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MSK II Exam II > Pharm Review > Flashcards

Pharm Review Flashcards

1
Q

Treatment for alopecia; it is a contact allergen applied to cause dermatitis which can be followed by hair growth

A

DPCP (Diphenylcyclopropenone)

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2
Q

2 examples of systemic imidazole therapy to treat tinea versicolor

A

Fluconazole

Itraconazole

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3
Q

Macrolide antibiotic, among uses is for topical or systemic treatment of acne; among the well known cytochrome P450 inhibitors to remember

A

Erythromycin

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4
Q

Antifungal agent with topical effects limited to candida infections, may temporarily stain the skin yellow (also administered IV, etc for other fungal infections as well including aspergillus and endemic mycosis)

A

Amphotericin B

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5
Q

Refers to agents such as glycerin, lecithin and propylene glycol found in moisturizers to draw water into the outer layer of skin

A

Humectant

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6
Q

FDA-approved conventional therapy for melanoma

A

Dacarbazine

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7
Q

Topical immune-response modifier used to treat actinic keratoses and basal or SCCs; also used to treat genital warts

A

Imiquimod

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8
Q

Retinoid administered orally for treatment of severe acne, powerful teratogen that mandates participation by young females in the iPledge program

A

Isotretinoin

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9
Q

Antiepileptic drug used to treat neuropathic pain and itching

A

Gabapentin

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10
Q

Radiation that may not cause erythema and sunburn but nevertheless still contributes to skin aging and photocarcinogenesis

A

UVA

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11
Q

What effect do agents such as iodine, chlorhexidine, and hydrogen peroxide have on wound healing?

A

Impede wound healing

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12
Q

An oral hedgehog signaling pathway inhibitor used to treat advanced basal cell carcinoma

A

Vismodegib

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13
Q

Topical calcineurin inhibitor that can help treat anogenital itching

A

Tacrolimus

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14
Q

Local vasoconstriction due to blood volume deficit, unrelieved pain, hypothermia, etc. can impair wound healing due to an inadequate amount of ______ in the tissue

A

Oxygenation

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15
Q

To heal best, wounds should be kept clean and _____

A

Moist

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16
Q

Common cause of diarrhea due to antibiotic-associated colitis, well-known example where handwashing with soap and water is superior to alcohol-based gels

A

C.difficile

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17
Q

Can be administered systemically to treat tinea capitis

A

Griseofulvin

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18
Q

Topical antimicrobial agent commonly used to treat acne; local skin irritant and may bleach hair and clothing

A

Benzoyl peroxide

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19
Q

Platelet-derived growth factor that promotes the cell proliferation and angiogenesis needed for diabetic ulcer repair, but must use cautiously as too much increases risk of malignancy

A

Becaplermin

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20
Q

Blocks enzyme needed for ergosterol synthesis; useful topically for fungal infections such as jock itch and athlete’s foot and systemically for fungal nail infections

A

Terbinafine

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21
Q

Late choice for treating ectoparasites, works by disrupting GABAergic transmission

A

Lindane

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22
Q

Active ingredient of vulvovaginal medications for candidiasis

A

Clotrimazole

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23
Q

~50% water and 50% oil with an emulsifier, base that is useful for covering large and/or wet areas with a drug but preservatives, etc., can cause allergic reactions

A

Creams

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24
Q

Antifungal applied topically that penetrates into nails to treat fungal infection

A

Efinaconazole

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25
Q

Important component of wound healing, conserves the local resources by limiting the need to synthesize proteases; stage when hydrogels are good wound covering

A

Debridement

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26
Q

Potent vasodilator due to hyperpolarization via activation of K+ channels, applied topically to grow hair

A

Minoxidil

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27
Q

Comprised of 20% water and 80% oils, best for dry skin, stay on surface of skin and are not well absorbed; permit more complete drug absorption and less likely to cause allergic reaction (no preservatives)

A

Ointments

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28
Q

Anti-inflammatory agent with keratolytic effects due to its ability to dissolve intercellular cement; makes it useful to treat acne, dandruff, and calluses

A

Salicylic acid

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29
Q

Component of plant defenses against bacteria, active against P.acne

A

Azaleic acid

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30
Q

Macrolide among the systemic therapies used to treat acne; noteworthy because it is not a CYP450 inhibitor, has unusual pharmacokinetics in that it is taken up in phagocytes and released by them at sites of infection

