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PHARMACOLOGY > CHAPTER 3 > Flashcards

CHAPTER 3 Flashcards

1
Q

DRUG VS MEDICINE
Any substance other than food which has a physiological effect when ingested or otherwise introduced into the body

A

DRUG

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2
Q

DRUG VS MEDICINE
A substance that is used in treating disease or relieving pain

A

MEDICINE

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3
Q

DRUG VS MEDICINE
Used for different purposes like treating disease, relieving pain, recreation & improving cognitive abilities

A

DRUG

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4
Q

DRUG VS MEDICINE
Mainly used to treat disease or relieve pain

A

MEDICINE

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5
Q

DRUG VS MEDICINE
May have either positive or negative effects

A

DRUG

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6
Q

DRUG VS MEDICINE
Usually has a positive effect on the health

A

MEDICINE

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7
Q

DRUG VS MEDICINE
Associated with negative connotations

A

DRUG

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8
Q

DRUG VS MEDICINE
Not associated with negative connotations

A

MEDICINE

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9
Q

the branch of pharmacology that uses drugs to treat, prevent, and diagnose disease.

A

CLINICAL PHARMACOLOGY

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10
Q

2 Key Concerns of CLINICAL PHARMACOLOGY

A
  1. The drug’s effects on the body (Pharmacodynamics)
  2. The body’s response to the drug (Pharmacokinetics)
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11
Q

The drug’s effects on the body

A

Pharmacodynamics

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12
Q

The body’s response to the drug

A

Pharmacokinetics

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13
Q

refers to all methods to be used for treatment of disease. In addition to drug therapy, this may include plans for special diets; use of hot packs, whirlpools, counselling, psychotherapy

A

THERAPEUTIC REGIMEN

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14
Q

SOURCES OF DRUGS

A

PLANTS
ANIMAL PRODUCTS
INORGANIC COMPOUNDS
SYNTHETIC SOURCES

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15
Q

are an important source of chemicals that are developed into drugs

A

Plants

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16
Q

are used to replace human chemicals that are not produced because of disease or genetic problems

A

Animal Products

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17
Q

Salts of various elements can have therapeutic effects in the human body

A

Inorganic Compounds

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18
Q

Drugs that are developed synthetically
Altered chemical with proven therapeutic effectiveness to make it better (more potent, more stable, less toxic)

A

Synthetic Sources

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19
Q

Identify which source of drug based on the example given:
Quinidine (for malaria)

A

Plants

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20
Q

Identify which source of drug based on the example given:
Insulin (from the pancreas of cows and pigs)

A

Animal Products

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21
Q

Identify which source of drug based on the example given:
Aluminum (Antacid), Flouride (dental cavities), Iron (Anemia)

A

Inorganic Compounds

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22
Q

The first synthetic Drug is ______, as a sedative hypnotic medication (induced sleep) and is still available today.

A

Chloral hydrate

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23
Q

A tablet or capsule taken by mouth goes through three phases:

A

Pharmaceutic
Pharmacokinetic
Pharmacodynamic

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24
Q

In the _______ phase, the drug becomes a solution so that it can cross the biologic membrane.

A

Pharmaceutic

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25
Q

There is no pharmaceutic phase when the drug is administered ______.

A

administered parenteraly by subcutaneous (subQ), intramuscular (IM), or intravenous (IV) routes

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26
Q

In the GI tract, drugs need to be in solution so they can be absorbed, a process known as ______.

A

dissolution

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27
Q

are fillers and inert substances used in drug preparation to allow the drug to take on a particular size and shape and to enhance drug dissolution.

A

Excipients

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28
Q

Some additives in drugs, such as the _______ and _______ or ________, increase the absorbability of the drug.

A

ions potassium; sodium in penicillin potassium or penicillin sodium

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29
Q

Drugs in _____ form are more rapidly available for GI absorption than are ____.

A

liquid; solids

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30
Q

Generally, drugs are both disintegrated and absorbed faster in _____ fluids with a pH of _ or _ rather than in _____ fluids.

A

acidic; 1 or 2; alkaline

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30
Q

Both the very young and older adults have less gastric acidity; therefore, drug absorption is generally _____ for those drugs absorbed primarily in the stomach.

A

slower

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31
Q

Stomach pH is __ to __ and the fluid of is __ – __ ml.

