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OSCEs > Common Presentations > Flashcards

Common Presentations Flashcards

1
Q

aortic stenosis

A
  • signs/symptoms; slow rising pulse, narrow pulse pressure, heaving and undisplaced apex bear, harsh ejection systolic murmur with radiation to the carotids, signs of decompensation
  • causes; bicuspid valve, rheumatic heart disease, senile calcification
  • treatment; valve replacement if lv dysfunction or valve gradient >50mmhg at angiography or 60mmhg on echo
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2
Q

aortic regurgitation

A
  • signs/symptoms; collapsing pulse, wide pulse pressure, thrusting displaced apex beat, high-pitched early diastolic murmur
  • causes; rheumatic heart disease, bicuspid valve, infective endocarditis, aortic root dilation, inflammatoru causes including syphilis
  • treatment; valve replacement based on symptoms and response to medical therapy
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3
Q

mitral stenosis

A

think af
- signs/symptoms; af, tapping undisplaced apex beat, loud s1, mid-diastolic rumbling murmur at apex in left lateral position, accentuated by exercise, malar flush, opening snap

  • causes; rheumatic heart disease, congenital heart disease, carcinoid syndrome, sle
  • treatment; antigcoagulation for af, percutaneous balloon valvuloplasty, valvotomy, valve replacement
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4
Q

mitral regurgitation

A

think af
- signs/symptoms; thrusting displaced apex beat, soft s1, loud pansystolic murmur radiates to axilla, best in left lateral position, signs of decompensation

  • causes; rheumatic heart disease, ihd lv impairment and annular dilation, endocarditis, connective tissue disease, collagen disorders
  • treatment; valve replacement surgery considered if nyha 2 and medical management failed
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5
Q

cabg

A
  • internal mammary artery or long saphenous vein used as graft vessel
  • midline sternotomy scar
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6
Q

prosthetic valves

A
  • listen for metallic click and where it appears in each cycle
  • assess if midline sternotomy scar and whether cabg was also performed
  • may have been replaced percutaneously
  • tissue vs mechanical
  • look for signs of anticoagulation

mechanical

  • starr-edwards, ball and cage
  • bjork-shiley, pivoted single tilting disc
  • st judes, double tilting discs
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7
Q

pacemaker/icd

A

-always assess upper chest and axilla for pacemaker/icd

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8
Q

tricuspid regurgitation

A
  • look for tender pulsatile hepatomegaly
  • af
  • elevated jvp
  • pansystolic murmur

causes

  • congenital
  • rheumatic heart disease, rare
  • endocarditis
  • carcinoid syndrome
  • blunt trauma
  • secondary to left heart failure
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9
Q

hocm

A

autosomal dominant myosin defect with family history of sudden cardiac death

manage with beta blockers, calcium channel blockers and icd insertion

  • jerky peripheral pulse
  • forceful apex beat
  • ejection systolic murmur
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10
Q

coarctation

A

radial-radial or radial-femoral delay

  • bp discrepancies
  • systolic murmur
  • weak femoral pulses

congenital or iatrogenic

associated with a bicuspid aortic valve in 50%

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11
Q

asd/vsd

A
  • murmur
  • maladie de roger
  • vsd can progress to eisenmengers syndrome
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12
Q

dextrocardia

A

consider primary cilliary dyskinesia

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13
Q

eisenmengers

A

increased right sided pressure eventually leads to right-left shunt through vsd which is cyanotic

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14
Q

blalock-taussig shunt

A

used to partially correct tetralogy of fallot

- usually connects pulmonary arteries with right subclavian artery

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15
Q

pulmonary fibrosis

A 
b - berylliosis
r - radiation
e - extrinsic allergic alveolitis
a - ankylosing spondylitis/allergic bronchopulmonary aspergillosis
s - silicosis/sarcoidosis
t - tuberculosis

r - rheumatoid arthritis
a - asbestosis
i - idiopathic pulmonary fibrosis
d - drugs; belomycin, methotrexate, amiodarone, nitrofurantoin, hydralazine, busulphan

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16
Q

copd

A
  • not fully reversible airway obstruction
  • look for cor pulmonale, lung cancer, ihd and alpha 1 antitrypsin deficiency; neutrophil elastase
  • mild >80% fev1, moderate 50-79% fev1, severe 30-49% fev1, very severe <30% fev1
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17
Q

bronchiectasis

A

characterised by;

