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Sheet1-表格 1 Flashcards

1
Q

Are hallucinations common in narcolepsy patients?

A

Yes. Both Hypnagogic (just before sleep) and Hypnopompic (with awakening).

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2
Q

Define Cataplexy.

A

Sudden collapse (falls asleep) while awake.

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3
Q

Define Sleep Apnea.

A

Person stops breathing for at least 10 seconds during sleep.

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4
Q

Distinguish between central and obstructive sleep apnea.

A
  • In central sleep apnea, no respiratory effort.

- In Obstructive sleep apnea, respiratory effort against airway obstruction.”

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5
Q

Does narcolepsy have a genetic component?

A

Yes

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6
Q

Does REM sleep increase or decrease with age?

A

Decreases

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7
Q

Extraocular movements during REM sleep are due to what portion of the brain?

A
  • Parapontine Reticular Formation

- Conjugate Gaze Center

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8
Q

How often does REM sleep occur?

A

Every 90 minutes (duration may increase during the night)

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9
Q

Name 1 neurotransmitter change associated with Alzheimer’s disease.

A

Decreased Ach

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10
Q

Name 1 neurotransmitter change associated with Parkinson’s disease.

A

Decreased Dopamine

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11
Q

Name 1 neurotransmitter change associated with Schizophrenia

A

Increased Dopamine

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12
Q

Name 2 effects of stress on the body.

A
  1. Induces production of FFA, 17-OH corticosteroids, lipids, cholesterol, and catecholamines
  2. Affects water reabsorption, muscular tonicity, gastrocolic reflex, and mucosal circulation.
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13
Q

Name 2 neurotransmitter changes associated with depression.

A

Decreased NE and Serotonin (5-HT)

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14
Q

Name 2 neurotransmitter changes associated with Huntington’s disease.

A

Decreased GABA and Ach

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15
Q

Name 3 changes in sleep stages often found in people with depression.

A
  1. Reduced slow-wave sleep
  2. Decreased REM latency
  3. Early morning awakening (important screening question!)
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16
Q

Name 3 possible findings in non-REM sleep.

A

“Sleepwalking, night terrors, and bedwetting”

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17
Q

Name 4 physiological actions found in REM sleep.

A
  • Increased/variable pulse
  • rapid eye movements
  • increased/variable blood pressure
  • penile/clitoral tumescence
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18
Q

Name 5 possible findings in REM sleep.

A
  • Dreaming,
  • loss of motor tone
  • possible memory processing function
  • erection
  • increased brain O2 use
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19
Q

Name 5 possible waveform patterns seen in the various sleep/wake stages.

A
  • Alpha, Beta (highest frequency, lowest amplitude)
  • Theta, Delta (lowest frequency, highest amplitude)
  • Sleep spindles with K-complexes
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20
Q

Name 7 functions of the Frontal lobe.

A

Concentration, Orientation, Language, Abstraction, Judgment, Motor regulation, Mood

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21
Q

Name 1 possible chronic outcome of sleep apnea.

A

Chronic fatigue

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22
Q

Name 5 findings associated with sleep apnea

A

Obesity, loud snoring, systemic/pulmonary HTN, arrhythmias, and possibly sudden death.

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23
Q

What 3 things does the differential diagnosis for sexual dysfunction include?

A
  1. Drugs (e.g. antiHTN, neuroleptics, SSRIs, and ethanol)
  2. Diseases (e.g. depression and diabetes)
  3. Psychological (e.g. performance anxiety)
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24
Q

What is a common treatment for narcolepsy?

A

Stimulants (e.g. Amphetamines)

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25
Q

What is a helpful mnemonic for the order of the corresponding waveform patterns in each stage of sleep?

A

At night, BATS Drink Blood.

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26
Q

What is considered the key to initiating sleep?

A

Serotonergic predominance of the raphe nucleus

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27
Q

What is the most notable change in function in a frontal lobe lesion?

A

Lack of social judgement

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28
Q

What is the principal neurotransmitter involved in REM sleep?

A

Ach

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29
Q

What medication shortens stage 4 sleep and Tx enuresis?

A

Imipramine

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30
Q

What medication shortens stage 4 sleep and Tx of night terrors and sleepwalking?

A

Benzodiazepines

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31
Q

What neurotransmitter can reduce REM sleep?