A

1.5 to 3.5; 20 – 100 ml

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32
Q

_____ are inactive substance used to make the active medicine easier to measure. Usually use in tablets and capsules

A

Fillers

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33
Q

The _______ phase, or what the body does to the drug, describes the movement of the drug through the body.

A

pharmacokinetic

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34
Q

4 processes of pharmacokinetics

A

Absorption
Distribution
Metabolism (biotransformation)
Excretion (elimination)

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35
Q

The _______ phase, or what the drug does to the body, involves receptor binding, postreceptor effects, and chemical reactions. A biologic or physiologic response results from this phase.

A

pharmacodynamic

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36
Q

is the movement of the drug into the bloodstream after administration.

A

Drug Absorption

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37
Q

Approximately __ of drugs are taken by mouth (enteral).

A

80%

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38
Q

For the body to use drugs taken by mouth, a drug in solid form (tablet or capsule) must disintegrate into small particles and combine with a liquid to form a solution, a process known as _______ (drugs in liquid form are already in solution), to be absorbed from the GI tract into the bloodstream.

A

dissolution

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39
Q

_____ are not 100% drug. Fillers and inert substances – such as simple syrup, vegetable gums, aromatic powder, honey, and various elixirs – called _______ are used in drug preparation to allow the drug to take on a particular size and shape and to enhance drug dissolution.

A

Tablets; excipients

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40
Q

is the breakdown of an oral drug into smaller particles.

A

Disintegration

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41
Q

is the time it takes the drug to disintegrate and dissolve to become available for the body to absorb it.

A

rate of dissolution

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42
Q

drugs resist disintegration in the gastric acid of the stomach, so disintegration does not occur until the drug reaches the alkaline environment of the small intestine.

A

Enteric-coated (EC)

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43
Q

EC tablets can remain in the stomach for a long time; therefore their effect may be ____ in onset.

A

delayed

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44
Q

_______ and _______ should not be crushed because crushing alters the place and time of absorption of the drug.

A

EC tablets or capsules and sustained-release (beaded) capsules

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45
Q

An example of EC tablets; it works stopping the production of certain natural substances that cause fever, pain, swelling and blood clots.

A

Aspirin

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46
Q

Drugs given ____ are absorbed slower than drugs administered by the oral route. Absorption is slower because the surface are in the rectum is _____ than the stomach, and it has _____. Additionally, the composition of the suppository base affects drug absorption.

A

rectally; smaller; no villi

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47
Q

After absorption of oral drugs from the GI tract, they pass from the intestinal lumen to the liver via the portal vein. In the liver, some drugs are metabolized to an inactive form and are excreted, thus reducing the amount of active drug available to exert a pharmacologic effect. This is referred to as _________.

A

first-pass metabolism

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48
Q

______ and ______, for example, are not given orally because they have extensive first-pass metabolism, and most of the drug is inactivated.

A

Lidocaine and some nitroglycerins

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49
Q

Drugs that are delivered by other routes (__, __, __, ____, ____, ______) do not enter the portal circulation and are not subjected to first-pass metabolism.

A

(IM, IV, SQ, nasal, sublingual, buccal)

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50
Q

refers to the percentage of administered drug available for activity.

A

Bioavailability

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51
Q

For orally administered drugs, bioavailability is affected by _____ and ________.

A

absorption and first-pass metabolism

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52
Q

The bioavailabilty of oral drugs is always ________ and varies based on the rate of first-pass metabolism.

A

less than 100%

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53
Q

The bioavailability of intravenous (IV) drugs is ____.

A

100%

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54
Q

Factors that alter bioavailability include the:

A

(1) drug form; (2) route of administration; (3) gastric mucosa and motility; (4) administration with nfood and other drugs; and (5) changes in liver metabolism

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55
Q

A decrease in liver function or a decrease in hepatic blood flow can _____ the bioavailability of a drug, but only if the drug is metabolized by the liver.

A

increase

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56
Q

is the movement of the drug from the circulation to body tissues.

A

Distribution

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57
Q

Drugs are easily distributed in ______ such as the liver, heart, and kidney. Tissues with decreased perfusion, such as muscle, fat, and peripheral organs, result in ______.

A

highly perfused organs; decreased drug distribution

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58
Q

can be defined as the extent or fraction to which a drug binds to receptors at any given drug concentration or the firmness with which the drug binds to the receptor.

