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Clin Med Exam 1 (Lauren) > Lectures 1-3 > Flashcards

Lectures 1-3 Flashcards

1
Q

Are the red scaling patches of atopic dermatitis well defined or ill defined?

A

Ill defined

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2
Q

What are some long term complications from SJS/TEN?

A

Scarring/contracture of skin
Vision loss/eye problems
Pulmonary complications

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3
Q

What is onychomycosis?

A

Infection of the nail by:
Fungus
Yeast
Non-dermatophyte molds

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4
Q

What color is tinea versicolor

A

Variety of colors!
Hypopigmented
Hyperpigmented
Erythematous

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5
Q

Clinical manifestation of melanoma?

A

Most de novo, with some arising from pre-existing nevus
Usually asymptomatic
Pigmented papule, plaque or nodule

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6
Q

DDx for BCC?

A

Sebaceous Hyperplasia- enlarged oil gland with central clearing.

Fibrous Papule-benign angiofibroma. Skin colored/pink papule on nose. No telangiectasia and lacks pearly texture.

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7
Q

On infants, is atopic dermatitis on the flexor surfaces or extensor surfaces?

A

Starts on extensor surfaces then moves to flexor surfaces once they start crawling/walking

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8
Q

Burning stinging pain on hands is associated with which skin condition

A

Irritant contact dermatitis

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9
Q

Presentation of proximal subungual onychomycosis

A

Starts near cuticle and progresses out
Uncommon
Usually seen in VERY immunocompromised ppl (like AIDS)

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10
Q

Is sweat isotonic or hypotonic?

A

It starts isotonic with plasma, but due to electrolyte reabsorption in duct, it becomes hypotonic

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11
Q

What is intertrigo

A

Any inflammatory condition of two closely opposed (intertriginous) skin surfaces
-often due to candida species

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12
Q

What might a patient report before a drug eruption?

A

A prodrome involving fever, malaise, flu-like symptoms

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13
Q

Which is more common, distal or proximal subungual onychomycosis?

A

Distal, by far

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14
Q

Why does tylenol get blamed for SJS/TEN?

A

Because people take tylenol for the prodrome they feel for 1-3 days before rash erupts and they blame it on that.

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15
Q

Which layer of epidermis has keratinization?

A

Stratum granulosum

Some cancers start here

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16
Q

Tx of nondermatophyte onychomycosis

A

Oral itraconazole
6wks for fingernails
12 wks for toes

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17
Q

What skin condition is associated with occupations like bartenders, hairdressers, cleaning ladies?

A

Irritant contact dermatitis

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18
Q

What does SJS/TEN look like before skin starts sloughing off?

A

TENDER red and purple macules with blisters

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19
Q

Clinical presentation of tinea corporis

A

Pruritic, annular, erythematous plaque
(Itchy, red, round plaque)
Central clearing **
RAISED advancing border (touch it)

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20
Q

What does a drug eruption look like

A

Erythematous macules and papules

Measles-like

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21
Q

Diagnosis of tinea versicolor

A 
KOH prep
Woods lamp (1/3 of them glow yellow-green) not very useful
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22
Q

What is Leser-Trelat sign?

A

Sudden onset of multiple SKs with inflammatory base
+skin tags
+acanthosis nigricans
=possible association with GI and lung cancers

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23
Q

What is the dominant symptom of allergic contact dermatitis?

A

Itch

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24
Q

Difference between acute and chronic tinea pedis?

A

Acute-self limited, intermittent, recurrent infection. Itchy painful blisters following sweating with 2* staph infections common.
Chronic- slowly progressive infx that persists indefinitely. Interdigital fissures and erosions/scales between toes (especially 3rd and 4th)

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25
Q

Clinical presentation of tinea capitis?

A

Scaly patches with hair loss
Hair loss with black dots
Widespread scaling w. Minimal hair loss
Kerion (boggy, edematous, painful plaque)
Favus (multiple cup shaped yellow crusts aka scutula)

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26
Q

Who is at risk for scabies infection

A

EVERYONE

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27
Q

Most common cell in epidermis?

A

Keratinocytes

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28
Q

Risk factors for Malignant melanoma?

A 
Genetic predispostion
Prolonged UV exposure 
Fair skin/hair/eyes
Immunosuppressed
6+ atypical nevi
26+ regular nevi
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29
Q

How long after taking a drug will a drug eruption occur

A

5-14 days

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30
Q

What are 5 common drugs that can cause drug eruptions?

