List I - Core Conditions Flashcards

Question

How should a swab be taken from a person with otitis externa?

Answer 1

* Take a swab from the medial aspect of the ear canal under visualisation to reduce contamination

Answer 2

* Manage any aggravating or precipitating factors * Consider cleaning the external auditory canal of earwax or debris obstructs the application of topical medication (this may require referral to an ENT specialist) * Prescribe analgesic for symptomatic relief if required - paracetamol or ibuprofen, codeine can be added for severe pain * Consider prescribing a topical antibiotic with or without a topical coticosteroid - Use for a minimum up to a maximum of 14 days - Topical acetic acid spray 2% is safe and effective can be used for mild cases - Be aware of amino-glycoside induced ototoxicity in people with a perforated TM

Answer 3

* Cellulitis extending beyond the external ear canal * When the ear canal is occluded by swelling and debris and a wick cannot be inserted * People with DBM or compromised immunity for severe infection for example with pseudomonas aeruginosa * For these presentations consider prescribing a 7 day course of flucloxacillin or clarithromycin (if penicillin allergic)

Answer 4

* Assess in the same way as for people with acute otitis externa, in addition, assess for: - Severity of itching (usually the most prominent symptom) and signs of scratching. - Signs of fungal infection in the ear canal — whitish cotton-like strands of Candida, or small black or white balls of Aspergillus. - Signs of generalized dermatitis — mild erythema and lichenification (thickening of the skin) in the ear canal, and signs of underlying disease elsewhere (for example seborrhoeic dermatitis, psoriasis). - Evidence of contact allergy or sensitivity — use of ear plugs, hearing aid, earrings, sensitizing medications (topical and systemic). - Evidence of a source for an id (auto eczematization) reaction — id reactions can result from an infection or inflammatory skin condition * Fungal infection elsewhere in the body for example skin, nails, vagina) can cause a secondary inflammatory process in the external ear canal (presents as an itchy rash with blisters or vesciles)

Answer 5

* May be challenging and may require more than one strategy * If fungal infection is suspected (signs of fungal growth in the ear canal): - Prescribe a topical anti-fungal preparation - Mild to moderate and uncomplicated infections consider one of the following options: - Clotrimazole 1% solution - Acetic acid 2% spray - Clioquinol and a corticosteroid (e.g. Locorten-Vioform) * If the cause is: - Irritant or allergic dermatitis - advise the person to avoid contact with the irritant or allergen and prescribe a topical corticosteroid - Seborrhoeic dermatitis - treat topically with an antifungal/corticosteroid combination * If no cause is evident: - Prescribe a 7 day course of a topical preparation containing only a corticosteroid without anti-biotic (consider co-prescribing an acetic acid spray) - If there is an adequate response, continue the corticosteroid treatment however reduce the potency of the corticosteroid and/or the frequency of the application to the minimum required to maintain control - if the course is inadequate, consider a trial of a topical anti-fungal preparation - If treatment needs to be continued beyond 2 or 3 months, seek specialist advice

Answer 6

* To aid recovery and reduce the risk of future infection: - Avoid damage to the external ear canal - avoid using cotton wool buds or other objects to clean the ear canal - Keep the ears clean and dry by using ear plugs and or a tight fitting cap when swimming - People with otitis externa should abstain from water sports for at least 7 to 10 days - Using a hair dryer (at the lowest setting) to dry the ear canal after hair washing, bathing or swimming - Keep shampoo, soap and water out of the ear when bathing and showering - Ensure skin conditions that are associated with the development of otitis externa are well controlled - Consider using acidifying ear drops or spray (such as Ear Calm) shortly before swimming, after swimming and at bedtime

Answer 7

* A normal physiological substance that protects the ear canal * Earwax is a combination of sheets of desquamated keratin squames (the dead flattened cells on the outer layers of the skin), cerumen (a wax like substance produced by ceruminous glands which are modified sweat glands), sebum (from sebaceous glands) and various foreign substances (for example cosmetics and dirt)

Answer 8

* Aids removal of keratin from the ear canal * Cleans, lubricates and protects the lining of the ear canal, trapping dirt and repelling water, it is mildly acidic and has antibacterial properties