  • infection and bronchial oedema
  • inflammation and remodelling, hypertrophy and tortuosity of airways and vessels, and neovascularisation
  • difficulty clearing secretions and increased propensity to acute and chronic infection, and to haemoptysis

causes;

  • genetic; cf, marfans, kartagener
  • chronic lung disease eg copd
  • connective tissue disease; third of ra patients
  • chronic inflammatory disease eg ibd
  • chemical damage; recurrent acid reflux aspiration
  • focal bronchial obstruction
  • infection
  • hypogammaglobulinaemia
  • allergic bronchopulmonary aspergillosis
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18
Q

pneumonectomy/lobectomy

A

indications for lobectomy

  • lung cancer; clubbing may suggest
  • bronchiectasis; clubbing may suggest
  • chronic lung abscess
  • tb; peripheral calcified lymph nodes may suggest
  • benign tumours
  • fungal infections; life threatening haemoptysis due to aspergillus infection
  • congenital abnormalities

other cause of thoracotomy scars

  • oesophageal surgery
  • heart valve replacement
  • diaphragmatic repair
  • thoracic aortic aneurysm repair
  • anterior spinal tumour excision
  • latissimus dorsi flaps

consider vats; video assisted thorascopic surgery, if small scars consistent with port entry

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19
Q

pneumonia

A

Streptococcus pneumoniae (pneumococcus)

  • Accounts for 80% of cases
  • Particularly associated with high fever, rapid onset and herpes labialis
  • A vaccine to pneumococcus is available

Haemophilus influenzae
- Particularly common in patients with COPD

Staphylococcus aureus
- Often occurs in patient following influenza infection

Mycoplasma pneumoniae

  • One of the atypical pneumonias, which often present a dry cough and atypical chest signs/x-ray findings
  • Autoimmune haemolytic anaemia and erythema multiforme may be seen

Legionella pneumophilia

  • Another one of the atypical pneumonias
  • Hyponatraemia and lymphopenia common

Klebsiella pneumoniae
- Classically seen in alcoholics

Pneumocystis jiroveci

  • Typically seen in patients with HIV
  • Presents with a dry cough, exercise-induced desaturations and the absence of chest signs

assess using curb-65

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20
Q

pleural effusion

A

exudates

  • infection; bacterial, pneumonia, mycobacterial
  • malignancy; commonest cause in over 60s
  • pulmonary embolism
  • autoimmune; rheumatoid, lupus
  • pancreatitis; may be haemorrhagic
  • drugs
  • post cabg

transudates

  • cardiac failure; commonest cause overall and usually bilateral
  • cirrhotic liver disease
  • peritoneal dialysis
  • nephrotic syndrome
  • hypothyroidism

assess

  • microscopy and culture
  • cytology
  • ph; <7.2 indicates the need for a chest drain in a parapneumonic effusion
  • ldh and protein to characterise using lights criteria
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21
Q

lung cancer; especially pancoast

A
  • squamous cell carcinoma 35%; PTHrp, clubbing, HPOA
  • adenocarcinoma 30%; commonest in non-smokers
  • small cell carcinoma 15%; ADH, ACTH, lambert-eaton myasthenic syndrome
  • large cell carcinoma 10%
  • other 5%
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22
Q

pulmonary oedema

A
  • fluid in the alveolar spaces
  • kerley b lines
  • increased vascular shadowing in a bats wing distribution
  • upper lobe diversion
  • pleural effusions
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23
Q

sarcoidosis

A

systemic inflammatory granulomatous disease of unknown origin

respiratory

  • Stage I: bilateral hilar lymphadenopathy (BHL) alone
  • Stage II: BHL with pulmonary infiltrates
  • Stage III: pulmonary infiltrates without BHL
  • Stage IV: fibrosis
  • skin
  • heart
  • eye
  • nervous system
  • blood
  • bones, joints and muscles
  • endocrine/exocrine
  • gi/gu
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24
Q

