ANP Certification Thyroid Diabetes Flash Cards.txt

  1. What do you need to teach patient about taking synthroid?
    Do not take with any other medication
  2. What adjustment needs to be made in pregnant person on synthroid?
    Need to adjust UP the dose 33%
  3. When is TSH checked after adjustment?
    Wait 8 weeks to check after dose adjustment
  4. What is starting dose of adult of synthroid?
    1.6 mcg/kg/day
  5. What is starting dose of elderly of synthroid?
    1.0 mcg/kg/day
  6. What does Armour thyroid originate from?
    Animal product, pig. Be cautious of religious beliefs.
  7. What does Goiter mean?
    Enlarged thyroid gland
  8. What medications can cause chance of hypothyroid disease?
    Amiodarone, lithium, interferon
  9. What is the best tests to draw for thyroid assessment?
    TSH and FREE T4
  10. Another name for Graves disease?
    Graves is a form of thyrotoxicosis hyperthyroidism
  11. What is treatment for graves associated ophthalmopathy?
    Diuretics and prednisone. If sever, XRT or surgical decompression
  12. Diseases associated with Graves�?
    Other autoimmune disorders: pernicious anemia, DM, MG
  13. What change on CBC is noted in Graves?
  14. What is non-thyroid laboratory abnormalities noted in elevated TSH?
    Elevated LDL, Leukopenia, elevated CAD risk
  15. What is most common worldwide cause of hypothyroidism?
    Worldwide, it is iodine deficiency
  16. What is myxedema skin disorder?
    Abnormal deposits of mucin on skin and cutaneous and dermal edema secondary to increased deposition of connective tissue components in subcutaneous tissue as seen in various forms of hypothyroidism and Graves'
  17. Where is myxedema noted on body?
    Pretibial and facial non-pitting edema
  18. Myxedema seen in hyper or hypo thyroid?
    Hypothyroidism. Treatment with synthroid may resolve.
  19. What medications will render synthroid inactive?
    Iron, calcium, aluminum antacids, carafate
  20. What medications can increase synthroid metabolism and cause drop in T4?
    Dilantin, Rifampin, Carbamazepine, Phenobarbital
  21. What thyroid problem can cause gynecomastia?
  22. What thyroid problem can cause thyroid bruit?
  23. Hypothyroidism and pregnancy? When is TSH checked? Dose adjustment needed?
    TSH checked every trimester and 6 weeks post partum. Will need 33% increase in dose during pregnancy
  24. Diagnosis of Diabetes fasting blood glucose?
    > 126 after 8 hour fast
  25. Diagnosis of Impaired Fasting Glucose?
    > 100 after 8 hour fast
  26. Diagnosis of Diabetes Oral Glucose Tolerance Test?
    > 200 after 75 Gram Glucose Load
  27. Diagnosis of PreDiabetes Oral Glucose Tolerance Test?
    140-199 after 75 Gram Glucose load
  28. Diagnosis of Diabetes based on A1C?
    A1C >6.5%
  29. Diagnosis of Pre-Diabetes based on A1C?
    A1C 6 to 6.4%
  30. What is the ADAs goal for glucose control A1C?
    < 7.0%
  31. What is the ADAs goal for glucose control for Fasting glucose?
    90-130 after 8 hour fast
  32. What does A1C 7.0 calculate to with average plasma glucose?
  33. What does A1C 10.0 calculate to with average plasma glucose?
  34. When is blood sugar monitored with Insulin Pump therapy?
  35. What is the BIDS therapy for diabetes?
    Bed time insulin, Daytime Sulfonylurea
  36. What does hyperinsulinemia due to blood vessels and HTN?
    Increased vascular endothelial cell layer thus decreased lumen. Increases sympathetic tone, increases cardiac contractility by increasing catecholamines.
  37. What does increase glucose doe to kidney and HTN?
    Elevated glucose causes distal nephrons to retain Sodium, thus increases fluid volume, and increases blood pressure.
  38. What medications all Diabetes automatically be placed on (other than anti-diabetic medication)?
    ASA, ACE, Beta Blockers, cholesterol drugs
  39. What does ACE inhibitor drug do for patient with DM?
    It is renal protective. ACE inhibits Renin Angiotensin system, decreases intraglomerular pressure.