A 
Penicillins
Cephalosporins
Sulfonamides
Carbamazepine
Phenytoin
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31
Q

What types of cells are in the hypodermis (subcutis)

A

Fibroblasts, adipose, and macrophages

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32
Q

What is distinctly different about SJS/TEN vs drug hypersensitivity syndrome?

A

SJS/TEN involves mucous membranes

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33
Q

Where is it NOT OK to use high potency steroids?

A

Face
Skin folds
Genitalia

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34
Q

Risk factors for tinea versicolor

A

Tropical climate
Adolescents
Hyperhidrosis
Immunosuppression

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35
Q

What are the 2 types of severe cutaneous adverse reactions?

A
  • drug hypersensitivity syndrome

- Stevens-Johnson/Toxic Epidermal Necrolysis

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36
Q

Where does tinea cruris begin?

A

Inguinal fold

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37
Q

What area is usually spared by atopic dermatitis in children?

A

DIAPER AREA

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38
Q

Treatment for solar lentigo?

A

No treatment required

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39
Q

Treatment of tinea versicolor

A 
Topical:
Clotrimazole x 2 weeks
Selenium sulfide x 1 week (shampoo, lotion, foam)
Zinc pyrithione shampoo x 2 weeks
Systemic:
Itraconazole
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40
Q

Appearance of tinea versicolor

A

Macules, patches, plaques on trunk & arms
Often have a fine scale
Can coalesce into a big patch
Might itch

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41
Q

What is the gold standard treatment for atopic dermatitis?

A

Petroleum (Vaseline) applied twice a day and right after bathing

Goal is to hydrate the skin with emollients

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42
Q

What are important features (not essential) of atopic dermatitis that would add support to your diagnosis?

A

Atopy (predisposition to developing allergic hypersensitivity rxns)
Early age of onset
Xerosis (dry skin)

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43
Q

What is a solar lentigo

A

“Age spot”
Flat, brown macule
Often in groups
Well circumscribed

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44
Q

What does nummular eczema look like?

A

Coin shaped red lesions

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45
Q

Features of nodular melanoma

A

AGGRESSIVE
Nodule is INFLAMED AND FRIABLE
Rapid vertical growth

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46
Q

Who should get systemic treatment for tinea corporis

A
  • immunocompromised
  • failed topical tx
  • tinea corporis gladiatorum (no participation for 10-15 days) (athletes are eager to get back)
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47
Q

What does irritant contact dermatitis look like?

A

Dry, red chapped skin with fissuring

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48
Q

Keratosis Pilaris is a disorder of what

A

Keratinization

Keratinocytes don’t slough off right

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49
Q

Associated signs of tinea capitis?

A
  1. Swollen cervical nodes
  2. Dermatophytid rxn-eczema like rxn after starting tx
  3. Erythema nodosum- leg lesions (rare)
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50
Q

From where does BCC arise?

A

Basal layer of epidermis (least concerning)

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51
Q

What will happen if you treat tinea corporis with a steroid?

A

It gets worse (mojocchi’s granuloma)

+you waste money

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52
Q

What is a positive Nikolsky sign?

A

Skin blisters and separates as a result of gentle mechanical pressure on the skin

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53
Q

Features of superficial spreading melanoma?

A 
Most common subtype (70%)
Confined to epidermis
Grows out not up
Younger people
Men:back
Women: back and legs
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54
Q

Where is atopic dermatitis usually found in infants?

A

CHEEKS
Trunk
Extremities

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55
Q

What skin condition is an example of a DELAYED hypersensitivity reaction

A

Allergic contact dermatitis

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56
Q

How is SJS/TEN diagnosed?

A

Clinically initially: blisters in mouth, been feeling feverish, has the rash…

Then,
biopsy looking for 2* infections
Culture blood, wound, mucosal lesions

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57
Q

Diagnosis of actinic keratoses?

A

Typically based on appearance and texture.
If over 1cm, rapidly growing, ulcerated or painful, you should biopsy.
If over 6mm, consider SCC in situ.