Answer 9

* Wet wax - Soft wet wax is moist and sticky and the sheets of keratin squames are small, more common in children - Hard wet wax has a dry, dessicated constituency, and the sheets of keratin are large and dense, it is more common in adults, hard wax is more likely to become impacted * Dry wax is dry, flaky and golden-yellow and is common in people from Asia

Answer 10

* Have narrow or deformed ear canals. * Have numerous hairs in their ear canals — cerumen impaction is more prevalent in older males as they tend to have more hair present in the ear canal. * Have benign bony growths in the external auditory canal (osteomata). * Have a dermatological disease of the peri-auricular area or scalp. * Produce hard or drier wax, as this is more likely to become impacted. * Are elderly, because as a person ages the cerumen glands atrophy causing the earwax to become drier. * Have a history of recurrent impacted wax. * Have learning disabilities — the reason for this is not known. * Have recurrent otitis externa. * Have Down's syndrome — people with Down's syndrome tend to have small ear canals and dry, scaly wax * Use of cotton buds as these push the earwax deeper into the canal * Wear a hearing aid or ear plugs as this prevents the wax being excreted

Answer 11

* Earwax removal is the most common ENT procedure performed in primary care with approximately 4 million ears irrigated annually in the UK

Answer 12

* Impacted earwax may cause conductive hearing loss - there may be conductive hearing loss of up to 40-50 decibels * If wax is in contact with the tympanic membrane it may cause discomfort and occasionally vertigo * Hearing loss due to impacted wax may cause frustration, stress, social isolation, paranoia and depression * Infection may sometimes occur as a result of wax impaction

Answer 13

* Problems due to earwax often recur

Answer 14

* Many people will self diagnose particularly if they have a history of recurrence * People may also complain of: - Blocked ears - Ear discomfort - Feeling of fullness in the ear - Earache - Tinnitus (noises in the ear) - Itchiness - Vertigo - Cough * May be a history of water exposure as this causes expansion of the earwax and may cause complete blockage of the ear canal * Children may present with yellow, waxy discharge, this is less common in adults * Ask about previous removal of impacted earwax, previous tympanic membrane perforation, recurrent or chronic ear problems, hearing aid use and other co-morbidities

Answer 15

* Examine both ears with an otoscope - Sit at the same level as the person - Examine the pinna, outer meatus and scalp for signs of previous surgery, discharge, swelling, signs of infection or skin lesions - Palpate the tragus to assess for pain - if pain is present proceed gently - Pull the pinna upwards and outwards (downwards and backwards in children) to straighten the external auditory meatus - Check for foreign bodies, localised infection or inflammation - Hold the persons head steady and insert the speculum into the meatus - Note whether wax is present, and whether it appears to be impacted - Whilst wax occluding the whole meatus may cause hearing loss it is more likely to cause a loss when adherent to the tympanic membrane - It may not be possible to view the tympanic membrane of wax is present

Answer 16

* Otitis externa * Foreign bodies * Keratosis obturans * Polyp of the ear canal * Osteoma of the ear canal

Answer 17

* If the earwax is totally occluding the ear canal and any of the following are present: - Hearing loss - Earache - Tinnitus - Vertigo - Cough suspected to be due to earwax * If the tympanic membrane is obscured by wax but needs to be viewed to establish a diagnosis * If the person wears a hearing aid, wax is present and an impression needs to be taken of the ear canal for a mould, or if wax is causing the hearing aid to whistle

Answer 18

* Explain that removal of earwax may not relieve the symptoms * Prescribe ear drops for 3-5 days initially to soften wax and aid removal - Olive oil, or almond oil drops can be used 3-4 times per day for 3-5 days - Sodium chloride 0.9% is not available as a proprietary ear drop product - off label 0.9% sodium chloride nasal drops can be used in the ear - Do not prescribe drops if you suspect the person has perforated tympanic membrane - Warn the person that instilling ear drops may cause transient hearing loss, discomfort, dizziness and irritation of the skin * If symptoms persist, consider ear irrigation, providing that there are no contraindications * If ear irrigation is unsuccessful, there are 3 options: - Advise the person to use ear drops for a further 3-5 days and then return for further irrigation - Instill water into the ear after 15 minutes irrigate the ear again - Refer to an ENT specialist for removal of the wax

