Neuro-peds exam 2

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  1. children are
    top heavy
  2. kids cranial bones
    thin, not developed
  3. kids brain are highly
    vascular with small subarachnoid space
  4. neonates have
    immature mylineation
  5. kids have excessive
    spinal mobility
  6. kids have what kind of vertebrae
    wedge-shaped cartilaginous 

  7. ICP means
    total pressured exerted by brain, blood, CSF w/in cranial fault
  8. ICP %
    • brain: 80%
    • CSF: 10%
    • blood: 10%
  9. which only two compartments in ICP can compensate
    • blood
    • CSF
  10. what causes increased CBF

    increase pCO2 will cause vasodilation and increase ICP
  11. what causes CBF
    acidosis / hypoxemia = vasodilation and increased ICP
  12. what causes CBF
    seizures and fever=increased CBF and increased metabolic rate
  13. causes of increased ICP
    • traumatic brain injury: 
    • hematoma
    • cerebral edema
    • cerebral ischemia
    • IVH 
    • intracerebral hemorrhage
  14. causes of increased ICP
    • hydrocephalus
    • infections: inflammatory response, cerebral edema, hydrocephalus, cerebral hyperemia (IICP following ischemia)
    • brain tumor: mass effect, peritumoral edea, hydrocephalus
    • intracranial hemorrhage: mass effect, cerebral edema
    • intraventricular hemorrhage: hydrocephalus
  15. history clues to etiology
    • family hx 
    • pregnancy hx: fetal distress, labor/delivery, apgar scores, maternal drug use, maternal diabetes
  16. MITTEN
    • M: metabolic (blood sugar abnormalities), electrolyte imbalances, inborn errors of metabolism 
    • I: infection, menigitis, congential viral infections
    • T: toxins, CO, lead, NAS
    • T: trauma; subdural hemotoma, shaken baby syndrome
    • E: endocrine; blood sugar abnormalitites
    • N: neur/neoplasm; malformations, intracranial hemorrhage, HIE
  17. NEURO assessment
    • "just doesn't act right"
    • eyes: crossed, droopy eyelids, unequal pupils, blurred or double vision
    • behavior: subtle initially, irritability, restlestness, lethargy 
    • motor function: movement? spontaneous?
    • skin: dry vs diaphoretic?
  18. Cushing's triad: Signs of Increased ICP
    • systolic: increases
    • diastolic: decreases 
    • pulse: decreases (brady) 
    • *wide pulse pressure 

    • maybe irregular breathing (Cheyvne-Stokes)
    • elevated temp (hyperpyrexia)
  19. neuro assessment in infant
    • irritability 
    • restlessness
    • full/bulging fontanels
    • poor feeding
    • poor sucking
    • vomiting (even projectile)
    • distention of superficial scalp veins
    • sunset sign
    • shrill/ high pitched cry
    • nuchal rigidity and seizures (LATE SIGNS)
    • sudden change in mood
    • HA, poor feeding
    • vomiting
    • difficulty waking
    • weakness on one side
    • nuchal rigidty
    • deterioation of cogn. ability
    • changes in vitals (Cushing's)
    • seizures
    • photophobia
    • positive Kernig's and Brudzinski's sign (infection)
    • opisthotonus (spasms causing backward arching of head, neck, spine)
  22. decerbrate posture
    • damange to upper brain stem 
    • arms abducted and extended, wrists pronated and fingers flexed 
    • legs are stiffly extended, plantar flexion of feet
  23. decorticate posture* worse
    • damage to one or both corticospinal tracts adducted and flexed, wrists and fingers on CHEST
    • legs are stiffly extended and internally rotated with plantar flexion of feet
  24. lab tests
    • CBC: increase in WBC(infection) and decrease H&H (bleeding)
    • metabolic panel: blood sugar-hypo or hyperglycemia (DKA), sodium, calcium
    • toxiocology screen (urine drug screen)
    • UA
    • blood gas: O2 and acid-base status
    • blood culture
    • CSF analysis and culture
    • infants: ammonia, metabolic screen
  25. lumbar puncture
    • cell count: over 40 WBCs
    • grain stain: presence of organism
  27. EEG Testing
    • may withhold sleep
    • no caffeine several hours prior
    • adminster sedatives as ordered
    • help attach electrodes to head
    • monitor
  28. neurodiagnostic testing
    CT scan: study of choice in child with acute neuro impairment or deteroiation 

