Brainscape's Knowledge GenomeTM

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


See full index

Neuro Shelf > UWorld > Flashcards

UWorld Flashcards

1
Q

Complications of subarachnoid hemorrhage

(a) First 24 hrs
(b) 5-14 days
(c) BMP abnormality

A

SAH complications

(a) Rebleeding in the first 24 hrs
(b) 5-14 days: vasospasm
(c) Hyponatremia 2/2 SIADH (syndrome of inappropriate antidiuretic hormone secretion)

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

Mechanism by which metoclopromide causes neck pain and stiff/tender neck muscles

A

Metoclopromide-induced dystonia 2/2 activity as a dopamine receptor antagonist

Extrapyramidal symptoms (tardive dyskinesia, dystonic rxns, and Parkinsonisms) are unfrequent but possible side effects of regional

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

Clinical manifestation of cerebellopontine angle tumors

A

Cerebellopontine angle tumors = acoustic neuromas/meningiomas

P/w HA, hearing loss, vertigo, tinnitus, balance problems

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

55 yo F w/ sudden onset severe l. periorbital pain and HA

  • blurry vision, sees halos of light
  • pupil dilated and poorly reactive to light

Dx

A

Dx = closed angle glaucoma

  • acute, accompanied by pain
  • buzzword = halos around lights
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Most common manifestation of lacunar strokes

A

Most often affect the internal capsule => result in pure motor hemiparesis

ex: pt w/ sudden onset right sided (arm and leg) weakness and normal NCHCT

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

Cavernous sinus thrombosis

(a) Bugs
(b) Clinical presentaiton

A

(a) Staph/strep from disseinated localized infection

(b) Headache, CN (3,4,V1,V2,6) paralysis, decreased vision, exopthalmous (bulging eyes), chemosis (conjunctival swelling)
- symptoms b/l b/c cavernous sinus has anastomoses crossing midline

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

3 day old ex-30 weaker born at 1.36 kg (3 lb) w/ hypotonia, seizures, and rapidly increasing head circumference

  • lethargic neonate, tense fontanels, generalized hypotonia
  • Head ultrasound shows hydrocephalus

Dx

A

Dx = intraventricular hemorrhage
-common complication in ex-30 or before seekers

Rapidly increasing head circumference and bulging fontanelles consistent w/ severe hemorrhage

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

12 yo M w/ symmetric paralysis, absent DTRs, decreased superficial touch and vibratory sense of LE b/l 10 days s/p febrile diarrheal illness

(a) Dx
(b) Mechanism
(c) Etiology

A

(a) Guillan-Barre
(b) Demyelinating polyneuropathy, demyelination of peripheral nerves: mostly motor but also can be sensory and autonomic
(c) In this case most likely 2/2 campylobacter jejuni infxn

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

58 yo F p/w severe HA (right sided, retro-orbital) and agitation

  • blurry vision, constipation, vom
  • PMH: Parkinson’s, hypothyroid, HTN, chronic Hep C

Which medication most likely responsible?

A

Trihyexyphenidyl (anticholinergic)

Recognize anticholinergic toxicity: dry skin, dry mouth, constipation, urinary retention, flushing, vision changes, confusion

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

58 yo M w/ sudden onset speaking difficulty (difficulty w/ word finding and can’t follow simple commands) and weakness (marked in RUE, mild RLE)

  • forced conjugate gaze preference to the left
  • neglect of right visual field
  • severe right lower facial droop

PMH: uncontrolled

  • HTN, HLD
  • severe LA enlargement
  • carotid US w/ 25% stenosis

BP 156/96, HR 124 irregulargly irregular

(a) Dx- be specific as to location
(b) Explain all findings

A

(a) Cardiogenic emboli to MCA (probably distal segment of M1)

  • Global aphasia (both expressive and comprehensive) localizes to the left hemisphere
  • forced gaze preference to the left = damage to frontal eye fields
  • right homnomymous hemianopsia (neglecting right visual field) = damage to upper and lower optic radiations in the lateral temporal and parietal lobes

Suggestive of large-occlusion- distal M1 segment of the left MCA
-right-sided weakness (face/arm over leg) consistent w/ left frontal lesion

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

Most common cause of intraparenchymal hemorrhage in adults vs. children

A

Adults = hypertensive vasculopathy

Children = AVM

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

Differentiate migraines and tension HA

A

Migraines: 4-72 hrs

  • unilateral
  • pulsatile
  • inhibits daily activity
  • aggravated by physical activity

Tension HA: 30 min-7 days

  • b/l
  • pressing/tightening, dull (non-pulsatile)
  • mild to moderate, may inhibit but doesn’t prohibit daily activity
  • not aggravated by physical activity
  • no N/V
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