Answer 19

* Do not use ear irrigation to remove wax for people with: - Previous problems with irrigation (pain, perforation, severe vertigo) - Current perforation of the tympanic membrane - History of perforation of the TM in the last 12 months - Grommets in place - History of any ear surgery (except extruded grommets within the last 18 months with subsequent discharge from an ENT department - Mucus discharge from the ear within the last 12 months - History of a middle ear infection in the previous 6 weeks - Cleft palate, whether repaired or not - Acute otitis externa with an oedematous ear canal and painful pinna - Presence of a foreign body, including vegetable matter in the ear - Hearing in only one ear if it is to be treated in that ear - Confusion or agitation and they may be unable to sit still - Inability to cooperate, for example young children and some people with learning difficulties * Use ear irrigation with caution in people with: - Vertigo, as this may indicate the presence of middle ear disease with perforation of the tympanic membrane - Recurrent otitis media with or without documented tympanic membrane perforation, as thin scars on the tympanic membrane can easily be perforated - Immunocompromised state - Careful instrumentation should be employed in people who are taking anticoagulants due to increased bleeding risk * Warn people with a history of recurrent otitis externa or tinnitus that ear irrigation may aggravate their symptoms

Answer 20

* Use an electric ear irrigator - should have a variable pressure control so that irrigation can begin at the minimum pressure * Prepare equipment as per local guidelines and manufacturers instructions - fresh speculum and jet tip for each person * Ensure the person is sitting comfortably and that you are sitting at the same level - young children should sit on an adults knee with their head held in place, use a good light source, preferably with a head lamp or head mirror throughout the procedure * Ensure that the temperature of the water used for irrigation is around body temperature * Pull the pinna upwards and outwards (downwards and backwards for children) to straighten the ear canal * Angle the jet tip so that the flow of the water is along the top of the posterior wall - compare the perimeter of the canal to a clock face - for the left ear direct the fluid towards 1 o'clock and for the right ear direct the fluid towards 11 o'clock * Inspect the ear canal periodically with an auriscope to check that the wax had been removed and the tympanic membrane is intact, look for healed perforations, inspect the canal for otitis externa * Seek immediate advice from an ENT specialist if severe pain, deafness or vertigo occur during or after irrigation or if a perforation is seen following the procedure

Answer 21

* Failure of wax removal * Otitis externa * Perforation of the tympanic membrane * Damage to the external auditory meatus - Necrotising (malignant) external otitis is a rare infection, occurring primarily in immunocompromised people, especially older people with diabetes mellitus and is often initiated by iatrogenic trauma to the external auditory canal - Pain - Vertigo - Otitis media due to water entering the middle ear when there is a previous perforation - Exacerbation of pre-existing tinnitus - Serious injury to the middle and inner ear * Bleeding * Nausea, vomiting and vertigo may result from temperature variations of the irrigating fluid

Answer 22

* Advise anyone who has had earwax removed to return if they develop earache or significant itching of the ear, discharge from the ear (otorrhoea) or swelling of the external auditory meatus, as this may indicate infection

Answer 23

* Disabiling hearing loss refers to hearing loss greater than 40 decibels (dB) in the better hearing ear in adults and a hearing loss greater than 30 dB in the better hearing ear in children (WHO) * Deaf people mostly have profound hearing loss which implies very little or no hearing - they often use sign language for communication

Answer 24

* Thresholds of 25 dB or better in both ears is said to have hearing loss (WHO)

Answer 25

* Infections - mumps, measles, rubella, meningitis, cytomegalovirus infections and chronic otitis media (31%) * Birth complications such as birth asphyxia, low birth weight, prematurity and jaundice (17%) * Use of ototoxic medicines in expecting mothers and babies (4%) * Others (8%)

