIS

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A 
OSTEOARTHRITIS: degenerative joint dz (DJD) - progressive deterioration
*NON-INFLAMMATORY* *NON-SYSTEMIC*
AFFECTS --> * WEIGHT BEARING *
-CAUSE
    -Age (women)    -Obesity      -Smoker
    -Genetics           -Hx stress on joints
-S/S
    -Pain WORSE WITH ACTIVITY, resolving with rest
    -DECREASE ROM and CREPITUS
    -Joint enlargement/stiffness
    -HEBERDEN NODES
    -BOUCHARD NODES
-DIAGNOSTICS
    -XRAY    -MRI     -Arthroscopy
    -ESR      -Bone Scan
    -Synovial Fluid Exam
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11
Q

GOUTY ARTHRITIS

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A

GOUT: accumulation of URIC ACID deposits in the joints.

  • INEFFECTIVE METABOLISM OF PURINES *
  • CAUSES
    • ALCOHOL
    • Surgery/Infection/Injury
    • Genetics
    • Obesity/HTN
  • S/S
    • SEVERE pain
    • Inflammation
    • TOPHI - bog toe, ankle, pinna
    • FEVER/Chills
    • High BP/High HR
  • DIAGNOSTICS
    • Serum URIC ACID LEVELS - blood and urine
    • CBC, ESR
    • XRAY
    • Aspiration of synovial fluid
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12
Q

RHEUMATOID ARTHRITIS

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A 
RHEUMATOID ARTHRITIS: a CHRONIC, SYSTEMIC, inflammatory AUTOIMMUNE dz characterized by SYMMETRICAL synovial membrane inflammation.
 * NON - WEIGH BEARING *   * HANDS/FEET *
-CAUSES
    -WOMEN at risk 3:1
      (onset 20-30 y/o)
-S/S
    -FATIGUE!!!!!
    -RED, SWOLLEN, WARM joints
    -Joint PAIN/STIFF IN AM
    -weight loss/anorexia/FEVER
    -DEFORMITIES
        * SWAN NECK
        * BOUTONNIERE
        * ULNAR DRIFT
-DIAGNOSTICS
    -ESR
    - +RF    +ANA
    -XRAY
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13
Q

FIBROMYALGIA

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A 
FIBROMYALGIA: * CHRONIC PAIN SYNDROME * characterized by body wide pain
-CAUSES
    -GENETICS (runs in fam)
    -INFECTION (some trigger/aggravate fibromylagia)
    -TRAUMA (ptsd)
-S/S
    -FATIGUE!!!!!!
    -SLEEP DISTURBANCE
    -DEPRESSION
    -Pain worse AT NIGHT and when COLD
    - +11/18 tenderpoints
-DIAGNOSTICS
    1. Widespread pain lasting >3 months
   2. At least 11/18 tenderpoints
    LABS - CBC, ESR, Thyroid fxn
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14
Q

GANGRENE

  • cause
  • signs/symptoms
  • affected areas
  • diagnostics/labs
A 
GANGRENE: necrosis of tissue caused by insufficient/lack of blood supply.
-CAUSES
    -INFECTION
    -frostbite
    -PERIPHERAL VASCULAR DZ (PVD)
    -Neurovascular Compromise
-S/S
    -Dark-red/BLACK TISSUE
    -no feeling
-DIAGNOSTICS
    -
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15
Q

What is a sprain? and interventions?

A

SPRAIN: injury to LIGAMENT involving tearing/TWISTING of a joint BEYOND NORMAL ROM.

  • Most Common –> ANKLE
  • S/S –> swelling, pain, inflammation
  • INTERVENTIONS
    • RICE
    • Intermittent ICE - 12-48hrs
    • Immobilize/splint
    • Analgesics
    • Surgery
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16
Q

What is a strain? and interventions?

A

STRAIN: injury to MUSCLE / TENDON caused by OVERSTRETCHING of the muscle which can result in a muscle tear.

*Common Causes –> Falls, Sprinting, Inadequate exercise warm-ups

  • INTERVENTIONS
    • RICE
    • ICE - 48hrs, THEN HEAT
    • Immobilize/Splint
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17
Q

What does RICE mean?

