CLI Week 5 Flashcards

Question

Recognition of severe asthma – 1 death a week in Australia:

Answer 1

* The term acute severe asthma is used to mean an exacerbation of asthma that has not been controlled by the use of standard medication. * Patients with *acute severe asthma* typically have: * The inability to complete a sentence in one breath   * A respiratory rate of ≥25 breaths/min   * Tachycardia ≥110 beats/min (pulsus paradoxus is not useful as it is only present in 45% of cases)   * PEFR \<50% of predicted normal or best.   * Features of life-threatening attacks are:   * A silent chest, cyanosis or feeble respiratory effort   * Exhaustion, confusion or coma   * Bradycardia or hypotension   * PEFR \<30% of predicted normal or best (approximately  150 L/min in adults).  * Arterial blood gases should always be measured in asthmatic patients requiring admission to hospital, with particular attention paid to the *P*aCO2. Pulse oximetry is ![]()useful in monitoring oxygen saturation during the admission and can reduce the need for repeated arterial puncture. Features suggesting very severe life-threatening attacks are: * A high *P*aCO2 \>6 kPa * Severe hypoxaemia \<8 kPa despite oxygen treatment * Low and falling arterial pH

Answer 2

* How long have you had the cough? * Do you cough up anything? What? How much? * Have you had sinus problems? * Is the sputum clear or discoloured? Is there any blood in the sputum? * Have you had high temperatures? * Does coughing occur particularly at night (acid reflux)? * Have you become short of breath? * Have you had lung problems in the past? * Have you been a smoker? Do you still smoke? * Have you noticed wheezing? (Asthma, COPD)? * Do you take any tablets? (e.g. ACE inhibitors)

Answer 3

* **Acute** * URTI * Common cold, sinusitis * LRTI * Pneumonia, bronchitis, exacerbation of COPD * Irritation – inhalation of bronchial irritant (e.g. smoke or fumes) * **Chronic** * COPD – smoking history * Asthma – wheeze, relief with bronchodilators * GORD – worse lying down, burning central chest pain * Upper airway cough syndrome – history of rhinitis, postnasal drip, sinus headache and congestion * Bronchiectasis – chronic, very productive * ACE inhibitor medication – drug history * Carcinoma of the lung – smoking, haemoptysis * Cardiac failure – dyspnoea, PND * Psychogenic – Variable, prolonged symptoms, usually mild