hepatomegaly; painful/non-painful

A
  • cirrhosis
  • congestive cardiac failure
  • neoplastic; secondary and primary eg heptatoma
  • infective; acute viral hepatitis, liver abscess, hydatid cyst
  • polycystic disease
  • tricuspid regurgitation; pulsatile hepatomegaly
  • budd-chiari syndrome
  • haemochromatosis
  • infiltrative; amyloidosis, sarcoidosis
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25
Q

splenomegaly

A
  • hepatic cirrhosis with portal hypertension
  • myeloprolferative disorders; cml, myelofibrosis
  • lymphoma
  • infections; bacterial endocarditis, infectious mononucleosis, viral hepatitis, malaria, kala-azar, brucellosis
  • sle, ra; felty’s syndrome, scleroderma, sarcoidosis
  • haemolytic anaemias
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26
Q

hepatosplenomegaly

A
  • portal hypertension; cirrhosis, budd-chiari syndrome
  • chronic myeloid leukaemia; pyrexia, anaemia, petechial rash, ecchymoses
  • non-hodgkin’s leukaemia; lymphadenopathy, pyrexia
  • infective endocarditis; pyrexia, vasculitic rash, heart murmur
  • myelofibrosis; cachexia, petechiae
  • infiltrative conditions; amyloidosis, gaucher’s disease
  • granulomatous conditions; tb, sarcoidosis, gpa
  • other causes; malaria, kala-azar, schistosomiasis
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27
Q

chronic liver disease

A

causes

  • alcohol
  • viral; eg. hep b/c, cmv, ebv
  • metabolic; eg. nash, haemochromatosis, wilsons, alpha1 antitrypsin deficiency
  • autoimmune; eg. hepatitis, pbc, psc

complications

  • portal hypertension
  • synthetic dysfunction
  • hepatic encephalopathy
  • hepatorenal syndrome
  • hepatopulmonary syndrome
  • hcc, esp in chronic hep b
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28
Q

renal failure; rrt

A
  • haemodialysis; look for fistulae
  • peritoneal dialysis; look for tunneled line or port
  • renal transplant; look for scars

common causes of ckd

  • diabetes
  • glomerulonephritis eg iga nephropathy
  • reflux nephropathy
  • obstructive uropathy
  • renovascular disease
  • hypertension
  • polycystic kidney disease
  • others eg myeloma or amyloidosis
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29
Q

renal transplant

A

immunosupressive regimes

  • prednisolone
  • calcineurin inhibitor eg ciclosporin or tacrolimus
  • antiproliferative agent eg mycphenolate or azathioprine

complications of renal transplant

  • acute rejection
  • chronic rejection
  • opportunistic infection eg cmv
  • malignancy, particularly skin cancer
  • cardiovascular disease, hypertension and hyperlipidaemia
  • recurrence of primary renal disease
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30
Q

pckd

A

autosomal dominant inheritance

differential

  • bilateral hydronephrosis
  • amyloidosis
  • tuberous sclerosis
  • von hippel-lindau disease

associations

  • cysts of pancreas liver and spleen
  • mitral valve prolapse and aortic regurgitation
  • berry aneurysms and sa bleeds
  • pkd-1/2 gene on chromosome 16

ultrasound is investigation of choice

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31
Q

post-operative abdo patient

A

complications of surgery

  • shock
  • haemorrhage
  • wound infection
  • dvt
  • atelectasis
  • urinary retention
  • analgesia complications
  • anastamotic leakage
  • visceral structure perforation or damage

colorectal cancer surgery resections

  • Caecal, ascending or proximal transverse colon = right hemicolectomy
  • Distal transverse, descending colon = left hemicolectomy
  • sigmoid colon = high anterior resection
  • upper rectum = anterior resection (tme)
  • low rectum = anterior resection (low tme)
  • anal verge = abdomino-perineal excision of rectum
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32
Q

parkinson’s disease

A
  • idiopathic parkinsons disease
  • drug-induced parkinsonism eg. antipsychotics, metoclopramide
  • progressive supranuclear palsy (tau)
  • multi-system atrophy (alpha synuclein)
  • lewy-body dementia (lewy bodies)
  • vascular parkinsons
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33
Q

cerebellar examination

A

main causes of cerebellar symptoms

  • stroke
  • tumour
  • degenerative
  • congenital
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34
Q