    MRI: assessment of brain tissue; precautions: metal, implants, o2 cycliners
  29. neuro monitoring
    • GCS <8! 
    • signs of increased ICP
    • post resusciation of acute traumatic IC hematoma or other procedure
    • others who have high chance of IICP
    • gold standard is intraventricular monitoring
  30. Increased ICP
    • A: rapid sequence intubation may be neccessary 
    • B: ventilation (normoventilation) or hyper for some
    • C: avoid hypotension
    • positioning: midline to facilitate JVdrainage (elevate for 15-30 degrees)
    • osmotic therapy: mannitol bolus every 4-6 hours, hypertonic saline infusion
  31. Increased ICP
    • maintain normal temp
    • prevent shivering, fever
    • sedation, anagelisc
    • seizure prevention, prophylaxis in kids <1 or those with TBI
    • no steriods
    • surgical intervetion: only for lesions producing mass effects
    • euvolemic, normoglycemic, avoid dextrose for 48 hours
  32. Seizures
    paradoxical electrical discharge of neurons in the brain that result in a change in function or behavior

    • 30k diagnoses / year
    • 10% of pop. will have 1 in lifetime
    • epilepsy: recurrence of seizures
  33. risk factors for seizures
    • genetic predisposition
    • acute febrile state
    • head trauma
    • cerebral edeam
    • abrupt cessation of AED meds
    • infections
    • metabolic disorders
    • exposure to toxins (leads)
    • hypoxia
    • acute drug and ETOH withdrawal
  34. triggering factors for seizures
    • increased physical activity
    • excess stress
    • overwhelming fatigue
    • acute EOTH ingestion
    • exposure of flashing lights
    • caffeine, coacine, aersols, glue products..
  35. subtle seizures in neonate/infant
    • more common in preterm
    • eye deviation
    • repetitive blinking, fluttering of eyelids, fixed stare (preemie)
    • repetitive mouth and tongue movements (drooling, sucking, tongue - thrusting, yawning)
    • apnea: 'if aint breathin, they a seiz'ing"
  36. tonic clonic in neonate/infant
    • single limb jerking
    • extension of arms/legs
    • decorticate like movements
    • myclonic jerks
    • abnormal movements: pedaling, swimming, rowing
  37. tonic clonic
    • eyes roll upward
    • LOC
    • tonic contractions
    • salivation
    • apnea->cyanosis
    • violent jerk
    • incontinence
    • gradual slowing til cessation
  38. post-ical phase
    • difficulty arousing
    • confused for several hours
    • impaired fine motor function
    • lack of coordination
    • possible vomit, HA
    • sleepy
    • no recollection of event
  39. absence seizures
    • 4-12 years common
    • brief periods of altered consciouness with sublte motor activity
    • appears to be day dreaming
    • lasts about 10 sec
    • no hisotry of motor involvemtn or resp. compromise
  40. myclonic
    • sudden, jerking or stiffening of extremities
    • may occur 100x a day
    • each episode lasts 1-2 sec
  41. atonic:
    • sudden loss of muscle tone and consciousness 
    • lasts a few seconds wihtout resp. signs 
  42. infantile spams
    • first 8 months of life 
    • sudden, brief, symmetric contraction 
    • head flexed with arms and legs extended
    • possible eye deviation
    • possible cry, giggle
    • possible flushing, pallor, cyanosis
  43. simple partial
    • aversive seizure
    • rolandic: tonic-clonic movements of face, most common during sleep
    • tinglining, numbness may spread
  44. complex partial
    • altered behavior 
    • unable to respond to environment
    • impaired consciousness
    • confusion, amneisa
    • aura*****
    • last 2-3 min to up to 10 min
  45. jitterness
    • responsive 
    • resolves with touch-passive flexion of extrememity
    • NO autonomic changes
    • gaze normal
    • predominant motion: tremors
  46. seizure
    • not responsive to stimuli
    • abnormal gaze
    • autonomic changes occur
    • predominant motion: clonic jerking
  47. tests for seizures
    • EEG
    • ct 
    • mri
    • lumbar punct
    • metabolic panel
    • tox screen
    • consider metabolic screenin for inborn errors of metabolism
  48. EEG interventions
    • adminster sedatives as ordered
    • assist w. position
    • no caffeine for several hours prior
    • wash hair before/after
    • may need to take deep breaths 
    • withhold sleep if instructed
    • not painful!!
  49. Seizure treatment
    • AEDs: phenobarbital, valium, phenytonin, carbamazepine, depakote, cerbyx, levitracin
    • monitor levels
    • be aware of food/med interaction
  50. vagal nerve stimulator
    implanted device used to abort or shorten seizures
  51. ketogenic diet
    • high-fat foods
    • limited CHO
    • useless in kids whose seizures cant be controlled by meds, start diet in hospital and supervise by a doctor
  52. brain surgery
    • kids with persistent seizures unresponsive to meds
    • remove part of brain responsible for seizures (corpus callosotomy, focal resection)
  53. cannabidiol
    major nonphyschoactive ingredient in weed