  40. What does inhibition of the RAS do for a kidneys?
    Causes efferent dilation, improves glomerular permeability, and decreases glomerular sclerosis.
  41. What is the leading cause of End Stage Renal Disease?
  42. What does restriction of proteins due for Renal disease?
    Delays renal complications
  43. What does microalbuminuria assess for?
    Identifies early nephropathy.
  44. What happens when urine is positive for microalbuminuria in DM pt?
    Must repeat again in 3-6 months for second positive finding. Once positive on UA must immediately start on ACE inhibitor and get tighter glycemic control.
  45. What is the major cause of hypercalcemia?
    Primary hyperparathyroidism
  46. What are the s/s of primary hyperparathyroidism?
    HTN, LVH, PUD, Pancreatitis, fatigue, anxiety
  47. What scan needs to be done in primary hyperparathyroidism?
    DEXA scan to assess skeletal involvement, as it causes bone loss
  48. Diagnosis of hyperparathyroidism?
    Persistent hypercalcemia and elevation of parathyroid hormone
  49. Treatment of primary hyperparathyroidism?
  50. Pheochromocytoma triggers?
    Full bladder, smoking, bending, exercising, straining, and drugs that increase catecholamines
  51. What drugs increase catecholamine release that can aggravate pheochromocytoma?
    Atropine, steroids, glucagon, opiates, some anesthetics
  52. How is pheochromocytoma diagnosed?
    24 hour urine for catecholamines
  53. S/S of pheochromocytoma?
    Attacks of HA, Palpitations, HTN, perspiration, nausea, weakness, pain, dyspnea, visual disturbances, weight loss
  54. Hypoparathyroidism lab results?
    Low calcium, high phosphate, hypophosphaturia,
  55. What signs are positive in hypoparathyroidism?
    Chvosteks and trousseaus signs
  56. How is Chvosteks sign elicited?
    Cheek tap, will reveal tetany of facial nerve and cause twitch
  57. How is trousseaus sign elicited?
    Occlude brachial artery with B/P cuff x3 minutes. Hand, wrist and fingers will spasm into a shape of bird hand
  58. What manifestation is noted in hypocalcemia?
    Tetany. Positive Chvosteks and trousseaus signs
  59. Diseases that can cause hypocalcemia?
    Phosphate excess, infection, vit D deficiency, hypoparathyroidism, malabsorption, pancreatitis, laxative abuse, pregnancy, renal failure
  60. How is treatment of low calcium evaluated?
    Check serum calcium levels. Once normalized, check urine calcium
  61. Causes of gynecomastia?
    Can be caused by hypogonadism, with low testosterone and normal estrogen. Also, COPD, cirrhosis, malnutrition, hypothyroidism, endocrine disorders, chronic renal disease
  62. Meds that cause gynecomastia?
    Tagamet, digoxin, aldactone, phenothiazines, anti TB drugs, pot, heroin, ETOH, and those receiving estrogen therapy for prostate CA
  63. Hirsutism grading scale?
    Ferriman- Gallivey scale. Evaluates hair growth in androgen sensitive areas. (Furryman- Hair)
  64. Galactorrhea?
    Lactation in absence of nursing a baby
  65. Cushing�s Syndrome is another name for?
  66. What lab work is diagnostic for Cushings syndrome?
    Elevated blood cortisol levels, elevated sodium, decreased potassium.
  67. Urine test for Cushings syndrome?
    24 hour urine for cortisol
  68. What can cause elevated cortisol blood levels?
    Iatrogenic: Steroids. Paraneoplastic tumors that produce ACTH, Adrenal or pituitary tumors
  69. Noted physical features of Cushings syndrome?
    Buffalo Hump, Moon face, weight gain, hyperhidrosis, thin skin, hirsutism, dry, brittle hair, alopecia, onychomycosis
  70. What causes Cushings Disease, rather than syndrome?
    Tumor of Pituitary Gland that causes increased ACTH which increases cortisol and adrenal androgens. A Corticotrophic pituitary adenoma.
  71. What can cause Addisonian Crisis?
    An Adrenal crisis. Often due to abrupt cessation of long term corticosteroids. Life threatening due to acute adrenal insufficiency.
  72. Signs of Addisonian Crisis?
    Severe hypotension, circulatory collapse.