Answer 26

* Immunising children against childhood diseases, including measles, meningitis, rubella and mumps * Immunising adolescent girls and women of reproductive age against rubella before pregnancy * Preventing cytomegalovirus infections in expectant mothers through good hygiene, screen for and treat syphilis and other infections in pregnant women * Strengthen maternal and child health programmes including promotion of safe child birth * Follow healthy ear practices * Reduce exposure (both occupational and recreational) to loud sounds by raising awareness about the risks; developing and enforcing relevant legislation and encouraging individuals to use personal protective devices such as ear plugs and noise cancelling earphones and head phones * Screening of children for otitis media, followed by appropriate medical or surgical interventions * Avoiding the use of particular drugs which may be harmful to hearing unless prescribed and monitored by a qualified physician * Referring infants at high risk such as those with a family history of deafness or those born with low birth weight, birth asphyxia, jaundice or meningitis for early assessment of hearing, to ensure prompt diagnosis and appropriate management as required * Implimenting the WHO-ITU global standard for personal audio systems and devices (mode 1 standard level for adults derived from 80 dBA for 40 hours per week, mode 2 standard level for sensitive users e.g. children derived from 75 dBA for 40 hours per week) * Educating young people and population in general on hearing loss, its causes and prevention and identification

Answer 27

* Earwax * Otitis media * Otitis externa

Answer 28

* Describes age related sensorineural hearing loss * Patients may describe difficulty following conversations * Audiometry shows bilateral high frequency hearing loss

Answer 29

* Autosomal dominant, replacement of normal bone by vascular spongy bone * Onset is usually at 20-40 years - features include: - Conductive deafness - Tinnitus - Tympanic membrane - 10% of patients may have a 'flamingo tinge' caused by hyperaemia - Positive family history

Answer 30

* Also known as otitis media with effusion - Peaks at 2 years of age - Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood) - Secondary problems such as speech and language delay, behavioural or balance problems may also be seen

Answer 31

* More common in middle aged adults - Recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural), vertigo is usually the prominent symptom - Sensation of aural fullness or pressure is now recognised as being common - Other features include nystagmus and a positive Romberg test - Episodes last minutes to hours

Answer 32

* Toxicity to hearing caused by drugs/toxins * Examples include: - Gentamicin - Furosemide - Aspirin - Number of cytotoxic agents - Cisplatin - Venk-alkaloid

Answer 33

* Workers in heavy industry are particularly at risk | * Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz

Answer 34

* Features can be predicted by the affected cranial nerves - CN VIII - hearing loss, vertigo, tinnitus - CN V - absent corneal reflex - CN VII - facial palsy * Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Answer 35

* Conductive * Sensorineural * Mixed

Answer 36

* Occurs due to abnormalities of the outer or middle ear which impair conduction of sound waves from the external ear (pinna, ear canal or tympanic membrane) through the ossicles (malleus, incurs and stapes) in the middle ear to the cochlea in the inner ear

Answer 37

* Occurs due to abnormalities in the cochlea, auditory nerve or other structures in the neural pathway leading from the inner ear to the auditory cortex

Answer 38

* Occurs when abnormalities causing both conductive and sensorineural hearing loss are present

Answer 39

* Mild (25-39 dB) * Moderate (40-69 dB) * Severe (70-94 dB) * Profound (>95 dB) Based on the quietest sound that can be heard measured in decibels (dB HL (decibel hearing level) on pure tone audiometry).

Answer 40

* Impacted earwax (cerumen) * Foreign bodies * Tympanic membrane perforation * Infection * Cholesteatoma * Middle ear effusion * Otoslerosis - abnormal bony growth affecting the small bones of the ear (mainly the stapes) * Neoplasm - SCC of the external ear and vascular glomus tumour behind the eardrum * Exostoses - hard bony growths in the ear canal (associated with swimming in cold water)

Answer 41

* Age related hearing loss (presbycusis) - most common * Noise exposure * Sudden sensorineural hearing loss (SSHL) - Defined as sudden onset (within 72 hours) hearing loss of 30 dB HL or more which involves 3 frequencies and cannot be explained by outer or middle ear conditions - In 90% of cases no underlying cause is identified and SSNHL is considered to be idiopathic - Hearing loss can range from mild to profound and may be temporary or permanent * Meniere's disease * Exposure to ototoxic substances - aminoglycosides, loop diuretics, NSAIDS, aspirin, anti-malarials (quinine and chloroquine) and cytotoxic drugs (cisplatin and bleomycin), pesticides, cigarette smoke and heavy metals e.g. mercury and lead * Labyrinthitis * Vestibular schwannoma (aka acoustic neuroma) - benign tumour causing hearing loss via compression of the cochlear nerve - may in some cases grow into the posterior cranial fossa and cause brain stem compression * Neurological conditions such as MS or stroke * Malignancy including nasopharyngeal cancer and intracranial tumours * Trauma to the head or ear * Systemic infections - CMV, toxoplasmosis, syphilis, meningitis, HIV measles, Lyme disease, herpes zoster, (Ramsay-Hunt syndrome) * Autoimmune conditions such as RA, SLE, sarcoidosis, Wegners granuloma and auto immune inner ear disease * Hereditary conditions such as Alports syndrome (genetic condition associated with progressive renal impairment and hearing loss)