45 yo M p/w wasting of extremity muscles more apparent on extensor side

  • weakness began distal and asymmetrically
  • recent difficulty w/ swallowing, chewing, and speaking
  • muscles stiffness
  • bowel, bladder, sensory, cognitive fxns intact
  • fasciculations and hyperreflexia of all extremities
  • decreased bulbar reflexes

Dx

A

Dx = ALS (amyotrophic lateral sclerosis

Presence of both UMN and LMN findings

UMN

  • spasticity
  • bulbar symptoms
  • hyperreflexia

LMN
-fasciculations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

36 yo F p/w daily bandlike HA, dizziness, and fatigue x1mo after a fall at work w/ LOC

Dx

A

Dx = postconcussive syndrome (following mild TBI)
Symptoms: HA, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alteration, sleep disturbance
-resolve w/in week to months, but sometimes can last over 6 mo

While a delayed subdural hemorrhage would result in focal neurologic finding

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

10 hour old newborn w/ swelling on scalp that wasn’t present at birth

  • swelling limited to surface of one cardinal bone
  • no visible pulsations, indentations of the skull, or discoloration of overlying scalp

Dx

A

Dx = cephalohematoma = subperiosteal hemorrhage

  • always limited to surface of one cranial bone (b/c it’s sub-periosteal)
  • swelling not visible at birth b/c subperiosteal bleeding is slow/gradual
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

6 mo old F w/ milestone regression

  • hypotonic, hepatosplenomegaly and protuberant abdomen
  • bright red macula, cervical lymphadenopathy

(a) Deficiency
(b) Dx

A

(a) Spingomyelinase deficiency
(b) Neimann-Pick disease

  • autorecessive, loss of motor milestones/hypotonia, cherry red macula
  • different from Tay-Sachs: HSM and areflexia (while hyperreflexic Tay-Sachs)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Pt w/ r. facial droop- what sign would localize facial nerve palsy to below the pons

A

Below the pons if pt is unable to close eye on affected b/c means forehead control is not intact

Lesion in CNS above the facial nucleus would cause lower facial weakness sparing the forehead b/c collaterals (peripherally) are intact

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

53 yo M w/ occasional shaking of r. hand x3 mo

  • present at rest, stops when reaches for remote
  • no other neurologic symptoms or PMH

Mechanism of disease?

A

Basal ganglia dysfunction

-resting tremor = early sign of Parkinson’s

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

Focal vs. absence seizures

A

Focal: longer (2-3 mins), can have post-ictal state
-often automatisms

Absence: shorter (10-20 sec), no post-ictal state
-easily provoked by hyperventilation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

8 yo M w/ multiple staring episodes that last 2-3 minutesduring which he tilts head and seems like he’s chewing, he is unresponsive during

  • he remains confused for 20 minutes after
  • EEG is unchanged w/ hyperventilation

Dx

A

Dx = focal seizures = originate in single hemisphere, can have lOC
-often have automatisms = repetitive semi-purposeful mov’ts (chewing, swallowing)

Different from absence seizures b/c this kid has post-ictal state, seizures not provoked by hyperventilation, and lasts longer than 10-20 seconds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What type of tremor is a cerebellar tremor?

A

Intention tremor- tremor increases steadily as hand reaches the target

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

Features of anterior cord syndrome

A

Anterior cord syndrome (often 2/2 burst fracture of the vertebra)

  • loss of motor fxn below the lesion
  • loss of pain and temp on both sides below the lesion
  • intact proprioception
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Describe physiologic tremor

A

Not visible under normal conditions, comes out during sympathetic tress (drugs, anxiety)
-usually worse w/ movement

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

56 yo M w/ b/l HA 3-4 per week

  • mild photophobia, no phonophobia
  • doesn’t interfere w/ work
  • unremarkable neuro exam

Most likely dx?

A

Tension HA

  • b/l
  • doesn’t prohibit activity, mod-mild intensity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

46 yo M develops severe HA only in certain postures, sometimes LOC

C/f

A

C/f intraventricular tumor b/c positionally blockage of CSF flow that causes sudden increase in ICP => acute HA w/ possible LOC

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

72 yo F w/ HTN, DM2, CAD suddenly drops fork while eating
-speech becomes slurred, develops r sided weakness

Dx

A

Dx = Lacunar stroke in basal ganglia
-intracranial bleed

-progressive symptoms w/ early focal neurologic symptoms and h/o HTN

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

Triad of Wernicke’s encephalopathy

A
  1. Encephalopathy (confusion)
  2. Ocular dysfunction
    - often opthalmoplegia = paralysis of one or more EOM
  3. Cerebellar/gait ataxia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

