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PPS - From Nelson's > Pulmo > Flashcards

Pulmo Flashcards

1
Q

total lung capacity

A

vital capacity + residual volume
inspiratory capacity + functional residual capacity
inspiratory capacity + expiratory residual volume + residual volume

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2
Q

what parameters decreased in lung pathology

A

Vital capacity, inspiratory capacity, and expiratory reserve volume are decreased in lung pathology but are also effort dependent

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3
Q

what parameters affected in Intrathoracic airway obstruction (asthma, cystic fibrosis)

A

Intrathoracic airway obstruction is associated with air trapping and abnormally high functional residual capacity and residual volume

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4
Q

major pathophysiologic conse- quence of decreased FRC

A

hypoxemia

encountered in alveolar interstitial diseases and thoracic deformities

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5
Q

what is disadvantage of infant lung

A

ribs more horizontal
diaphragm flatter
decreased capacity
lungs more compliant

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6
Q

elastance

A

change in pressure / change in volume

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7
Q

compliance

A

change in volume / change in pressure

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8
Q

resistance

A

poiseuille’s law
proportional to length, viscosity
indirectly proportional to radius

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9
Q

if airway lumen is decreased by half what is resistance

A

16 fold

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10
Q

tunica media of pulmonary arteries become more muscular at __ trimester

A

3rd

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11
Q

3 days after birth PVR is _% SVR

A

50%

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12
Q

2 - 3 mo after birth PVR is _% SVR

A

15%

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13
Q

pulmonary vasculature constricts

A

hypoxemia
acidosis
hypercarbua

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14
Q

pulmonary vasculature dilates

A

increased o2

hypocarbia

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15
Q

third leading cause of infant mortality in USA

A

SIDS

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16
Q

implicated in SIDS

A 
VEGF
5HT
autonomic nervous sys polymorphism
Ca ion channel
complement/cytokine
prematurity
prone
smoking
soft bedding
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17
Q

greatest risk for SIDS __ months

A

2-3mo

most deaths by 6 mo

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18
Q

risk for regurgitation/aspiration highest in

A

prone

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19
Q

t or f

risk for SIDS in sibling same as general population

A

false

higher

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20
Q

internal nasal airway doubles in size by

A

6 months

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21
Q

nasal passages contribute to __% total resistance of normal breathing

A

50

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22
Q

most common nose congenital anomaly

A

choanal atresia

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23
Q

most common syndrome associated with choanal atresia

A 
CHARGE
coloboma
heart disease
atresia chonae
retarded growth/devt or CNS
genital abnormalities/hypogonadism
ear anomalies/deafness

CHD7 chromatin organization

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24
Q

imaging of choice for choanal atresia

A

CT

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25
Q

repair of choice for choanal atresia

A

transnasal repair

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26
Q

perforation of nasal septum most common after birth due to

A

syphilis
tb
trauma

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27
Q

most common cause of septal deviation at birth

A

trauma

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28
Q

common site of bleeding in epistaxis

A

kiesselbach plexus

in anterior septum where vessels from internal and external carotid meet

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29
Q

common cause of epistaxis

A

trauma
foreign bodies
dry air
inflammation

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30
Q

drug to stop epistaxis

A

oxymetazoline

may do cautery with silver nitrate

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31
Q

adolescent with recurrent profuse bleeding

A

juvenile nasopharyngeal angiofibroma

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32
Q

nasal polyps commonly arise

A

ethmoidal sinus, middle meatus

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33
Q

most common childhood cause of nasal polyposis

A

cystic fibrosis

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34
Q

nasal polyp
aspirin sensitivity
asthma

A

samter triad

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35
Q

it is normal to have _ colds per year in kids

A

6-8

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36
Q

prolonged use of topical adrenergic agents (oxymetazoline, phenyleprine, xylometazoline) lead to rebound nasal obstruction

A

rhinitis medicamentosa

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37
Q

most common complication of cold

A

otitis media

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38
Q

use of oseltamivir in influenza can help reduce incidence of

A

otitis media

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39
Q

bacterial sinusitis is likely if

A

mored than 10-14 days
fever
facial pain
swelling

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40
Q

what sinuses are present at birth

A

ethmoidal (pneumatized)

maxillary (pnuematized at 4 yrs old)