A

Rest
Ice
Compression
Elevate

Tx for strains/sprains

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18
Q

CALCITONIN SALMON (MIACALCIN)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

CALCITONIN SALMON (MIACALCIN)

** TX for OSTEOPOROSIS **

CLASS: bone re-absorption inhibitor
( * PULLS CALCIUM FROM BLOOD –> BONE * )

NURSING

- assess nasal cavities
- monitor for hypocalcemia
- ALLERGY TESTING

S/E TO REPORT

- Hypocalcemia
- Allergic rxn
- decreased therapeutic effectiveness
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19
Q

GLUCOSAMINE

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

GLUCOSAMINE

** TX for ARTHRITIS **

CLASS: Supplement
( * REBUILDS CARTILAGE * )

NURSING

- monitor for BLEEDING
- contraindicated with preg/breastfeed.

S/E TO REPORT

- BLEEDING
- Allergic rxn
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20
Q

HYALURONIC ACID (SYNVISC)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

HYALURONIC ACID (SYNVISC)

** TX for OSTEOARTHRITIS (of the KNEE) **

CLASS: anti-inflammatory - replaces body’s natural hyaluronic acid that is destroyed by joint inflammation.
( * INTRA-ARTICULAR INJECTION * )

NURSING

- ALLERGIES: BIRDS/FEATHERS/EGGS   * ****Made from COMBS OF THE CHICKEN******
- Monitor for infection

S/E TO REPORT

- Allergic rxn
- s/s of infection
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21
Q

ALENDRONATE (FOSAMAX)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

ALENDRONATE (FOSAMAX)

** TX for OSTEOPOROSIS **

CLASS: Amniobiphosphate –> INHIBITS AUTOCLASTS –> gradually increases bone mass.
( * BONE RE-ABSORPTION INHIBITOR * )

NURSING

- REMAIN UPRIGHT 30 MINS AFTER TAKING MED
- Take with  8oz water

S/E TO REPORT

- JAW PAIN/chest pain
- DIFFICULTY SWALLOWING
- bloody emesis
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22
Q

ZYLOPRIM (ALLOPURINOL)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

ZYLOPRIM (ALLOPURINOL)

** PREVENTATIVE TX for GOUT **

CLASS: xanthine oxidase inhibitor/ anti-gout
( * INHIBITS URIC ACID PRODUCTION * )

NURSING

- INCREASE FLUIDS: promotes excretion of uric acid
- ASPIRIN COUNTERACTS THIS MED

S/E TO REPORT

- HEAMTURIA / DYSURIA
- S/S of infection
- Allergic rxn
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23
Q

METHOTREXATE (RHEUMATREX)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

METHOTREXATE (RHEUMATREX)

** TX for RA **

CLASS: antirheumatic
( * IMMUNOSUPPRESSIVE effective at suppressing T & B lymphocytes * )

NURSING

- CYTOTOXIC!!
- TERATOGENIC
- INCREASE FLUIDS: prevents adverse GU effects
- monitor for INFECTION (this med is an immunosuppresant)

S/E TO REPORT

- S/S of INFECTION
- kidney damage
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24
Q

CELECOXIB (CELEBREX)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

CELECOXIB (CELEBREX)

** TX for OSTEOARTHRITIS **

CLASS: blocks COX-2 enzyme which activates inflammation.
( * NSAID * )

NURSING

- have pt report s/s bleeding (BLACK TARRY STOOL)
- Monitor BUN/Creatinine/LFT

S/E TO REPORT

- BLEEDING ( * BLACK TARRY STOOL * )
- Indigestion
- SOB
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25
Q

ASPIRIN

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

ASPIRIN

CLASS: salicylate, BLOOD THINNER, antiinflammatory, analgesic, antipyretic

NURSING

- monitor for BLEEDING
- CONTRAINDICATED WITH ALLOPURINOL

S/E TO REPORT
-BLEEDING
(GI, HEMATURIA)
-Allergic reaction

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26
Q

CYCLOBENZAPRINE (FLEXERIL)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

CYCLOBENZAPRINE (FLEXERIL)

CLASS: * SKELETAL MUSCLE RELAXANT *
(acts on brain to reduce/abolish tonic muscle hyperactivity)

NURSING

- may cause DROWSINESS
- FALL SAFETY
- Avoid alcohol and other CNS depressants

S/E TO REPORT

- SEIZURES
- Cardiac disturbance --> MI, CVA, arrhythmia
- heat stroke
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27
Q

DEMEROL (MEPERIDINE)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

DEMEROL (MEPERIDINE)

CLASS: * OPIOID ANALGESIC *
(binds with opioid receptors in spinal cord causing higher levels)

NURSING

- monitor: BOWELS, RESPIRATIONS
- INCREASE FLUIDS
- Have pt be aware of withdrawal sx