58 yo F p/w difficulty walking

  • b/l foot numbness and tinging
  • currently on bleomycin, doxorubicin, and vicristine for Hodgkin lymphoma

Dx

A

Dx = chemotherapy-induced peripheral neuropathy
-stocking-glove distribution

Most likely from vincristine
-also from cisplatin and paclitaxel

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

Pt p/w Hemi-Neglect of the left side

Locate the lesion

A

Lesion = right parietal cortex
-responsible for spatial orientation

-ignoring side of space = non-dominant parietal lobe

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

Immediate reversal agent for

(a) Wafarin
(b) Heparin

A

(a) Warfarin can be reversed with prothrombin complex concentrate (KCentra) which contains vitamin-K dependent clotting factors for rapid reversal
- also give IV vitK: takes about 12 hrs to kick in (b/c need to remake factors)

(b) Protamine sulfate binds to heparin to inactivate it

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

55 yo M w/ impaired vision x6 mo

  • intermittent morning headaches and decreased libido
  • decreased vision in temporal fields b/l

Dx

A

Dx = craniopharyngioma = benign sellar mass

  • compression of the optic chiasm => bitemporal blindness
  • symptoms of pituitary hormone deficiency (ex: hypogonadism)
32
Q

(a) How to make a diagnosis of NPH

(b) How to tx NPH

A

(a) Dx NPH w/ enlarged ventricles on neuroimaging and LP not showing elevations in ICP
(b) Serial CSF removal w/ large volume LP, eventually VP shunt

33
Q

Type of tremor often relieved w/ alcohol

A

Essential tremor

-usually b/l action tremor of the hands

34
Q

64 yo F BIB son for cognitive impairment

  • started 3 mo ago
  • unsteady gait, mild muscle weakness on left, prominent pronator drift of left arm, positive Romberg’s sign
  • PMH: HTN, stable CAD, diet-controlled DM
  • normal affect

Dx

A

Dx = Vascular dementia
-b/c of the focal neurologic finding

Not Alzheimer’s which would be more specific memory loss and language deficit w/o focal neurologic finding

35
Q

Path report shows grade IV astrocytoma

Best tx?

A

Cranial radiotherapy (???)

36
Q

Guillain-Barre

(a) CSF finding
(b) Tx

A

GB

(a) Albuminocytologic dissociation: elevated protein w/ normal cell count
(b) IVIG or plasmaphoresis

37
Q

Mechanism of disease in Parkinson’s

A

Alpha-synuclein accumulation in the neurons of the substantia nigra

38
Q

23 yo M w/ worsening HA x1wk

  • insect on right cheek 2 wks ago
  • b/l eye swelling
  • T 101F, TTP b/l on forehead and mid face

Dx

A

Dx = cavernous sinus thrombosis

= blood clot in cavernous sinus, usually 2/2 spreading infection from sinus, ears, teeth etc

39
Q

S/p generalized seizure 6 yo boy is alert and awake but unable to move r. arm and leg

  • normal speech and behavior
  • normal imaging

Mgmt?

A

Mgmt = supportive b/c this will self-resolve w/in 36 hours

Todd’s paralysis = postictal partial or complete hemiplegia involving ipsilateral upper and lower extremity
-mechanism thought to involve neuronal exhaustion or inhibition

40
Q

32 yo F p/w LE paresthesias and balancing difficulties

  • tingling in feet
  • PMH: severe Crohns
  • reduced vibration and proprioception in LE
  • hyperreflexia of UE
  • H/H 8/24 w/ MCT 108

Dx

A

Dx = Vitamin B12 deficiency

  • most likely 2/2 chronic malabsorption from Crohn’s
  • hint = macrocytic anemia

Neurologic sign = subacute combined degeneration

  • progressive symmetric polyneuropathy, usually LE
  • early degeneration of dorsal columns
  • late degeneration of corticospinal
41
Q

25 HIV+ M p/w AMS

  • disoriented, lethargic
  • last CD4 40, on Bactrim ppx
  • MRI shows solitary, irregular, weakly ring-enhancing mass in periventricular area
  • seriology +Toxo
  • PCR of CSF shows EBV DNA

Most likely dx?

