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Hark and Paul's clinical review > Neurology > Flashcards

Neurology Flashcards

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1
Q

What are the causes of Parkinsonism?

A
  • Idiopathic (Parkinson’s disease) most common
  • Parkinson Plus Syndromes e.g. PSP, MSA, CBD, DLB
  • Basal ganglia disorders e.g. tumours, Wilson’s disease
  • Normal pressure hydrocephalus
  • Dementia Pugilistica (chronic head injury)
  • Drugs e.g. chlorpromazine, metoclopramide, prochlorperazine
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2
Q

Charcot-Marie-Tooth Disease

What are the causes of pes cavus?

A 
>BILATERAL
-Charcot-Marie-Tooth disease
-Friedrich's ataxia
-Muscular dystrophies
-Spinal muscular atrophy
-Spinal cord tumours
-Syringomyelia
-Hereditary spastic paraparesis
-Cerebral palsy
>UNILATERAL
-Polomyelitis, Malunion of calcaneal/talar fractures
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3
Q

Cerebellar Syndrome

What are the causes of bilateral cerebellar signs?

A

> Mnemonic: MAPLE

  • MS
  • Alcohol, Arnold-Chiari malformation
  • Phenytoin
  • Large space occupying lesion
  • Endocrine (hypothyroidism)
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4
Q

Myotonic Dystrophy

Name the trinucleotide repeat expansion disorders.

A
  • Myotonic dystrophy
  • Huntington’s disease
  • Friedrich’s ataxia
  • Fragile X syndrome
  • Spinocerebellar ataxia
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5
Q

Myotonic dystrophy

What myopathies cause distal wasting and weakness?

A
  • Myotonic dystrophy
  • Inclusion body myositis
  • Oculopharyngodistal myopathy
  • Welander distal myopathy
  • Finish distal myopathy
  • Markesbury distal myopathy
  • Miyoshi myopathy
  • Hereditary Motor & Sensory Neuropathy
  • Distal spinal muscular atrophy
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6
Q

What are the causes of Peripheral Neuropathy?

A

> Mnemonic DAM IT BITCH:

  • Drugs
  • Alcohol
  • Metabolic (diabetes, uraemia)
  • Idiopathic & Infiltrative (amyloidosis)
  • Toxins (botulism)
  • B12 deficiency
  • Infection (HIV, leprosy) & Post-Infectious (GBS)
  • Tumour (paraneoplastic)
  • Connective tissue & Congenital
  • Hypothyroidism
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7
Q

What drugs can cause Peripheral Neuropathy?

A 
>Motor:
-Dapsone
>Sensory: Antimicrobials
-Metronidazole
-Isoniazide
-Pyridoxine
-Chloroquine
>Sensorimotor: Chemotherapy
-Vincristine
-Vinblastine
-Cisplatin
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8
Q

Peripheral Neuropathy

What conditions can cause thickening of peripheral nerves?

A
  • Leprosy
  • Amyloidosis
  • Charcot-Marie-Tooth disease
  • Acromegaly
  • Neurofibromatosis
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9
Q

Friedrich’s Ataxia

What are the causes of an absent ankle jerks with extensor plantar response?

A
  • Friedrich’s ataxia
  • Motor neurone disease
  • Subacute combined degeneration of the cord (B12 deficiency)
  • Tabes dorsalis
  • Conus medullaris lesion
  • Combination of conditions e.g. peripheral neuropathy & stroke or peripheral neuropathy & cervical myelopathy
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10
Q

What are the differential diagnoses of Multiple sclerosis?

A
  • Neuromyelitis Optica (Devic’s disease)
  • Acute Disseminated Encephalomyelitis
  • Progressive Multifocal Leukoencephalopathy
  • Paraneoplastic Encephalomyelitis
  • Isolated Optic Neuritis
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11
Q

What are the different types of Nystagmus?