A

AFFINITY

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59
Q

describes the maximum response that can be achieved with a drug.

A

EFFICACY

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60
Q

Blood vessels in the brain have a special endothelial lining where the cells are pressed tightly together (tight junctions); this lining is referred to as the ______.

A

blood-brain barrier(BBB)

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61
Q

The BBB protects the brain from _______, which includes about __ of the drugs on the market. Some drugs that are highly lipid soluble and of low molecular weight (benzodiazepines) are able to cross the BBB through ___, and others cross via _______.

A

foreign substances; 98%; diffusion; transport proteins

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62
Q

_______ (atenolol and penicillin) and drugs that are not bound to transport proteins (_____) are not able to cross the BBB, which makes it difficult for these drugs to reach the brain.

A

Water-soluble drugs; free drugs

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63
Q

During ____, drugs can cross the placenta much as they do across other membranes, and this affects both the fetus and the mother.

A

pregnancy

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64
Q

Drugs taken during the first trimester can lead to _______, ______, or other subtler defects.
During the third trimester, drugs may alter ________.
The ________ should be considered before any drugs are given during pregnancy.

A

spontaneous abortion, teratogenesis

fetal growth and development

risk-benefit ratio

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64
Q

Drugs taken during the first trimester can lead to _______, ______, or other subtler defects.
During the third trimester, drugs may alter ________.
The ________ should be considered before any drugs are given during pregnancy.

A

spontaneous abortion, teratogenesis

fetal growth and development

risk-benefit ratio

65
Q

________, is the process by which the body chemically changes drugs into a form that can be excreted.

A

Metabolism, or biotransformation

66
Q

The _____ is the primary site of metabolism.

A

liver

67
Q

– collectively referred to as the cytochrome P450 system, or the P450 system, of drug metabolizing enzymes – convert drugs to metabolites.

A

Liver enzymes

68
Q

A large percentage of drugs are ______, thus the liver metabolizes the _______ drug substance to a water-soluble substance for renal excretion.

A

lipid soluble

69
Q

_______ such as cirrhosis and hepatitis alter drug metabolism by inhibiting the drug-metabolizing enzymes in the liver.

A

Liver diseases

70
Q

When the drug metabolism rate is _____, excess drug accumulation can occur and can lead to toxicity.

A

decreased

71
Q

is a compound that is metabolized into an active pharmacologic substance.

A

prodrug

72
Q

Prodrugs are often designed to ________; instead of administering a drug directly, a corresponding prodrug might be used instead to improve pharmacokinetics (absorption, distribution, metabolism, or excretion), decrease toxicity, or target a specific site of action.

A

improve drug bioavailability

73
Q

An example of prodrug is ____. _____ itself has very little intrinsic activity at endogenous opioid receptors. However, drug-metabolizing enzymes in the liver convert ____ into morphine. Morphine, in turn, exhibits greater affinity for opioid receptors.

A

codeine

74
Q

The _______is the time it takes for the amount of drug in the body to be reduced by half.

A

drug half-life (t ½)

75
Q

_____, ______, ______, and ______ affect the half-life of a drug.

A

The amount of drug administered, the amount of drug remaining in the body from previous doses, metabolism, and elimination

76
Q

With _______, the half-life of the drug is prolonged, and less drug is metabolized and eliminated.

A

liver or kidney dysfunction

77
Q

A drug goes through several half-lives before complete elimination occurs, and drug half-life is used to determine _______.

A

dosing interval

78
Q

By knowing the half-life, the time it takes for a drug to reach a steady state (______) can be determined.

A

plateau drug level

79
Q

A _______ occurs when the amount of drug being administered is the same as the amount of drug being eliminated; a steady state of drug concentration is necessary to achieve optimal therapeutic benefit.This takes about 4 half-lives, if the size of all doses is the same.

A

steady state

80
Q

The main route of drug excretion, elimination of drugs from the body, is through the _____.

Drugs are also excreted through bile, the lungs, saliva, sweat, and breast milk.

A

kidneys

81
Q

The kidneys filter ____ drugs, _____ drugs, and drugs that are ______.

A

free drugs, water-soluble drugs, and drugs that are unchanged

82
Q

The ____ eliminate volatile drug substances, and products metabolize to carbon dioxide (CO2) and water (H2O).