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41
Q

sphenoidal sinus present at

A

5 yrs old

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42
Q

frontal sinus

A

develops at 7-8 years old

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43
Q

etiology of chronic sinusitis

A

h. influenzae
a and b strep
m. catarrhalis
strep pneumo

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44
Q

initial therapy for sinusitis

A

amoxicillin 45mkday

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45
Q

tx if fail to respond to amoxicillin

A

coamoxiclav 80-90mkday

azithromycin

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46
Q

osteomyelitis of frontal bone

edema and swelling of forehead

A

Pott puffy tumor

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47
Q

tx for intracranial extension of sinusitis

A

cefotaxime/ceftriaxone + vancomycin

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48
Q

treatment for GABHS strep

A

pen V 250mg <27kg/60lb or 500mg >60lb BID x 10 days
amoxicillin 50mkd OD x 10 days
must be given within 9 days of illness

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49
Q

tx for eradicating strep carriages

A

clindamycin 20mkday TID x 10 days

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50
Q

indication for tonsillectomy

A

> 7 episodes in 1 yr
5 episodes in 2yr
3 episodes in 3yr

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51
Q

retropharyngeal abscess occurs most commonly in

A

children 3-4 yr old

boys more than girls

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52
Q

usual pathogens in retropharyngeal abscess

A

GABHS
anaerobic bacteria
staph

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53
Q

tx for retropharyngeal abscess

A

3rd gen cephalosporin + ampisul/clinda

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54
Q

septic thrombophlebitis if internal jugular vein

cause?

A

lemierre disease

fusobacterium necrophorum

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55
Q

tx for lemierre disease

A

penicillin or cefoxitin

surgical drainage

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56
Q

lymphoid tissue that surrounds opening of oral and nasal cavities

A

waldeyer ring

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57
Q

lymphoid tissue of waldeyer ring most active

A

4-10 yr old

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58
Q

larynx composed of 4 cartilages (in order)

A

epiglottic, erytenoid, thyroid, cricoid

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59
Q

steeple sign

A

croup

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60
Q

tripod position
dyspnea
drooling
thumb sign

A

acute epiglottitis

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61
Q 
occuring most commonly at night
resembles croup 
recurrent
1-3 yrs old
no history of viral prodrome
A

spasmodic croup

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62
Q

sudden onset respiratory obstruction
6mo-3yr old
no prodromal signs of infection

A

foreign body

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63
Q

MOA of racemic epinephrine

A

contriction of precapillary arterioles through B adrenergic receptors
causes: fluid resorption and decrease in edema

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64
Q

etiology of bacterial tracheitis

A

staph (most common)
m. catarrhalis
hib
anaerobes

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65
Q

major pathologic feature of bacterial tracheitis

A

swelling at level of cricoid

with copius secretions or pseudomembranes

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66
Q

treatment of bacterial tracheitis

A

vancomycin (life threatening)

or nafcillin/oxacillin

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67
Q

T or f

Obstruction of pharyngeal airway worse in sleep

A

True

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68
Q

T or f

Obstruction of laryngeal, tracheal and bronchial airway worse when awake

A

True

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69
Q

Most common congenital laryngeal anomaly

A

Laryngommalacia

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70
Q

Most common cause of stridor in infants

A

Laryngomalacia

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71
Q

Symptoms of laryngomalacia appear

A

1-2 weeks old and increased severity 6mo

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72
Q

Diagnosis for laryngomalacia

A

Flexible laryngoscopy

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73
Q

Surgical procedure for laryngomalacia

A

Supraglattoplasty

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74
Q

Second most common cause of stridor

A

Congenital subglottic stenosis

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75
Q

Narrowest part of upper airway in kids

A

Subglottis

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76
Q

Typical presenting symptom for subglottic stenosis

A

Biphasic or primarily inspiratory stridor

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77
Q

Diagnosis of subglottic stenosis

A

X-ray and confirmed with laryngoscopy

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78
Q

Third most common congenital laryngeal anomaly that cause stridor

A

Vocal cord paralysis

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79
Q

Iatrogenic causes for vocal cord paralysis

A

TEF and PDA repair

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80
Q

Diagnosis of vocal paralysis

A

Laryngoscopy

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81
Q

Treatment for vocal cord paralysis

A

Resolve spontaneously 6-12 mo
If does not resolve in 2-3yrs then permanent
Bilateral vocal cord paralysis require tracheostomy