A

Azithromycin

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31
Q

Organophosphate anticholinesterase insectiside; kills ectoparasites

A

Malathion

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32
Q

Has 7 potency classes for topical administration so that it is possible to taper down to the lowest dose needed to control inflammation; administered systemically to control pain and inflammation of rheumatoid arthritis until DMARD effects manifest; can also be injected directly into inflamed joints

A

Glucocorticoids

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33
Q

Aminoglycoside antibiotic of neosporin with activity against gram-negative bacteria

A

Neomycin

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34
Q

Synthetic insecticide similar to that of chrysanthemums, ectoparasite therapy that binds to insect Na+ channels and prevents membrane repolarization

A

Permethrin

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35
Q

Inhibits the mutated BRAF V600D MAP kinase found in ~60% of melanomas

A

Vemurafenib

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36
Q

Prescription synthetic topical antimycotic agent with broad spectrum of activity against fungal skin infections such as ringworm, athlete’s foot, tinea versicolor, dandruff

A

Ciclopirox

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37
Q

Drug class useful for systemic treatment of acne, photosensitivity, GI distress, and contraindication in pregnancy and young children d/t gray discoloration of permanent teeth are noteworthy adverse effects

A

Tetracyclines

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38
Q

Synthetic detergents minimize skin irritation during home skin care due to lower ____

A

pH

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39
Q

Blocks the conversion of testosterone to more potent androgen dihydrotestosterone, among its uses is to treat male pattern baldness in men and second-line agent in women

A

Finasteride

40
Q

Monoclonal antibody against IL-12 and IL-23, a biologic agent used to treat psoriasis

A

Ustekinumab

41
Q

Alpha2-agonist administered topically as a gel to treat rosacea

A

Brimonidine

42
Q

Biologic DMARD directed against IL-17a, used to treat psoriasis and psoriatic arthritis and, for some, works much better than anti-TNF therapies

A

Secukinumab

43
Q

Effective topical therapy for actinic keratoses, causes fast-proliferating dysplastic cells to die a thymidine-less death; necrosis/erosion gives way to re-epithelialization over several weeks

A

5-fluorouracil

44
Q

Tetracycline used to treat acne, noteworthy for its ability to cause dark pigmentation in skin and sclera

A

Minocycline

45
Q

Orally active phosphodiesterase type IV inhibitor that inhibits numerous pro-inflammatory mediators, used in moderate-to-severe plaque psoriasis and psoriatic arthritis; severe diarrhea is adverse effect

A

Apremilast

46
Q

Urea, alpha-hydroxyl acids and allantoin are among the agents found in moisturizers to soften ______ _____ and give skin a smoother feeling

A

Horny substance

47
Q

The formation of a ______ for a drug in the skin may prolong its half life and permit QD dosing

A

Reservoir

48
Q

Refers to substances in moisturizers that form an oily layer to trap water in the skin; petroleum, lanolin, and mineral oil are among common examples

A

Emollients

49
Q

Titanium dioxide is an example of a _______ that could be applied, for example, to your nose when on the beach

A

Sunshade

50
Q

Among the imidazole drugs commonly used to treat vulvovaginal candidiasis

A

Miconazole

51
Q

Substance P antagonist used to treat nausea and vomiting of chemotherapy, also useful to treat intense itching of cutaneous T cell lymphomas (sezary syndrome)

A

Aprepitant

52
Q

Mu-opioid receptor antagonist that can treat pruritis associated with CKD and cholestasis

A

Naltrexone

53
Q

Peptide antibiotic with activity against gram-positive organisms and some anaerobes; only applied topically to limit systemic toxicity, often causes contact dermatitis

A

Bacitracin

54
Q

Alpha-adrenergic agonist in Visine known for its ability to “get the red out”

A

Tetrahydrozoline

55
Q

Prototypical non-steroid androgen antagonist, uses besides prostate cancer include treatment of male pattern baldness in women

A

Flutamide

56
Q

When used to treat thrush, it is held in the mouth before swallowing; has negligible GI absorption

A

Nystatin

57
Q

Treatment for actinic keratoses derived from Euphorbia peplus sap; causes chemoablation with neutrophil-mediated antibody dependent cellular cytotoxicity eliminating remaining tumor cells

A

Ingenol mebutate

58
Q

Drug class that may (e.g., for urticaria) or may not stop the itch, but the associated drowsiness may help pts deal with it