  73. Treatment for Addisonian Crisis?
    IVF, IV glucocorticosteroids
  74. What skin manifestation is seen in Addisons disease?
    Hyperpigmented skin
  75. What is caused by long term corticosteroid use?
    Cushings syndrome
  76. What happens with long term corticosteroid use to cells and tissue?
    See protein catabolism, loss of adipose and lymph tissue. Decreased collagen will cause easy bruising, skin friability and thin/atrophic skin
  77. Cushings syndrome can lead to?
    HTN, Insulin resistance, DM
  78. What is visceral neuropathy?
    Complication of DM. Causes hand/feel anhidrosis (non-sweat), dysphagia, anorexia, GERD, constipation or diarrhea, pupil constriction
  79. What is Somatic Neuropathy?
    Complication of DM. Changes in sensation of feet and hands. Palsy of CN 3 with eye pain headache (cant move eyeballs). Pain or loss of sensation to chest.
  80. Macrocirculation changes in DM?
    Early onset of arthrosclerosis, PAD, gangrene
  81. Microvascular changes in DM?
    Diabetic retinopathy with retinal ischemia. Vision loss. Nephropathy with HTN. Albuminuria. Edema. Progressive Renal Failure
  82. What happens, pathologically, in the diabetic neuropathy process?
    Blood vessel walls of nerves thicken cause less nutrients to get to nerves. Sorbitol forms and accumulates in Schwann Cells and impairs nerve conduction. Demyelization of schwann cells, no nerve insulation- no nerve conduction.
  83. S/S of DKA?
    Kussmaulss breathing, elevated blood sugar, glucosuria, polys x3. Anorexia, HA, ketonuria, acidosis
  84. If a diabetic misses a meal and took insulin, what should they do?
    15-30 gram of complex carbohydrate
  85. What certain pre-tests restrictions should be followed prior to an oral glucose tolerance test?
    3 days prior NO: Vitamin C, ASA, BCP, corticosteroids, estrogens, Dilantin, thiazide diuretics, and nicotinic acid
  86. What is first manifestation of renal dysfunction in DM?
    Proteinuria. Often after DM 5-10 years it will be noted.
  87. Why does proteinuria occur in DM?
    Due to increased permeability of capillaries with resultant leakage of albumin into glomerular filtrate causing albuminuria.
  88. What organ secretes aldosterone?
    Adrenal Cortex
  89. Disease causes of secondary obesity?
    Cushings disease, PCOS, hypothalamic disease, hypothyroidism.
  90. Medication side effect causes of secondary obesity?
    Glucocorticoids, TCAs, phenothiazines
  91. What HEENT infection is seen with elderly?
    Malignant otitis Externa. Caused by pseudomonas. Invasive necrotizing infection. High mortality rate due to meningitis spread. Ear pain, parotid gland swelling.
  92. What cranial nerves can be affected by Malignant Otitis Externa?
    Paralysis of CN 6,7,8,9,10,11,12
  93. Examples of Sulfonylureas?
    The Gs. Glipizide, Glyburide, Glimepiride (also 1st generation Chlorpropamide (Diabenese) very long half life, not good in elderly)
  94. Examples of Biguanides?
    Only one. Metformin (Glucophage)
  95. Examples of Thiazolidinediones?
    TZDs. The As/ the glitazones. Pioglitazone (Actos). Avandia was recently pulled off market but may still be on test....Rosiglitazone (Avandia)
  96. Examples of Meglitinides?
    -glinides. Repaglinide (Prandin) Nateglinide (Starlix)
  97. Examples of Alpha-glucosidase inhibitors?
    Acarbose (Precose) Miglitol (Glyset)
  98. Examples of Amylin Analog?
  99. Examples of Incretin Mimetics?
  100. Examples of Dipeptidyl peptidase-4 (DPP-4) inhibitor?
    -gliptin. Sitagliptin(Januvia) Saxagliptin(Onglyza)
  101. Examples of rapid onset, short acting insulin?
    Lispro(Humalog), Aspart(Novolog), Glulisine (Apidra)
  102. Examples of short-acting insulin?
    Regular, Novolin R, Humulin R
  103. Examples of Intermediate acting insulin?
    NPH, Novolin N, Humulin R
  104. Examples of Long Acting insulin?
    Glargine(Lantus), Detemir(Levemir)
  105. Peak of rapid onset, short acting insulin?
    1-3 hours
  106. Peak of short-acting insulin?
    2-3 hours
  107. Peak of Intermediate acting insulin?
    6-14 hours
  108. Peak of Long Acting insulin?
    Levemir has 6-8 hour peak, Lantus no peak
  109. Onset of rapid onset, short acting insulin?
    15 minutes

    • Onset of short-acting insulin?