A
  • Cerebellar Nystagmus: Coarse horizontal nystagmus, Fast component towards side of lesion.
  • Peripheral Vestibular Nystagmus: Horizontal nystagmus, Fast component away from side of lesion
  • Central Vestibular Nystagmus:Horizontal/Vertical/Rotatory/Mixed. Can be bidirectional.
  • Ataxia Nystagmus: INO
  • Pendular Nystagmus: Blindness/Congenital
  • Downbeat Nystagmus: Lesion at Foramen magnum.
  • Upbeat Nystagmus: Cerebellum or Medulla
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12
Q

Ophthalmoplegia

What are the features of a VI Nerve Palsy?
What are the causes of a VI Nerve Palsy?

A

> Features:
-Convergent strabismus at rest
-Impaired abduction of affected side
Causes:
-Raised intracranial pressure
-Cavernous sinus lesions (tumour, infection, thrombosis, aneurysm)
-Vascular (infarct, haemorrhage, basilar artery aneurysm)
-Inflammation (multiple sclerosis, sarcoidosis)
-Infection (syphilis)
-Mononeuritis Multiplex

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13
Q

Ophthalmoplegia

What are the features of a III Nerve Palsy?
What are the causes of a III Nerve Palsy?

A 
>Features:
-Divergent strabismus
-Pupil down & out
-Pupil fixed & dilated
>Causes:
-Posterior communicating artery aneurysm
-Cavernous sinus lesions
-Vascular
-Inflammation
-Infection
-Mononeuritis Multiplex
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14
Q

Ophthalmoplegia

What are the features of a IV Nerve Palsy?
What are the causes of a IV Nerve Palsy?

A 
>Features:
-Affected eye higher than normal eye in primary gaze
-Adduced eye cannot look down
-Characteristic head tilt away from affected side
>Causes:
-Trauma
-Cavernous sinus lesion
-Mononeuritis Multiplex
-Brainstem lesion
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15
Q

Ophthalmoplegia

What are the structures in the cavernous sinus?
What are the causes of a cavernous sinus syndrome?

A

> Structures:
-Cranial nerves III, IV, VI, Va/Vb
-Sympathetic carotid plexus
-Intracavernous carotid artery
Causes:
-Tumour (meningioma, neurofibroma, nasopharyngeal)
-Trauma
-Thrombosis
-Infection & Inflammation (HZA, TB, Sarcoidosis, GPA)
-Aneurysm (Intracavernous carotid artery, PCOM artery)

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16
Q

What are the differential diagnoses for Myasthenia Gravis?

A
  • Botulism
  • Lambert Eaton Myasthenic Syndrome
  • Mitochondrial myopathy
  • Miller-Fisher Syndrome
  • Snake bites
  • Avoid Aminoglycosides, Phenytoin, Antimuscarinic agents
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17
Q

Where is the lesion in the following visual field defects:

bitemporal hemianopia, homonymous hemianopia, homonymous upper quadrantanopia, homonymous lower quadrantanopia?

A
  • Bitemporal hemianopia: Optic chiasm.DDx include pituitary tumour, craniopharyngioma, suprasellar meningioma.
  • Homonymous hemianopia: Optic tract or radiation.
  • Homonymous upper quadrantanopia: Temporal cortex.
  • Homonymous lower quadrantanopia: Parietal cortex.

DDx include cerebrovascular accident, intracranial tumour, trauma.

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18
Q

What are the differential diagnoses of wasting of small muscles of the hands?

A

> Anterior Horn Cells at C8-T1:
-Motor neurone disease, Syringomyelia, Cervical Cord tumour, Distal spinal muscular atrophy, HMSN, Friedrich’s ataxia, Old poliomyelitis, Polyneuropathy
Nerve Root at C8-T1:
-Pancoast tumour, Neurofibroma, Cervical myelopathy
Lower Brachial Plexus:
-Pancoast tumour, Cervical myelopathy
Muscle Disorders:
-Myotonic dystrophy, Distal muscular dystrophies
Trophic: Disuse, Complex pain syndrome

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19
Q

What are the clinical features of syringomyelia?

What are other causes of dissociated sensory loss?