A

CNS lymphoma

Not toxo- pt is on pox, MRI would show multiple, ring enhancing lesions in the basal ganglia, tons of ppl have positive serology

42
Q

57 yo M p/w right arm/leg weakness x2 hrs, mild constant HA x3 days

  • BP 180/100
  • NCHCT normal

Dx

A

Dx = lacunar stroke 2/2 small-vessel lipohyalinosis

43
Q

Tx for spinal abscess

A

In addition to abx, need immediate surgical decompression to prevent cauda equina syndrome and complications of spinal cord compression

44
Q

64 yo M p/w falls

  • loses balance when he tried to turn or stop suddenly while walking
  • hand tremor that started in left hand, now affects both hands

Most likely dx

A

Dx = Parkinson’s

Tremor often started unilaterally then generalizes

45
Q

General effect of Arnold-Chiari and Dandy-Walker malformations

A

Both Arnold-Chiara and Dandy-Walker are congenital malformations causing noncommunicating hydrocephalus due to blockage of the CSF flow in the posterior fossa

46
Q

2 features of Kluver-Bucy syndrome

A

Hyperphagia and hypersexuality

47
Q

34 yo postpartum F s/p epidural injection c/o severe HA upon standing, relieved whenever lie down

(a) Dx
(b) Tx

A

(a) Dx = intracranial hypotension

(b) Tx = autologous blood patch

48
Q

Manifestation of chemotherapy-induced peripheral neuropathy

A

Symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern

  • so hands and feet, symmetric
  • numbness/tinging over weakness
49
Q

Side effect of trihexyphenidyl

A

Trihexyphenidyl = anticholinergic

Dry mouth, blurred vision, constipation, nausea, urinary retention
dry as a bone, mad as a hatter…

50
Q

2 features specific to intraventricular tumors

A
  • positional/postural headaches (develop HA in certain postures/positions)
  • LOC due to sudden increase in ICP if there is an acute obstruction
51
Q

2 most common bugs that cause brain abscess

A

Brain abscess: most commonly from direct extension (dental work, sinusitis, otitis media) of strep viridans or staph aureus

2 bacteria = strep viridans and staph aureus

52
Q

9 yo F w/ unsteady gait and LE weakness

  • wide based gait
  • decreased vibratory/position sense in LE, absent ankle jerks b/l
  • deformed feet w/ high plantar arches
  • MRI: atrophy of cervical spinal cord
  • EKG: T-wave inversions of inferior and lateral chest leads

Dx

A

Dx = Friedrichs Ataxia = autosomal recessive of trinucleotide repeats

P/w gait incoordination (ataxia) 2/2 degeneration of spinal cord neurons

-also causes degeneration of cardiac muscle fibers => myocarditis

53
Q

Differentiate early vs. late signs of diabetic neuropathy

A

Usually starts w/ alterations in sensation
-loss of proprioception

Very late manifestation is motor findings, and def no UMN findings
So if pt p/w motor weakness, hyperreflexia, upgoing plantar reflex- no diabetic neuropathy

54
Q

34 yo M p/w difficulty walking for several days

  • lower back pain x1 wk since lifting injury
  • h/o URI 1 mo ago
  • smokes and occasional IVDU
  • reduced strength in LE, normal UE
  • mild hyperreflexia LE, positive Babinski

(a) First test
(b) Dx

A

(a) MRI of the spine to diagnose
(b) spinal cord compression

-signs of UMN distal to site of compression

55
Q

Positive pronator drift- locate the lesion

A

Pronator drift is also called pyramidal drift- indicates UMN lesion where pronation is stronger than supination

=> lesion localizes to the pyramidal tract

56
Q

Clinical presentation of acute intervertebral disk prolapse

A

Severe radicular pain w/ positive straight leg raising test

57
Q

56 yo M w/o h/o HA p/w dull moderate HA x2 mo over right temple

  • worse in mornings or after a nap
  • unremarkable neuro exam

Most likely dx

A

CNS neoplasm

Red flag signs

  • new onset HA in adult w/o h/o HA
  • localized
  • morning HA
58
Q

17 yo F BIB father 30 mins s/p LOC at home

  • stressed and sleep deprived
  • 3 similar episodes over the last mo
  • normal vitals/physical exam, oriented to name but not time/place
  • FS 100

Other expected finding?

