Brainscape's Knowledge GenomeTM

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


See full index

UCPEX > Paeds > Flashcards

Paeds Flashcards

1
Q

Difference in presentation between vasovagal syncope and anaphylaxis with collapse

A

Vasovagal - pale, bradycardic
Anaphylaxis - flushed, tachycardia

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

Presentation for simple febrile seizure

A

6-60 month child, previously well

generalised tonic-clonic, no focal component
<15 mins
No more than once in 24 hours
No prev neuro problems

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

Admission criteria for febrile seizure

A

> 15 mins
Recurrence within 24 hours
Focal component
Needing medication to terminate

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

Treatment for status epilepticus (>5 mins)

A

Position semi-prone
O2 via face mask

Diazepam
0.25mg/kg PO or IV
0.7mg/kg PR
Max 10mg

Midazolam
0.5mg/kg, buccal
Max 10mg

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

Types of seizures

A

Partial:
From focal lesion, often temporal lobe

Simple partial (unimpaired consciousness)
- motor, somatosensory, autonomic, psychic signs

Complex partial (impaired consciousness, amnesia)
- +/- automatism

Complex partial proceeding to generalised

Generalised:
Absence - lapse of consciousness
Myoclonic - sharp jerking
Clonic - rhythmic shaking
Tonic - increased rigidity
Tonic-clonic - rigidity + rhythmic shaking
Atonic - drop attack

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

Appropriate parent given emergency medication doses for child with prev hx non-febrile seizure

A

Diazepam 0.3-0.5mg/kg PR
Midazolam 0.2-0.3mg/kg buccal
Repeat only under medical supervision

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

HR range in children

A

<1 - 110-160
1-2 - 100-150
2-5 - 95-140
5-12 - 80-120
12+ - 60-100

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

Sinus tachycardia vs SVT

A

Sinus tachycardia: <220bpm, normal wave form, child unwell/in pain

SVT: >220, abnormal P wave axis, child looks well

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

Management of SVT in children

A

Vagal manoeuvres:

Infants - cold water immersion
Child - ice cold face cloth
5+ - blowing on thumb with straining, handstand, trendelenburg, legs up

Adenosine:
100mcg/kg
200mcg/kg
300mcg/kg

Amiodarone - usually used in post-op setting

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

Causative organisms for meningitis in neonates and children

A

Neonates: Group B Strep, Enterococci, E. coli, Listeria

Children: Strep pneumoniae, N meningitidis, H influenza type B

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

Antibiotics for suspected meningicoccal disease in children

A

Ceftriaxone 100mg/kg (max 2g) IV/IM

Benzyl penicillin 50mg/kg (max 2g) IV/IM

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

Risks for asthma in children

A

Atopy
Passive smoker
Crowded home, damp, mouldy
Family hx asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

When to consider prednisolone in child with asthma

A

Moderate to severe asthma
Age >5

Or age 1-5 if
- severe attack
- Hx prev severe attacks
- Likely prolonged hospital stay (>6 hours)

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

Management of asthma in children

A

Mild:
6 puffs salbutamol via spacer
Discharge when can space to 2hours

Moderate:
Above plus:
May need full blast
Prednisolone 1mg/kg if >5 or meeting criteria
Discharge when can space to 2 hours and no O2 requirement

Severe:
Above plus:
Salbutamol 2.5-5mg nebs
Ipratropium 4 puffs or 250mcg nebs

Life threatening:
Urgent transfer
Nebs - continuous
High flow O2
IV lines
Hydrocortisone 4mg/kg IV

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

Symptoms of hypovolaemic shock in children

A

Early:
Pallor, cool peripheries, drowsiness/disinterest, tachycardia disproportionate to fever/distress, reduced urine output
Cap refill not reliable

Late:
Low BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of shock in children

A

IV access - aim 24G + or intraosseous
IVF - 20mg/kg bolus
Consider trauma - C spine immobilisation, exsanguination - FFP and blood

Hypotension refractory to volume replacement - dopamine 5mcg/kg/min increase to 10-15
Consider spinal shock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Age group for unintentional poisoning

A

12-36 months

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

Medications where 1-2 tabs can be lethal to <10kg toddler

A

CCBs
Amphetamines
Dextropropoxyphene
Chloroquine
TCAs
Opioids
Sulphonylureas
Theophylline

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

Non pharmaceuticals which can results in severe toxicity if ingested

A

Organophosphates
Paraquat
Camphor
Naphthalene
Hydrocarbons, solvents, eucalyptus oil, kerosene