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82
Q

Anomaly associated with laryngeal web

A

Chromosome 22q11 deletion

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83
Q

Diagnosis of laryngeal web

A

Laryngoscopy

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84
Q

Laryngeal clefts associated with

A 
Tracheal agenesis
Tef
G syndrome
opitz Frias syndrome
Pallister hall syndrome
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85
Q

Most common cause of secondary tracheomalacia

A

Aberrant inominate artery

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86
Q

Vascular anomalies from abnormal aortic arch complex

A

Vascular ring

87
Q

Most common open/incomplete vascular ring

A

Aberrant right subclavian artery

88
Q

Leading cause of mortality and morbidity in kids

A

Choking

89
Q

Most foreign body obstruction at

A

Right bronchus

90
Q

Immediate complication of foreign body airway obstruction

A

Air trapping/obstructive emphysema

91
Q

90% acquired subglottic stenosis due to

A

Endotracheal intubation

92
Q

Subglottic stenosis treated with

A

Endoscopy using gentle dilations and co2 laser

93
Q

Primary tracheomalacia commonly seen in

A

Premature infants

Male to female 2:1

94
Q

Diagnosis of tracheomalacia

A

Bronchoscopy

95
Q

Diagnosis of subglottic stenosis

A

X-ray then confirmed with scope

CT not useful

96
Q

B adrenergic should be avoided in bronchomalacia and tracheomalacia in the absence of asthma because

A

because they can exacerbate loss of airway patency due to decreased airway tone

97
Q

Bronchomalacia and tracheomalacia resolve

A

3 years

98
Q

most common respiratory tract neoplasms in children

A

Papillomas

99
Q

Papillomas cause by

A

Hpv

100
Q

Treatment for recurrent respiratory papillomatosis (RRP)

A

Surgery

101
Q

Treatment of congenital hemangioma

A

Prednisone 2-4 mg/kg/day for 4-6 wk then taper

Propranolol 2-3 mg/kg/day

102
Q

most common benign tumors of trachea

A

inflammatory pseudotumor and hamartoma

103
Q

Most common malignant tumor of trachea

A

Bronchial adenoma

104
Q

Second most common bronchial malignant tumor

A

Bronchogenic carcinoma

105
Q

Characteristic of asthma

A

airway inflammation, bronchial hyperreactivity, and reversibility of obstruction

106
Q

Three identified patterns of infant wheezing are

A

transient early wheezer, the persistent wheezer, and the late-onset wheezer

107
Q

Transient wheezer characteristic

A

(resolved by 6 yr of age)

• Initial risk factor is primarily diminished lung size

108
Q

Persistent wheezers

A

(persists beyond 6 yr of age)
• Initial risk factors include parental asthma history, atopic dermatitis, allergen sensitization, peripheral eosinophilia (>4%) and wheezing unrelated to colds in the 1st yr of life
• At increased risk of developing clinical asthma

109
Q

Late-onset wheezer

A

(symptoms begin after age 3 yr and persist)

110
Q

Cardiac wheeze

A

Pulmonary edema caused by heart failure can also cause wheezing by lymphatic and bronchial vessel engorgement that leads to obstruction and edema of the bronchioles and further obstruction

111
Q

results from partial obstruction of a bronchus or bronchiole

causing air trapping

A

obstructive overinflation

112
Q

hyperresonance
small lung
mediastinal shift towards the abnormal lung
brought about by insult to lower respiratory tract

A

swyer james or macleod syndrome

113
Q

site most commonly affected by congenital lobar emphysema

A

left upper lobe

114
Q

important cause of early-onset severe panacinar pulmonary emphysema in adults in the 3rd and 4th decades of life and an important cause of liver disease in children

A

homozygous deficiency of α1-antitrypsin (α1-AT)

115
Q

what does α1-antitrypsin (α1-AT) and other proteases do

A

inactivate proteolytic enzymes released from dead bacteria or leukocytes in the lung.