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58
Q

Clinical presentation of tinea cruris

A
  • WELL MARGINATED, scaly round plaque with a RAISED border
  • extends from inguinal fold to inner thigh
  • scrotum typically spared
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59
Q

Presentation of white superficial onychomycosis

A
  • starts w dull white spots on nail
  • spreads OUT over entire nail
  • soft lesions that can be scraped for sampling
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60
Q

Poison ivy, oak, and sumac contain what oil that causes allergic contact dermatitis 12-24hrs later?

A

Urushiol oil

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61
Q

Is irritant contact dermatitis an immune response?

A

No

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62
Q

Most common type of skin cancer?

A

Basal cell carcinoma

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63
Q

What effect does more melanin have on skin tone and vitamin D production?

A

Darker skin tone

Difficulty synthesizing vitamin d

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64
Q

Where is the Basement Membrane Zone

A

Between the epidermis and dermis.

It is a barrier for malignant cells.

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65
Q

What distinguishes SJS from TEN?

A

SJS is less than 10% surface area
TEN is more than 30% surface area

(SJS/TEN overlap if 10-30%)

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66
Q

Where is dyshidrotic eczema found

A

Hands, sides of fingers, palms/soles

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67
Q

Treatment of Tinea capitis

A

Systemic anti fungal therapy- Griseofulvin x 6-12 weeks

Tx of choice for Microsporum genus or EMPIRIC tx

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68
Q

Treatment of tinea pedis

A

Clotrimazole x 4 wks (topical)
itraconazole (oral) for chronic/extensive disease.
+Burow’s wet dressings for vesiculation/maceration 20 min 2-3x/day
+foot powder/better shoes etc
(SIMILAR to tinea corporis but typically requires longer tx bc its stubborn)

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69
Q

4 layers of epidermis

A 
Stratum corneum
Stratum lucidum *palms/soles
Stratum granulosum 
Stratum spinosum
Stratum basale

“Come lets get sun burned”

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70
Q

Dermatitis and Eczema are used interchangeably, but dermatitis is most often used to describe ____ causes

A

Exogenous.

Ex: irritant contact dermatitis, allergic contact dermatitis, seborrheic dermatitis etc

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71
Q

How do you treat pubic lice?

A

Permethrin 1%, repeat in 10 days (same stuff as for scabies but less potent)
Treat sex partners
Take detailed sexual history because they have another STI 30% of the time

72
Q

Management of multiple actinic keratoses?

A

Field treatment:

  • photodynamic therapy
  • Topical 5-FU
  • Imiquimod (Aldara)
73
Q

Can sarcoptes scabei mites live away from a host

A

Yes for 3 days

74
Q

What is the treatment for dyshidrotic eczema?

A
  • Reassurance (2-3 wks spontaneous remission)
  • topical steroids
  • wet dressings (Burows soaks)
75
Q

Concern with actinic keratoses?

A

Precancerous. 8% progress to SCC.

76
Q

What is the treatment for eczema herpeticum?

A

Prompt treatment with an antiviral (acyclovir/valacyclovir)

its herpes

77
Q

Hallmark of Actinic Keratosis

A

Feels like sandpaper

78
Q

Where is atopic dermatitis usually found on older children/adults?

A

Flexor surfaces and backs of hands/feet

Neck

79
Q

How do you treat lichen simplex?

A

You have to stop the itch-scratch cycle!

  • high potency topical steroids (thick skin)
  • moisturizers
  • SSRI’s (histamine effect)
  • hydroxyzine or doxepin for sedative effect that prevents nighttime scratching
80
Q

Colloquial name for tinea pedis?

A

Athletes foot

81
Q

What does Keratoacanthoma look like?

A

RAPID GROWTH over 6-8 was

Round, flesh colored nodule with CENTRAL KERATIN PLUG

82
Q

Treatment of tinea corporis

A

Clotrimazole x 2 wks (at least)

Systemic tx for special cases: Itraconazole

83
Q

What is a Type IV pathogenetic mechanism?

A

Delayed sensitivity

24-48 hrs after exposure. Cell mediated immunity

84
Q

What is the concern with a lesion that never heals?

A

SCC

85
Q

What causes tinea versicolor

A

Overgrowth of NORMAL fungal skin flora that transforms into the mycelial form

86
Q

What kind of cell gives rise to Squamous cell carcinoma?

A

keratinocytes

87
Q

How is atopic dermatitis diagnosed?