A

> Clinical Features of Syringomyelia:
-Distal wasting & weakness, Prominent wasting of small muscles of the hands
-LMN signs in upper limbs, UMN signs in lower limbs
-Trophic & vasomotor changes (painless scars, ulcers, digital amputations)
-Sensory involvement in cape like distribution with dissociated sensory loss (affected pain/temperature, preserved vibration/proprioception)
Causes of Dissociated Sensory Loss:
-Syringomyelia, Anterior Spinal Artery Occlusion, Small Fibre Neuropathies

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20
Q

What are the features of ulnar nerve palsy?

A

> Features of Ulnar Nerve Palsy:

  • Wasting of 1st dorsal interossei & adductor digiti minimi-Weakness of finger adduction & abduction
  • Weakness of flexion of 4th/5th DIP joints (if proximal)
  • Claw hand if distal lesion
  • Froment’s Sign (affected thumb flexes on gripping piece of paper between lateral half of index finger)
  • Sensory loss in ulnar distribution
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21
Q

What are the features of radial nerve palsy?

A

> Features of Radial Nerve Palsy:

  • Wrist drop (weakness of wrist & finger extension)
  • Sensory loss over 1st dorsal interossei
  • Weak forearm supination & elbow extension & impaired triceps jerk with sensory loss over posterior forearm & triceps if proximal lesion
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22
Q

What are the features of median nerve palsy?

A

> Features of Median Nerve Palsy:

  • Wasting of abductor pollicis brevis
  • Weakness of thumb abduction
  • Weakness of flexion of 1st/2nd DIP joints if proximal
  • Numbness in median nerve distribution
  • Tinel’s, Phalen’s positive if carpal tunnel compression
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23
Q

What are the features of a relative afferent pupillary defect (RAPD)?

What are the causes of a RAPD?

A

> Features:
-Direct & Consensual reflexes intact. During swinging torch test affected pupil dilates.
Causes:
-Optic nerve disorders e.g. optic neuritis
-Retinal disorders e.g. central retinal vein occlusion, central retinal artery occlusion, severe ischaemic diabetic retinopathy, retinal detachment

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24
Q

What are the features of an Argyll-Robertson pupils?

What are the causes of an Argyll-Robertson pupils?

A

> Features:
-Mnemonic Like a Prostitute (accommodate but do not react), Occurs in Prostitutes
-Both pupils are small & irregular
-They react to accommodation but not to light
Causes:
-Neurosyphilis (most common)
-Diabetes
-Lyme disease, Wernicke’s encephalopathy
-Brainstem encephalitis
-Midbrain lesions e.g. tumour, infarct, haemorrhage, demyelination, syringobulbia, sarcoidosis