    • used for unrelenting seizures
    • mechanism is unkwonw
    • studies underway
  54. status epilepticus
    greater than 10 min long or cluster of seizures where child does not awake between seizures

    • if prescribed: give Diazepam gel (DIASTAT) into rectum
  55. documenting seizure
    • time begins and ends
    • precipating event
    • body parts involved
    • description of motor involvement
    • description of eye movement
    • resp. status, color, desaturation
    • behavioral state (LOC)
    • postical state
    • all nursing interventions and childs response
    • know warning signs
    • use padded side rails and keep up
    • move child away from furniture
    • bed in lowest position
    • safety helmet for repetitive seizures
    • use TM themometer
    • remove glasses
    • do not restrain!
    • reorient, obtain v/s after 
    • adminster meds as ordered
  57. seizure nursing dx
    • ineffective airway clearance
    • avoid gum, small candy
    • supine with head turned to side
    • loosen restrictive clothes
    • no padded tongue blades
    • sunction prn
    • provide O2 ,,PPV if indicated
    • emergency equipment ready
  58. after seizure
    • maintain sidelying
    • check vitals
    • assess injuries
    • perform neuro check
    • allow rest
    • orient
    • encourage child to describe before/after and if aura?
    • no foods/liquids until fully awake and can swalow
    • try to determien trigger
    • complete documentation
  59. low self-esteem nursing dx for seizure
    • explore feelings about self and disorder
    • ecournage expression 
    • use play therapy
    • treat child as nomrla and not vulnerable
    • refer to suppor group
    • routine eval for sucidie risk
  60. knowledge deficient for seizure
    • discss triggers
    • promote good dental care
    • what to do
  61. seizure education
    • avoid biking, skating, skateboarding on streets with heavy traffic
    • avoid activities at height
    • supervise around water
    • tell teachers
    • ID bracelet
    • driving restrictions by state
    • counsel on effects of seziures and AEDS on sex
    • avoid recreational drugs and EOTH
  62. neural tube defect
    • most common birth defect in CNS
    • results: neural tube failure to close during embyronic development in 1st 3-5 weeks of gestation 
    • latin term: "spilt" or "open" spine
    • elevated alpha-feto-protein in mother may indicate fetus with NTD 
    • most common in girls
  63. risks for spina bifida
    • insufficent folic acid intake during pregnancy
    • maternal malnutrition
    • medications
    • exposure to radiation/chemicals
    • prepregnancy conditions; diabets, obseity, hyperthermia, low b12 
    • genetic predisposiiton
  64. incidence of spina bifda
    • 0.7 per 1000 in Us
    • 4.45 per 1000 in TN