A

NE

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32
Q

What percentage of time is spent in REM sleep?

A

0.25

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33
Q

What percentage of time is spent in stage 1 sleep?

A

0.05

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34
Q

What percentage of time is spent in stage 2 sleep?

A

0.45

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35
Q

What percentage of time is spent in stage 3-4 sleep?

A

0.25

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36
Q

What phenomenon caused REM sleep to be known as ‘paradoxical’ or ‘desynchronized’ sleep?

A

The EEG pattern during REM sleep is the same as the EEG of a person that is awake and alert.

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37
Q

What waveform pattern is seen in a young adult who is awake (eyes open), alert, and has active mental concentration?

A

Beta waves

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38
Q

What waveform pattern is seen in a young adult who is awake but has his/her eyes closed?

A

Alpha waves

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39
Q

What waveform pattern is seen in a young adult who is in deeper (stage 2) sleep?

A

Sleep spindles and K-complexes

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40
Q

What waveform pattern is seen in a young adult who is in light (stage 1) sleep?

A

Theta waves

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41
Q

What waveform pattern is seen in a young adult who is in REM sleep?

A

Beta waves

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42
Q

What waveform pattern is seen in a young adult who is in the deepest, Non-REM (stage 3-4) sleep?

A

Delta waves

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43
Q

A person who is unable to remember things that occurred after a CNS insult has?

A

Anterograde Amnesia

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44
Q

Anterograde amnesia caused by thiamine deficiency?

A

Korsakoff’s amnesia

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45
Q

Are DT’s life threatening?

A

Yes

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46
Q

Are the illness production and motivation in somatoform disorders consicous drives?

A

No

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47
Q

Bipolar I describes?

A

manic

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48
Q

Bipolar II describes?

A

hypomanic

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49
Q

Define a Manic episode.

A

“Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week”

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50
Q

Define a panic disorder.

A

Discrete period of intense fear and discomfort peaking in 10 minutes with 4/5 characteristics

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51
Q

Define Anosognosia.

A

being unaware that one is ill

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52
Q

Define Autotopagnosia.

A

Being unable to locate one’s own body parts

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53
Q

Define Conversion disorder.

A

“symptoms suggest motor or sensory neurologic or physical disorder, but tests and PE are negative”

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54
Q

Define depersonalization.

A

body seems unreal or dissociated

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55
Q

Define Personality disorder

A

“when patterns become inflexible and maladaptive, causing impairment in social or occupational functioning or subjective distress”

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56
Q

Define Personality trait.

A

“an enduring pattern of perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of important social and personal contexts”

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57
Q

Delusions are?

A

false beliefs not shared by other memebers of culture/subculture that are firmly maintained in spite of obvious proof to the contrary

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58
Q

Describe a Paranoid Personality

A

distrustful and suspicious; projection is main defense mech

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59
Q

Describe a Schizoid Personality.

A

voluntary social withdrawl; no psychosis; limited emotional expression

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60
Q

Describe a Schizotypal Personality.

A

“interpersonal awkwardness, odd thought patterns and appearance”

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61
Q

Does the person who has the phobia recognize their fear as excessive?

A

“yes, they are exhibiting insight”

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62
Q

Does the phobic fear interfere with normal routine?

A

yes

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63
Q

Hallucinations are?.

A

perceptions in the absence of external stimuli

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64
Q

How are Cluster A personalities described?

A

as odd or ecentric; cannot develop meaningful social relationships; Weird

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65
Q

How are Cluster B personalities described?

A

“Dramatic, emotional, or erratic; Wild”

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66
Q

How are Cluster C personalities described?

A

“Anxious and fearful, ‘Worried’”

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67
Q

How is a major depressive disorder characterized?

A

Recurrent-requires 2 or more depressive episodes with a symptom free interval of 2 months

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68
Q

How is a major depressive episode characterized?

A

“5 of the following for 2 weeks, including
(1) depressed mood or (2) anhedonia: Sleep disturbances, Loss of Interest, Guilt, Loss of Energy, Loss of Concentration, Change in Appetite, Psychomotor retardation, Suicidal ideation, Depressed mood”

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69
Q

How is maladaptive pattern of substance abuse defined?

A

3 or more of the above signs in 1 year

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70
Q

How is Schizophrenia described?