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25
What is the Holmes-Adie Syndrome?
- Idiopathic benign disorder in middle aged females - Adie tonic pupil (unilateral dilated pupil that reacts slowly to light & accommodation) with Absent deep tendon reflexes +/- Autonomic disturbances
26
Horner's Syndrome What are the causes of Horner's Syndrome?
>1st. Central: Anhidrosis of face, arm, upper trunk -Demyelination, Brainstem or Spinal cord tumour/haemorrhage/infarction, Syringomyelia, Arnold-Chiari malformation >2nd. Peripheral (preganglionic): Anhidrosis of face only -Pancoast tumour, Cervical rib, Central venous catheterization, Neck surgery >3rd. Peripheral (postganglionic): No anhidrosis -Internal carotid artery dissection, Carotico-cavernous fistula, Herpes Zoster*Common causes incl. Apical lung cancer, Neck cancer, Cartodi artery aneurysm, Syringomyelia, etc.
27
Horner's Syndrome What are the causes of bilateral ptosis?
- Myaesthenia - Myopathies e.g. myotonic dystrophy, chronic progressive external ophthalmoplegia, oculopharyngeal muscular dystrophy - Bilateral Horner's Syndrome e.g. syringomyelia - Tabes dorsalis
28
Cerebellopontine Angle Lesion What structures are affected? What are the causes of a cerebellopontine angle lesion?
``` >Structures Affected: -Multiple cranial neuropathies (CN V, VI, VII, VIII). >Causes: -Acoustic neuromas most common cause -Meningiomas second most common cause -Nasopharyngeal carcinoma -Medulloblastoma -Cholesteatoma -Haemangioblastoma -Granuloma -Basilar artery aneurysm -Metastases ```
29
Bulbar & Pseudobulbar Palsy What are the causes of Bulbar Palsy?
>Bulbar Palsy is caused by LMN disease: - Motor neurone disease - Brainstem e.g. vascular, tumour - Poliomyelitis - Guillain-Barre syndrome - Myasthenia gravis - Muscular dystrophies
30
Bulbar & Pseudobulbar Palsy What are the causes of Pseudobulbar Palsy?
>Pseudobulbar palsy is caused by UMN disease: - Bihemispheric vascular disease - Multiple sclerosis - Motor neurone disease - Brainstem eg. vascular, tumour - Trauma
31
Brainstem Syndrome What is the brainstem rule of fours?
>4 Cranial Nerves: APM -Above Pons I-IV, Pons V-VIII, Medulla IX-XII >4 Medial Structures: 4 M's -Medial lemniscus - contralateral loss vibration/proprioception -Motor pathway - Contralateral arm/leg weakness -MLF - Ipsilateral INO -Motor nucleus/nerve - Ipsilateral Cranial nerve loss >4 Lateral Structures: 4 S's -Spinothalamic - Contralateral loss pain/temperature -Spinocerebellar - Ipsilateral Ataxia -Sympathetic - Ipsilateral Horner's -Sensory Nucleus CN V - Ipsilateral facial loss pain/temp
32
Peroneal Nerve Lesion What are the clinical features?
- Motor: Weak dorsiflexion & eversion. Inversion is preserved. - Little or No Sensory loss, with anaesthesia over the lower lateral aspect of their legs and dorsa of the feet - Risk Factors include tight plaster casts, sports injuries, diabetes
33
Charcot-Marie-Tooth Disease What is the inheritance? What are the clinical features?
``` AD inheritance Clinical features: -Pes cavus (short high-arched feet, hammer toes) -Distal muscle atrophy -Thickened nerves -Absent reflexes -Slight or no sensory loss ```
34
Muscular Dystrophy What are the clinical features of Duchenne's & Becker's Muscular Dystrophy?
- Calf hypertrophy - Proximal muscle weakness - Preserved reflexes - Dilated cardiomyopathy - Ducenne's is more severe
35
Brown Sequard Syndrome What are the clinical features?
- Ipsilateral loss of vibration, proprioception | - Contralateral loss of pain, temperature
36
Friedrich's Ataxia What is the inheritance? What are the clinical features?
``` >Inheritance: -AR-Mutation is Frataxin on Chromosome 9 >Clinical Features: -Young patient -Bilateral cerebellar signs -Loss of dorsal columns (vibration, proprioception) -Absent ankle jerks -Pes cavus -Other features incl. cardiomyopathy, diabetes, kyphoscoliosis ```