A

lungs

83
Q

The _____ influences drug excretion. Normal urine pH varies from __ to __. _____ promotes elimination of weak base drugs, and _______ promotes elimination of weak acid drugs.

A

urine pH; 4.6 to 8.0; acidic urine; alkaline urine

84
Q

____, ___, and ____ conditions affect drug excretion.

A

Prerenal, intrarenal, and postrenal conditions

85
Q

such as dehydration, or hemorrhage, reduce blood flow to the kidney and result in decreased glomerular filtration.

A

Prerenal conditions

86
Q

such as glomerulonephritis and chronic kidney disease (CKD), affect glomerular filtration and tubular secretion and reabsorption.

A

Intrarenal conditions

87
Q

that obstruct urine flow – such as prostatic hypertrophy, stones, and neurogenic bladder – adversely affect glomerular filtration.

A

Postrenal conditions

88
Q

Common tests used to determine renal function include ____ and _______.

A

creatinine and blood urea nitrogen (BUN)

89
Q

_____ is a metabolic by-product of muscle excreted by the kidneys; ______ is the metabolic breakdown product of protein metabolism.

A

Creatinine; urea nitrogen

90
Q

is the study of the effects of drugs on the body. Drugs act within the body to mimic the actions of the body’s own chemical messengers. Drug response can cause a primary or secondary physiologic effect or both.

A

Pharmacodynamics

91
Q

A drug’s ______is the desirable response, and the ______ may be desirable or undesirable.

A

primary effect; secondary effect

92
Q

An example of a drug with a primary and secondary effect is ______, an antihistamine. The primary effect of ______ is to treat the symptoms of allergy; the secondary effect is a central nervous system depression that causes drowsiness. The secondary effect is undesirable when the patient drives a car, but at bedtime it could be desirable because it causes mild sedation.

A

diphenhydramine

93
Q

The ______ is the body’s physiologic response to changes in drug concentration at the site of action.

A

dose-response relationship

94
Q

refers to the amount of drug needed to elicit a specific physiologic response to a drug. A drug with high potency, such as fentanyl, produces significant therapeutic responses at low concentrations; a drug with low potency, such as codeine, produces minimal therapeutic responses at low concentrations

A

Potency

95
Q

Then point at which increasing a drug’s dosage no longer increases the desired therapeutic responses is referred to as ________.

A

maximal efficacy

96
Q

Closely related to dose-response and efficacy is the ______, which describes the relationship between the therapeutic dose of a drug (ED50) and the toxic dose of a drug (TD50).

A

therapeutic index (TI)

97
Q

Closely related to dose-response and efficacy is the therapeutic index (TI), which describes the relationship between the _______ and ________.

A

therapeutic dose of a drug (ED50) and the toxic dose of a drug (TD50).

98
Q

is the dose of a drug that produces a therapeutic response in 50% of the population; _____ is the dose of a drug that produces a toxic response in 50% of the population.

A

ED50; TD50

99
Q

is the difference between these two points.
If the ED50 and TD50 are close, the drug is said to have a narrow ______.

A

therapeutic index

100
Q

Drugs with a __ – such as warfarin, digoxin, and phenytoin – require close monitoring to ensure patient safety.

A

TI

101
Q

To be safe, plasma drug levels of drugs with a narrow therapeutic index must fall within the _____ (also known as the therapeutic window).

A

therapeutic range

102
Q

is a range of doses that produce a therapeutic response without causing significant adverse effect inn patients.

A

therapeutic range

103
Q

is the time it takes for a drug to reach the minimum effective concentration (MEC) after administration.

A

Onset

104
Q

The ___ is the minimum amount of drug required for drug effect.

A

MEC

105
Q

A drug’s ___ occurs when it reaches its highest concentration in the blood.

A

peak

106
Q

is the length of time the drug exerts a therapeutic effect.

A

Duration of action

107
Q

If the drug plasma concentration _____ below the MEC, adequate drug dosing is not achieved; too high of a drug concentration can result in _____.

A

decreases; toxicity

108
Q

Drugs act by _______. Binding of the drug may activate a receptor, producing a response, or it may inactivate a receptor, blocking a response.

A

binding to receptors

109
Q

The activity of many drugs is determined by the ability of the drug to bind to a specific receptor. The ____ the drug ____ at the receptor site, the more _____ the drug is.

A

The better the drug fits at the receptor site, the more active the drug is.