A

“periods of psychosis and disturbed behavior lasting > 6months, “

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71
Q

How long does the disturbance due to PSSD last?

A

> 1 month and causes distress or social/

occupational impairment

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72
Q

How many criteria sets exist for bipolar disorder?

A

“6 separate criteria exist for bipolar disorders with combinations of manic, hypomanic, and depressed episodes”

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73
Q

How many hallucination types are there? Name them.

A

7: Visual, Auditory, Olfactory, Gustatory, Tactile, Hypnagogic, Hypnopompic”

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74
Q

How many heroin addicts are there in the US?

A

~500,000

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75
Q

How would you decribe a dependent personality?

A

“submissive and clinging, excessive need to be taken care of, low self-confidence”

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76
Q

How would you decribe an obsessive-compulsive?

A

“preoccupation with order, perfectionism and control”

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77
Q

How would you describe a Borderline personality?

A

“unstable mood and behavior; impulsive, sense of emptiness”

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78
Q

How would you describe a histrionic personality?

A

“excessive emotionally, somatization, attention seeking, sexually provocative”

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79
Q

How would you describe an Antisocial?

A

“as having a disregard for and violation of rights of others, criminality”

80
Q

How would you describe an avoidant personality?

A

“sensitive to rejection, socially inhibited, timid, feelings of inadequacy”

81
Q

How would you desribe a Narcissistic personality?

A

“grandiosity; sense of entitlement, many demand ‘top’ physician/best health care”

82
Q

“If a patient consciously fakes or claims to have a disorder in order to attain a specific
gain, how is this behavior described?”

A

Malingering

83
Q

Illusions are?

A

“misinterpretation of actual external stimuli, ex. Mistaking coat rack for man”

84
Q

In what kind of disorder does a person consciously create symptoms in order to assume a sick role and get medical attention?

A

Factitious Disorder

85
Q

Is Heroin prescribable?

86
Q

Is the motivation concious in Munchausen’s by proxy?

87
Q

Name the 5 subtypes of schizophrenia.

A

“Disorganized, Catatonic, Paranoid, Undifferentiated, Residual”

88
Q

Name the types of Cluster B personalities.

A

Antisocial, Borederline, Histrionic, Narcissistic

89
Q

To be a manic episode what characteristic behaviors must be present?

A

3 or more of the following:
Distractibility, Insomnia, Grandiosity, Flight of Ideas, Inc in Activity/pyschomotor agitation, Pressured Speech, Thoughtlessness

90
Q

What are the signs of Barbiturate withdrawal?

A

Anxiety, seizures, delirium, life-threatening CV collapse

91
Q

What are the signs of nicotine withdrawl?

A

“Irritablility, headache, anxiety, weight gain, craving, tachycardia”

92
Q

What are the 4 A’s of schizophrenia?

A
  • Ambivalence (uncertainty),
  • Autism (self-preoccupation and lack of communication),
  • Affect (blunted),
  • Associations (loose)
93
Q

What are the characteristics of Dementia?

A

development of mulitple cognitive deficits: memory, apahasia, apraxia, agnosia, loss of abstract thought, behavioral/personality changes, impaired judgement

94
Q

Whare are the signs of Benzodiazepine intox?

A

Amnesia, ataxia, somnolence, minor resp depression

95
Q

What are are the signs of caffeine intox?

A

restlessness, insomina, increased diuresis, muscle twitching, cardiac arrhythmias

96
Q

Whare are the signs of Marijuana intox?

A

Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired jugdment, social withdrawl, increased appetite, dry mouth and hallucinations

97
Q

Whare are the signs of PCP intoxication?

A

Belligerence, impulsiveness, fever, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia, homicidality, psychosis and delirium

98
Q

What are 2 opioid comptetitive inhibitors?

A

Naloxane and Naltrexone

99
Q

What are some common causes of delirium?

A

substance use/abuse or medical illness

100
Q

What are some related diagnoses of Heroin addicts?

A

substance use/abuse or medical illness

101
Q

What are the 5 characteristics of panic?

A

Palipitations, Abdominal distress, Nausea, Increased perspiration, Chest pains, chills and choking

102
Q

What are the 6 somatoform disorders?