37
Facial Muscle Weakness | What are the causes of bilateral facial weakness?
``` >UMN causes incl. Stroke, Tumour, Demyelination >LMN known as Bell's Palsy >Bilateral Facial Weakness: -Guillain Barre Syndrome -Myopathy incl. myotonic dystrophy, fascio-scapulo-humeral dystrophy -Myasthenia Gravis -Sarcoidosis -Motor Neurone Disease ```
38
Parinaud's Syndrome Where is the lesion? What are the causes? What are the clinical features?
``` >Lesion: -Dorsal midbrain >Causes: -Central: MS, Pinealoma, Vascular -Peripheral: Diabetes, Trauma >Clinical Features: -Loss of upward gaze -Convergence retraction nystagmus -Pseudo Argyll Robertson Pupil ```
39
Foot DropWhat are the causes?
``` >Unilateral -Common peroneal nerve lesion -L5, S1 Radiculopathy -Sciatic nerve lesion -Peripheral neuropathy -Myopathy -Motor Neurone Disease >Bilateral: -Neuropathy e.g. diabetes, vasculitis -Bilateral radiculopathy -Cauda equina or conus medullaris lesion -Motor neurone disease -Spastic paraparesis ```
40
Subacute Combined Degeneration of the Spinal Cord What are the clinical features?
- Absent dorsal column (vibration, proprioception) - Absent ankle jerk with extensor plantar - Ataxic gait-Others: Optic atrophy, Dementia
41
Obturator Nerve Lesion What are the clinical features? What are the risk factors?
``` >Clinical Features: -Weak hip/thigh adduction -Sensory changes medial aspect of thigh >Risk factors: -Labour -Pelvic malignancy ```
42
Lateral cutaneous nerve of thigh lesion What is the name? What are the clinical features? What are the risk factors?
``` >Name: -Meralgia paraesthetica >Clinical Features: -Paraesthetsia anterolateral aspect of thigh>Risk Factors: -Pregnancy -Obesity -Rapid weight loss ```
43
Femoral Nerve Lesion What are the clinical features? What are the risk factors?
>Clinical Features - Weak thigh flexion - Absent knee reflex - Sensory loss anteromedial thigh - Wasting of quadriceps>Risk Factors: - Diabetes - Retroperitoneal haematoma - Pelvic malignancy - Femoral hernia - Femoral aneurysm
44
Cervical Rib Syndrome | What are the clinical features?
>Clinical Features: - Wasting & weakness of small muscles of the hand - Sensory loss on medial hand & forearm - Unequal radial pulses & blood pressure - Subclavian bruit - Palpable cervical rib
45
Myopathy | What are the differential diagnoses for myopathy?
``` >Mnemonic: PACE PODS for Acquired -Hereditary -Acquired includes: Polymyositis, Dermatomyositis Alcohol Carcinoma Endocrine (hypothyroidism, hyperthyroidism, Cushing's syndrome, hypopituitarism) Periodic paralysis Osteomalacia Drugs e.g. steroids Sarcoidosis ```
46
Charcot-Marie-Tooth Disease | What are the differential diagnoses?
``` >Hereditary: -Hereditary neuropathy with liability to pressure palsy -Hereditary neuralgic amyoptrophy -Friedrich's ataxia -Spinal muscular atrophy >Acquired: -CIDP -Peripheral neuropathy e.g. alcohol, diabetes, vasculitis, amyloid, heavy metal poisoning ```
47
Klumpke Lower Brachial Plexus Lesion Where is the lesion? What are the clinical features?
>Lesion: - C8/T1 lesion>Clinical Features: - Claw hand - Paralysis of intrinsic muscles of hand - Sensory loss on ulnar side of arm/forearm - Horner's syndrome
48
Erb-Duchenne Upper Brachial Plexus Lesion Where is the lesion? What are the clinical features?
>Lesion: - C5/6 lesion>Clinical Features: - Loss of shoulder movement & elbow flexion (waiter's tip position) - Sensory loss over lateral aspect of arm/forearm
49
Motor Neurone Disease What are the clinical features? What does EMG demonstrate? What is the management?
>Clinical Features: - Bulbar or Pseudobulbar palsy - Mixed LMN & UMN signs with spasticity, extensor plantars, fasciculations, atrophy - Dementia, Dysphagia, Dysarthria>EMG: - Diffuse denervation with fibrillation>Management: - PT/OT/SP/Dietitian - PEG feeding if Dysphagia - NIV if respiratory failure - Riluzole - Antidepressants