Answer 42

* Many can be treated with full return to usual hearing (for example uncomplicated infections of the outer or middle ear and wax impaction) * Some causes of conductive hearing loss such as necrotising otitis externa can be life threatening if not identified and treated early

Answer 43

* Hearing loss associated with age and excessive noise is usually slowly progressive and permanent * Sudden sensorineural hearing loss has a variable prognosis - early intervention with steroids is the mainstay of treatment

Answer 44

Can adversely affect: * Relationships with family and friends due to communication difficulties * Social engagement and participation in leisure activities which may lead to social withdrawal, isolation and loneliness * Risk of unemployment and lower income * Reduced quality of life and ability to function independently * Increased risk of developing depression and anxiety

Answer 45

* Onset and progression - sudden (over 72 hours), rapidly progressive (within 90 days), slowly progressive or fluctuating * Bilateral or unilateral * Associated features: - Tinnitus - Vertigo - Otorrhoea (discharge) or otalgia (ear pain) - Sensation of fullness or pressure in the ear - Head/neck trauma, pain or swelling - Neurological symptoms * Past medical history - Previous chronic ear infections or hearing loss - ENT surgery of head trauma - Exposure to noise (including occupational) - Chronic disease * Medication including use of ototoxic drugs * Occupation including exposure to environmental toxins * Family history of hearing loss * Impact of hearing loss on communication, relationships, function (at home, in work/education and socially) quality of life and mood

Answer 46

* The pinna and surrounding skin looking for signs of inflammation, infection or abnormal lesions. * The ear canal and tympanic membrane (using an otoscope) to identify clinical features suggestive of conductive hearing loss. * If full visualisation is not possible due to earwax arrange wax removal and review to reassess. * Weber and Rinne tuning fork tests to help distinguish between conductive and sensorineural hearing loss. * Cranial nerves and cerebellar function to exclude focal neurology. * The head and neck for lymphadenopathy or other masses. * For clinical features of underlying systemic causes such as infective, autoimmune, metabolic or neurological conditions

Answer 47

* Hold a 512 Hz tuning fork by its stem and strike one side (two thirds of the way from the base) on a padded surface or the ball of the hand For the Weber test * Place the vibrating tuning fork on the person’s forehead (alternatively it can be placed on the vertex, bridge of the nose or chin) and hold in place for up to 4 seconds. * Ask the person where the tone is heard — in both ears, centrally, in the head or towards the left or right. If sound is heard: - Centrally this suggests symmetrical hearing or a symmetrical hearing loss. - In the poorer/affected ear this suggests an asymmetrical conductive hearing loss. - In the better/unaffected ear this suggests an asymmetrical sensorineural hearing loss. * The Weber test can be complicated by the presence of a unilateral or asymmetrical conductive hearing loss, where the tone can be heard on the conductive side or the side with the greater conductive loss For the Rinne test * Start with the ear that the Weber test lateralised to (if applicable). * Hold the vibrating tuning fork approximately 25mm from the entrance to the ear canal for about 2 seconds then without touching the tines press the footplate of the tuning fork firmly over the mastoid and hold the tuning fork in place for 2 seconds. * Ask the person if the tone is louder next to the ear or behind the ear. If sound is heard: - Better/louder by air conduction (next to the ear canal) this is ‘Rinne positive’ suggestive of a sensorineural hearing loss or normal hearing. - Better/louder by bone conduction (held on the mastoid) this is ‘Rinne negative’ suggestive of conductive hearing loss in that ear