proximal myopathy

A

causes

  • duchenne muscular dystrophy
  • thyroid disease
  • parathyroid dysfunction
  • addison’s diseasea
  • cushings disease
  • hypokalaemia
  • dermatomyositis
  • polymyositis
  • statins and other drugs
  • infections eg hiv
  • polymyalgia rheumatica (muscle tenderness as well)
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35
Q

peripheral neuropathy

A
  • Genetic diseases: Friedreich’s ataxia, Fabry disease,Charcot-Marie-Tooth disease, hereditary neuropathy with liability to pressure palsy
  • Metabolic and endocrine diseases: diabetes mellitus, chronic kidney failure, porphyria, amyloidosis, liver failure, hypothyroidism
  • Toxic causes: drugs (vincristine, metronidazole, phenytoin, nitrofurantoin, isoniazid, ethyl alcohol, statins), organic herbicides TCDD dioxin, organic metals, heavy metals, excess intake of vitamin B6 (pyridoxine). Peripheral neuropathies also may result from long term (more than 21 days) treatment with Linezolid (Zyvox).
  • Adverse effects of fluoroquinolones: irreversible neuropathy is a serious adverse reaction of fluoroquinolone drugs
  • Inflammatory diseases: Guillain–Barré syndrome,systemic lupus erythematosus, leprosy, multiple sclerosis, Sjögren’s syndrome, Babesiosis, Lyme disease, vasculitis, sarcoidosis,
  • Vitamin deficiency states: Vitamin B12 (Methylcobalamin), vitamin A, vitamin E, vitamin B1 (thiamine)
  • Physical trauma: compression, pinching, cutting, projectile injuries (for example, gunshot wound), strokes including prolonged occlusion of blood flow, electric discharge, including lightning strikes
  • Effect of chemotherapy - see Chemotherapy-induced peripheral neuropathy
  • Exposure to Agent Orange
  • Others: electric shock, HIV, malignant disease, radiation, shingles, MGUS (Monoclonal gammopathy of undetermined significance).
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36
Q

multiple sclerosis

A

.

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37
Q

polio

A

.

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38
Q

mixed umn and lmn signs

A
  • mnd
  • friedrich’s ataxia
  • conus medullaris
  • scdc
  • taboparesis
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39
Q

stroke

A

assess for;

  • hemiplegia
  • cortical signs; hemianopia, expressive or receptive dysphasia, sensor inattention

taci - hemiplegia, hemianopia and at least one other cortical sign

paci - hemiplegia and one other cortical sign

laci - lacunar infarct, hemiplegia without cortical signs

assess for posterior circulation infarcts concerning visual loss and cerebellar syndromes

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40
Q

essential tremor/postural tremor

A

.

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41
Q

myotonic dystrophy

A

.

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42
Q

syringomyelia

A

.

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43
Q

foot drop

A

L5 and common peroneal

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44
Q

charcot-marie-tooth

A

.

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45
Q

friedrich’s ataxia

A

.

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46
Q

spastic paraparesis

A

.

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47
Q

spina bifida

A

.

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48
Q

cerebral palsy

A

.

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49
Q

internuclear ophthalmoplegia

A

medial longitudinal fasciculus syndrome

  • defect in adducion of the ipsilateral eye
  • nystagmus in the contralateral eye
  • double vision on looking away from the side of the lesion
  • associated with multiple sclerosis
  • steroids induce remission
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50
Q

relative afferent pupillary defect

A

.

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51
Q

bell’s palsy

A

.

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52
Q

field defects

A

.

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53
Q

myasthenia gravis

A

.

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54
Q

thyroid eye disease

A

.

55
Q

horner’s syndrome

A

.

56
Q

bulbar/pseudobulbar palsy

A

bulbar palsy; lmn

  • nasal, atrophic, decreased jaw jerk, -ve gag
  • vascular; meedullary infarct
  • degenerative; mnd
  • infective; gbs, lyme disease, polio
  • malignant; brainstem glioma
  • toxin; botulism

pseudobulbar palsy; umn, bilateral

  • slow spastic, increased jaw jerk
  • brainstem stroke; corticobulbar
  • mnd
  • ms
57
Q

complex ophthalmoplegia

A

.

58
Q

cerabello-pontine angle syndrome

A

.