    *significant decrease since folic acid supplement was made mandatory
  65. spina bifida occulta
    • veretebral body fails to close
    • spinal cord is intact
    • no meninges are exposed
    • no neuro deficient seen
  66. menigocele
    • protustion involves sac-like cysts that contains CSF in the midline of the back 
    • spinal cord not involved
    • neuro deficient usually not present
  67. myelomeningocele
    • protrustion involves meninges, CSF, nerve roots, and spinal cord
    • neuro deficients evident*
  68. s/s of spina bifida
    • visible spinal defect-inspect to see if intact
    • flaccid paralysis of legs
    • hip/joint deformtities
    • altered bowel and bladder function
  69. preop care of spina bifida
    • prepare parents for surgery within 24-48 hours
    • position prone with hips flexed and legs abducted
    • cover defect with a moist, nonadhearing dressing using NS, change q 2 hours
    • maintain infant in open warmer
    • inspect sac closely for leaking, irritation
  70. postop care of spina bifida
    • monitor vitals
    • assess for infection
    • provide pain relief
    • incisional care as prescribed
    • assess for CSF leak
    • maintain PRONE until okayed by neurosurgeon
    • begin ROM to lower extremities 
    • monitor HC daily
  71. d/c care of spina bifida
    • teach ROM, incisional care
    • allergies
    • teach signs of ICP
    • asses bowel/bladder function
  72. nuring dx for spina bifida
    • risk for infection:
    • monitor temp
    • ATB
    • change dressing
    • prevent soiling of wound from urine and feces 
    • meticulous aspetic technique 
    • monitor for UTIs
  73. at risk for injury SB*
    • avoid rectal temp
    • keep pressure off site
    • coordinate OT/PT
    • monitor HC in infants
    • evaluate nutritional status
    • keep pressure of bony prominences
    • reposition q 1-2 hours
    • observe skin under splints and braces
    • ROM to legs
    • position in proper alignment
  74. bowel/urniary incontinence nrusing dx for spina bif
    • intermittent self-cath
    • note color and blah blah crap
    • monitor for UTIs
    • no rectal temps
    • adminster laxative or enmeas as needed
    • antispasmodics as prescribed
  75. at risk for latex allergy -sb nursing dx
    • nonlatex gloves, caths, equipment
    • provide parents iwth list of household items
    • s/s of latex allergy
    • provide info on epi-pen
  76. mobility: impaired physical d/tneuro muscular impairment ---nursing dx for sb
    • assess mobilit skills
    • assist devices
    • passive ROM TID
  77. surgical recovery:delayed --nursing dx for sb
    • measure Hc and abd girht
    • signs of IICP
    • Monitor for skin breakdown
    • reposition
    • monitor for bleeding
  78. school aged children with sp
    • IEP
    •  legal 
    • created by parents
  79. teens with spina bif -independnece
    • foster it
    • encourage act. with friends
    • talk to professionals about sexuality
    • contraception, folic acid intake
    • safety important
  80. hydrocephalaus
    a syndrome, sign, resluting from distrubances in the dynamics of CSF which may be caused by several diseases
  81. hydrocephalus incidence
    • 3-4 q 1000 births
    • congenital or acquired
    • congential: due to maldevelopment of intraurterine infection
    • acquired: due to infection, neoplasms (rare), or hemorrhage (common)
  82. patho of hydrocephalus
    • CSF is formed by 2 mechanisms:
    • secretion by choroid plexus
    • lymphatic-like drainage by the ECF in brain 

    CSF circulates thru ventricular system and is absorbed within subarachnoid spaces by unknown mechanisms
  83. mechanisms of fluid imbalance
    • hydrocelphalus results from:
    • impaired absorption of CSF within the subarachnoid space (communicating hydrocephalus) or 
    • obstruction to the flow of CSF: through the ventricular system (noncommunicating)

    • both lead to increase accumulation of CSF in ventricles
    • ventricles become dilated and compress brain---> cranial sutures are closed, skull enlarges
  84. non communication (obstructive) hydrocephalus
    result from development malformations 

    other: neoplasms, intrauterine infections, trauma
  85. Arnold Chiari Malformation
    type 2 malformation of brain seen most exclusively with myelomeningocele, is charactered by herniation of a small cerebellum, medualla, pons, and 4th ventricle into cervical spinal canal through enlarged foramen magnum
  86. manifesations of hydrocephlaus
    depends on acutiy of onsent and presence of preexisitng structural lesions
  87. signs of hydrocephalus
    • head grows at alarming rate!
    • 1st signs: bulging of fontanels without head enlargement
    • tense, bulging, non-pulsatile ant. fontanel
    • thin skull bones with separated sutures (cracked pot head sounds on percussion)
    • increasing HC: more than 0.5 cm/day
    • setting sun eyes, may signify brain damage
    • vomiting, lethary, irritability
  88. best way to detect hydrocephalus in neonate
    • ultrasound
    • easy, quick, not painful
  89. preterm infants 30 weeks or less (some say 32 weeks)
    should have ultrasound at 7 days or age (sooner if suspect significant IVH)