S/E TO REPORT

- CONSTIPATION    - SOB (<12rpm)    - Severe nausea
- Allergic reaction
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28
Q

GABAPENTIN (NEURONTIN)

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

GABAPENTIN (NEURONTIN)

** TX of PHANTOM LIMB PAIN and NEUROPATHY **

CLASS: * ANTI-CONVULSANT *

NURSING

- capsules can be crushed in juice of soft foods
- avoid hazardous activities until response known   * **ALSO GIVEN TO TRAUMA PTS TO LOWER OPIOID USE***

S/E TO REPORT

- Suicidality
- Allergic reaction
- Seizures
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29
Q

CORTISONE

  • Classification
  • Nursing/Patient Education
  • Side effects to report
A

CORTISONE

** TX for OSTEOARTHRITIS **

CLASS: * GLUCOCORTICOID *
( ANTI-INFLAMMATORY / IMMUNOSUPPRESANT )

NURSING

- LONG TERM use can cause: OSTEOPOROSIS, and rise in blood glucose in patients with diabetes.
- Monitor for S/S OF INFECTION

S/E TO REPORT

- S/S OF INFECTION
- symptoms of electrolyte imbalance
30
Q

Tophi deposits are a clinical sign of what disorder?

A

Gout.

31
Q

Proper stump care is done to prepare the amputee for prosthesis use how soon after surgery and why?

A

Pt is fitted for prosthesis ASAP AFTER SURGERY (usually a few days, after swelling goes down)

32
Q

Describe what could be the cause of compartment syndrome, s/s, and interventions.

A

COMPARTMENT SYNDROME: results from inadequate/obstructed blood flow to muscles, nerves, and tissues.

CAUSES

- EDEMA
- SOFT TISSUE INJURY
- Tight dressing
- BURNS
- Hemorrhage

INTERVENTIONS
-REMOVE CONSTRICTING ITEM
(cast, bandage, etc..)
-FASCIOTOMY

33
Q

Describe what acute osteomyelitis is, possible causes, s/s, and tx.

A

OSTEOMYELITIS: a serious BONE INFECTION

CAUSES
-compound fx causing bone exposure

S/S

- FEVER     -ELEVATED ESR
- PAIN        -ELEVATED WBC
- limited mobility
- erythema, edema

TREATMENT

- MULTIPLE ABX
- Surgical debridement
- AMPUTATION
34
Q

What is the rationale on why a pt who has had a hip replacement, NOT supposed to sit and cross legs, but can do straight-leg exercises?

A

CROSSING LEGS, and SITTING LOW could cause DISLOCATION.

Straight-leg exercises help STRENGTHEN (quad) MUSCLES.
( * The patient has been favoring their injury and has muscle weakness and atrophy * )

35
Q

What are the signs & symptoms of gout?

A

GOUT
-INEFFECTIVE METABOLISM OF PURINES –> accumulation of URIC ACID in blood –> deposits in joints

S/S
   -Severe PAIN
   -SWOLLEN GLANDS
   -DECREASE MOBILITY
   -TOPHI (common in big toe)
   -EDEMA in effected joint
     (usually in PM)
   -fever/chills
36
Q

What can cause gout?

A

GOUT
-INEFFECTIVE METABOLISM OF PURINES –> accumulation of URIC ACID in blood –> deposits in joints.

Gout can be caused by:

  • ORGAN MEATS
  • SHELLFISH
  • CARBONATED DRINKS
  • ALCOHOL
  • fatty foods
  • surgeries
  • stress
  • fasting diet
37
Q

What are lab tests to confirm gout?

A
  • URIC ACID –> blood and urine
  • CBC
  • ESR
38
Q

What would be symptoms you’d expect to see on your assessment on a patient getting ready to have a lower leg amputated?

A
  • DIMINISHED PEDAL PULSES
  • COOL TEMP
  • DUSKY COLORED
  • NECROSIS
  • LACK OF HAIR GROWTH
39
Q

Describe BUCKS TRACTION, what it is commonly used for, and nursing care.

A

BUCKS TRACTION: (SKIN) - provides straight-pull on extended extremities in hip fractures.

USES: PRE-OP for HIP FX for IMMOBILIZATION of adult pt.

NURSING

  • Make sure the WEIGHT NOT ON FLOOR
  • PT NOT AT FOOT OF BED
  • monitor CMST/NEUROVASCULAR STATUS
40
Q

Describe BRYANT’S TRACTION, what it is commonly used for, and nursing care.

