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$$MS3 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Weight neutral 2nd gen antipsychotic drugs

A

Aripiprazole and ziprasidone

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2
Q

Side effect of 2nd gen antipsychotic drugs?

A

Metabolic syndromes

Increase BP/glucose/weight/cholesterol

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3
Q

Symptoms of NMS?

A

Fever/confusion/”lead pipe” rigidity/increased CPK/leukocytosis/increase HR/RR/BP

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4
Q

Name this drug!
Side effect—>retinal pigmentation

Side effect—>deposits in lens and cornea

A

Thioridazine

Chlorpromazine

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5
Q

Tx plan for schizophreniform disorder

A

6 month of antipsychotic

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6
Q

Schizoaffective disorder critieria

A

at least 2 weeks of delusion and hallucination without mood disorder (distinguish from mood disorder with psychotic features)

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7
Q

Criteria for delusional disorder

A

Delusion for a year/function well over 1 month
Erotomanic (sb in love with ya)/grandeur/persecution/somatic/jealous/mixed
Could have hallucination

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8
Q

Koro/Amok/Brain fag?

A

Koro—>anxious that penis would recede into the body
Amok—>burst of violence with suicide
Brain fag—>somatic disturbance among African males

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9
Q

Criteria for major depressive disorder
Pt with what medical condition tend to develop it?
How does it affect sleep stages?

A

5 out of SIG E CAP for over 2 weeks
Stroke
Increase duration of REM and decrease stage 3 and 4

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10
Q

What is a psychiatric emergency? and what is its criteria?what about hypomania

A

Maniac episode/ symptoms over 7 days

Over at least 4 days

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11
Q

Tx for atypical depression (mood reactivity)?

A

SSRI (not MAOi)

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12
Q

Criteria for Bipolar I and II

A 
Bipolar I (highest genetic linkage)--->manic episodes with or without depression
Bipolar II--->major depression and hypomania
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13
Q

Li+ side effect?

A 
LMNOP
Li+
Movement (tremor)
Nephrogenic DI
HypOthyroidism
Pregnancy
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14
Q

Tx for rapid cycling bipolar

A

Carbamazapine or volproic acid

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15
Q

Prego with manic episode, tx?

A

ECT

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16
Q

Criteria of persistent depressive disorder (dysthymia)? MDD is episodic

A

Over 2 years and never asymptomatic over 2 months

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17
Q

Criteria for cyclothymic disorder and tx

A

Alternate between symptoms of hypomania and depression (not full hypomania and depression otherwise it would be bipolar II) over 2 years
Tend to become bipolar
Tx—>Li+

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18
Q

Tx for premenstral dysphoric disorder

A

SSRI/OCP can reduce symptoms

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19
Q

Criteria for disruptive mod dysregulation disorder

A

severe verbal and physical outbursts >3 times a week for 1 year before age of 10
At least 2 settings

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20
Q

Tx for anxiety disorder

A

Psychotherapy for mild (CBT)
Drugs combo for severe
Use benzo to bridge till SSRI start working

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21
Q

Risk factor for panic attacks?

A

Smoking

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22
Q

Timeline for criteria of agoraphobia or phobia

A

over 6 months

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23
Q

Criteria for selective mutism/tx?

A

Failure to speak in social settings for at least 1 month (related to anxiety)
Tx—>SSRI/CBT

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24
Q

when does stranger and separation anxiety start? and when does it become pathologic
Tx?

A 
6 month, peaks at 9 month
1 year, peaks at 1 year and half 
Separation anxiety disorder---->reluctant to leave home/sleep alone
At least for 1 month in children 
Tx--->CBT/SSRI
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25
Q

GAD criteria? tx?

A

Excessive worrying over 6 month
Fatigue/impaired attention/restlessness
Tx—>CBT/SSRI

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26
Q

Ketamine usage and MOA?

A

NMDA antagonist

Start and maintain anesthesia

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27
Q

Side effect of risperidone that is different from the rest of the atypical?

A

Increase prolactin—>amenorrhea/infertility/sexual dysfunction

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28
Q

Criteria for panic disorder
Increase or decrease risk for suicide?
Tx?