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

Medications that cause sodium channel blockade

A

TCA
propanolol
Quinidine, flecainide, first gen antihistamines
Cocaine
Bupivicaine
Dextropropoxyphene
Carbamazepine

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

Management of poisoning

A

Airway - intubate if airway corrosion, GCS <8, prolonged seizure

Breathing - O2, ventilations as required

Circ - IV fluid bolus 20mg/kg, inotropes
Avoid B blockers in sympathomimetic OD
NaHCO3 if sodium channel blockade

Disability
Seizures - Midazolam 0.15mg/kg IV, repeat
Phenobarbitone 20mg/kg IV (2nd line)
Do not use phenytoin (prolongs Na channel blockade)
Naloxone if suspect opioid OD - 0.1-0.8mg/kg
If suspect benzo OD - observe. Flumazenil dangerous in mixed OD

Correct hypoglycaemia
- dextrose 10% 5mL/kg bolus + 4mL/kg/hour infusion
Maintain normothermia

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

Criteria for referral for fever in child

A

<28 days (adjusted age)
<3 months (adjusted age) discuss with paeds, bloods
>3 months: significant illness, sepsis, unknown source

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

NICE traffic light fever risk in children

A

Amber:
Age 3-6 months, temp >39
Fever >5 days
Reported pallor, decreased activity
Increased WOB, sats <95
Tachycardia
Mild dehydration
Signs of bone/joint pain

Red:
Age <3 months, temp >38
Pale, mottled, appears ill
Severe WOB, RR>60
Reduced skin turgor
Signs of meningitis
Seizures

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

Types of croup

A

Viral laryngotracheitis
- Parainfluenza, RSV, adenovirus, influenza
- Younger age group
- Coryzal illness

Recurrent/spasmodic croup
- older children
- Without URTI signs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

RR normal values for children

WHO criteria for tachypnoea

A

<1: 30-60
1-2: 24-40
2-5: 22-34
5-12: 18-30
12+: 12-16

WHO:
<2 months: >60
2-12months: >50
1-5 years: >40

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

Symptoms of epiglottis

A

Sniffing position
Drooling
Sudden onset fever, dysphagia

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

Symptoms of mild, moderate, severe croup

A

Mild
No iWOB, stridor with distress, no hypoxia

Moderate
Stridor at rest, mild WOB, no hypoxia

Severe
Severe WOB, tachycardia, pallor, restlessness, lethargy, cyanosis, reduced breath sounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Management of croup

A

Mild-moderate
Dexamethasone 0.16mg/kg, or prednisolone 1mg/kg 2 days
Reduce anxiety
Usually resolves in <48 hrs
Contagious for 4-6 days

Severe
Dexamethasone 0.6mg/kg
O2 high flow
Consider nebulised adrenaline
Refer to hospital

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

Causes of gastroenteritis

A

Viral >70% rotavirus, norovirus, enteric adenovirus

Bacteria 10-20%
Salmonella, Campylobacter, E coli, Shigella

Parasites <10% - giardia, cryptosporidium

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

Causes of bacillary dysentery

Abx management

A

Entero-invasive E coli - no abx

Enterohaemorrhagic E coli - abx contraindicated, risk of HUS

Salmonella - amoxicillin/cotrimoxazole 7/7

Campylobacter - erythromycin 5-7/7

Shigella - ceftriaxone
Yersinia - 3rd gen cef
C diff

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

Gastroenteritis notifiable diseases

A

Campylobacter
Cryptosporidium
Cholera
Giardia
Shigella
Salmonella
Yersinia

Suspected outbreak, person in high risk category
Chemical/bacterial/toxic food poisoning - botulism, toxic shellfish poisoning, verotoxin, shiga toxin E coli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Indication for NG rehydration

A

Refusing oral fluids
Failed oral rehydration
Intractable vomiting/profuse diarrhoea
Caregiver not coping with giving oral fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Indication for IV rehydration in children

A

Shock
Unsafe (decreased LOC, ileum, surgical abdo)
Hyperosmolality (Na >170, osmol >350)
Failed oral and NG
>4 years old, better tolerating IV than NG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Ondansetron dose in children

A

8-15kg 2mg
15-30kg 4mg
30kg + 8mg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Presentation and management of haemolytic uraemia syndrome

A

Enterohaemorrhagic E coli or Shiga toxin producing Shigella (outside NZ)

Severe anaemia, thrombocytopenia, AKI

  • Do not use antibiotics, antidiarrhoeals
  • Early aggressive rehydration
  • Paeds urgent referral
36
Q