    see dilated ventricles on ultrasound
  90. goals of hydrocephalus
    • releive it
    • treat complications
    • manage problem resutling from effects of disorder on psychomotor development
    • usually surgical!
  91. lumbar puncture- hydrocephalus
    • for infants with hydro from IVH: lp done to relieve pressure
    • espeically if infant to small for surgery
    • Allow CSF to drain freely (amount depends on MD)
  92. lumbar puncture-hydro
    • key is successful positioning!
    • sitting up or lying on side
  93. care during lumbar puncture
    • monitor CP status
    • hold infant still in proper position
    • chin to chest
    • bend in C shape
    • send CSf to lab for cell count, glucose, protein, culture, gram stain
  94. surgical treatment for hydro
    • therapy of choice!
    • direct removal of source of obstruciton (neoplasm, cyst, and hematoma)
    • most require shunt procedure to drain CSF from ventricles to extracranial area; usually peritoneum (VP shunt), or right atrium (VA shunt) for absorption
  95. VP shunt
    • neonates and young infants
    • greater allowance for excess tubing: which minimizes number of revisions needed as child grows
  96. VA shunt
    • older children who have attained most of smoatic growth or children with abnromal patho
    • contraindicated in children with cardiopulmnoary diseaes or with elevated CSF protein
  97. major complications of shunt
    • infection!****
    • greatest risk period: 1-2 months following placement 
    • staph and strep most common organisms
  98. complications of shunt
    • mechanical difficulities; kinking, plugging, migration of tubing
    • malfunction is most often by mechanical obstructin!
    • look for signs of increased ICP, fever, lethargy, vomiting
  99. post op care for shunt
    • place on un-operated side to prevent pressure on shunt valve
    • keep HOB flat: rapid decrease in IC fluid cause subdrual hemotoma due to small vien rupture in cerebral cortex
  100. VP shunt requires
    incision on the head, behind ear, and on the abd
  101. post op care for shunt
    • may indicate obstruction of shunt
    • assess pupil size; as pressure on oculomotr nerve may cause dilation on same side as pressure
    • blood pressure may be variable due to hypoxia to brainstem
    • abd distention: due to CSf peritonitis or post-op ileus due to cath placement
  102. postop for shunt
    • monitor for I/O: may be on fluid restriction or NPO for 24 hours to prevent fluid overload 
    • monitor VS : increased temp may indicate infection
    • give good skin care to prevent tissue damage
  103. family support
    • fear
    • support: provide info
    • prepare for discharge: teach signs of ICP and when to call the doctor
    • teach positioning, wound care
    • have PT/OT teach parents
  104. hypoxic-ischemic encephalopathy
    dx based on clicnal and lab evidence of brain injury due to lack of O2 and reduced blood flow to brain
  105. hypoxia
    partial or complete lack of O2 in the brain or blood stream
  106. asphyia
    state in which the placental or pulmonary gas exchange is compromised or cases
  107. birth asphyxia
    occurs during 1st and 2nd stages of labor when fetus is otherwise nml
  108. perinatal asphyxia
    occurs anytime during the perinatal period from conception through 1st month of life
  109. HIE
    abnormal neuro behavior in neonates from hypoxic-ischemic event
  110. HIE incidence
    • 2-8 gases per 1k live births
    • 23% of all neonatal deaths worldwide
    • severe cases: mortality rate: 25-50%
  111. causes of HIE
    • antepartum risk factors
    • labor/delivery
    • postnatal events
  112. definition of HIE
    profound metabolic or mixed acidosis (ph less than 7)

    perisistance of an Apgar score of 3 or less for longer than 5 min 

    neontal neuro sequalae, such as seizures or hypotonia

    multiple organ involvement
  113. neonatal brain
    • immature: lower metabolic rate
    • immature balance of neurotransmitters
    • plasticity of immature CNS
    • glucose: only substrate used for energy metabolism
  114. cooling the brain and or total body
    • reduces cerebra metabolism, decreases rate of energy ultiziation
    • decreases neurotrans release
    • supresses free radical activity
    • reduces vascular permeability and edema
    • reduces secondary neurnoal death
    • decreases degree of global brain damage
  115. indications for cooling
    • infants born at 36 weeks or greater
    • within 6 hours of insult
    • evidence of acute injury around the time of birth
    • specific criteria for cooling events
  116. prognosis of HIE
    good signs: 7 days old, EEg with normal background activity, absence of seizures, adequate head growth, able to take oral feedings