A 
Recurrent panic attacks
Fear of future panic attacks--->change behaviors
Lead to agoraphobia
Increase risk for suicide
CBT and SSRI
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29
Q

pathophysiology of OCD and tx

A

Intrusive obsession that pt tries to suppress using compulsions (repetitive behaviors)—>causing anxiety
CBT (exposure response)/SSRI/ECT (last resort)

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30
Q

Pt underwent multiple plastic surgeries/repetitive grooming/comparing looks with others, diagnosis and tx?

A

Body dysmorphic disorder/SSRI and CBT

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31
Q

What precedes hoarding disorder and what tx?

A

Stressful and traumatic event

CBT

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32
Q

Tx for trichotillomania and excoriation disorder?

A

SSRI/2nd antipsychotic/N-acetylcysteine/Li+

CBT (habit reversal training)

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33
Q

Criteria for PTSD and acute stress disorder? tx? what med is used for nightmares?

A

Nightmares/flashbacks/avoidance/increase arousal
Acute stress disorder—> >1 month
SSRI/CBT (cognitive processing therapy)
Prazosin (alpha 1 antagonist)

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34
Q

What comorbid disorder occur with PTSD?

A

Substance abuse disorder so don’t use addictive meds for PTSD pts

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35
Q

Criteria for adjustment disorder? tx?

A

Stressful event happens within 3 month and resolve by 6 months
Supportive psychotherapy

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36
Q

Difference between PTSD and adjustment disorder?

A

Event happened in PTSD is life threatening, and not so in adjustment disorder

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37
Q

What are the 3 clusters of personality disorder? tx?

A

Cluster A—>eccentric/like psychotic disorders
Cluster B—>emotional/dramatic/like mood disorders
Cluster C—>anxious/fearful/like anxiety disorder
Use psychotherapy since most of pt are not aware

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38
Q

Cluster A

A

Paranoid—>jealous (think others are cheating on them)/everybody is against them
Schizoid—>happy to be alone, forever and ever/cold
Schizotypal—>odd and magical/social anxiety

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39
Q

Cluster B

A

Antisocial—>adult version (18yr) of conduct disorder/no remorse/manipulative (charming)
Borderline personality disorder—>impulsivity/extreme love-hate relationship/recurrent suicide attempts
Histrionic—>theatrical and attention seeking/seductive/easily influenced
Narcissistic—>superiority/need for admiration/lack empathy/arrogant—>depressed if recognition are not gained

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40
Q

What kind of defense mechanism does pt with boarderline personality disorder/histrionic/dependent personality disorder use?

A

boarderline—>Splitting

Histrionic and dependent—>Regression

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41
Q

Cluster C

A

Avoidant personality disorder—>social anxiety/fear of rejection, unliked/want relationships/very shy
Dependent—>poor self confidence/helpless when left alone/always in relationships/submissive/clinging
Obsessive compulsive—>perfectionism/inflexible/no delegation/frugal/rigid

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42
Q

Avoidant personality disorder looks like which other disorder?

A

Social anxiety disorder

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43
Q

Difference between OCD and OCPD?

A

OCD is ego-dystonic—>pts are aware

OCPD is ego-syntonic—>pts are not aware

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44
Q

EtOH can cause what kind of medical condition?

A

Metabolic acidosis

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45
Q

Withdraw symptoms of EtOH?

A

Irritability—>seizure—>DT (2 to 3 days)

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46
Q

Tx for alcohol use disorder

A

Naltrexone—>decrease craving
Acamprosate—>for relapse prevention after detox/contraindicate in pt with renal disease
Disulfiram—>block aldehyde dehydrogenase
Topiramate—>decrease craving

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47
Q

Symptoms of DT

A

disorientation/agitation/hallucination/increase RR, HR and BP

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48
Q

Cocaine MOA and complication

A

Block reuptake of DA/NE/Epi

MI/stroke/hemorrhage

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49
Q

Methamphetamine MOA and complication

A

Block reuptake of DA and NE

Induce psychosis/tooth decay

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50
Q

What is MDMA? and does it show up on tox screen?

A

Amphetamine and no

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51
Q

What kind of drug is heroin?

A

Opioid

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52
Q

High and low potency typical antipsychotics

A

High (NMS/TD)—>trifluoperazine/fluphenazine/haloperidol

Low (antihistamine/antiM/anti alpha1)—>chlorpromazine/thioridazine

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53
Q

What drug class are prochlorperazine and metoclopramide?