A

Antihistamines

59
Q

Cyclosporine and tacrolimus are among these agents that revolutionized transplantation therapy (didn’t cause bone marrow suppression), among other uses includes topical or systemic administration for psoriasis and topical administration for anogenital pruritis

A

Calcineurin inhibitors

60
Q

k-opioid agonist/mu-opioid receptor antagonist administered intranasally to treat intractable/nocturnal pruritis

A

Butorphanol

61
Q

Imidazole antifungal drug applied topically for a range of fungal infections, also noteworthy as a classic inhibitor of CYP450

A

Ketoconazole

62
Q

Orally administered insecticide to treat ectoparasites, binds glutamate-activated Cl- channels to hyperpolarize the nerve and muscle cells

A

Ivermectin

63
Q

Biologic DMARDs, also administered systemically to treat other autoimmune diseases such as psoriasis

A

TNF alpha inhibitors

64
Q

Among OTC drugs (e.g., tinactin) used to treat jock itch and athlete’s foot; like terbinafine, inactive against yeasts

A

Tolnaftate

65
Q

K+ sparing diuretic with partial agonist properties at androgen receptors that can make it useful for treating menstrual cycle-linked acne or male pattern baldness in adult women

A

Spironolactone

66
Q

Antibiotic that works similar to macrolides, kills anaerobes, useful for range of infections including topical treatment of acne and for osteomyelitis; associated with increased risk for C.diff

A

Clindamycin

67
Q

Broad-spectrum antimicrobial agent widely used in homes and hospitals due to efficacy on skin and oral mucosa with low irritability

A

Chlorhexidine

68
Q

Topical retinoid administered for the treatment of acne; alters gene expression to normalize keratinization, decrease keratinocyte cohesiveness, and reduce microcomedone formation

A

Tretinoin

69
Q

Class of antifungal drugs with a wide range of activity, blocks ergosterol synthesis

A

Imidazoles

70
Q

Peptide antibiotic with efficacy against gram-negative bacteria including pseudomonas, has a detergent-like effect that damages the bacterial cell membrane

A

Polymixin B

71
Q

Photosensitizer administered in conjunction with UVA treatment of psoriasis

A

Psoralen

72
Q

Topical therapy for treating herpes labialis (also used systemically for herpes infections at other sites)

A

Acyclovir

73
Q

Class of adrenergic agonists administered topically to treat rosacea or red eyes

A

Alpha agonists

74
Q

Type of dressing useful for the granulation stage of wound repair

A

Foam

75
Q

Very old remedy for psoriasis; works but color and smell create a challenge

A

Tar

76
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable.

What is the most likely diagnosis?

A. Antihistamine overdose
B. Botulinum poisoning
C. Myasthenia gravis
D. Neomycin-induced paralysis
E. Organophosphate poisoning
A

C. Myasthenia gravis

77
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable. He is diagnosed with MG.

Which agent may be used to support a diagnosis of myasthenia gravis?

A. Dantrolene
B. Edrophonium
C. Pralidoxime
D. Succinylcholine
E. Tacrine
A

B. Edrophonium

78
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable.

Edrophonium is administered. Which AE may be expected?

A. Bradycardia
B. Decreased lacrimation
C. Fever
D. Histamine release
E. Psychosis
A

A. Bradycardia

79
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable.

The pt is referred to a neurologist for treatment and prescribed an AChE inhibitor. He is at highest risk for hallucinations and seizures if prescribed which of the following:

A. Ambenonium
B. Neostigmine
C. Physostigmine
D. Pyridostigmine

A

C. Physostigmine

[lipid-soluble AChE inhibitors that cross the BBB are inappropriate due to CNS adverse effects. Lipid-soluble agents include physostigmine, donepezil, rivastigmine, galantamine, tacrine, and organophosphates]

80
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable.

The patient is treated appropriately with pyridostigmine. Which AE is most likely?