A

Dx = seizure
-not syncope b/c there is a post-ictal state (while syncope returns to baseline immediately)

Also expect tongue lacerations, Tonic-clonic seizure

59
Q

45 yo M p/w HA x4 mo

  • HA generalized and constant, worsened by bending/coughing
  • personality changes, N/V, papilledema
  • nonfocal neuro exam
  • CT: butterfly lesion w/ central necrosis

Dx

A

Dx = high-grade astrocytoma = glioblastoma multiforme

60
Q

56 yo M w/ acute right sided weakness and numbness

  • hyperreflexia RUE/RLE, decreased sensation to pinprick and light touch on r
  • mild dysarthria
  • NCHCT shows hyperdensity in the left basal ganglia

Mechanism of disease and Dx

A

Mechanism = hypertensive vasculopathy causing lacunar stroke

61
Q

Neimann-Pick disease vs. Tay-Sachs

(a) Age of onset
(b) Main features
(c) Differentiating factors

A

(a) Both have 2-6 mo age of onset, autosomal recessive
(b) Both: loss of motor milestones, hypotonia, cherry-red macula
(c) NP: areflexic w/ hepatosplenomegaly
TS: hyperreflexic w/o HSM

62
Q

Two main features of Friedreich’s ataxia

A

Ataxia- gait instability/imbalance
-LE weakness

Cardiac abnormalities
-myocarditis, EKG abnormalities

Autosomal recessive, trinucleotide repeat d/o

63
Q

Type of stroke that shows normal NCHCT

A

Lacular stroke

64
Q

4 yo p/w worsening ear pain

  • s/p 10d abx for otitis media
  • morning HAs improved after vomitting
  • bulging, opaque left TM
  • tender, erythematous left mastoid
  • WBC 17k (80N)

(a) First step in dx
(b) Dx

A

(a) CT w/ contrast (or can do MRI, CT just faster)
CT: hypointense center w/ ring enhancement, surrounding edema = brain abscess

(b) Brain abscess
- otitis and mastoiditis => direct spread of infection into temporal brain abscess

65
Q

Main features of neuroleptic malignant syndrome

A
  • fever (can be super high like 104)
  • mental status change
  • generalized rigidity
  • autonomic instability: tachycardia, labile BP, tachypnea, diaphoresis

Rigidity and hyperthermia may induce muscle necrosis => CK elevation

66
Q

29 yo M w/ h/o PSA p/w sudden onset confusion and fever to 102.6F

  • recently admitted for hallucinations, d/c on meds
  • BP 150/110, HR 112, RR 24, profuse diaphoresis
  • diffuse muscle rigidity x4 extremities
  • tremor

Dx

A

Dx = NMS (neuroleptic malignant syndrome) 2/2 antipsychotic use
-or can be 2/2 antiparkinsonian (DA agonist) withdrawal

Tetrad of findings

  • change in mental status
  • fever
  • generalized rigidity
  • autonomic dysregulation (tachy, tachypneic, diaphoretic)

Can also see CK elevations due to muscle necrosis from rigidity/fever

67
Q

In addition to triptans, name another drug that can be used as abortive therapy for migraine headaches

A

IV antiemetics: chlorpormazine, prochlorperazine, or metoclopramide

Prochlorperazine = antiemetic

68
Q

84 yo F p/w progressive confusion and increased weakness x2 wks

  • baseline is normal activity, now very somnolent/difficult to arouse
  • muscle strength 4/5 r, 3/5 left
  • upgoing plantar reflex on left

Dx

A

Dx = subdural hematoma
-insidious onset of HA, somnolence, confusion, and possibly focal neurologic deficits (hemiparesis) 2/2 compression of underlying cortex

Not internal capsule infarct: would be super acute and no findings of somnolence

69
Q

Type of paralysis caused by tick vs. botulism

A

Mostly all types of paralysis besides botulism are ascending
-tick paralysis is ascending (so is Guianne-Barre)

While botulism causes descending paralysis

70
Q

Acute tx for botulism

A

Equine antitoxin therapy = heptavalent botulinum antitoxin

-provides passive immunity

71
Q

First line tx for absence seizures

A

Ethosuxamide

72
Q

S/p IPH in the right cerebellar hemisphere, pt will present w/ ataxia of which side?

A 
Right sided (ipsilateral) ataxia
-b/c corticopontocerebellar fibers decussate twice
73
Q

What physical exam finding is rather specific for a pyramidal tract lesion

A

Positive pronator drift: eyes closed and arms outstretched w/ palms upwards, arm involuntarily drifts downward and palm turn towards the floor

Pyramidal (corticospinal) tract disease: pronation is stronger than supination

74
Q

Symptoms in addition to Parkinsonian features that indicate diagnosis of MSA

A

Think MSA (multiple system atrophy) when a pt w/ Parkinsonism experiences orthostatic hypotension, impotence, incontinence, or other autonomic symptoms

75
Q

Mgmt for Multiple system atrophy

A
  • Anti-Parkinsonian drugs are generally ineffective
  • tx aimed at intravascular volume expansion (counteract the orthostatic hypotension) w/ fludrocortisone (synthetic mineralocorticoid), salt supplementation, alpha agonists, and compression stockings

Neuro Shelf (12 decks)

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