A

conversion, somatoform pain disorder, hypochondriasis, somatization disorder, body dysmorphic disorder, pseudocyesis

103
Q

What are the characteristics of Delirium?

A

Decreased attention span and level of arousal, disorganized thinking, hallucinations, illusions, misperceptions, disturbance of sleep-wake cycle, cognitive dysfxn

104
Q

What are the etiologic factors for schizophrenia?

A

genetics and environment, genetics outweigh env

105
Q

What are the maladaptive signs of substance use?

A

Tolerance, Withdrawl, Substance taken in larger amounts than intended, Persistent desire or attempst to cut down, lots of energy spent trying to obtain substance, withdrawl from responsibility, used continued in spite of knowing the problems that it cause

106
Q

What are the negative symptoms of schizophrenia?

A

flat affect, social withdrawl, thought blocking, lack of emotion

107
Q

What are the Positive symptoms of Schizophrenia?

A

Hallucinations, delusions, strange behavior and loose associations

108
Q

What are the signs of alcohol use?

A

Disinhibition, emotional lability, slurred speech, ataxia, coma, blackouts

109
Q

What are the signs of alcohole withdrawl?

A

Tremor, Tachycardia, HTN, malaise, nausea, seizures, delirium tremens, tremulousness, agitation, hallucinations

110
Q

What are the signs of Amphetamine intoxication?

A

Psychomotor agitation, impaired judgement, pupillary dilation, HTN, tachycardia, euphoria, prolonged wakefulness and attention, cardiac arrhythmias, delusions, hallucinations, fever

111
Q

What are the signs of Amphetamine withdrawl?

A

Post-use crash, including anxiety, lethargy, headache, stomach cramps, hunger, severe depression, dysphoric mood, fatigue, insomnia/hypersomnia

112
Q

What are the signs of Barbiutate intox?

A

respiratory depression

113
Q

What are the signs of benzo withdrawl?

A

Rebound anxiety, seizures, tremor, insomnia

114
Q

What are the signs of ca!eine withdrawl?

A

Headache, lethargy, depression, weight gain

115
Q

What are the signs of cocaine intoxication?

A

Euphoria, psychomotor agitation, impaired judgment, tachycardia, pupillary dilation, HTN, hallucinations (including tactile:bugs on skin), paranoid ideations, angina, and sudden cardiac death

116
Q

What are the signs of cocaine withdrawl?

A

Hypersomnolence, fatigue, depression, malaise, severe craving, suicidality

117
Q

What are the signs of LSD intoxication?

A

Marked anxiety and depression, delusions, visual hallucinations and flashbacks

118
Q

What are the signs of narcotic abstinence syndrome?

A

dilated pupils, lacrimation, rhinorrhea, sweating, yawning, irritability, and muscle aches

119
Q

What are the signs of opioid intoxication?

A

CNS depression, nausea and vomiting, constipation, pupillary constriction, seizures

120
Q

What are the signs of opioid withdrawl?

A

Anxiety, insomnia, anorexia, sweating/piloerection(cold turkey), fever, rhinorrhea, nausea, stomach cramps, diarrhea, flu-like symptoms, yawning

121
Q

What are the signs of PCP withdrawl?

A

Recurrence of intoxication symptoms due to reabsorption in GI tract, sudden onset of severe, random, homicidal violence

122
Q

What are the symptoms of DT’s (in order of appearance)?

A

ANS Hyperactivity (tachycardia, tremors, and anxiety), Psychotic symptoms (hallucinations, delusions), confusion

123
Q

What are the symptoms of nicotine intoxication?

A

Restlessness, insomnia, anxiety, arrhythmias

124
Q

What are the types of Cluster A personalities?

A

Paranoid, Schizoid, Schizotypal

125
Q

What are the types of Cluster C personalities?

A

Avoidant, Obsessive-Compulsive, Dependent

126
Q

What are treatment options of phobias?

A

systematic desensitization

127
Q

What can be confused with dementia in elderly?

A

depression

128
Q

What complication result from ECT?

A

complications associated with anesthesia and retrograde amnesia

129
Q

What does exposure to object of phobia evoke?

A

an anxiety response

130
Q

What drug is used for long term maintenance of heroin detox?

131
Q

What else is classically associated with Korsakoff’s?

A

“Confabulations, ie. Making it up as you go along”

132
Q

What is a hallmark sign of heroin addiction?