Answer 4

**Chest radiograph:** Patients referred to specialist cough clinics most commonly have a normal chest radiograph. However, review of a recent film is mandatory as any significant abnormality will alter the diagnostic algorithm and avoid unnecessary investigation. **Spirometric and peak expiratory flow measurements:** Baseline spirometric results are likely to be normal in patients referred for specialist opinion. Spirometry is available in most hospitals and in an increasing number of primary care clinics. When available, it should be performed with reversibility testing in all patients with chronic cough. Peak expiratory flow (PEF) measurement in patients with persistent cough presenting in primary care has focused on the diagnosis of airflow obstruction. For this purpose, it may have some merit, but the use of PEF measurements to assess bronchodilator response appears to have limitations compared with conventional measurements of forced expiratory volume in 1 second (FEV₁). The value of serial PEF measurements for determining diurnal variability has not been properly assessed and is infrequently requested by specialist cough clinics. **Bronchoprovocation testing:** Bronchial challenge testing can provide very useful clinical information about patients with chronic cough. Virtually every diagnostic protocol for cough uses direct challenge methods (usually histamine or methacholine) and this review will be restricted to these. Bronchial hyperreactivity in a patient with cough and normal spirometric measurements raises the possibility of cough variant asthma. However, a definitive diagnosis cannot be made until the cough responds to specific asthma treatment. Airway hyperreactivity may develop during an acute viral respiratory illness and may persist for some months afterwards. Cough may persist for many weeks following an upper respiratory tract infection and a positive challenge test in this circumstance may be diagnostically misleading. Airway hyperreactivity to methacholine has also been found in patients with reflux oesophagitis but no respiratory complaints. * A negative bronchial challenge effectively excludes asthma as the diagnosis but does not eliminate a cough that may respond to steroid treatment. Particular interest has focused on patients with chronic cough and an eosinophilic bronchitis but with none of the airway dysfunction typically associated with asthma. A negative bronchial challenge may therefore prompt the clinician to assess the airway (most commonly using induced sputum) for evidence of an eosinophilia. **Upper airway provocation studies:** Extrathoracic airway dysfunction may account for asthma-like symptoms in particular cough. Extrathoracic airway responsiveness can be assessed by recording the maximal inspiratory flow-volume curve during conventional bronchial challenge testing. Extrathoracic airway hyperresponsiveness in the absence of bronchial hyperresponsiveness may be an indicator of upper airway disease as a cause for cough. Using flow-volume loops, variable extrathoracic upper airway obstruction has been observed in a series of patients with cough due to postnasal drip syndrome which improved with treatment. Precise interpretation of extrathoracic reactivity is difficult and the test is likely to remain primarily a research tool. **Sinus imaging:** Plain sinus radiographs therefore are of little value in the evaluation of chronic cough, and sinus CT scanning should be reserved for refractory cases which may require surgical intervention. **Gastrointestinal investigations:** Although not always available, 24-hour oesophageal pH monitoring is currently the best single test to help characterise any link between gastro-oesophageal reflux and cough. Dual probe pH studies are now commonly used and have extended our knowledge of the site and extent of reflux disease. However, 24 hour oesophageal pH monitoring is not without limitations and no consensus exists as to how best to define the temporal association between a cough and a reflux episode or to identify individuals most likely to benefit from antireflux therapy. There needs to be some caution in the interpretation of a negative pH profile. **Induced sputum:** A number of groups have recently adapted the conventional diagnostic strategies for chronic cough to include induced sputum. The key aspect has been the demonstration of an airway eosinophilia in patients without functional abnormalities, in particular bronchial hyperreactivity associated with asthma. Ideally, induced sputum should be requested after exclusion of the other common causes and after demonstration of normal airway hyperresponsiveness (provocative concentration of methacholine or histamine producing a 20% decrease in FEV₁ (PC₂₀) \>16 mg/ml). **Exhaled breath:** Exhaled nitric oxide (NO) levels appear to be lower in non-asthmatic coughers, allowing some differentiation from asthmatic cough. Exhaled NO may represent a simpler alternative to induced sputum tests, but currently it has no clear diagnostic role in the management of chronic cough. The measurement of many different inflammatory molecules in breath condensate, although currently a research procedure, may have a place in the diagnosis of chronic cough in the future. **Inhalation cough challenge:** Patients with persistent cough have a hypersensitive cough reflex to a range of tussive agents which diminishes with successful treatment.[¹⁰](http://thorax.bmj.com/content/59/4/342.full#ref-10) Citric acid and capsaicin are the two most widely used in cough challenge testing, although others include tartaric acid and ultrasonically nebulised distilled water.[^39,](http://thorax.bmj.com/content/59/4/342.full#ref-39)[⁴⁰](http://thorax.bmj.com/content/59/4/342.full#ref-40) The methodology involved is similar to bronchial provocation testing but, in contrast to these inhalation tests, no agreed universal standards for cough challenge testing exist.[⁴¹](http://thorax.bmj.com/content/59/4/342.full#ref-41) The particular value of cough reflex testing is in assessing the efficacy of antitussive therapy. There are no discriminating features on cough challenge testing which are likely to be of diagnostic value, and hence its place outside a research capacity is likely to remain limited. **Cough recording** Interest in cough monitoring has concentrated mainly on developing an objective means of measuring cough frequency and assessing severity. Differences in the characteristics of the cough sound and flow pattern between asthma, bronchitis, and interstitial fibrosis have been reported. Analysis of overnight cough recording determined differences in character and intensity of cough sounds between patients with cystic fibrosis and cryptogenic fibrosing alveolitis. These observations open the possibility of using cough monitoring as a diagnostic tool. **Psychological assessment** Psychogenic cough can be included in the range of recognised functional respiratory disorders. In children a characteristic “honking” or barking sound is described and is often attributed to a “habit cough”. However, a more complex “cough tic” disorder may underlie the problem. Psychogenic cough in an adult patient should only be considered following thorough exclusion of a physical cause. The value of a prompt and accurate diagnosis is manifest in the successful outcomes reported after psychotherapy. As cough is known to have an adverse impact on the quality of an individual’s life (in particular psychosocial aspects), cough specific quality of life questionnaires have been developed. Although not diagnostic, such instruments provide a measurement of the size and nature of this effect.