    poor signs: lack of spontaneous resp. effort 30 min after birth, seizures, persistent feeding difficulty, poor head growth
  117. states on HIE
    • 10%: generally healhty
    • 10%: minor disabilites
    • 30-50 may develop mod-severe disability
    • 30 may have disabling CP
    • 16% epilepsy
    • 14-70 blindness
    • 6 hearing impair
    • others: ADD, ADHD, intellect challenges
  118. neonatal abstinence syndrome
    • infant born to a drug affected mother-withdrawal
    • withdrawal:set of symptoms as the body attempts to remove an addictive substance
    • accurately assessed*
    • therapetuic measures and often medication
  119. common symptoms of NAS baby
    • depends on drug
    • how each individual baby metabolizes the drug
    • baby's own tolerance

    *no two babies will react the same. responsibility of caregiver to monitor and read the infant and signs
  120. hypersensitivty to stimuli-NAS baby
    • common trait
    • little tolerance
    • swallowing, closenes, sound, can escalate baby into frantic state

    babies need protection from overstimulation but should NOT be stimulus-deprieved
  121. NAS baby muscle tone
    • muscle tone is degress of stiffness
    • unusually limp of stiff
    • particularly in limbs and neck 
    • stiffness may come and go
    • tremors, jerking, other signs of distress-sign of baby tryin to control uncomfortable sensations
  122. GI problem-NAS baby
    • drugs attack gastric system-at 12 mon
    • watery stool, explosive diarrhea, excoiatred butttocks, gas, constipation 
    • need proper handling to prevent serious health concerns
    • distress and high stimulation can increase
    • diarrhea can irritate fragile lining of the intestines and also lead to dehydration
  123. other r/t complications of NAS baby
    • chronic ear infection
    • unexplained fecer(opioates and opioids)
    • sleep/week irregualr
    • extreme appetitie (barbitures, cocaine)
    • hyperrefleia, moro
  124. critical for management of NAS baby
    • comforting techniques ! 
    • basica principeles of handling apply to all
  125. 8 principels of NAS baby
    • swaddling: contains extremties
    • C position: allows infant to relax
    • vertical rock
    • clapping: stop if infant does not respond 
    • feeding: get infant relaxes, minimize stimulation 
    • controlling environment: next
  126. prinicple 7 - control environment
    • limit number of caregivers
    • offer calm surroujndings
    • minimize loud noise--low volume
    • keep lights low
    • caregiver should have calm presence
    • rountine beneficial *
  127. Neonatal abstience scoring
    • determines level of therapetuic intervetion necessary
    • helps to determine effectivness of intervnetions being used
    • assess sjmptoms
    • oringiallydevelped by Loretta Finnegan
  128. NAS scoring tool
    • set of observed signs and sympotms in the infant
    • obsereved at regular intervals=every 3 hours
    • should refelct all symptoms obsereved sing the last scoring
    • high scores are nOT lowered by therapuetic handling should assessed for medical intervention
  129. medication for NAS baby
    • begun depneding on Finnegan scores
    • once stable, medicated is tapered, based on Fs
    • med of choice: morphine sulfate
    • 2nd line: clonidine
    • 3rd line: phenobarbital (use contravseral )
  130. SB1391
    • ENacted 4/29/14
    • expires 7/1/16
    • prosecuted for illegal use of narcotic if infant is harmed
    • aggravated assault (up to 15 years)
    • homicide if infant dies!
    • new to redue NAs babies
    • inform, resoureces, newroom, hint for families and firneds 
    • explore website
  132. menigititis
    • viral: wide variety of viral agents or enterovirus
    • bacterial: haemophilus influenzae (type B), streptococcus pneumonia, neisseria minigities (meningococcal)
  133. priority nursing dx for menigities
    • risk for ineffective breathing pattern
    • pain
    • risk for injury
    • risk for ineffective thermoregulation
  134. bacterial medication therapy for menigititis
    Iv ATB senstive to culture oragnism for 7-14 days (droplet precautions for 24 hours)

    • viral: tylenol for symptomoatic treatment 
    • preventive carE: HiB vaccine to prevent from hemo in B infection
Card Set:
Neuro-peds exam 2
2015-03-23 21:05:46

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