A

Prochlorperazine—>typical antipsychotic

Metoclopramide—>D2 antagnonist

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54
Q

Rotatory nystamus and what is its MOA

A

PCP intoxication

Anti NMDA

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55
Q

tx for barb intoxication and barb withdraw mimics?

A

Alkalinize urine with NaCO3

Alcohol

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56
Q

MAOi and what opioid taken together can cause serotonin syndrome?

A

Meperidine

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57
Q

Opioid withdraw symptoms?

A

insomnia/nasal discharge/yawning/sweating/dilated pupils

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58
Q

Tx for prego with opioid-dependence?

A

Mathadone

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59
Q

What is in suboxone

A

Buprenorphine (partial agonist) and naloxone

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60
Q

Difference between naloxone and naltrexone

A

Naloxone—>for emergency opioid intox

Naltrexone—>long acting, for long term dependence

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61
Q

What drug is used to treat the autonomic symptoms of opioid withdraw

A

Clonidine

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62
Q

What is dronabinol?

A

FDA approved THC

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63
Q

what are the 4 mood stabilizers and their side effects

A

Li+—>LMOP
valproic acid—>weight gain/hepatitis
carbamazapine—>aplastic anemia
lamotrigine—>steven johnson

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64
Q

Which TCA has the fewest antiM side effect?

A

Nortriptyline

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65
Q

Effect of mirtazapine

A

Antidepressant—>cause weight gain and sedating

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66
Q

How long should bereavement be abated?

A

Within 6 months

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67
Q

Criteria for intellectual disability

A

Deficits in intellectual/adaptive functioning

Require ongoing support of daily life

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68
Q

Global developmental delay

A

Failure to meet expected developmental milestones

need future reevaluation

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69
Q

Criteria for ADHD

A

Inattention and hyperactivity/impulsivity (2 types)
> 6 months and in 2 or more settings
Diagnosed

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70
Q

Comorbid disorders with ADHD?

A

Oppositional defiant/conduct/learning disorder

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71
Q

ADHD tx

A

First line —>methylphenidate or other stimulants
Second line —>atomoxetine (NE reuptake inhibitor)
alpha 2 agonist —>clonidine (sedating)/guanfacine

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72
Q

What should be checked and be aware before starting Li+/valproic acid/carbamazapine

A

Li+—>check for kidney and thyroid function and Na+ level /dont change diet or use salt wasting diuretics
Valproic acid—>check liver function
Carbamazapine—>aplastic anemia

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73
Q

Which opioid has the highest affinity for mu receptor?

A

Buprenorphine

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74
Q

And when is opioid withdraw fetal

A

during pregnancy for the fetus

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75
Q

What is the symptoms of acute Li+ toxicity?

A

Confusion/mimic CVA

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76
Q

What to do with a manic pt who’s on max dose of Li+?

A

Add a 2nd gen antipsychotic

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77
Q

What to give bipolar pt who’s depressed?

A

Lamotrigine or seroquel

78
Q

Criteria for Autism spectrum disorder

A

Impaired in social interaction and communication—->no eye contact/no interest in making friends
Peculiar and intense interest (like bugs)
Rigid routine/repetitive motor movement (hand flapping)
Aggression/disruptive
Associated with epilepsy

79
Q

What syndromes are associated with autism

A

Fragile X syndrome/Down/Rett/tuberous sclerosis

80
Q

Tx for autism

A

Behavioral therapy

Low dose atypical antipsychotic for aggression/irritability

81
Q

Characteristics and criteria of Tourette’s disorder

A

Worst of tic disorder—>many motor and at least one vocal tic for at least 1 year (eye blinking/throat clearing) before age of 18
Pt feel urge before the tic and feel tension released after
Fluctuating course

82
Q

What aggravate tic disorder? and what are its comorbid disorders?