Symptoms to suspect hypernatraemia/hyperosmolality in gastroenteritis

A

Moderately dehydrated
Symptoms disproprotionate to level of dehydration
- Irritability, lethargy, doughy skin, fever

37
Q

ORT amounts in child with gastroenteritis

A

Mild dehydration ~50ml/kg deficit
Shocked ~100mL/kg deficit

5mL/min or 25mL/5 mins
Or 25mL/kg/hour for 4 hours

Extra 10mL/kg for each loose stool

38
Q

Bronchiolitis age group

A

6-12 months
12-24 months less common

39
Q

Timeline of bronchiolitis infection

A

Cough, wheeze, WOB, nasal discharge, fever

Peaks day 2-3
Resolves by day 7
Cough for 3 weeks

40
Q

Risk factors for bronchiolitis

A

Premature <37 weeks
Young <10 weeks
Maori/Pacific
Low SES
Smoking
Crowded, damp housing
<2 months breastfeeding
Comorbidities - Down, congenital heart disease, chronic lung disease, CF, immunodeficiency, chronic neurological disease

41
Q

Mild, moderate, severe bronchiolitis

A

Mild
Normal behaviour, normal RR, no accessory muscles, sats >92, no apnoea, normal feeding

Moderate
Some irritability, mild increased RR, tracheal tug/nasal flare, sats 90-92, brief apnoea, some trouble with feeding

Severe
Lethargy, fatigue, severe raised RR, marked chest wall retraction, sats <90, frequent, prolonged apnoea, unable to feed

42
Q

Indications for chest xray in children

A

Ambiguous clinical findings
Unresponsive to abx therapy
<3 months age
Severely unwell

43
Q

Management of CAP in children

A

Amoxicillin 25mg/kg tds 7 days
or
Erythromycin 10mg/kg QID 7 days (>5 years)

44
Q

Signs of sexual abuse in child with UTI

A

Unusual/excessive genital itching
Bruising, swelling, bleeding, redness in genitals
Age inappropriate sexual play/knowledge/interest
Fear of certain people/places

45
Q

Indication for USS in child with UTI

A

<12 months with first febrile UTI
Severe illness
Recurrent febrile UTI
Atypical hx

Outpatient USS renal tracts within 6 weeks

46
Q

Indication for empiric treatment of UTI

A

Specific urinary symptoms
3 months - 3 years with non-specific symptoms (fever, lethargy, abdo pain)
>3 years, dipstick positive for nitrites
>3 years, dipstick with leuks, urinary symptoms

Do not treat asymptomatic bacteriuria in children/infants

47
Q

Types of UTI in children

A

Cystitis - lower UTI without fever
Pyelonephritis/febrile UTI - renal or lower UTI with fever

Atypical UTI - sepsis, bacteraemia, obstructive uropathy, fail to respond to abx in 48 hrs, renal impairment, non-E.coli organism

Recurrent UTI -
2+ episodes febrile UTI
1 febrile UTI + 1 cystitis
3x cystitis

48
Q

ABx for mild uncomplicated UTI in children

A

Cotrimoxazole 24mg/kg, BD 3/7
Cefalexin 25mg/kg BD 3/7
Augmentin 30mg/kg tds 3/7
Nitrofurantoin 1.5mg/kg QID 3/7 - nor for pyelo or renal impairment

Moderate - treat for 7 days
Severe - single dose IV gentamicin, then 6/7 oral

49
Q

Types of lice

A

Head lice - Pediculus humanus, captitis
Body lice - Pediculus humanus, corporus
Pubic lice - Phthirus pubis

50
Q

Management of lice

A

Environmental - hot wash, dryer or dry clean or seal in bag for 2/52, vacuum environment

Medication:
Head lice - dimethicone, 2 treatments, 7/7 apart
Wet combing every 4 days until no lice with 3 consecutive combings

Pubic lice - permethrin, 2 treatments, 7/7 apart

51
Q

Scabies presentation

A

Symmetrical lesions, sparing head and neck, burrows in peripheries

Crusted scabies in elderly, young, immunocompromised - can occur on neck + face

Intense itch, may last for weeks after completing treatment

52
Q

Management of scabies

A

Launder/air for 72 hours
Vacuum
Clean nails

Medical
- permethrin for pt and all close contacts. 2 treatments 7/7 apart
- PO ivermectin - failure of topical treatment, crusted scabies, outbreak
Repeat in 2/52

Topical steroids/antihistamines for itch

53
Q

Modified GCS for children

A

Eyes:
4 - open spontaneously
3 - open to shout/speech
2 - open to pain
1 - not opening