116
Q

therapy for α1-AT deficiency is

A

intravenous replacement with enzyme derived from pooled human plasma

117
Q

t or f

right lung agenesis has higher morbidity and mortality than left

A

true

118
Q

consequence when right lung is absent

A

aorta can compress the trachea

119
Q

pulmonary agensis seen in

A

VACTERL

120
Q

four types of CCAM

A

Type 0 (acinar dysplasia)

Type 1 (60%)

Type 2 (20%)

Type 3 (<10%)

Type 4 (10%)

121
Q

Type 0 CCAM

A 
Type 0 (acinar dysplasia) 
is least common (<3%) and consists of microcystic disease throughout the lungs
prognosis is poorest for this type, and infants die at birth
122
Q

Type 1 ccam

A

Type 1 (60%)
is macrocystic and consists of a single or several large (>2 cm in diameter) cysts lined with ciliated pseudostratifed epithelium;
Presentation is in utero or in the newborn period
Cartilage is rarely seen in the wall of the cyst.
good prognosis for survival

123
Q

type 2 ccam

A

Type 2 (20%)
is microcystic and consists of multiple small cysts
associated with other serious congenital anomalies (renal, cardiac, diaphragmatic hernia) and carries a poor prognosis

124
Q

type 3 ccam

A 
Type 3 (<10%) 
is seen mostly in males; the lesion is a mixture of microcysts and solid tissue with bronchiole-like structures lined with cuboidal ciliated epithelium and separated by areas of nonciliated cuboidal epithelium
poor prognosis
125
Q

type 4 ccam

A 
Type 4 (10%) 
is commonly macrocystic and lacks mucus cells. It is associated with malignancy
126
Q

what lesion can appear similar to CCAM

A

pleuropulmonary blastoma

127
Q

common location of intrapulmonary sequestration

A

lower lobe

128
Q

common location extrapulmonary sequestration

A

left lung

129
Q

common sex extrapulmonary sequestration

A

more common in boys

130
Q

common location of bronchogenic cyst

A

right near midline structure

131
Q

congenital weakness of spurapleural membrane in neck

A

sibson’s fascia

132
Q

most common type of lung hernia

A

cervical

133
Q

what can we use to differentiate cardiogenic from non cardio pulmo edema

A

brain natriuretic peptide BNP
>500 if cardiogenic
<100 if non cardio

134
Q

what does PEEP do to help pulmo edema

A

prevents complete closure of alveoli
recruits collapsed alveoli
leads to increased functional residual capacity FRC, improved compliance, dec pulo vascular resistance

135
Q

treatment for high altitude pulmonary edema

A

hyperbaric chamber
supplement o2
nifedipine
beta adrenergic

136
Q

pulmonary edema caused by

INCREASED PULMONARY CAPILLARY PRESSURE

A

Cardiogenic, such as left ventricular failure
Noncardiogenic, as in pulmonary venoocclusive disease, pulmonary
venous brosis, mediastinal tumors

137
Q

pulmonary edema caused by

INCREASED CAPILLARY PERMEABILITY

A 
Bacterial and viral pneumonia
Acute respiratory distress syndrome
Inhaled toxic agents
Circulating toxins
Vasoactive substances such as histamine, leukotrienes,
thromboxanes
Diffuse capillary leak syndrome, as in sepsis Immunologic reactions, such as transfusion reactions Smoke inhalation
Aspiration pneumonia/pneumonitis
Drowning and near drowning
Radiation pneumonia
Uremia
138
Q

pulmonary edema caused by

LYMPHATIC INSUFFICIENCY

A

Congenital and acquired

139
Q

pulmonary edema caused by

DECREASED ONCOTIC PRESSURE

A

Hypoalbuminemia, as in renal and hepatic diseases, protein-losing states, and malnutrition

140
Q

pulmonary edema caused by

INCREASED NEGATIVE INTERSTITIAL PRESSURE

A

Upper airway obstructive lesions, such as croup and epiglottitis Reexpansion pulmonary edema

141
Q

pulmonary edema caused by

MIXED OR UNKNOWN CAUSES

A

Neurogenic pulmonary edema High-altitude pulmonary edema Eclampsia
Pancreatitis
Pulmonary embolism
Heroin (narcotic) pulmonary edema

142
Q

gastric aspirate with increased severity

A

0.8ml/kg

ph<2.5

143
Q

what kind of hydrocarbons have more potention for aspiration

A

lower surface tensions (gasoline, turpentine, naphthalene) rather than mineral/fuel oil

144
Q

ingestion of __ml is assoc with severe pneumonitis

A

> 30ml

145
Q

CHAMP have inherent systemic toxicity

A

camphor, halogenated carbons, aromatic hydrocarbons, and those associated with metals and pesticides