A

Clinical diagnosis based on history, morphology and distribution

88
Q

What percentage of Rxs written for a new medication cause a drug eruption

A

2%

89
Q

What drugs do you treat candidal intertrigo with

A

Topical nystatin

Itraconazole (oral) for resistant/severe cases

90
Q

What is the pathognomic sign of scabies?

A

Burrow

91
Q

Other treatments for tinea cruris?

A
  • treat concomitant tinea pedis and/or onychomycosis
  • daily talcum powder
  • avoid tight clothing
  • weight loss
  • avoid hot baths? (Hot water might irritate skin)
92
Q

Clinical presentation of BCC

A

Pearly, shiny
Telangiectasia
Rolled border

93
Q

Where does sweat from apocrine glands go?

A

Into hair follicles. it is odorless at first. Becomes smelly when bacteria eats it.

94
Q

Management of isolated actinic keratosis?

A
  • Isolated lesion: CRYOTHERAPY or surgical intervention

- May resolve spontaneously, but could reoccur

95
Q

3 main layers of skin

A

Epidermis
Dermis
Hypodermis

96
Q

What medications commonly cause SJS/TEN?

A

Allopurinol
Anticonvulsants (phenobarbital, phenytoin, carbamazepine, lamotrigine)
Sulfonamides (Bactrim)
NSAIDs

97
Q

Presentation of distal subungual onychomycosis?

A
  • white/brown/yellow starts at distal corner and spreads toward the cuticle
  • usually starts with big toe
  • end of nail breaks, exposing nail bed
98
Q

How is scabies transmitted?

A

Direct contact

99
Q

What is included in the atopic triad?

Group of 3 diseases that all come together

A

Atopic dermatitis
Allergic rhinitis
Asthma
(In this order known as atopic march)

100
Q

Features of acral lentiginous melanoma

A 
AFRICAN/ASIAN ancestry (dark skin)
Spreads out, then grows up
Usually males
Large due to delay in dx
Often palmar, plantar, or subungual

BOB MARLEY

101
Q

When is atopic dermatitis usually diagnosed?

A

before age 5

60% are in the first year of life!

102
Q

What two things make dyshidrotic eczema worse?

A

Emotional stress and hot weather

103
Q

Features of Lentigo maligna

A

Common in OLD PEOPLE
Slowly grows out, but rapidly grows UP
Usually remains more superficial

104
Q

What is the main prescribed treatment for atopic dermatitis?

A

Topical steroids, increasing the potency accordingly based on the severity of the eczema

105
Q

What condition is associated with a positive nikolsky sign?

A

SJS/TEN

106
Q

What does dishydrotic eczema look like?

A

Tapioca.

Deep seated vesicles that coalesce and rupture.

107
Q

Considerations for tx of onychomycosis

A

Topical medications usually don’t work

HIGH RATES of failure/recoccurence

108
Q

What type of reaction is allergic contact dermatitis?

A

Delayed-type hypersensitivity reaction. CELL MEDIATED.

109
Q 
TBSA of:
Head: 
1 arm:
1 leg:
Back:
Torso: 
Genitals:
A 
Head: 9%
1 arm: 9%
1 leg: 18%
Back: 18%
Torso: 18%
Genitals: 1%
110
Q

Reasons to treat onychomycosis

A
  • history of cellulitis
  • diabetic
  • cosmetic
  • pain/discomfort
111
Q

What are the essential features that must be present in order to make a diagnosis of atopic dermatitis

A
  1. Pruritus

2. Eczema with typical morphology and age specific patterns, as well as a chronic or relapsing history.

112
Q

What complication of atopic dermatitis involves thickening/deepening of skin lines?

A

Flexural lichenification

113
Q

Pharmacological treatment of tinea cruris

A

Topical: clotrimazole

Resistant cases: oral itraconazole

114
Q

What are important questions to ask the pt in the evaluation of any rash?

A 
Who
What 
When
Where
Why
Associated symptoms (itch, pain,fever)
STI risk
115
Q

What can you prescribe for contact dermatitis?

A

Topical steroids for 1-2 wks

But you should consider prednisone if it involves the face or more than 20% body surface area (.5-1mg/kg)

116
Q

What is a Type III pathogenetic mechanism?

A

Immune Complex

Antigen-antibody complexes cause tissue inflammation. IgG or IgM.

117
Q

Topical steroids are grouped based on potency. Which group is the most potent?