Answer 48

* Dementia | * Depression

Answer 49

* Sudden onset (over 3 days or less) unilateral or bilateral hearing loss which has occurred within the past 30 days and cannot be explained by external or middle ear causes * Unilateral hearing loss associated with focal neurology such as altered sensation or facial droop - if stroke is suspected follow the stroke referral pathway * Hearing loss associated with head or neck injury * Hearing loss associated with severe infection such as necrotising otitis externa or Ramsay Hunt * Otalgia and otorrhoea that has not responded to treatment within 72 hours in a person who is immuno-compromised is suggestive of necrotising otitis externa

Answer 50

* Sudden onset over 3 days * Rapidly progressive hearing loss over 4-90 days * Suspected head and neck malignancy

Answer 51

* If the person presents for the first time with hearing loss and there are no indications for referral to ENT or the emergency department * Exclude or treat the causes of hearing loss such as impacted wax, acute ear infection and middle ear effusion due to acute upper respiratory tract infection * Discuss with/refer to ENT if after initial treatment for earwax or acute infection: - Eardrum cannot be examined because of partial or complete obstruction of ear canal - Pain in or around the ear persists for more than one week and has not responded to first line treatment - Discharge from either ear has not resolved with treatment or is recurrent - Abnormalities of the outer ear or eardrum are visible - Middle ear effusion which is not associated with or persists after upper respiratory tract infection is suspected * Arrange for audiology assessment: - If sensorineural hearing loss is confirmed and no underlying cause suspected, hearing aids will be considered - If hearing aids are fitted, face to face follow up (after 6-12 weeks) should be arranged by audiology - Bilateral hearing aids should be offered to people with aidable hearing loss in both ears as this can improve sound quality and make speech easier ti understand against background noise * Provide information and support

Answer 52

* Consist of a microphone, a battery powered amplifier, a receiver and a means to route amplified sound into the ear canal * As hearing aids cannot improve deficits in frequency, temporal and spatial resolution (which are often associated with age related and noise induced hearing loss) the person may continue to have some hearing difficulties, even when wearing hearing aids * Use of bilateral hearing aids improves intelligibility of speech in background noise, sound localisation and sound quality * If only one hearing aid is used over time, deficits may develop in the unaided ear due to reduced stimulation in that ear

Answer 53

* ALD's can improve hearing in situations with background noise by amplifying sound from a specific source such as a person speaking or a television and sending it straight to the ears * Other ALD's such as doorbell sensors, baby alarms and smoke detectors alert the person to environmental sounds through flashing lights, vibration or loud sounds

Answer 54

* Such as cochlear implants or bone conducting hearing implants may be appropriate for people whose sensorineural hearing loss is too severe for hearing aids - these require referral to ENT for surgical intervention

Answer 55

* Inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs * Labyrinthitis can be viral, bacterial or associated with systemic diseases * Viral labyrinthitis is the most common form of labyrinthitis

Answer 56

* Vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment * Labyrinthitis is used when both vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment

Answer 57

* 40-70 years

Answer 58

* Acute onset of: - Vertigo - not triggered by movement but exacerbated by movement - Nausea and vomiting - Hearing loss - may be unilateral or bilateral, with varying severity - Tinnitus - Preceding or concurrent symptoms of upper respiratory tract infection

Answer 59

* Spontaneous unidirectional horizontal nystagmus towards the unaffected side * Sensorineural hearing loss - shown by Rinnes and Webers test * Abnormal head impulse test signifies an impaired vestibulo-cular reflex * Gait disturbance - patient may fall towards the affected side * Normal skew test * Abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

Answer 60

* Diagnosis is largely based on history and examination * Glucose is helpful in excluding hypoglycaemia * In most patients with suspected viral labyrinthitis, no other investigation is necessary

Answer 61

* Pure tone audiometry can be done to assess hearing loss * FBC and blood culture if systemic infection is suspected * Culture and sensitivity testing if any middle ear effusion * Temporal bone CT scan - indicated if suspecting mastoiditis or cholesteatoma * MRI scan - helpful to rule out causes such as suppurative labyrinthitis or central causes of vertigo * Vestibular function testing may be helpful in difficult cases and/or determining prognosis

List I - Core Conditions Flashcards

(85 cards)