A. Anhydrosis
B. Cutaneous vasodilation
C. Diarrhea
D. Dry mouth
E. Mydriasis
A

C. Diarrhea

[due to effects of mAChR stimulation on smooth muscle in GI tract —> increased motility]

81
Q

A healthy 61 y/o male presents to an ophthalmologist complaining of double vision and droopy eyelids. He first noticed this double vision about 1 year ago and says it has been gradually worsening. He says it also gets worse during the day (he doesn’t typically notice it first thing in the morning). Later in the day, particularly during a long meal such as dinner, he notices progressive difficulty with chewing as his “jaw muscles get really tired” and he even has to stop eating. The jaw fatigue doesn’t go away until after 1 to 2 hours rest. His past medical history is unremarkable. He takes one aspirin (81 mg) mg daily as a precaution against developing coronary artery disease. He was treated 2 weeks ago with ophthalmic neomycin‐dexamethasone for 5 days for conjunctivitis. On physical exam, there is fatigable ptosis of the left eye. His general physical exam and overall neurological exam is otherwise unremarkable.

He is treated appropriately with pyridostigmine leading to AE of diarrhea. Which of the following drugs may be used to reduce the pt’s diarrhea and could be paired with pyridostigmine?

A. Epinephrine
B. Glycopyrrolate
C. Pyridoxine
D. Pralidoxime
E. Vecuronium
A

B. Glycopyrrolate

[other options include propantheline or hyoscyamine]

82
Q

An 82 y/o male is admitted to the hospital for a transthoracic esophagectomy due to esophageal carcinoma. He had a 60 year history of smoking 30 cigarettes/day and was diagnosed with esophageal squamous cell carcinoma by upper gastrointestinal endoscopy during a physical checkup. His medical and family history are unremarkable.

Anesthesia is induced with propofol and a neuromuscular blocking agent that produces muscle fasciculations upon administration. Which of the following fits this description?

A. Atracurium
B. Neostigmine
C. Rocuronium
D. Succinylcholine
E. Tubocurarine
A

D. Succinylcholine

[depolarizing agent]

83
Q

A 65 y/o female undergoes hysterectomy for endometrial carcinoma. The general anesthesia protocol includes sodium thiopental, isoflurane, nitrous oxide, and tubocurarine. The anesthesiologist also administers another drug to counteract tubocurarine‐induced hypotension. To which of the following classes does this drug most likely belong?

A. Beta-1 agonists
B. Dopamine-1 antagonists
C. Muscarinic agonists
D. Cholinesterase inhibitors
E. Histamine-1 antagonists
A

E. Histamine-1 antagonists

84
Q

A 29 y/o male is brought to the emergency department unconscious, with nonreactive, pinpoint‐sized pupils, massive oral foaming, and muscle fasciculations. Other than a 12 year history of depression, past medical history is unremarkable. Current medications include sertraline (Zoloft) and bupropion (Wellbutrin). He was recently prescribed varenicline for smoking cessation. He recently ate at a sushi restaurant. What is the most likely cause of his current presentation?

A. Cocaine intoxication
B. Lambert Eaton myasthenic syndrome
C. Organophosphate exposure
D. Tetrodotoxin intoxication
E. Varenicline overdose
A

C. Organophosphate exposure

85
Q

A 25 y/o female presents with spasticity and muscle pain due to a recent automobile accident. She also notes feelings of anxiety and depression due to the slow rehabilitation process. Past medical history is unremarkable. Which drug is appropriate in this situation due to its anxiolytic and sedative properties?

A. Baclofen
B. Cyclobenzaprine
C. Dantrolene
D. Carisoprodol
E. Tizanidine
A

D. Carisoprodol

86
Q

A 10 y/o male diagnosed with hereditary spastic paraparesis 2 years ago was treated with several spasmolytic drugs with limited success. Recently, the neurologist prescribed another spasmolytic agent that acts as an alpha‐2 receptor agonist in the spinal cord. Which drug was most likely prescribed?

A. Dantrolene
B. Diazepam
C. Alprazolam
D. Mivacurium
E. Tizanidine
A

E. Tizanidine

87
Q

A 54 y/o male who had been suffering from amyotrophic lateral sclerosis for 1 year complained of generalized muscle spasms. His physician prescribed diazepam to reduce spasticity. Which of the following best explains the mechanism of the spasmolytic effect of diazepam in this patient?

A. Activation of GABA(B) receptors in the spinal cord
B. Blockade of acetylcholine release from motor nerves
C. Blockade of calcium release from the sarcoplasmic reticulum
D. Depolarization blockade of nAChR skeletal muscle receptors
E. Facilitation of GABA(A) actions in the spinal cord

A

E. Facilitation of GABA(A) actions in the spinal cord

88
Q

A 63 y/o male undergoes abdominal surgery for prostate cancer. General anesthesia is supplemented with tubocurarine. What anatomical structure represents the main site of action of the drug for this clinical application?