A

track marks

133
Q

What is a Hypomanic Episode?

A

it is like a manic episode except mood disturbance is not severe enough to cause marked impairment in social and/or occupational functioning or to necessitate hospitalization; no psychotic features

134
Q

What is a pain somatoform disorder?

A

pain that is not explained completely by illness

135
Q

What is a phobia?

A

“fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or entity”

136
Q

What is a schizoaffective disorder?

A

a combo of schizophrenia and a mood disorder

137
Q

What is a somatization disorder?

A

Varitey of complaints in multiple organ systems

138
Q

What is Cyclothymic disorder?

A

milder form of bipolar lasting at least 2 years

139
Q

What is dementia characterized by?

A

commonly irreversible memory loss

140
Q

What is destroyed in Korsakoff’s Amnesia?

A

Mamillary bodies(bilaterally)

141
Q

What is drug of choice for bipolar?

142
Q

What is Dysthymia?

A

milder form of depression lasting at least 2 years

143
Q

What is Electroconvulsive Therapy(ECT)?

A

a tx option for major depressive disorder refractory to other tx. It is painless and produces a seizure with transient memory loss and disorientation.

144
Q

What is Hypochondriasis?

A

“misinterpretation of normal physical findins, leading to preoccupation with and fear of having a serious medical illness in spite of medical reassurance”

145
Q

What is it called when a parent causes their child to become ill in order to receive attention?

A

Munchausen’s by proxy

146
Q

What is post-traumatic stress disorder?

A

when a person experienced or witnessed an event that involoved actual or threatened death or serious injury. The traumatic event is reexperienced; person persistently avoids stimuli associated with the trauma and experiences persistent symptoms of increas

147
Q

What is primary gain?

A

what the symptom does for the patient’s nternal psychic economy

148
Q

What is retrograde amnesia a complication of?

A

ECT-electroconvulsive therapy(shock)

149
Q

What is secondary gain?

A

What the symptoms gets the patient(sympathy or attention)

150
Q

What is tertiary gain?

A

what the caretaker gets

151
Q

What is the criterion for dx of substance abuse?

A

“One or more of the following in 1 year: Recurrent use resulting in failure to complete responsiblities, recurrent use in physically hazardous situations, recurrent legal problems, continued use in spite of persistent problems of use”

152
Q

What is the definition of substance abuse?

A

“maladaptive pattern of use leading to clinically significant impairment or distress, symptoms have not met criteria for dependence”

153
Q

What is the difference between delusions and loose associations?

A

delusion is a disorder in the content of thought (the actual idea) where a loose association is a disorder in the form of thought (the way the idea is tied together)

154
Q

what is the fear of heights?

A

acrophobia

155
Q

what is the fear of marriage?

A

gamophobia

156
Q

what is the fear of open places?

A

agoraphobia

157
Q

what is the fear of pain?

A

algophobia

158
Q

What is the Fifth A?

A

Auditory hallucinations

159
Q

What is the inability to remember things that happened before CNS insult?

A

Retrograde Amnesia

160
Q

What is the key to delirium diagnosis?

A

Waxing and waning level of conciousness that develops rapidly

161
Q

What is the key to dementia diagnosis?

A

“rule out delirium-patient is alert, no change in level of conciousness. More often gradual onset. “

162
Q

What is the lifetime prevalence for Major Depressive Disorder in Males and Females:

A

“13% for males, and 21% for females”

163
Q

What is the lifetime prevalence for schizophrenia?

A

“1.5%-(males/females, blacks/whites) presents earlier in men”

164
Q

What is the most common psych illness on medical and surgical floors?

A

Delirium, often reversible

165
Q

What is the order of loss or orientation?

A

Time, place, and Person

166
Q

What is the response to the traumatic event?

A

“intense fear, helplessness or horror”

167
Q

What is the trigger for DT’s?

A

alcohols withdrawl

168
Q

What patient population will you see Korsakoff’s?

A

Alcoholics

169
Q

What questions do you have to answer when assessing an patient’s orientation?

A

Is the patient aware of him/herself as a person? Does the patient know his/her name?

170
Q

What syndrome is manifested by a chronic history of multiple hospital admissions and willingness to receive invasive procedures?

A

Munchausen’s

171
Q

What is body dysmorpic disorder?