A

Anxiety/excitement/fatigue

OCD and ADHD

83
Q

Tx for Tic disorders

A

Clonidine or guanfacine
Typical or atypical antipsychotics
habit reversal therapy

84
Q

Criteria for Persistent motor or vocal tic disorder/provisional tic disorder

A

Persistent—>either motor or vocal (not both)

Provisional—>Tourette under 1 year

85
Q

Criteria for oppositional defiant disorder and tx

A

anger/irritable/argumentative/vindictive/involve at least 1 non sibling over 6 months
Tx—>behavior therapy/parent management training

86
Q

Difference between oppositional defiant disorder and conduct disorder

A

ODD does not involve physical aggression or violet other people’s basic rights

87
Q

Criteria for conduct disorder and tx

A

aggression (physical and sexual) to people and animal/property destruction/theft/lie/violation of rules (run away) over 1 year
Tx—>behavioral therapy/parent management training

88
Q

What are the primary and secondary enuresis and encopresis

A

Primary—>never continence
Secondary—>achieved continence before
Enuresis—>2x a week for 3 months/wetting when sleep or wake/ >5 year old
Encopresis—>poop in not normal places/1x month for 3 months/ >4 year old

89
Q

Genetic predisposition for nocturnal enuresis

A

Higher risk for paternal urinary incontinence

90
Q

Tx for enuresis and encopresis

A

Enuresis—>behavioral therapy with rewards/urine alarm/desmopressin (ADH analog)/imipramine (TCA)
Encopresis—>bowel training/treat constipation if that is the cause

91
Q

Criteria for dissociative amnesia and tx

A

Unable to recall autobiographical info following traumatic event/memories are retrievable
Tx—>CBT or supportive therapy

92
Q

What is dissociative fugue

A

Under dissociative amnesia—>sudden travel away from home with amnesia of autobiographical info

93
Q

What are depersonalization and derealization

A

Depersonalization—>out of body experience
Derealization—>experience the surrounding as if they are in a dream or movie
Common during time of stress

94
Q

Criteria for dissociative identity disorder and what usually precede it?

A

2 or more personalities/memory impairment
Preceding events—>childhood physical/sexual abuse/neglect
Comorbid with PTSD/MDD/suicidality

95
Q

Tx for dissociative identity disorder

A

Psychotherapy/meds for comorbid disorders

96
Q

What is the normal duration for acute dissociative reaction following stressful events

A

up to 1 month

97
Q

Criteria for somatic symptom disorder and tx

A

1 or more somatic symptoms/anxiety from them/frequent change of physicians/ >6 months
Tx—>schedule regular visit with ONE PCP and avoid unnecessary medical workups

98
Q

Criteria for illness anxiety disorder and tx

A

Hypochondria/anxious about their health/no medical problems or mild in severity/ >6 months
Similar tx with somatic symptom disorder

99
Q

Criteria for factitious disorder

A

Maunchhausen syndrome/intentionally pretend to be sick without external rewards (otherwise it would be malingering)

100
Q

Comorbid for factitious disorder

A

Personality disorder/might with childhood abuse

101
Q

Criteria for intermittent explosive disorder and tx

A

Recurrent verbal or physical outbursts or rare physical outbursts that damage people or property/reaction out of proportion
tx—>SSRI/anticonvulsant or Li+/CBT

102
Q

What do you find in lab in impulsive or aggressive people like intermittent explosive disorder

A

Low serotonin or 5-HIAA in CSF

103
Q

Criteria for kleptomania and comorbid and tx

A

Steal useless stuff that release tension/follow by guilt and depression
Comorbid—>eating disorder (bulimia)/anxiety disorder
tx—>CBT/SSRI

104
Q

Criteria for pyromania

A

Set fire to release tension/fascinated about fire

105
Q

Criteria for anorexia nervosa and tx

A

restricting or binge and purge type
Low BMI/amenorrhea/disturbed body image/electrolyte abnormality/lanugo/salivary gland enlargment/Russell’s sign
Tx—>hospitalization if BMI below 18/CBT especially family therapy

106
Q

Comorbid with anorexia

107
Q

Criteria for bulimia and tx

A

Binge eating and compensatory behaviors 1x week for 3 months (compensatory behaviors can be throwing up, excessive working out and etc.)
Normal or overweight
Tx—>SSRI (fluoxetine) and CBT

108
Q

Cortisol is increase or decease in anorexia pt

109
Q

Which antidepressant is known to lower seizure threshold and shouldn’t give pt with what disorder?

A

Bupropion

Eating disorder

110
Q

Criteria for binge eating disorder and tx

A

Binge eating without purging or compensatory behaviors/over 3 months/obese pt with metabolic syndromes like DM
Tx—>CBT/drugs to suppress appetite

111
Q

What drugs can be used for weight lost?