    • 30 minutes
  110. Onset of Intermediate acting insulin?
    1-2 hours
  111. Onset of Long Acting insulin?
    1 hour
  112. Duration of action of rapid onset, short acting insulin?
    3-5 hours
  113. Duration of action of short-acting insulin?
    4-6 hours
  114. Duration of action of Intermediate acting insulin?
    16-24 hours
  115. Duration of action of Long Acting insulin?
    Lantus 24 hours, Levemir 12-24 hours depending on dosing
  116. What are the AA,B,CC,D,EE,F & G of T2DM care?
    ASA, ACE. Beta-Blocker. Cholesterol, Creatinine. Diet. Eye exam, Exercise. Foot exam. Goals reviewed with pt periodically
  117. What are examples of the insulin secretagogues?
    Sulfonylureas, Meglitinides, DPP-4 inhibitors
  118. What medication class allergy is of concern for one of the oral diabetic agents?
    Sulfa allergies and taking Sulfonylurea
  119. How does the biguanide work?
    Reduces hepatic glucose production and intestinal absorption. An insulin sensitizer- by increasing peripheral glucose uptake and utilization.
  120. How does a medication have the effect of an insulin sensitizer?
    It increases peripheral glucose uptake and use.
  121. What should be checked prior to initiating biguanide therapy?
    Check Creatinine and dont start or discontinue if impaired renal function (creatinine >1.5)
  122. What co-morbidities are a contraindication for starting biguanide?
    Presence of heart failure, ETOH, acidosis, renal disease/insufficiency,
  123. Complications seen with Biguanides?
    Lactic acidosis, especially in states of hypovolemia, advanced age of >80, and impaired renal fxn.
  124. What DM medication should be placed on hold prior to a radiologic test?
    Biguanides should be held day of and 48 hours after any radiocontrast use, or surgery, or any other condition that may alter hydration. Also, check creatinine before and after test.
  125. How does the TZDs work?
    Insulin sensitizer via action at PPAR-gamma receptors found in muscle, adipose, and other tissues. Decreases hepatic gluconeogenesis. Decreases peripheral tissue resistance.
  126. What lab tests should be monitored in TZD use?
    LFTs (ALT) must be monitored periodically. Per FDA mandate, due to hepatic toxicity. D/C if 3x upper limits of norm, or with myalgias, jaundice
  127. What side effect can be seen in TZD use?
    Edema risk, especially with used with insulin or SU.
  128. What can TZD exacerbate?
    Can cause or exacerbate heart failure
  129. How long until see TZD effects?
    It takes 12 weeks to see full TZD effects
  130. How do Meglitinides work?
    Insulin secretagogues
  131. What�s the caution with insulin secretagogues?
    Concern with hypoglycemia because causes increased insulin release
  132. How do Sulfonylureas work?
    Insulin secretagogues
  133. What oral DM medication is taken 1-30 minutes prior to meal?
    The Secretagogues. Meglitinides & SUs & Meglitinides. Provide quick burst of insulin 20 minutes after taken to cover the meal.
  134. What DM medication should not be used in combination with SU?
  135. How does the Alpha-Glucosidase inhibitors work?
    delays intestinal carbohydrate absorption by reducing digestion of starches and disaccharides, by inhibiting the enzyme to digest CHO
  136. Side effects of Alpha-Glucosidase inhibitors?
    GI side effects big issue, bad flatus.
  137. Sig: for Alpha-glucosidase inhibitors?
    Take with first bite of meal
  138. How does the Amylin analog work?
    Modulates gastric emptying thus prevents postprandial glucagon release and also increases feeling of satiety causing decreased CHO intake and weight loss.
  139. What DM medications are contraindicated in gastroparesis?
    Amylin analog and Incretin mimetics
  140. What medications can cause hypoglycemia?
    Insulin secretagogues (Meglitinides and SU), and also Amylin analog has boxed warning about hypoglycemia risk.