Voice:
5 - appropriate words, smiles, coos
4 - inappropriate words (<5), confused, consolable crying
3 - inappropriate words (>5), inconsolable, cries/screams (<5)
2 - incomprehensible, grunts, agitation
1 - none

Movement:
6 - follow commands, normal movement
5 - localises pain
4 - flexion withdrawal
3 - flexion - abnormal decorticate
2 - extension - decerebrate
1 - no movement

54
Q

Causes of chest pain in children

Signs of organic disease

A

Idiopathic - most common
MSK
Resp/asthma
GI/GORD
Psychogenic
Cardiac < 1%

Wakes from sleep, acute origin, fever

55
Q

Indications for investigation in children with chest pain

A

Sudden onset, exertional
Fever, cough, SOB
Foreign body, trauma, drooling
Unwell, abnormal vital signs, examination
Tall, thin, pectus excavatum/carinatum

Cardiac risk factors - systemic inflammatory disorder, malignancy, thrombophilia, myopathy
FHx sudden unexplained death, cardiomyopathy, severe familial hyperlipidaemia,

56
Q

Most common medical and surgical causes for abdominal pain in children

A

Medical - gastroenteritis (vomiting, then pain)
Surgical - appendicitis (pain then vomiting)

57
Q

Ddx child with abdo pain

A

Constipation (LLQ, suprapubic)
Obstruction - intussusception, incarcerated hernia, volvulus (colicky)
Mesenteric lymphadenitis
PID
Abdominal trauma

Don’t forget
Diabetes
HSP
pneumonia
Sickle cell crisis
Mediterranean fever
HUS
Drugs
Porphyria

58
Q

Presentation of appendicitis in <3

A

Late presentation, non classical symptoms
Pain, fever, vomiting, diarrhoea
Cough, rhinitis, grunting, pain on right hip movement

59
Q

Presentation of appendicitis age 3-6

A

24hr vague abdo pain
fever, vomiting, anorexia

60
Q

Paediatric Appendicitis Score

A

+2 each:
- RLQ tenderness to cough/percussion/hop
- Tenderness RIF

+1 each:
Anorexia
Fever
Nausea/vomiting
leukocytosis
Neutrophilia
Migration to RLQ

<4 low risk, 4-6 equivocal, >6 high risk

61
Q

Alvarado score for paediatric appendicitis

A

+2 each:
RLQ tenderness
Leukocytosis

+1 each:
Fever
Rebound tenderness
Migration to RLQ
Anorexia
Nausea, vomiting
Neutrophilia

<4 low risk, 4-6 equivocal, >6 high risk

62
Q

Most common cause of bowel obstruction in <3

A

Intussusception

63
Q

Risk factors for intussusception

A

Male
Intestinal malrotation
Prev intussusception
Sibling with intussusception
cystic fibrosis
Intestinal polyps
Recent viral illness

64
Q

Symptoms + signs of intussusception

A

Intermittent crying, pulling knees to chest
Blood in stool - currant jelly
Vomiting, fever, diarrhoea
Abdominal mass, sausage shape, usually in RUQ, enlarges during episodes of pain

65
Q

Status of inguinal hernia

A

Reducible - sac completely empties
Irreducible - cannot completely empty sac, due to adhesions, faeces, fibrosis of neck of sac
Obstructed - causing mechanical bowel obstruction, loop of bowel viable
Strangulated - blood supply impaired, imminent gangrene

66
Q

Cause of inguinal hernia

A

Patent processus vaginalis
Herniation of bowel, omentum, ovaries, peritoneal fluid (hydrocele)

67
Q

Risk factors for inguinal hernia

A

Males
Prematurity
Undescended testes
Family history hernias
Cystic fibrosis
Developmental hip dysplasias
Urethral abnormalities

68
Q

Indications for referral for inguinal hernias

A

Irreducible
Strangulated
Obstructed
Suspected ovary - do not attempt reduction
Signs of perforation, peritonism, sepsis

Reducible hernias - outpatient referral
Neonate <1 week
Infant 2-4 weeks
Child 1-3 months

69
Q

Rome III criteria for functional constipation

A

Under 4:
2 of following over at least 1 month

Over 4:
2 of following at least weekly over last 2 months, IBS excluded

  • <2 BM/week
  • > 1 faecal incontinence/week (toilet trained)
  • Excessive stool retention
  • Painful/hard BM
  • Large faecal mass in rectum
  • Large diameter stool obstructing toilet
70
Q