Answer 5

* Examination * Throat Swab * CXR * Epiglottitis and croup are often confused because they share symptoms and signs including stridor. However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis. **Asthma:** 1^st line treatment of acute asthma. Tachycardia, increase RR and inability to form full sentences is indicative of sever attack. When PEFR \<150 L/min need to admit to hospital. Nebulise 5mg salbutamol. Hydrocortisone sodium succinate 200mg i.v. Oral prednisolone 200mg. O2 40-60%.

Answer 6

**_Document_**: supine film is more plethoric due to distension of vessels due to gravity. On full inspiration diaphragm should sit at 11^th rib posteriorly. Dextrocardia. **_Chest:_ Lung:** upper zone 2 costal cartilage, middle zone 2^nd-4^th and lower zone 4^th -6^th. Apices of the lung is less perfusion but with LVF there will be increase opacity due to congestion. The right upper lobe has 3 segments, middle has 2 and 4 at lower lobe. The left upper has 4 and 4 lower. **Airway:** Trachea is normally deviated to the left due to the aortic knuckle. The aortic becomes wider and unfold with age. **Mediastinum:** hilum composed of pulmonary arteries and veins, lymphoma or pulmonary hypertension will cause enlargement of hilum. Heart. **Diaphragm:** peritoneal gas. **And Pleura.** **_Bone and soft tissue:_** breast shadow, soft tissue gas after thoracotomy, calcified glands in the neck and erosion/arthritis. **_Apices and review:_** Apices for TB and Pancoast’s tumors. Retrocardiac region for collapse left lower lob, appear as triangle. Lateral film: 4to4 rule for oblique fissure – 4cm behind anterior costal margin to hilum of T4 vertebral. Pulmonary venous congestion occur when venous pressure reach 15mmHg. Occur in LV failure cause redirection of blood to upper zone so blood vessels above the hila is larger. Interstitial pulmonary oedema when capillaries pressure exceed 25mmHg. Kerley B lines caused by odematous interlobular septae. Alveolar odema is seen when pressure reaches 30mmHg, giving bat’s wing appearance. Bulging of any cardiac boarder suggest ventricular aneurysm post MI. Pulmonary plethora indicate left to right shunt, there is mark dilatation of the pulmonary artery at the left hilum. Hydropneumothorax – air and fluid in pleura so no meniscus sign.

Answer 7

Risk: associated with asthma, emphysema and TB. Spontaneous Idopathic pneumothorax occur in young. Sign – reduce lung expansion. SOB. Hyperresonance. Reduce breath sound. Subcutaneous emphysema. Primary: spontaneous rupture of subpleural bullae usually at the apice. Occur commonly tall young male, postulate there is underlying CT defects in the alveolar. Secondary: trauma, emphysema bullae, iatrogenic (caused by med intervention). Treatment – the air is absorbed at a rate of 1.25% of the radiographic volume of the hemithorax per day. \<20% radiographic volume – re-access in two weeks avoid strenuous exercise. Medium 20-50% and large \>50% aspirate air. If recurrence intercostal drainage tube in place for 2-3 days. If pneumothorax remain and tube bubbling, Video Assisted Thoracoscopic (VATS). Recurrence more than twice -\> VATS

Answer 8

Pneumococcal pneumonia Consolidation with air bronchogram & arrows show bulging of oblique fissure (arrows). TB pneumonia Arrows show paratracheal lymphadenopathy. Arrowhead show enlarged nodules at parenchyma indicative of miliary TB Lung abscess A large circumscribed lesion with a well defined wall and air-fluid level is consistent. Radiology Right heart boarder – right middle lobe. Fat less dense than muscle/ soft tissue. Right parasternal margin. Mass (tumor, abscess, fungus), nodule (\<1cm tb, granuloma, pneumoconiosis, allergic alveolitis, metastasis), consolidation, atelectasis – pneumonia (air bronchogram - consolidation, lung expansion occur) or collapse (plate atelectasis – lobule collapse) due to mass obstruction (white no air, lose volume diaphragm move, hilum and mediastinum shift), interstitial lung marking – odema kurlley b line, fibrosis, inflammatory – viral (check old x-ray acute or chronic). Non small cell - SCC – cavitate, hilum and bronchus where most expose to smoke and squamous cells are. Smoker.Adeno – fill aveloar because they secrete mucus, start off small consolidation. Starts off in the periphery and apice. Small cell – neuroendocrine. Hilum and medisternum tropisium. Metastatic – cannon ball round. Sihouette sign blurring of margins. Reticulonodular – white lines kurlley b line interstitial.