A

BRYANT’S TRACTION: (SKIN) - legs suspended in air at 90deg from hips, knees slightly flexed, butt off bed.

USES: CHILDREN with unstable HIP/FEMUR FXs

NURSING
-Monitor CMST/NEUROVAS. STATUS (7 p’s)

41
Q

If a bone is protruding out of the skin, why do we cover it with a sterile dressing prior to surgery?

A

open wound = RISK OF INFECTION

Covering with sterile dressing * REDUCES RISK FOR INFECTION. *

42
Q

Why do patients with open fractures need a tetanus injection or booster?

A

open wound = RISK OF INFECTION

Tetanus —> * REDUCES RISK FOR INFECTION. *

43
Q

Name types of food high in purines? calcium?

A

FOODS HIGH IN PURINES

  • Fish (SARDINES)
  • ORGAN MEATS
  • SWEETBREAD
  • BEER
  • GRAVY

FOODS HIGH IN CALDIUM

  • DAIRY
  • DARK GREEN LEAFY VEGGIES
  • WHITE BEANS
44
Q

What is phantom limb pain?

A

PHANTOM LIMB PAIN: theVERY REAL sensation of PAIN, pressure, or ithing that occurs in the location of the extremity AFTER THE AMPUTATION.

  • PT will describe pain as: BURNING, SHOOTING, CRAMPING, ACHING
  • Tell patient to “MOVE LIMB” as much as possible –> activates damaged nerves –> helps decrease pain

GABAPENTIN –> can tx pain of phantom limb pain since nerves in brain still sending pain signals.

45
Q

Why is Gabapentin (Neurontin), an antiepileptic, prescribed for phantom limp pain?

A

GABAPENTIN –> can tx pain of phantom limb pain since nerves in brain still sending pain signals.
- works on NEUROTRANSMITTERS

46
Q

If pain is not relieved after giving medication to pt with a cast or a pt with a fx bone, what do you expect is the problem?

A

COMPARTMENT SYNDROME

47
Q

What assessment finding (in pt with unrelieved pain suspected of compartment syndrome) would warrant a call to the PCP?

A

Excruciating/SHARP PAIN

48
Q

What is a dx of ineffective tissue perfusion in relation to assessing distal pulses in post-op hip replacement pt?

A
  • COMPARTMENT SYNDROME

- DVT

49
Q

What is your discharge teaching for your hip replacement pt?

A
  • PREVENT DISLOCATIONS
    * ** PT CANNOT SIT IN LOW CHAIRS
    * ** PT CANNOT CROSS LEGS
  • LOG ROLL to move pt
  • Use ABDUCTOR PILLOW
  • Suggest a TOILET SEAT MODIFIER
  • Observe for S/S OF INFECTION
50
Q

What are the 7 P’s in relation to neurovascular checks on patients?

A
  1. PARASTHESIA (unrelieved numbness, pins/needles)
  2. PAIN
  3. PALLOR (slow cap. refill, pale looking skin)
  4. PARAYLSIS
  5. PUFFINESS (edems/swelling)
  6. PULSELESSNESS (decreased/absent distal pulses)
  7. POLAR TEMP (cool extremities)
51
Q

Describe care and interventions you’d implement for post-BEA pt.

A
  • Encourage DEPENDENT POSITION DOCUMENT!
  • Wrap in FIGURE 8
  • Encourage pt to TALK ABOUT FEELINGS
    • (altered body image)*
52
Q

Why is it important to have wire cutters and suction at the bedside of a pt who has facial fractures?

A

EMERGENCY (swelling, edema, emesis)

  • Pts with facial fx’s usually have JAWS WIRED
    • Cutters to cut wires
    • Suction to suction out emesis
53
Q

Why do we have post-op BKA pts in the prone position several times per day?

A

This PREVENTS HIP CONTRACTURES

  • To reduce edema –> ELEVATE F.O.B, not stump
54
Q

Describe ORIF

A

Open Reduction Internal Fixation (ORIF): visualization of fx thru an INCISION IN SKIN, and internal fixation with PINS, SCREWS, RODS, and prosthesis as needed.

WITHOUT TRACTION

NURSING

  • Monitor NEUROVASCULAR STATUS (7 P’s)
  • Assess DRAINAGE
  • Monitor S/S INFECTION
  • Observe for S/S of PE and FE
55
Q

How would you care for your pt with ORIF?