110
Q

Most receptors, which are protein nature, are found on ________ or _______.

A

cell surface membrane; within the cell itself

111
Q

Drug-receptor interactions are similar to the fit of the _______.

A

right key in a lock

112
Q

Drugs with complete attachment and response
are called _____.
Drugs that activate and produce a desired response are called

A

agonists

113
Q

Drugs that attach but do not elicit a response are called ____.
Drugs that prevent receptor activation and block a response are called _____. Blocking receptor activation either increases or decreases cellular action, depending on the endogenous action of the chemical messenger that is blocked.

A

antagonists

114
Q

Drugs that attach and elicit a small response but also block other responses are called ______.

are drugs that elicit only moderate activity when binding to receptors; also prevent receptor activation by other drugs.

A

partial agonists

115
Q

Mechanisms of drug action include:

A

(1) stimulation, (2) depression, (3) irritation, (4) replacement, (5) cytotoxic action, (6) antimicrobial action, and (7) modification of immune status.

116
Q

A drug that ____ enhances intrinsic activity (adrenergic drugs that increase HR, sweating, and RR during fight-or-flight response).

A

stimulates

117
Q

_____ drugs decrease neural activity and bodily functions (barbiturates and opiates)

A

Depressant

118
Q

Drugs that ____ have a noxious effect, such as astringents.

A

irritate

119
Q

_____ drugs such as insulin, thyroid drugs and hormones replace essential body compounds.

A

Replacement

120
Q

_____ drugs selectively kill invading parasites or cancers.

A

Cytotoxic

121
Q

_____ drugs prevent, inhibit, or kill infectious organisms.

A

Antimicrobial

122
Q

Drugs that ________ modify, enhance, or depress the immune system

A

modify the immune status

123
Q

Factors that influence drug toxicity include ____, _____, and ____.

A

disease, genetics, and age

124
Q

are occur that can be effects of drug therapy. All drugs have ______. Even with correct dosage, ______ occur that can be predictable and range from inconvenient to severe or life threatening.

A

Side effects

125
Q

are unintentional, unexpected reactions to drug therapy that occur at normal drug dosages. The reactions may be mild to severe and include anaphylaxis (cardiovascular collapse). ___ are always undesirable and must be reported and documented because they represent variances from planned therapy.

A

Adverse drug reactions (ADRs)

126
Q

occurs when drug levels exceed the therapeutic range; _____ may occur secondary to overdose (intentional or unintentional) or drug accumulation.

A

Drug toxicity

127
Q

refers to a decreased responsiveness to a drug over the course of therapy; an individual with drug _____ requires a higher dosage of drug to achieve the same therapeutic response.

A

Tolerance

128
Q

refers to an acute, rapid decrease in response to a drug; it may occur after the first dose or after several doses.

A

Tachyphylaxis

129
Q

is a drug response not attributed to the chemical properties of the drug.

A

Placebo effect

130
Q

The response (placebo effect) can be positive or negative and may be influenced by the ___, ___, ____ of the patient.

A

beliefs, attitudes, and expectations

131
Q

Although the placebo effect is psychological in origin, the response can be ____, resulting in changes in __, __, _____.

A

physiologic; HR, BP, and pain sensation.

132
Q

____, _____, ______, and ___ are an increasing problem.

A

Drug-drug, drug-nutrient, drug-disease, and drug-laboratory interactions

133
Q

is defined as an altered or modified action or effect of a drug as a result of interaction with one or multiple drugs.

A

drug interaction

134
Q

Drug interactions can be divided into two categories:

A

pharmacokinetic and pharmacodynamic interactions

135
Q

are changes that occur in the absorption, distribution, metabolism, and excretion of one or more drugs.

A

Pharmacokinetic interactions

136
Q

When a person takes two drugs at the same time, the rate of absorption of one or both drugs can change. A drug can block, decrease, or increase the absorption of another drug. It can do this in one of three ways:

A

(1) by increasing or decreasing gastric emptying time, (2) by changing the gastric pH, or (3) by forming drug complexes.

137
Q

Drugs that _______, such as laxatives, may cause an increase in gastric and intestinal motility and a decrease in drug absorption.