Answer 9

Written asthma action plans are one of the most effective asthma interventions available. An asthma action plan helps the person with asthma and/or their carer recognise worsening asthma and gives clear instructions on what to do in response. Every adult and child with asthma should have their own written asthma action plan that provides clear instructions on how to adjust medication in response to asthma symptoms, and when and how to get medical care, including during an emergency. Written asthma action plans should be individualised for the patient (e.g. clearly naming the medicines the person uses, using words they will understand, identifying individual signs of flare-ups). They should be reviewed regularly.

Answer 10

* Relievers (prescribe a reliever and train the patient to use it correctly): * Advise all patients with asthma to carry a reliever containing a rapid-onset inhaled beta₂ agonist at all times and use it when they experience difficulty breathing * Preventers (consider regular preventer treatment with inhaled corticosteroids or other preventer): * Explain to the patient that preventers should be taken every day and continued long term to reduce the risk of flare-ups * For adults prescribed low-dose ICS for an indefinite period, explain that: * The main purpose of long-term low-dose ICS-based preventer is to reduce the risk of flare-ups, even if day-to-day symptoms are infrequent * Even if the person has not experienced asthma symptoms for some time, they should not stop taking their preventer without discussing first

Answer 11

* Beta₂-agonists (bronchodilators) are a group of drugs prescribed to treat asthma * Short-acting beta-agonists (SABAs) are used for quick relief of asthma symptoms, such as wheezing, ‘feeling tight’ when breathing, coughing and shortness of breath. SABAs act within minutes to temporarily relieve these symptoms by reversing the muscular bronchospasm in the airways; they are very effective in opening the airways * Examples – salbutamol and terbutaline * Long-acting beta agonists cause relax the muscle bands that surround the airways (bronchodilation) and allow you to breathe in and out more easily. These medicines can improve asthma control only when used in combination with an inhaled corticosteroid medicine. They are used every day, even when there are no asthma symptoms. LABAs are not rescue medicines and do not relieve sudden asthma symptoms. They are often used in people who have asthma symptoms at night or used to prevent exercise-induced asthma symptoms * Examples – salmeterol, formoterol

Answer 12

Inhaled corticosteroids are the most effective preventer medicines for adults. ICS are effective in reducing asthma symptoms, improving quality of life, improving lung function, decreasing airway hyper-responsiveness, controlling airway inflammation, reducing the frequency and severity of asthma flare-ups and reducing the risk of death due to asthma

Answer 13

The most important point of management for both of these conditions is to try and avoid the precipitating allergen. Allergen testing by skin prick or IgE blood test is recommended for those with persistent allergic rhinitis- the evidence is less substantial for eczema. _Drug treatment for allergic rhinitis:_ (as per eTG) ![]() ![]()

Answer 14

* Modification of lifestyle to avoid exacerbating factors * Avoid wool and synthetics * Avoid soaps and shampoos etc. use soap substitutes * Avoid HOT baths * Cold windy weather exacerbates it * Use moisturisers and bath additives * Investigation and treatment of infection * MCS if there is a flare up * Treatment appropriate antibiotics e.g. cephalexin against staph infection * Use of topical anti-inflammatory agents * Use of wet dressings