  141. What medication has boxed warning about hypoglycemia risk?
    Amylin analog
  142. What medications are given by injection, but are not insulin?
    Amylin analog (Pramlintide) and Incretin mimetic (Byetta)
  143. Indications for Amylin Analog use?
    Only use with meal greater than 250 kcal and 30 g of CHO. Used as adjunct for patient on mealtime insulin and has inadequate glucose control despite optimal insulin therapy.
  144. What injection non insulin medication is also given with Insulin?
    Amylin analog
  145. How does the Incretin mimetic work?
    Stimulates insulin production in response to increase in plasma glucose, inhibits glucagon post-prandial release, and slows gastric emptying, leading to appetite suppression and weight loss.
  146. What medications are contraindicated in pancreatitis or hx?
    Incretin mimetic (Byetta) and DPP-4 inhibitors. Which both work on Incretin.
  147. How does the DPP-4 inhibitors work?
    Increases levels of Incretin, increasing synthesis and release of insulin by stimulating pancreatic beta-cells, decreases release of glucagon.
  148. DPP-4s are often used in conjunction with?
    TZD or metformin. Janumet
  149. What is the master endocrine gland and what does it do?
    Hypothalamus. Produces Oxytocin & Directs the pituitary
  150. Role of posterior pituitary?
    Storage site for Vasopressin (ADH) and oxytocin
  151. Role of anterior pituitary?
    Produces hormones that target other glands
  152. Common hormones anterior pituitary produces?
    FSH, TSH, LH, GH, ACTH, Prolactin, Beta-endorphin
  153. What does Parathyroid glad do?
    Produces ADH
  154. What is the work-up once hyperthyroidism is found? (low TSH, high T4)
    First do thyroid uptake scan to check for metabolically active nodules
  155. What is the most common cause of hyperthyroidism?
    Graves disease
  156. Who is at higher risk for Graves disease
    Autoimmune disorders, RA, Pernicious anemia, lupus
  157. What hyperthyroid meds are OK for pregnancy?
    PTU (P- Pregnancy)
  158. What disease is patient at risk for if they have hyperthyroidism?
    Osteoporosis. Treat accordingly and prophylax.
  159. Examples of microvascular DM damage?
    Retinopathy, nephropathy
  160. Examples of macrovascular DM damage?
    CAD, CVA, BV damage
  161. Target organs susceptible to damage from DM?
    Eyes, heart, vascular, kidney, peripheral nerves
  162. What is a normal HgA1c?
  163. What is the next step when urine is positive for microalbuminuria?
    Perform 24 hour urine for protein/creatinine
  164. What changes are noted in feet sensation with DM?
    Loss of vibratory sense, numbness, changes in light/deep touch
  165. Points to tell patient who exercises with diabetes?
    Hypoglycemia will be seen later in the day. May need to dose down meds or have snack before exercise.
  166. What percentage of glucose uptake is in muscle?
    80%, which increases with exercise.
  167. Specific fundoscopic exam changes in DM?
    neovascularization of retina with Microaneurysms.
  168. Secondary causes of hyperglycemia due to medication?
    Niacin, Corticosteroids, thiazide diuretics
  169. How does stress affect blood glucose level?
    Increase in blood glucose. Stress causes adrenal glands to secrete cortisol, will results in increased gluconeogenesis and insulin antagonism.
  170. How does DM affect estrogen in CAD risk?
    DM negates estrogens protective effect
  171. When does DM patient become nephrology consult?
    Cr >3.0
  172. When is ASA given in DM?
    For everyone, it is either primary or secondary prevention, depending on other co-morbidities
  173. What is Dawn Phenomenon?
    Morning hyperglycemia. At dawn hours (4-8am) normally blood sugar elevates. With insulin resistance, this will results in elevated fasting blood sugar.
  174. What causes Dawn Phenomenon to occur?
    Glucagon, GH, Epinephrine and cortisol
  175. What is the Somogyi Effect?
    Nocturnal rebound hyperglycemia. Patient becomes hypoglycemic during night and body releases glucagon and cortisol to correct.
  176. What iatrogenic RX is cause of somogyi effect?
    Caused by over treating/overdosing insulin at evening or nighttime dose
  177. How is Somogyi diagnosed?
    Perform 3am blood sugar check for several weeks.
  178. How is Somogyi treated?
    Snack before bedtime, or lower or eliminate NPH evening or bedtime dose.