A

increase the speed of gastric emptying

138
Q

___ and ______ such as atropine decrease gastric emptying time and GI motility, causing an increase in absorption rate.

A

Opioids and anticholinergic drugs

139
Q

______ account for 70% of the body’s microbes. They play a major role in the absorption of drugs and nutrients and in the metabolism of bilirubin, bile acids, cholesterol, and steroid hormones as well as the synthesis of vitamins B and K.

A

GI bacteria

140
Q

A drug can increase the metabolism of another drug by ______.

A

stimulating liver enzymes

141
Q

Increased metabolism promotes ______ and decreases _______; the result is a ________.

A

drug elimination; plasma concentration of the drug; decrease in therapeutic drug action

142
Q

leads to an increase in hepatic enzyme activity and can increase theophylline clearance. Asthmatics who smoke and take theophylline to manage their disease may require an increase in theophylline dosage.

A

Chronic cigarette smoking

143
Q

a group of naturally occurring compounds found in the juice and pulp of citrus fruits, are potent inhibitors of the metabolism of certain drugs (carbamazepine, calcium channel blockers, and drugs for erectile dysfunction)

A

Flavanoids

144
Q

Drugs that decrease cardiac output decrease blood flow to the____; decreased blood flow results in decreased ____, which can decrease or delay drug excretion.

A

kidneys; GFR

145
Q

______ promote water and sodium excretion from the renal tubules. The renal loss of potassium can result in _____, which can alter the action of some drugs; for example, it can enhance the action of digoxin and can lead to toxicity.

A

Diuretics; hypokalemia

146
Q

With decreased renal or hepatic function, there is usually an _______. It is essential to closely monitor these patients for drug toxicity when they take multiple drugs.

A

increase in free drug concentration

147
Q

When two drugs are administered in combination, and the response is increased beyond what either could produce alone, the drug interaction is called an ______.

A

additive effect

148
Q

Additive effects can be:

A

desirable or undesirable

149
Q

When two or more drugs are given together, one drug can have a _______.

A

synergistic effect on another

150
Q

When drugs with antagonistic effects are administered together, one drug _______ the effect of the other.

A

reduces or blocks

151
Q

_____ may increase, decrease, or delay the body’s pharmacokinetic response to drugs.

A

Food

152
Q

______ is a potent vasoconstrictor, and when taken in conjunction with a MAOI, the result could be a hypertensive crisis.

A

Tyramine

153
Q

Nutritional deficiencies such as protein-energy malnutrition (PEM) like _____ and _____ may alter pharmacokinetic processes and drug responses, resulting in toxicity. Persons with either form of PEM may have decreased drug absorption and decreased protein binding, altered volume of distribution and biotransformation, and decreased drug elimination.

A

kwashiorkor and marasmus

154
Q

Drugs often interfere with clinical laboratory testing by _____, ______, ______.

A

cross-reaction with antibodies, interference with enzyme reactions, or alteration of chemical reactions.

155
Q

Drug-laboratory interactions may lead to ______, resulting in additional health care costs associated with unnecessary repeat laboratory testing or additional testing.

A

misinterpretation or invalidation of test results

156
Q

Drug-laboratory interactions may also lead to ________.

A

missed or erroneous clinical diagnosis

157
Q

A _______ is a skin reaction caused by exposure to sunlight.
It is caused most often by the interaction of a drug and exposure to ultraviolet A (UVA) light, which can cause cellular damage; however, ultraviolet B (UVB) light may also contribute.

A

drug-induced photosensitivity reaction

158
Q

The two types of photosensitivity reactions are:

A

photoallergic and phototoxic

159
Q

A ______ reaction occurs when a drug (sulfonamide) undergoes activation in the skin by UV light to a compound that is more allergenic than the parent compound. Because it takes time to develop antibodies, ______ reactions are a type of delayed hypersensitivity reaction.

A

photoallergic

160
Q

With a ______ reaction, a photosensitive drug undergoes photochemical reactions within the skin to cause damage. This type of reaction is not immune mediated. The onset of a _____ reaction with erythema can be rapid, occurring within 2 to 6 hours of sunlight exposure.

A

phototoxic

161
Q

Most photosensitive reactions can be avoided by using _____ with a sun protection factor (SPF) greater than __; avoiding excessive sunlight, especially at the height of the daylight hours; and wearing protective clothing.

A

sunscreen; 15

162
Q

Decreasing the drug dose may decrease the risk of _____ if treatment is required.

A

photosensitivity

PHARMACOLOGY (11 decks)

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