59
Q

cavernous sinus syndrome

A

Cavernous sinus syndrome is characterized by multiple cranial neuropathies. The clinical presentation includes impairment of ocular motor nerves, Horner’s syndrome, and sensory loss of the first or second divisions of the trigeminal nerve in various combinations. The pupil may be involved or spared or may appear spared with concomitant oculosympathetic and parasympathetic involvement. Various degrees of pain may be involved

60
Q

jugular foramen syndrome

A

palsies of cranial nerves 9-11 with/without 12

caused by;

  • glomus tumours
  • meningiomas
  • acoustic neuromas
61
Q

hip oa; replacement

A

.

62
Q

trendelenburg gait positive

A

weakness of the abductor muscles of the lower limb

63
Q

trochanteric bursitis

A

.

64
Q

knee oa; replacement

A

.

65
Q

acl tear

A

.

66
Q

knee ra

A

.

67
Q

rheumatoid hands

A

.

68
Q

dupuytrens contracture

A

flexion contracture of the hand due to a palmar fibromatosis

associated with;

  • men
  • smoking
  • hand trauma
  • manual work
  • family history
  • alcoholics
  • epilepsy
  • diabetes
  • hiv
69
Q

hand oa

A

.

70
Q

ulnar/median/radial lesions

A

.

71
Q

marfans syndrome

A

fibrillin-1 gene

72
Q

scleroderma

A

Limited cutaneous systemic sclerosis

  • Raynaud’s may be first sign
  • scleroderma affects face and distal limbs predominantly
  • associated with anti-centromere antibodies
  • a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

Diffuse cutaneous systemic sclerosis

  • scleroderma affects trunk and proximal limbs predominantly
  • associated with scl-70 antibodies
  • hypertension, lung fibrosis and renal involvement seen
  • poor prognosis

Scleroderma (without internal organ involvement)
- tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear

Antibodies

  • ANA positive in 90%
  • RF positive in 30%
73
Q

acj oa

A

.

74
Q

painful arc syndrome

A

.

75
Q

rotator cuff problems

A

.

76
Q

apprehension test positive

A

.

77
Q

ankylosing spondylitis

A
  • seronegative arthopathy
  • hla-b27
  • bamboo spine
  • dagger spine
  • sacro-iliac fusion
78
Q

spine; fusion

A

.

79
Q

varicosities

A

dilated tortuous vessels of the superficial venous system

80
Q

saphena varix

A
  • A saphena varix is a dilation of the saphenous vein at its junction with the femoral vein in the groin. Saphena varix is a common surgical problem. Patient can present with a groin swelling due to saphena varix.

It displays a cough impulse and may be mistaken for a femoral hernia. However it has a bluish tinge and disappears on lying down. On auscultation a venous hum may be heard. It is frequently associated with varicose veins. Saphena varix can be easily diagnosed by ultrasound. Saphena varix shows flow on duplex ultrasonography.

81
Q

previously stripped veins

A

.

82
Q

arterial disease

A
  • pallor
  • pain
  • paraesthesia
  • pulselessness
  • paralysis
  • poikilothermia; cold
83
Q

fem-pop bypass

A

.

84
Q

fem-fem bypass

A

.

85
Q

amputations

A

.

86
Q

multi-nodular thyroid

A

.

87
Q

graves’ disease

A

.

88
Q

hypo/hyperthyroidism

A

.

89
Q

single thyroid nodule/cyst

A

.

90
Q

parotid tumour

A

.

91
Q

post-breast surgery

A

.

92
Q

fibroadenoma

A

.

93
Q

fibrocystic disease of the breast

A

.

94
Q

breast carcinoma

A
  • suspensary ligaments of cooper

- triple assessment; clinical examination, fine needle biopsy, uss or mammography dependant on breast density

95
Q

paget’s disease of the nipple

A

.

96
Q

inguinal hernia

A

.

97
Q

hydrocele

A

.

98
Q

varicocele

A

.

99
Q

testicular cancer

A

.

100
Q

arterial ulcers

A
  • small
  • deep
  • regular
  • painful
  • pressure areas
101
Q

venous ulcers

A
  • large
  • shallow
  • irregular
  • painless
  • medial gaiter region
102
Q

neuropathic ulcers

A

think diabetes

103
Q

inflammatory ulcers

A

pyoderma

104
Q

infective ulcers

A

.