A. Autonomic cholinergic nerve terminals
B. Ganglionic neuron membranes
C. Postjunctional folds of motor end plates
D. Skeletal muscle cell membranes
E. Spinal motor neuron membranes
A

C. Postjunctional folds of motor end plates

89
Q

A 68 y/o female presents with a 6 month history of impaired memory, language difficulties, and diminished ability to perform motor activities. She has trouble recognizing common objects and often gets lost in familiar places. Dementia is suspected and she initiates drug therapy. A drug from which drug class is prescribed?

A. Choline acetyltransferase inhibitor
B. Direct-acting nicotinic acetylcholine receptor agonist
C. Muscarinic acetylcholine receptor antagonist
D. SNARE complex inhibitor
E. Tertiary acetylcholinesterase inhibitor

A

E. Tertiary acetylcholinesterase inhibitor

90
Q

A 22 y/o male suffering from stabismus starts treatment with local injections of botulinum toxin into the extrinsic ocular muscles. What structures are targeted?

A

SNARE complex

91
Q

A 22 y/o male is admitted to surgery after an automobile accident. Anesthesia is induced. After 15 minutes, his body temperature and PaCO2 rise dramatically. Malignant hyperthermia is suspected. Which agent was most likely given to this patient in combination with an inhaled volatile anesthetic during anesthesia induction?

A

Succinylcholine

92
Q

A 38 y/o male is admitted to the Emergency Department with extensive soft tissue burns. He is semiconscious and is artificially ventilated. His uncoordinated respiratory movements are interfering with the mechanical ventilation. What drug would be most effective to decrease his spontaneous breathing?

A

Neuromuscular blocking drugs provide adequate gas exchange and prevent atelectasis in pts who have ventilatory failure; neuromuscular blocking drugs reduce chest wall resistance and improve thoracic compliance

93
Q

A 57 y/o female is admitted semiconscious to the ED after an accident at home. Artificial ventilation is needed, and a drug is given to facilitate intubation. This drug has the shortest duration of action among skeletal muscle relaxants. Which drug was most likely administered?

A

Succinylcholine

94
Q

A 72 y/o male undergoes thoracic surgery to remove a lung cancer. General anesthesia is supplemented with vecuronium. What molecular action most likely mediates the muscle relaxant effect of the drug?

A

nAChR blockade (antagonist)

95
Q

An 82 y/o male is admitted to the hospital for a transthoracic esophagectomy due to esophageal carcinoma. He had a 60 year history of smoking 30 cigarettes/day and was diagnosed with esophageal squamous cell carcinoma by upper gastrointestinal endoscopy during a physical checkup. His medical and family history are unremarkable.

Anesthesia is induced with propofol and succinylcholine. General anesthesia is maintained with sevoflurane while muscle relaxation is most likely maintained with which agent?

A. Ambenonium
B. Galantamine
C. Mivacurium
D. Succinylcholine
E. Vecuronium
A

E. Vecuronium

[nondepolarizing, intermediate acting]

96
Q

An 82 y/o male is admitted to the hospital for a transthoracic esophagectomy due to esophageal carcinoma. He had a 60 year history of smoking 30 cigarettes/day and was diagnosed with esophageal squamous cell carcinoma by upper gastrointestinal endoscopy during a physical checkup. His medical and family history are unremarkable.

Anesthesia is induced with propofol and succinylcholine. General anesthesia is maintained with sevoflurane while muscle relaxation is maintained with vecuronium. Body temp is 36 C at induction. At 4.5 hours after incision, body temp is 40.9 C. At this time, a rise of more than 0.5 C is observed in less than 15 mins. Which of the following agents is most appropriate to treat this pt?

A. Cisatracurium
B. Dantrolene
C. Pralidoxime
D. Pyridostigmine
E. Rocuronium
A

B. Dantrolene

97
Q

A 25 y/o female presents with spasticity and muscle pain due to a recent automobile accident. She also notes feelings of anxiety and depression due to the slow rehabilitation process. Past medical history is unremarkable. Carisoprodol is prescribed. Which metabolite of the parent drug is likely to address her feelings of anxiety?

A. Alprazolam
B. Cyclobenzaprine
C. Diazepam
D. Meprobamate
E. Tizanidine
A

D. Meprobamate

MSK II Exam II (10 decks)

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