50
Cranial Nerve III (Oculomotor nerve palsy) What are the clinical features? What are the causes?
>Clinical Features: -Divergent strabismus -Ptosis -Fixed dilated pupil not reactive to light or accommodation >Causes: - Central: Vascular, Tumour, Demyelination, Trauma - Peripheral: PCOM aneurysm, Nasopharyngeal carcinoma, Meningitis, ORbital lesion (Tolosa Hunt syndrome)
51
Parkinson's Disease What are the clinical features?
- Gait festinating, freezing, short arm swing - Postural instability - Asymmetric resting tremor - Bradykinesa, MIcrographia - Rigidity - Masked facies - Hypometric saccades - Neuropsychiatric: Dementia
52
Parkinson's Disease What are the investigations?
- CT Brain to exclude normal pressure hydrocephalus - MRI Brain - PET/SPECT - Wilson's Disease: 24-hour urine copper, Caeruloplasmin
53
Parkinson's Disease What is the management?
- Dopamine plus peripheral dopamine decarboxylase inhibitor e.g. levodopa/carbidopa, levodopa benserazide - Monoamine oxidase inhibitor e.g. rasagiline - Dopamine agonist e.g. pramipexole, apomorphine - NMDA antagonists e.g. amantadine - COMT inhibitor e.g. entecapone - Deep Brain Stimulation*Avoid Metoclopramide
54
Multiple Sclerosis | What is the management?
``` >Acute Relapses: -Pulsed methylprednisolone -Plasma exchange >Disease Modifying Drugs: -Interferon beta-1a or beta-1b -Glatiramer acetate -Teriflunomide-Dimethyl fumarate -Fingolimod (sphingosine-1-receptor modulator) -Natalizumab (MAb to alpha-4-integrin) -Alemtuzumab (MAb to CD52) ```
55
Multiple Sclerosis What are the clinical features? What are the investigations?
``` Clinical Features: -Optic neuritis, INO -Bladder/Bowel incontinence/retention -Uhthoff phenomenon -Dysphagia, Dysarthria -Fatigue, Depression, Cognitive impairment >Investigations: -MRI Brain/Spinal Cord Gadolinium (periventricular, juxtacortical, Infratentorial, spinal cord lesions) -CSF (elevated IgG oligoclonal bands) -Visual & Auditory evoked potentials -Anti-Aquaporin 4 antibody ```
56
Movement Disorders What are the causes of chorea? What are the causes of Tic?
``` >Chorea: -Huntington's disease -Sydenhams' chorea -SLE -Polycythaemia >Tic: -Tourette's syndrome ```
57
Hereditary Spastic Paraparesis What are the clinical features? What are the differential diagnoses?
``` >Clinical Features: -Increased tone, Clonus -Increased reflexes, Crossed adductors -Weakness, Mild wasting -Scissor gait -Extensor plantar response >Differential Diagnoses: -Cord compression, tumour, abscess, ischaemia etc -Demyelination -Motor Neurone Disease -Friedrich's ataxia -Syringomyelia ```
58
Spinocerebellar Ataxia | What are the clinical features?
- Cerebellar ataxia - UMN signs - Sensory neuropathy - Sometimes LMN signs - Cognitive impairment
59
Multiple Cranial Nerve Palsies? | What are the causes?
``` >Central: -Vascular -Tumour -Demyelination -Motor Neuron Disease -Syringomyelia/Syringobulbia >Peripheral: -Nasopharyngeal carcinoma -Cerebellopontine angle lesion e.g. acoustic neuroma -Chronic meningitis -Guillain Barre Syndrome -Trauma e.g. basal skull fracture ```
60
Inclusion Body Myositis What are the clinical features? What are the investigations?
``` >Clinical Features: -Elderly male -Proximal muscle weakness -Neck flexor weakness -Quadriceps & Forearm atrophy >Investigations: -CK, Anti-CN1a -Muscle biopsy - CD8+ T-cells, Congophilic amyloid deposits, Ragged red fibres*Does not respond to immunosuppressionS ```
61
Sciatic Nerve LesionWhat are the clinical features?What are the risk factors?
Clinical Features: -Weak knee flexion and muscles below knee, Foot drop -Sensory loss on sole & dorsum of foot, posterior & lateral leg >Risk Factors: -Trauma -Pelvic fracture -Pelvic malignancy

Hark and Paul's clinical review (12 decks)

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