Patients who ingest these compounds in volumes >30 mL
may benefit from gastric emptying

146
Q

most common underlying problem in recurrent aspiration

A

oropharyngeal coordination

147
Q

anticholinergics for recurrent saliva aspiration

A

glycopyrrolate and scopolamine

148
Q

nitrogen dioxide toxicity (corn silo)

A

silo filler disease or silage gas poisoning

149
Q

primary eosinophilic lung disease

A

loffler syndrome

150
Q

most common pathogen in pcap kids 3wk-4yr old

A

strep

151
Q

most common pathogen in pcap kids >5yr old

A

mycoplasma pneumoniae

chlamydophila pneumoniae

152
Q

major cause of hospitalization and death from pcap

A

strep
hib
staph

153
Q

pathogen pcap neonate

A

Group B streptococcus, Escherichia coli, other Gram-negative bacilli, Streptococcus pneumoniae, Haemophilus in uenzae (type b,* nontypeable)

154
Q

pathogen pcap

3 wk-3 mo

A

Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parain uenza viruses, in uenza viruses, adenovirus), S. pneumoniae, H. in uenzae (type b,* nontypeable); if patient is afebrile, consider Chlamydia trachomatis

155
Q

pathogen pcap

4 mo-4 yr

A

Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parain uenza viruses, in uenza viruses, adenovirus), S. pneumoniae, H. in uenzae (type b,* nontypeable), Mycoplasma pneumoniae, group A streptococcus

156
Q

pathogen pcap

≥5 yr

A

M. pneumoniae, S. pneumoniae, Chlamydophila pneumoniae, H. in uenzae (type b,* nontypeable), in uenza viruses, adenovirus, other respiratory viruses, Legionella pneumophila

157
Q

most common cause of parapneumonic pleural effusion

A

staph
strep pneumoniae
strep pyogenes

158
Q

if aspiration happened while lying down

A

right and left upper lobes and apical segment of right lower lobe

159
Q

if aspiration happened while upright

A

posterior segment of upper lobes

160
Q

primary abscesses are found left or right?

A

right

161
Q

secondary abscesses are found left or right?

A

left

162
Q

duration of tx for lung abscess

A

2-3 weeks IV if uncomplicated followed by oral antibiotics to complete 4-6 weeks
if no improvement after 7 days, surgery

163
Q

most common life limiting autosomal recessive trait among whites

A

cystic fibrosis

164
Q

problem with cystic fibrosis

A

failure of epithelial cells to secrete chloride in response to CAMP

165
Q

xray finding of meconium ileus

A

(cystic fibrosis)
dilated loops with air fluid levels
ground glass in lower central abdomen

166
Q

diagnosis of cystic fibrosis

A

positive quantitative sweat test (Cl− ≥60 mEq/L)
PLUS
1 or more:
typical chronic obstructive pulmonary disease
documented exocrine pancreatic insuffciency
positive family history

167
Q

test used in cystic fibrosis to check for exocrine pancreatic dysfunction

A

stool elastase

168
Q

acid base balance seen in cystic fibrosis

A

hypochloremic alkalosis

169
Q

to confirm diagnosis of meconium ileus

A

enema with diatrizoate

diagnotic and for passage of meconium plug

170
Q

surfactant secreted by

A

type II pneumocytes

171
Q

what are the four surfactant proteins

A

surfactant proteins A and D (SP-A, SP-D)
participate in host defense in the lung

surfactant proteins B and C (SP-B, SP-C)
contribute to the surface tension–lowering activity of the pulmonary surfactant

172
Q

iron-deficiency anemia, hemoptysis, and multiple alveolar infiltrates on chest radiographs

A

pulmonary hemosiderosis

173
Q

most common cause of primary pulmonary hemosiderosis causing hemoptysis

A

goodpasture

anti basement membrane hyperreactivity

174
Q

cow milk hypersensitivity presenting as hemoptysis and pulmonary hemosiderosis

A

heiner syndrome

175
Q

seen on histopath with recurrent or chronic pulmonary hemorrhages

A

hemosiderin laden macrophages

detected by prussian blue

176
Q

type of vasculitis that is ANCA antineutrophil cytoplasmic antibody positive

A

wegener granulomatosis

177
Q

treatment for idiopathich pulmonary hemosiderosis

A

corticosteroids

for immunosuppresion

178
Q

most common embolus

A

thromboemboli

179
Q

common risk factor of pulmo embo in kids

A

central venous catheter

180
Q

prothrombotic diseases linked to pulmo embo

A 
factor V leiden mutation
hyperhomocysteinemia
anticardiolipin antibody
elevated lipoprotein a
nephrotic
antiphospholipid antibody
sle
181
Q

occlusion of artery bu pulmo embo leads to

A

increase in dead space
increase alveolar arterial oxygen difference
increase pulmonary vascular resistance