  179. How often should a Type 2 DM self-monitor their own blood sugar?
    Three times a WEEK
  180. What is the inhaled insulin and what would contraindicate its use?
    Exubera. Need baseline PFT and contraindicated in smoker, recent smoker, or active lung disease
  181. What is good about the rapid acting, short duration insulins?
    They decrease the chance of hypoglycemia between meals and at h.s.
  182. How does the insulin resistant person maintain euglycemia?
    Over working the pancreas causing a hyperinsulinemia state to help get more glucose into the resistant cells
  183. Screening for DM?
    FBS Q3 years if >45 and no risk factors.
  184. What medications are increased risk for causing heat stroke?
    Those drugs that cause negation of bodys attempt to increase cardiac output and vasodilation to decrease temp. TCAs, Bblockers, vasoconstrictors. Other causes are obesity, ETOH, very young and very old.
  185. Life threatening side effects of hyperthermia?
    Hyperkalemia, rhabdo, renal failure
  186. What do plant stanols or sterols do?
    Decrease LDL
  187. What does Omega 3 fatty acid do at high doses?
    Decreases triglycerides
  188. How does physical activity help in diabetes?
    Will decrease insulin resistance, increase HDL, and decrease triglycerides
  189. What needs to be present to be diagnosed with metabolic syndrome?
    Presence of central obesity within ethnic guidelines, as well as two or more risk factors of Triglycerides >150, HDL <40f <50m, BP >130/>85 or on HTN meds, FBS >100 or on meds
  190. What does IR/MS do to blood vessels and plaque formation?
    Contributes to pro-thrombotic and pro-atherogenic state. Also increased levels of PAI, Plasminogen activator inhibitor lead to enhanced clot formation.
  191. What does elevated blood pressure and hyperinsulinemia in Metabolic syndrome do to kidneys?
    Leads to increased renal sodium Resorption which increases intravascular volume and increases PVR.
  192. Vascular changes in HTN and Met. Syndrome?
    Endothelial dysfunction. Increased vascular smooth muscle, increased responsiveness to angiotensin II and increased sympathetic activation.
  193. What is noted in hypertriglyceridemia?
    Most likely person has insulin resistance
  194. Lifestyle changes to help with Insulin Resistance?
    These will decrease insulin resistance: Smoking cessation, Exercise, Weight loss,
  195. Weight loss of 1-2 pounds per week can be attained by cutting how many calories?
    Deficit of 500-1000 kcal/day
  196. Anti-obesity drugs that cause malabsorption of fat? How are they taken and with side effects are there?
    Orlistat (Xenical, Alli) Taken TID with meals. Fat comes out undigested and cause loose stool, GI upset
  197. What are the two classes of Anti-obesity drugs that cause appetite suppression? How do they work and with side effects are there?
    Meridia. CNS effect to increase mood and well being and decrease appetite. Elevates neurotransmitters Norepi, Serotonin, and DA. Side effects: dry mouth, constipation, disturbed sleep, HTN. Also sympathomimetics such as dexamphetamine, phentermaine work similarly. Side effects: sleep disturbances, nervousness
  198. What neurotransmitter facilitates satiety?
    Serotonin. Satiety-S.
  199. Who is candidate for obesity surgery?
    BMI >40. Or BMI >35 with HTN, OSA, DM, CVD, GERD, DJD, and other therapy has failed
  200. Contraindications to obesity surgery?
    Untreated psyche problems, Drug, ETOH abuse, poor surgical candidate
  201. How does the gastric band work?
    Restricts food and calories ingested. Can lose 50% of excess weight. Low malnutrition risk because food still passes through duodenum.
  202. How does Roux-en Y gastroplasty or Gastric bypass work?
    Stomach restriction with duodenum bypass with minimal calorie absorption. Can lead to malnutrition. Can lose 75% of excess weight.
  203. When would you consider screening for T2DM in an adolescent?
    Overweight in >85 percentile plus two additional risk factors of physical signs of IR including acanthosis nigricans, HTN, dyslipidemia, PCOS, SGA at birth, +FHx, race, maternal hx of DM or gestational DM.
  204. If a child meets criteria for screening for T2DM, when should it start and how often?
    Fasting glucose at age 10 of onset of puberty. Then check every 3 years.
Card Set
ANP Certification Thyroid Diabetes Flash Cards.txt
ANP Certification Thyroid Diabetes Flash Cards