A

Group 1 is super high potency

Group 7 is least

118
Q

What does seborrheic keratosis look like?

A

“Barnacle of aging”
-Tan to black, Warty, waxy, “stuck on” appearance

  • Well demarcated, oval/round/irregular shape
  • Common on chest back head and neck
119
Q

Dermatitis and eczema can be used interchangeably, but eczema is more often used to describe _____

A

Endogenous disease

Ex: atopic eczema, nummular eczema, etc

120
Q

Presentation of candidal intertrigo?

A
  • erythematous, macerated plaques and erosions
  • Satellite papules/pustules
  • fine peripheral scaling
121
Q

So if you can’t put steroids on face or in skin folds, what topical treatment can you prescribe for atopic dermatitis?

A

Topical calcineurin inhibitors
Which is a cream/ointment that ends in “-crolimus”
(Trade names: Elidel or Protopic)

122
Q

What group of people has a 100-fold increase of SJS/TEN incidence?

A

HIV+

123
Q

Pharm treatments of scabies

A

Topical or systemic tx:
Permethrin 5%-slather all over once and then again 10-14 days later
OR
Oral ivermectin-single dose repeated two weeks later

124
Q

What type of antibodies are associated with atopic dermatitis?

A

IgE (the ones attached to mast cells)

125
Q

What causes lichen simplex chronicus/neurodermatitis?

A

excessive scratching or rubbing

126
Q

Who is most at risk for getting tinea capitis?

A

Children,
African-Americans
Decreased personal hygiene
Overcrowding

127
Q

What should pt education about scabies involve?

A
  • postscabetic itch can persist for 2 wks
  • close contacts and housemates must be treated as well
  • wash linens in hot water and dry under high heat
  • oral antihistamines and emollients can provide relief
128
Q

ABCDEs of melanoma?

A 
A-asymmetry
B-border (uneven borders bad)
C-color (multiple colors bad)
D-Diameter (bigger than .25 inch bad)
E-evolving
129
Q

Other name for tinea versicolor

A

Pityriasis versicolor

130
Q

Who is more likely to get tinea corporis?

A

Caregivers for children with tinea capitis

Athletes w. Skin to skin contact (tinea corporis gladiatorum)

Immunocompromised ppl

131
Q

What are the most common types of drug eruptions (appearance-wise)?

A

Morbilliform (measles like)
Exanthematous

-basically a widespread measles-like rash

132
Q

Management of keratoacanthoma?

A

Majority resolve spontaneously in 6-9 months

BUT you are too stupid to differentiate from SCC so you will biopsy these.

133
Q

What is Norwegian scabies

A

Crusty, fissured, extreme scabies in the immunocompromised

Fissures provide route for bacterial infection too

134
Q

What causes scabies

A

Sarcoptes scabei mite

135
Q

Tx of dermatophyte onychomycosis

A

Oral terbinafine
6wks for fingernails
12wks for toes

136
Q

What skin condition causes a dry, leathery appearance with exaggerated skin markings and pigmentation?

A

Lichen simplex chronicus

137
Q

If a kid has a rash all around their lips cause they lick them all day, what condiiton is that’/

A

Irritant contact dermatitis

138
Q

What are the fatal complications of SJS/TEN?

A

Infection of skin, lungs, mucus membranes, septicemia **

Dehydration & malnutrition 
GI ulceration/perforation
Shock/organ failure
Thromboembolism
Acute respiratory distress syndrome
139
Q

Most common cause of onychomycosis in fingernails

A

Yeast, usually Candida albicans

May cause chronic paronychia-infection of nail margin/cuticle

140
Q

Nickel, latex, cosmetics, preservatives, and neomycin can cause what skin condition?

A

Allergic contact dermatitis

141
Q

What is the most common dermatophytosis in the world?

A

Tinea pedis

142
Q

Side effects of topical steroids

A 
Pigment changes
Atrophy
Striae
Bruising
Tenlangiectasias
143
Q

Clinical presentation of SCC?

A 
Scaly
Exophytic (grows out)
Indurated (hardened)
Friable
Often appears warty
144
Q

What are some other presentations of chronic tinea pedis?

A

Moccasin ringworm-sharp demarcation around whole foot w/accumulated scale in skin creases.