A

Phentermine/amphetamine/topiramate/orlistat

112
Q

What are dyssomnias and parasomnias

A

Dyssomnias—>insomnia or hypersomnia

Parasomnias—>unusual sleep behaviors

113
Q

Timeline for acute and chronic insomnia and tx for chronic insomnia

A

Acute 3 month

Tx for chronic—->CBT/benzo for acute/three Zs/trazodone

114
Q

Physiological change in REM sleep

A

Increase BP/HR/RR

115
Q

Possible causes and tx for hypersomnias

A

Viral infection

Modafinil/methylphenidate/atomoxetine

116
Q

Causes of central sleep apnea

A

Cheyne-Stokes breathing due to HF/stroke

Opioid use

117
Q

What can sleep hypoventilation cause

A

Pul HTN/cor pulmonale/eventual respiratory failure

118
Q

Criteria for narcolepsy and tx

A

daytime sleepiness/unable to move/hypnagogic or hypnopompic hallucination/cataplexy
Tx—>stimulant (modafinil/sodium oxybate)

119
Q

What drug is effective against cataplexy

A

Sodium oxybate

120
Q

What level is low for narcolepsy pt

A

Hypocretin

121
Q

What are the non-REM sleep disorder

A

Sleepwalking (eyes are open)/sleep terrors/nightmare disorder (no confusion upon awakening unlike the other two)

122
Q

What tx is for nightmares disorder or PTSD

A

Imagery rehearsal therapy or prazosin

123
Q

What are REM sleep disorders and tx

A

Sleep talking/limb jerking/yelling/punching
No confusion upon awakening
Tx—>clonazepam/melatonin

124
Q

How does progesterone and serotonin affect libido

A

Inhibit libido in both men and women

Serotonin inhibit sexual function

125
Q

Tx for premature ejaculation/male and female hypoactive sexual desire disorder

A

Premature—>SSRI/TCA

Hypoactive—>testosterone for both genders

126
Q

Gender dysphoria

A

transsexual

127
Q

MC paraphilia?

A

Pedophilia/voyeurism/exhibitionism

128
Q

How old is the victim of pedophilia

129
Q

What are voyeurism/frotteuritism/transvestism

A

Voyeurism—>peeping tom
frotteuritism—>rubbing against a nonconsenting person
Transvestism—>cross dressing

130
Q

What is split tx in psychiatry

A

Psychiatrist prescribe meds and therapist provide therapy

131
Q

What are Id/superego/ego

A

Id—>unconscious/primal
Superego—>what we want to be (ideal)
Ego—>mediator between Id and superego—>use defense mechanism

132
Q

What are the mature defense mechanism

A

Altruism/humor/sublimation (like to fight, instead of beating up ppl become a boxer/channeling)/suppression (conscious)

133
Q

What are the neurotic defense mechanism

A

Controlling
displacement (boss yell at you, you yell at your kid)
intellectualization (focus on irrelevant details—>doctor dying from colon cancer explain to his son the pathophysiology of his disease)
Isolation of affect—>no emotion
Rationalization
Reaction formation
Repression—>unconscious

134
Q

What are the immature defense mechanism

A

Acting out/denial/regression/projection

135
Q

What is the goal of psychoanalysis and what are the target population of patients?

A

Bringing unconscious to conscious

Stable patients

136
Q

What techniques are used in psychoanalysis

A

Free association/dream interpretation/alliance/transference/counter transference

137
Q

Difference between classic and operant conditioning

A

Classic—>tie behavior to a stimulus (Pavlov’s dog)

Operant—>behaviors follow positive or negative reinforcement

138
Q

What are aversion therapy/token economy/biofeedback

A

Aversion—>e.g. disulfram
Token economy—>give reward for doing something (use on psych ward to encourage pt to take showers and what not)
Biofeedback–>give pt physiological stats for them to control

139
Q

What therapy is used to reduce self harm from borderline personality disorder

A

Dialectical behavioral therapy

140
Q

Symptoms of serotonin syndrome

A

Confusion/flushing/sweating/tremor or myoclonus/hyperthermia

141
Q

Drug for EPS syndrome

A

Benztropine (anti M)

142
Q

SSRI with the longest half life?

A

Fluoxetine

143
Q

SSRI with what drug besides MAOi can produce serotonin syndrome

144
Q

What is the unique side effect of Effexor

A

Increase BP

145
Q

SSRI are CYP450 inhibitor or inducer?