Answer 15

Oxygen is the most commonly used drug in acute clinical settings. Normal atmospheric oxygen is 21% - another way of expressing this is talking about the amount of ‘inspired oxygen’. This is often written as FiO2. This means room air has an FiO2 of 0.21. It is essential for cell function and without oxygen some cells (such as the brain) may become damaged or dysfunctional very quickly (minutes). Therefore neurological dysfunction is an early sign of hypoxia. The following values hold for otherwise healthy individuals (with illness symptoms may appear earlier) PaO2 of 90 mmHg - normal person with no symptoms PaO2 of 55 mmHg - short term memory loss, euphoria, impaired judgement PaO2 of 30 -55 mmHg - progressive loss of cognitive and motor function PaO2 \< 30 mmHg - loss of consciousness Oxygen is indicated in the treatment of most respiratory diseases, asthma, COPD, restrictive lung conditions, fibrotic lung conditions, pneumonia etc. By increasing the FiO2 we increase the amount of oxygen getting down to the alveoli without having to increase the patients tidal volume or respiratory rate (which are usually limited in these diseases). * Remember: before using oxygen we MUST SECURE THE AIRWAY- if we have a blocked trachea, oxygen is not going to do the patient any good. Oxygen of limited effectiveness in conditions where the alveoli themselves are destroyed (such as ARDS). * When we have a patient who comes in with COPD- we must use a venturi mask to control the oxygen flow and ensure their O2 sats do not rise above 95%. This is because patients with COPD have chronic CO2 retention and thus rely on their HYPOXIC DRIVE.

Answer 16

* The administration of influenza vaccine to persons at risk of complications of infection is the single most important measure in preventing or attenuating influenza infection and preventing mortality * After vaccination, most adults develop antibody levels that are likely to protect them against the strains of virus represented in the vaccine * There is also likely to be protection against many related influenza variants ![]() **Influenza vaccine:** * Trivalent and quadrivalent flu vaccines: 2xFlu A (H3N2 & H1N1) plus 1 or 2 Flu B strains * Subunit vaccines prepared from purified inactive influenza virus (it is an egg vaccine) Efficacy is 70-90% depending on the age and immunocompetence

Answer 17

and quarternary prevention Primary prevention * Eat from 5 food groups, limiting intake of fatty, processed foods à increases asthma risk in children * Aim for healthy weight as obese people have higher rates of asthma due to mechanical, inflammatory and genetic/developmental factors * Promote breastfeeding as it is preventative against early childhood wheezing and development of asthma Secondary prevention * Continue to avoid tobacco smoke/ airway pollutants * Encourage environmental control for patients sensitised to house dust mites * Screen for asthma using spirometry à look for improvement in FEV1/FVC following bronchodilator therapy * Screen those at high risk- family history, existing atopic tendencies to promote early detection and appropriate management Tertiary prevention * Eliminate/reduce exposure to sensitised allergens * High fat and low fibre diets associated with increased airway inflammation and lower lung function in people with asthma. High fat meals reduce efficacy of bronchodilator response * Maintain physical activity as it improves cardiopulmonary fitness (exercise induced bronchoconstriction can be managed effectively). Recommend structured exercise and training as part of comprehensive asthma management * Weightloss improve asthma- improved airway hyperresponsiveness, lung function, asthma symptoms and control, and medication needs * Vaccinate against influenza and pneumococcal – to prevent acute exacerbations of asthma * Screen patients with asthma for depression and anxiety- as these conditions can also contribute to asthma Quaternary prevention (prevent overdiagnosis and overtreatment) * Focus on maintaining quality of life with asthma * Minimise side effects or drug-drug interactions from treatment * Avoid unnecessary or excessive intervention of the health system by still promoting lifestyle modifications in conjunction with Ventolin/corticosteroids [https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/asthma-healthy-living](https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/asthma-healthy-living)