A

patient is convinced that part of one’s own anatomy is malformed

172
Q

Whate is pseudocyesis?

A

false belief of being pregnant associated with objective signs of pregnancy

173
Q

When are the halluinations common?

A
  • Visual (acute organic brain syndrome ),
  • Auditory (Schizophrenia),
  • Olfactory (aura of psychomotor epilepsy),
  • Gustatory (rare),
  • Tactile (DT’s and Cocaine abusers),
  • Hypnagogic (while going to sleep),
  • Hypnopmpic(while waking from sleep)”
174
Q

When do DT’s peak?

A

2-5 days after last drink

175
Q

When must a painc disorder be dx?

A

in the context of the occurrence

176
Q

Who are more likely to be antisocial, male or female?

177
Q

Who are more likely to be borderline, male or female?

178
Q

Who do you need to see to witness caffeine withdrawl approx every six weeks?

A

Blake Williams

179
Q

Define Autonomy.

A

Obligation to respect pts as individuals and to honor their preferences in medical care

180
Q

“Legally, what does informed consent require?”

A
  • discussion of pertinent information
  • obtaining the patient’s agreement to the plan of care
  • freedom from coercion
181
Q

Pt autonomy vs. beneficence: when does autonomy win out?

A

If pt makes an informed decision, ultimately, the pt. has the right to decide.

182
Q

What 3 proofs are required for a sucessful malpractice civil suit for neglegence?

A
  • Dr. breach of duty to patient
  • pt. suffers harm
  • breach of duty causes harm

Note
- beyond reasonable doubt not needed, just more likely than not

183
Q

What are the 4 exceptions to confidentiality?

A
  • potential harm to others is serious
  • likelihood of harm is great
  • no alternative means exist to warn or to protect those at risk
  • Drs. Can take steps to prevent harm
184
Q

What are the 4 exceptions to informed consent?

A
  • pt. lacks decision-making capacity (not legally competent)
  • implied consent in an emergency
  • therapeutic privilege
  • withholding information when disclosure would severly harm the pt or undermine informed decision-making capacity
  • waver
185
Q

What are the 5 signs of a pt’s decision-making capacity?

A
  • pt. makes and communicates a choice
  • pt. is informed
  • decision remains stable over time
  • decision consistent w/ pt’s values and goals
  • decision not a result of delusions or hallucinations
186
Q

What are the types of written advance directives?

A
  • LIVING WILLS-
  • pt. directs Dr. to withhold/withdraw life-sustaining tx if the pt develops terminal disease or enters a persisitent vegative state
  • DURABLE POWER OF ATTORNEY
  • pt designates a surrohate to make medical decisions in an event
187
Q

What is beneficence?

A

Dr. have special ethical responsibility to act in the pt’s best interest. Pt. autonomy may conflict with beneficience

188
Q

What is confidentiality?

A

Confidentiality respects pt. privacy and autonomy. Disclosure to family and friends should be guided by what pt. would want. Pt can waive right to confidentiality (i.e. to insurance co.)

189
Q

What is nonmaleficence?

A

Do no harm. But, if benefits of intervention outweigh risks, pt may make an informed decision to proceed.

190
Q

What must patients understand in informed

consent?

A
  • risks
  • benefits
  • alternatives, which includes no intervention
191
Q

When is an oral directive valid?

A

Incapacitated patient’s prior oral statements commonly used as guide, but problems arise from variance in interpretation. if pt was INFORMED, directive is SPECIFIC, pt. MAKES A CHOICE and decision is REPEATED over time, the oral directive is more valid.

192
Q

At what ages does sexual abuse in children peak?

A

9 to 12 years of age

193
Q

At what time (minutes after birth) do you run an APGAR score?

A

after 1 min. and 5 min., score 0-2 in 5 categories (10 is perfect score)

194
Q

Define low birth weight

A

less than 2500g

195
Q

Irreversible changes of long term deprivation of affection occurs after how long?

196
Q

Physical abuse in children leads to how many deaths in the U.S.?

A

~3000 deaths/yr.

197
Q

What are evidence of physical abuse in children?

A
  • healed fractures on x-ray
  • cigarette burns
  • subdural hematomas
  • multiple bruises
  • retinal hemorrhage or detachment

Behavior Science (2 decks)

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