105
Q

necrobiosis lipoidica

A
  • shiny, painless areas of yellow/red skin typically on the shin of diabetics
  • often associated with telangiectasia
106
Q

colostomy

A

loop colostomy

  • To defunction a distal segment of colon
  • Since both lumens are present the distal lumen acts as a vent

end colostomy
- Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable

107
Q

ileostomy

A

both usually in right iliac fossa

loop ileostomy

  • Defunctioning of colon e.g. following rectal cancer surgery
  • Does not decompress colon (if ileocaecal valve competent)

end ileostomy

  • Usually following complete excision of colon or where ileocolic anastomosis is not planned
  • May be used to defunction colon, but reversal is more difficult
108
Q

ileal conduit

A

urostomy formed from refashioned ileum

109
Q

parastomal hernia

A

.

110
Q

abdominal surgical scars

A 
kochers
- cholecystectomy
rooftop/mercedes-benz
- liver tranplant
midline
- aaa
- laparotomy
lanz incision
- appendicectomy
groin incision
- inguinal hernia
left paramedian
- colectomy
pfannenstiel
- cystectomy
- prostatectomy
vertical groin incision
- femoral artery
- embolectomy
111
Q

inguinal hernia

A

indirect; patent processus vaginalis
direct; defect in hesselbach’s triangle

  • Medial border: Lateral margin of the rectus sheath, also called linea semilunaris
  • Superolateral border: Inferior epigastric vessels
  • Inferior border: Inguinal ligament, sometimes referred to as Poupart’s ligament
112
Q

femoral hernia

A
  • more common in females
  • high risk of strangulation
  • located below inguinal ligament lateral to the pubic tubercle
113
Q

epigastric hernia

A
  • Lump in the midline between umbilicus and the xiphisternum

- Most common in men aged 20-30 years

114
Q

divarification of the recti

A

Diastasis of this muscle occurs principally in two populations: newborns and pregnant women. It is also known to occur in men.

115
Q

umbilical hernia

A

Symmetrical bulge under the umbilicus

Associations

  • Afro-Caribbean infants
  • Down’s syndrome
  • mucopolysaccharide storage diseases

usually resolve on their own by 3 years of age

116
Q

paraumbilical hernia

A

Asymmetrical bulge - half the sac is covered by skin of the abdomen directly above or below the umbilicus

117
Q

incisional hernia

A

May occur in up to 10% of abdominal operations

118
Q

spigelian hernia

A

Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)

119
Q

sle

A

.

120
Q

nf1/2

A

.

121
Q

haemochromatosis

A

.

122
Q

wilson’s disease

A

.

123
Q

osteogenesis imperfecta

A

.

124
Q

marfans syndrome

A

.

125
Q

acromegaly

A

.

126
Q

ehlers-danlos syndrome

A

.

127
Q

cushing’s syndrome

A

.

128
Q

addison’s

A

.

129
Q

scleroderma

A

.

130
Q

hereditary haemorrhagic telangiectasia

A

.

131
Q

peutz-jeughers syndrome

A

.

132
Q

sturge-weber syndrome

A

rare, port wine stain on face and neurological feature; most notably seizure activity from early age, associated with learning difficulty

133
Q

tuberous sclerosis

A

autosomal dominant

Cutaneous features;

  • depigmented ‘ash-leaf’ spots which fluoresce under UV light
  • roughened patches of skin over lumbar spine (Shagreen patches)
  • adenoma sebaceum (angiofibromas): butterfly distribution over nose
  • fibromata beneath nails (subungual fibromata)
  • café-au-lait spots* may be seen

Neurological features;

  • developmental delay
  • epilepsy (infantile spasms or partial)
  • intellectual impairment

Also;

  • retinal hamartomas: dense white areas on retina (phakomata)
  • rhabdomyomas of the heart
  • gliomatous changes can occur in the brain lesions
  • polycystic kidneys
  • renal angiomyolipomata
  • lymphangioleiomyomatosis: multiple lung cysts
134
Q

dermatomyositis

A

idiopathic inflammatory myopathy characterised by;

  • heliotrope rash
  • gottron’s papules
  • muscle weakness; no pain

related to polymyositis

  • anti-jo antibody

OSCEs (17 decks)

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