146
Q

Which antidepressat cause priapism

147
Q

What are the NE/DA reuptake inhibitor antidepressant

A

Trazodone/nefazodone

148
Q

MOA of TCA

A

inhibit reuptake of NE/serotonin

149
Q

What are the secondary amines and what are they different from tertiary amines

A

Nortiptyline/despramine—>less anti M effect

150
Q

Which TCA is used to treat OCD/sleep aid

A

OCD—>clomipramine

Sleep aid—->doxepin

151
Q

What to give for TCA overdose

A

Sodium bicarb

152
Q

Cause of hypertensive crisis

A

MAOi + tyramine

153
Q

What to use during serotonin syndrome

A

Benzo/cyproheptadine

154
Q

What to use for IBS

155
Q

Side effect of chlorpromazine

A

blue-gray skin discoloration

156
Q

MOA of atypical antipsychotic

A

block NE/DA reuptake

157
Q

What drugs increase level of Li+

158
Q

Check what before starting carbamazapine and valproic acid

159
Q

If a pt has liver damage from let’s say alcoholism, what benzo can you give?

A

LOT
Lorazepam
Oxazepam
Temazepam

160
Q

Which benzo has a long half life and rapid onset?

A

Diazepam (Valium)

161
Q

Conditions for malpractice

A

Duty to care/negligence (perform subpar care)/pt is harmed/harm comes from negligence

162
Q

What minors are considered emancipated? can they make their own medical decision?

A

Self-supporting/in military/married/have children or pregnant
Yes

163
Q

What are the definition for capacity and competence

A

Capacity—>assessed by physician

Competence—>assessed by a judge

164
Q

What is the most important factor when assessing violence

A

Past violent history

165
Q

What drug to give elderly pt for agitation and aggression? and what to give for an elderly pt with Parkinson’s with the same scenario?

A

Citalopram

Quietapine

166
Q

What group of drugs can enhance the affect of antidepressant?

A

Atypical antipsychotic

167
Q

Which antipsychotic decrease prolactin

168
Q

What else can illicit tactile hallucination besides alcohol withdraw?

A

Stimulants

169
Q

What are K2 and spice?

A

Synthetic marijuana

170
Q

What opioid causes seizure? and what else can it cause?

A

Tramadol/serotonin syndrome

171
Q

When do you see delirium?

A

Postop/infection/starting a new med

172
Q

How to treat delirium

A

antipsychotic

DONT USE BENZO

173
Q

What is Ecstasy or Molly?

174
Q

MOA of bupropion?

A

DA and NE reuptake inhibitor

175
Q

First line tx for bipolar?

A

Monotherapy first, if don’t response then combo:

Li+ or valproic acid + a second gen antipsychotic like seroquel or lamotrigine

176
Q

How to distinguish between psychosis and delirium

A

If the patient is confused/disorientated—>delirium

If cognitively normal—>psychosis

177
Q

Tx for catatonia and akathisia?

A

Catatonia - benzo or ECT

Akathisia - benzo or beta blocker

178
Q

What is acute stress disorder

A

PTSD under 1 month

179
Q

What is the most effective tx for MDD, side effect, and what drugs to give before that?

A

ECT/increase ICP/atropine, barb, succinylcholine

180
Q

What drugs can used as adjunct for antidepressants?

A

Li+/T3 or T4/amphetamine/estrogen/abilify

181
Q

What is paradoxical reaction of benzo and what to use for that?

A

Benzo induce agitation/use flumazenil

182
Q

What can Ambient cause?

A

Amnesia and sleep disorder such as sleep eating

183
Q

What is ICU triad?

A

Pain/agitation/delirium

184
Q

What drugs to use for delirium?

A

Antipsychotic

NO benzo!

185
Q

What 2 features must have for MDD? either or

A

Depressed mood or anhedonia

186
Q

What drug is used fro conduct disorder?

A

Risperidone

187
Q

What does amphetamine intoxication and withdraw present?

A

Intox - psychosis/anorexia/dilated pupil

Withdraw - increase appetite/depression

188
Q

What drugs can cause delirium?

A

Benzo/anti M/antibiotics

189
Q

Ketamine intox

A

Dissociative (depersonalization/derealization)
Hallucination
Amnesia

190
Q

Tx for acute mania

A

Antipsychotic

$$MS3 (8 decks)

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