A

NURSING

  • Monitor NEUROVASCULAR STATUS (7 P’s)
  • Assess DRAINAGE
  • Monitor S/S INFECTION
  • Observe for S/S of PE and FE

Dressing changes with pins are STERILE

56
Q

What compartment syndrome symptoms would you see in a patient with ORIF?

A
  • Increased PAIN UNRELIEVED BY MEDS
  • Increased PAIN WITH P.R.O.M
  • 7 P’s

if untreated–> necrosis –> amputation.

57
Q

What are Heberden’s Nodes?

A

DISTAL joint enlargement that occurs with OSTEOARTHRITIS

58
Q

What is unique about where hyaluronic acid is made from?

A

Made from COMBS OF THE CHICKEN

*assess for ALLERGIES–> egg, feathers, bird

59
Q

Can ptts who are wearing a cast use a hair dryer on the cool setting to blow air into their cast if they are itching?

A

YES

Cool air acts as a VASOCONSTRICTOR

60
Q

What are s/s of compromised circulation in your cast pt your assessing?

A
  • 7 P’s
    • *PALLOR first sign of compromise**
  • FOUL ODOR could be sign of INFECTION
61
Q

Why is sleep so important to pts with autoimmune conditions like fibromylagia?

A

FATIGUE is #1 S/S of autoimmune disorders.

* Finding a ROUTINE SLEEPING PATTERN is an important part of their care.

62
Q

What is an intra-articular injection? What medications are used?

A

INTRA-ARTICULAR INJECTION: injections administered directly into the joints.

TX FOR OSTEOARTHRITIS

  • GLUCOCORTICOIDS
  • HYALURONIC ACID

GOAL: decrease inflammation and pain.

63
Q

What types of pts get intra-articular injections?, how does it work, and what is the goal?

A

INTRA-ARTICULAR INJECTION: injections administered directly into the joints.

TX FOR OSTEOARTHRITIS

  • GLUCOCORTICOIDS
  • HYALURONIC ACID

GOAL: decrease inflammation and pain.

64
Q

What is a “hot spot” when a pt is wearing a cast?

A

“HOT SPOT” –> when there is a specific area of warmth felt on the cast.
– SIGN OF INFECTION!

65
Q

What is each lab, and what can it confirm?

  • WBC
  • ANA
  • RF
  • ESR
  • H&H
A

WBC: white blood cell count

  • CONFIRMS INFECTION
  • HIGH —> infection
  • LOW —-> immunocompromised

ANA: antinuclear antibody
-can help DX AUTOIMMUNE DISORDER

RF: rheumatoid factor
-CONFIRMS R.A

ESR: erythrocyte sedimentation rate

  • DETECTS INFLAMMATION
  • not location specific

H&H: hemoglobin & hematocrit
-assesses BLOOD LOSS –> (indicator of o2)

66
Q

Describe each term:

  • Atrophy
  • Hemiparesis
  • Apraxia
  • Hypertrophy
A

ATROPHY - deterioration in size/fxn of muscle and tissue

HEMIPARESIS - weakness to ONE SIDE of the body

APRAXIA - inability to perform purposeful movements or to use objects properly.

HYPERTROPHY - enlargement of muscles/tissues

67
Q

Describe the following diagnosic tests for carpal tunnel syndrome:

  • PHALEN’S TEST
  • TINEL’S SIGN
A

PHALEN’S TEST
* hands in FORCED FLEXION for 60 secs –> if there is a production of pins/needles along thumbside half of hand…. +CARPAL TUNNEL

TINEL’S SIGN
* TAPPING medial nerve in wrist –> if pins/needles, or electric shock sensation… +CARPAL TUNNEL

68
Q

Normal adult VS ranges

A 
HR: 60-100
RR: 12-20
BP: 90/60 - 138/89
TEMPERATURE
   Aux.: 96.8 - 101.3
   Rect.: 97.7 - 100.4
   Temp.: 95.5 - 99.5
PAIN: 0-10; medicate at or above 3.
69
Q

What assessment finding would you expect to see with a fx femoral neck in your hip trauma pt?

A
  • PAIN, reduced mobility
  • INABILITY TO BEAR WEIGHT
  • SHORTENED EXTREMITY (one leg usually shorter than the other)
  • Bruising, swelling
70
Q

What are long term effects on bones in pts taking glucocorticoids?

A

BONELOSS!

decreased mineral density

71
Q

Pitting edema post-amputation warrants a call to the PCP if pt was wearing an ace bandage…. why??

A

This indicates COMPROMISED CIRCULATION and is serious.

MUSCULOSKELETAL (2 decks)

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