182
Q

ecg finding of pulmo embo

A 
st segment changes
RV failure (cor pulmonale)
183
Q

diagnostic of choice to detect for pulmo embo

A

helical or spiral ct

184
Q

gold standard for diagnosis of pulmo embo

A

pulmo angiography

185
Q

target APTT value for anticoagulation in pulmo embo

A

1.5 - 2 times control

186
Q

anemia of idiopathic pulmonary hemosiderosis similar to

A

hemolytic anemia

187
Q

malignancies that metastasize to lungs

A

wilms, osteosarcoma, hepatoblastoma

188
Q

most common cause of pleural effusion in children

A

bacterial pneumonia

other causes: heart failure, rheuma, malignancy

189
Q

rate of fluid formation in pleural effusion dictated by

A

starling law

190
Q

normal fluid in pleural space

A

4-12ml

191
Q

exudative pleural effusion

A

AT LEAST 1:
protein level >3.0 g/dL
pleural fluid : serum protein ratio >0.5
pleural fluid lactic dehydrogenase values >200IU/L
fluid:serum lactic dehydrogenase ratio >0.6

pH <7.20 suggests an exudate

192
Q

rapid removal of pleural effusion >1L associated with

A

reexpansion edema

193
Q

empyema most assoc with

A

strep pneumoniae

194
Q

stages of empyema

A

Empyema has 3 stages: exudative, fibrinopurulent, and organizational

195
Q

exudative stage of empyema

A

fibrinous exudate forms on the pleural surfaces

196
Q

fibrinopurulent stage of emypema

A

fibrinous septa form, causing loculation of the fluid and thickening of the parietal pleura

197
Q

organizational stage of empyema

A

fibroblast proliferation

198
Q

collagen defects prone to spontaneous pneumothorax

A

ehlers danlos

marfan

199
Q

related to menses

associated with diaphragmatic defect and pleural blebs

A

catamenial pneumothorax

200
Q

chemical pleurodesis for pneumothorax

A

talc
doxycycline
iodopovidine

201
Q

fibronlytic treatment in empyema

A

urokinase
streptokinase
tissue plasminogen activator

202
Q

mediastinal crunch

A

hamman sign

pneumomediastinum

203
Q

chylothorax most common after

A

thoracic duct injury after TCVS surgery

204
Q

in no resolution of chylothorax in 1-2weeks, may do

A

total parenteral nutrition

IF IT DOESN’T WORK, then a pleuroperitoneal shunt, thoracic duct ligation, or application of brin glue is considered

205
Q

neonates with chylothorax and indication for surgery

A

chyle output of >50 mL/kg/day despite maximum medical therapy for 3 days

206
Q

pectus excavatum occurs most commonly in what sex

A

males

207
Q

most common chest wall deformity

A

90%

pectus excavatum

208
Q

ecg in pectus excavatum

A

RAD

wolff parkinson white syndrome

209
Q

2 main surgical intervention in pectus excavatum

A

Ravitch

Nuss

210
Q

pectus carinatum occurs most commonly in what sex

A

males

211
Q

bell shaped chest on xray with short horizontal flaring ribs and high clavicles

A

Thoracic-Pelvic-Phalangeal Dystrophy

or Asphyxiating Thoracic Dystrophy

212
Q

as the severity of scoliosis increases, the following respi parameters will have

A

Vital capacity, forced expiratory volume in 1 sec (FEV1), work capacity, oxygen consumption, diffusion capacity, chest wall compliance, and partial pressure of arterial oxygen decrease

213
Q

spinal curve more than __ degrees define scoliosis

A

10

214
Q

chronic respiratory failure defined as

A

pulmonary insufficiency for a protracted period, usually 28 days or longer

PPS - From Nelson's (24 decks)

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