Tinea manuum-two feet, one hand

145
Q

What type of reaction is drug eruptions

A

TYPE IV DELAYED TYPE IMMUNE REACTIONS

CELL MEDIATED

146
Q

With SJS/TEN, should the pt keep taking the offending medication?

A

No lol

147
Q

4 types of melanoma?

A

Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous

148
Q

Is tinea versicolor contagious

A

No

149
Q

Where are Merkel cells and what do they do?

A

They are in the epidermis and are for perception of light touch. Abundant in fingertips.

150
Q

What is a dermatophyte?

A

Fungus that causes infection

Tinea capitis, tinea corporis, tinea cruris, tinea pedis

151
Q

What type of reaction is atopic dermatitis?

A

Type 1 Hypersensitivity

IgE Mediated

152
Q

How do you know if you have SCC in situ?

A

Only from biopsy

153
Q

What is a Type I pathogenetic Mechanism?

A

Immediate/anaphylaxis

Allergic reaction involving IgE, Mast cells, basophils, hives, laryngeal spasm, edema

154
Q

What are the 2 types of contact dermatitis?

A

Allergic Contact Dermatitis

Irritant contact dermatitis

155
Q

Which type of contact dermatitis is associated with papules, blisters and edema?

A

Allergic contact dermatitis

156
Q

Treatment of melanoma

A

WIDE SURGICAL EXCISION IS GOLD STANDARD with 2cm of clear margins

-lymph node biopsy,
Chemotherapy, immunotherapy, gene therapy, follow up every 3 months

157
Q

What is the colloquial name for tinea cruris

A

Jock itch

158
Q

What is the most common type of contact dermatitis

A

irritant contact dermatitis (80%)

159
Q

How is tinea capitis acquired?

A

Direct contact with infected person, animal, or fomite

160
Q

How does Mohs surgery affect recurrence rates?

A

Lowers recurrence rates

Higher cure rates than excisional biopsy

161
Q

What two bacteria can cause fatal SJS/TEN complications like septicemia and pneumonia?

A

S. Aureus

P. Aeruginosa

162
Q

How to diagnose scabies?

A
  • visualization of the burrow w naked eye
  • microscopic identification of the mite, eggs, or poop pellets
  • dermatoscope can be used to actually visualize mites
163
Q

What is a Type II pathogenetic mechanism?

A

Cytotoxic
Involves IgG or IgM
Reaction to surface antigen and activate complement

164
Q

How would you empirically treat fingernail vs toenail onychomycosis?

A

Toes are USUALLY dermatophyte, so you would go with terbinafine x 12 wks

Fingers are USUALLY yeast (nondermatophyte), so you would go with itraconazole x 6wks

(Both are oral)

165
Q

What oral meds can be taken for atopic dermatitis?

A

Oral antihistamines for itching
Antibiotics for 2* infection
Oral steroids for BAD cases

166
Q 
Scalp
Back of neck
Wrists
Forearms
Lower legs
Genitals esp scrotum
Are common areas for which skin condition?
A

Lichen simplex chronicus

167
Q

What are the symptoms of drug hypersensitivity syndrome?

A

High Fever
Rash (morbilliform)
Internal organ involvement

Hematological weirdness (labs)
Lymphadenopathy
168
Q

To what disease does the phrase “The itch that rashes” refer to?

A

Atopic dermatitis

-vicious cycle of scratching that makes it worse

169
Q

Where are apocrine sweat glands

A

Axillary and Anogenital regions

170
Q

Concerns with onychomycosis?

A
  • primarily cosmetic
  • can be painful
  • increases risk of other infections, esp in immunocompromised
171
Q

Management of Seborrheic Keratoses?

A

Biopsy if ISK looks really nasty
Reassure pt it is benign
Consider removal for cosmetic reasons, or if irritated (under bra strap, etc)
(Usually cryotherapy, but can be shaved off or curettage and electrodessication

172
Q

In what skin layer does the female scabies mite burrow and lay eggs

A

Stratum corneum

173
Q

From where are Langerhans cells derived?

A

Bone marrow

-“macrophages of skin”

174
Q

SCC treatment?

A

Usually surgical. Either wide excision or Mohs.

C&D or cryotherapy on an AK may reveal it was SCC in situ.

175
Q

Usual areas affected by candidal intertrigo

A

Groin, mammary/abdominal folds, web spaces, axilla

Clin Med Exam 1 (Lauren) (5 decks)

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