Red flags for organic causes of constipation in children

A

Onset <1 month
Delayed meconium passage
Failure to thrive
Abdo distension
Intermittent diarrhoea + explosive stools
Empty rectum
Tight anal sphincter
Pilonidal dimple with hair
Midline pigmentation of lower spine
Abnormal neuro exam
Occult blood in stool
Extraintestinal symptoms
Gushing of stools with rectal exam
No hx withholding/soiling
No response to conventional treatment

71
Q

Treatment of constipation

A

Increased fruit, vegetable, fluid intake
Regular toileting after meals

  1. Lactulose
  2. Molaxole - can be used for disimpaction + maintenance
  3. Glycerol supps for significant faecal impaction

Treat for duration of constipation, wean slowly

72
Q

Most common epiphyseal injury in children

A

Salter Harris II

73
Q

Most common site for Salter Harris III fracture

A

Proximal and distal tibial epiphyses

74
Q

Most common site for Salter Harris IV fracture

A

Lateral condyle humerus

75
Q

Complications of elbow fractures

A
  • Vascular - brachial artery, median nerve injury
  • Compartment syndrome - anterior compartment swelling, compression of median nerve, radial artery
  • Volkmann’s isachaemic contracture - flexor compartment > flexion + pronation
  • Malunion
  • Myositis ossificans
76
Q

Child with a limp - ddx

A

Fracture
Acute abdomen, psoas abscess
Discitis, vertebral OM
Malignancy
Haemarthrosis
Lyme disease
Acute rheumatic fever, gonococcal arthritis
Rheumatological
Meningitis
Septic arthritis

77
Q

Types of gait

A

Steppage - abnormal hip and knee flexion. Foot drop.
Trendelenburg - pelvis tilts towards unaffected side. DDH, weak hip abductors
Circumduction - knee hyperextended, abduction of hip. Leg length discrepancy, neurological joint stiffness.
Equinus - tip toed. Club foot, cerebral palsy, tight Achilles, calcaneal fracture, foreign body, leg length discrepancy.

78
Q

SUFE - mild, moderate, severe slip

A

Mild <33% or <30 degrees
Moderate 33-50% or 30-50 degrees
Severe >50% or >50 degrees

79
Q

Complications of SUFE

A

AVN
Early OA
Necrosis of articular cartilage
Gentle manipulation or traction can cause aseptic necrosis

80
Q

Non-pharmalogical ways to manage pain

A

Explanation
Relaxation
Distraction
Splinting

81
Q

Indication for EMLA

A

3-5mm tissue depth for 2 hours
Apply 90 mins prior to procedure
To intact skin under occlusive dressing
Venepuncture, cannula, LP, bladder aspiration

82
Q

Maximum dose EMLA

A

1 tube = 5g

3-11 months - 2g over 20cm2
1-5 years - 10g over 100cm2
6-11 years - 20g over 200cm2

Complications
Methaemoglobinaemia
Local oedema, vasoconstriction

83
Q

Symptoms of LA toxicity

A

Mild:
Perioral tingling, tongue numbness
Tinnitis, dizziness
Flushing
Anxiety/agitation

Severe:
Muscle twitch
Nystagmus
Hypertonia, seizure
Bradycardia, hypotension
Arrhythmia
LOC, coma

84
Q

Risk factors for NAI

A

Child - behavioural difficulties, chronic illness, disability, preterm, unwanted child, unplanned pregnancy

Parent - Low self esteem, poverty, poor impulse control, substance/ETOH, young parent, hx abuse, mental illness, poor knowledge of child development/unrealistic expectation, negative perception of normal child behaviour

Environment - isolation, poverty, unemployment, low education, single parent, non-biological male, family-partner violence

85
Q

Red flags in presentation for NAI

A

Delayed presentation - no reasonable explanation
No hx injury, uncorroborated, changes, vague
Injury inconsistent with development
Injury inconsistent with history
Repeated trauma
Young child <2 with head injury

86
Q

Injuries suspicious for NAI

A

Complex skull #, parental, linear fracture, subdural bleed, hypoxic-ischaemic brain injury, retinal haemorrhage

Bite marks, bruises of different ages, clustered/patterned bruises, bruises in shielded places (axilla, inner arm, thigh)

Burns - sharply demarcated, shielded areas (posterior body, LL buttock, perineum, back of hand), bilateral/symmetrical

Contusion, laceration, ruptured internal organs without major trauma

Rib fractures
Metaphyseal fractures (corner, bucket handle)
Unusual fracture site - lateral clavicle, hand, feet sternum, scapula, spine
Femoral fracture in child not yet walking
<3 years old with humeral shaft fracture

Ligature marks
Oral injuries
Genital/perineal trauma without straddle injury

UCPEX (13 decks)

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