Answer 18

![]() **Management process:** * Confirm diagnosis * Assess asthma control (table above) * Choose initial treatment in collaboration with patient to ascertain their preference * Provide information, skills and tools for self management * Correct inhaler technique * A written asthma action plan * Information about avoiding triggers where appropriate * Manage flare ups * Manage comorbid conditions affecting asthma or contribute to respiratory conditions * Provide advice about smoking, healthy eating, physical activity, healthy weight and immunisation **Working with indigenous populations** * Utilise interpreter where appropriate * Involve aboriginal and Torres Straight Islander health workers/practitioners * Be trained in how to provide culturally appropriate secure care * Ask if they smoke/ are exposed to another person’s smoke * Take comprehensive respiratory health history * Routinely ask about coughing (frequency and type), observe for cough even if patient does not mention it * When cough is present (especially wet or productive), consider possibility of other lung diseases (bronchiectasis, chronic suppuratives lung disease and COPD) * Offer referral to specialist in children with symptoms and signs suggestive of chronic suppuratives lung disease (if possible) * Consider existing comorbidities: diabetes, cardiovascular and kidney disease, and ear problems **Incidence/prevalence of Asthma and smoking in Indigenous populations** * Asthma prevalence: Higher among ATSI than non ATSI Australians * 2004-2005: overall prevalence 16.5% compared to 10.2% non ATSI * Fewer ATSI people living in remote areas report having asthma compared to those living in non-remote areas * Rate of hospitalisation for asthma is twice as high in ATSI population * Smoking rates: 45% ATSI \>15yrs old smoke daily (more than twice the rate of non ATSI) * 50% ATSI mothers smoked during pregnancy (3.7 times the rate among non ATSI) * 65% ATSI children live in households with someone who smokes daily (twice the rate of non indigenous children) * Note: smoking hinders asthma medication efficacy and makes asthma harder to control since inducing airway inflammation and irritation **Language and cultural awareness in long term management and prevention of smoking related diseases** * See above- ‘working with indigenous populations’ [http://www.asthmahandbook.org.au/populations/atsi-peoples/diagnosis](http://www.asthmahandbook.org.au/populations/atsi-peoples/diagnosis)

Answer 19

1/9 Australians have asthma à around 2.5 million * More common in males 0-14yrs * More common in females \>15yrs * More common in socioeconomically disadvantaged areas * Prevalence is significantly higher in people living in inner regional areas compared to those in major cities, outer regional or remote areas $655 million spend on asthma in 2008-2009 [https://www.asthmaaustralia.org.au/national/about-asthma/what-is-asthma/statistics](https://www.asthmaaustralia.org.au/national/about-asthma/what-is-asthma/statistics)

Answer 20

Concept of Chronic Disease and Self Management. * Self management = active participation by people in their own health care à allows people with chronic illnesses to develop the skills to manage their risk factors, monitor their diseases, make effective use of services and medications and cope with the impact of the disease on their lives * Example: asthma – patient needs to know/manage/avoid triggers, use preventer and reliever as required/prescribed, inhaler technique, written asthma action plan, PEFR devices to monitor asthma control, when to use emergency department, the importance of regular medical review * Incidence of allergies and atopy –environment, genetic factors. ![]() * 20% of the Australian population have an allergic disease (increasing) * 3 atopic diseases: allergic rhinitis, eczema, asthma 1. asthma: 11% of Australian population 2. eczema: 3. allergic rhinitis: 20% of individuals in western populations * The risk of developing atopy increases by a factor of two with each first-degree family member already suffering from atopy * 20% of all children develop atopic dermatitis in sometime in their lives, a child with mod-severe dermatitis has a 50% chance of developing asthma and a 75% chance of developing allergic rhinitis * 75% children with asthma have a history of atopy: 50% of adults with asthma have a history of atopy * Study carried out on monozygous and dizygous twins – all with a history of atopy àindicated that for the large part genetic makeup does influence inheritance of atopy however there is still some observed variability – ie. Not 100% genetic à it is believed that only 30% of the observed variability can be explained by environmental factors, and that the remaining 70% must be due to such a “third factor”, currently attributed to epigenetics

Answer 21

* Not easy to gauge – no evidence with exact values (depends on staging, age, comorbidities, smoking status) * Different staging of COPD – higher the stage the shorter the life expectancy *GOLD staging* ![]() *GOLD classification for COPD* ![]() * The GOLD classification uses risk factors (GOLD 1 to 4 and number of exacerbations) and symptom severity (mMRC or CAT scale). In case both risk factors would fall in a different category, the highest risk factor is used (eg: GOLD 1 (GOLD A or B) with 2 COPD exacerbations last year (GOLD C or D) would be GOLD C or GOLD D). * GOLD A and B are low risk, GOLD C and D are high risk patients. * GOLD A and C have few symptoms, GOLD B and D have more symptoms * BODE index can be used to measure life expectancy * B: body mass index * O: obstruction of airflow (FEV1) * D: dyspnea (note: grade 0-4 of dyspnea) * E: exercise capacity (distance walked in 6 minutes) ![]() * *Fletcher-Peto graph* below clearly shows that smoking cessation can extend life expectancy and improve QOL even in late stage COPD ![]()

CLI Week 5 Flashcards

(45 cards)