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AMC MCQ > Surgery > Flashcards

Surgery Flashcards

1
Q

Most common type of esophageal cancer?

A

Squamous cell CA

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2
Q

MEN Syndrome

A

MEN 1….PPP
MEN 2A..MPP (med, ca, Pheo,Parathyroid)
MEN 2B..MMP *med. CA, Mucosal nueroma, Pheo)

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3
Q

what is the screening in place for prostate cancer?

A

ALL men >50….voluntary yearly PSA

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4
Q

Pt with family history of prostate cancer, when to start screening if concerned?

A

40 years

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5
Q

Steroid regiment for steroid dependent individual going for surgery

A

100mg IV preop….
100mg IV intra op
100mg iv upto 24 hrs post op
then oral steroids when tolerated

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6
Q

hard throid nodule with elevated TSH, think?

A

Hashimotos thyroiditis

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7
Q

5 tests for the knee

A
  1. ACL ==Lachman test
  2. PCL==posterior draw test and posterior sag
  3. Meniscus injury ==Mcmurray test
  4. Collateral ligament== Varus and valgus test
  5. Patellar disloc==patellar apprehension test
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8
Q

Best ABX to cover abdominal surgery prophylactic?

A

Metronidazole +

Gent or cephazolin

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9
Q

Which Hernia is unlikely to strangulate?

A

Direct Hernias

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10
Q

MCC of acute limb ischemia?

A

Thrombosis

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11
Q

Tension pneumothorax, where to place needle and tube?

A

Needle = 2 intercoastal space mid clavicular

Tube = 5 th ICS mid Axillary

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12
Q

Pt with abdominal trauma, hemodynamically unstable, what to do?

A

FAST

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13
Q

Fracture of mid shaft of humerus, what nerve is affected?

A

Radial Nerve

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14
Q

Suspected urethral injury, what to do?

A

Retrograde Urethrogram

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15
Q

Common Peroneal nerve damage sign?

A

foot drop….inability to dorsiflex

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16
Q

Any male or post menopausal female with iron deficiency, what to do?

A

Refer for colonoscopy

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17
Q

Unknown hx of tetanus vaccination, what to do?

A

give both IVIG and toxoid

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18
Q

Unilateral neck mass with no symptom, most likely diagnosis

A

Multinodular goiter

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19
Q

Bilateral neck mass with no symptom, most likely diagnosis

A

Adenocarcinoma or carcinoma

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20
Q

Tx of choice for Pleomorphic Adenomas?

A

Superficial paroidectomy

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21
Q

Most common cardiac tumor?

A

Myxoma

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22
Q

MC complication of TURP?

A

UTI

Followed by bleeding

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23
Q

1st investigation in suspected esophageal malignancy?

A

Barium swallow

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24
Q

MC cause of bone tumor in pelvis of young adult?

A

Metastatic tumor

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25
Tx of calcified gall bladder (porcelain)
Prophylactic cholecystectomy
26
Pt present to ER after blunt force trauma, FAST or CT?
``` Stable = CT Unstable = FAST ```
27
Which drug gives rebound htn when stopped suddenly?
clonidine (an alpha blocker)
28
Migratory superficial thrombophlebitis and DVT, suspect?
Pancreatic cancer
29
MC cause of large bowel obstruction in Australia?
Colon Cancer
30
Most useful inv. for detecting gallstones?
US
31
Melanoma and clear margins for excision
depth of 1mm ---1cm clear margin required 2 - 4 mm ----1-2cm margin required 4mm ---2cm margin required
32
when do you do prophylactic cholecystectomy?
gallstone >3cm or porcelin gallbladder
33
Pt after trauma presents to ER after lucid interval, suspect?
Epidural hematoma
34
investigation of choice in recurrent kidney stones?
US + X Ray
35
How to monitor secondary spread in seminoma?
LDH Lactate dehydrogenase
36
First line investigation for chronic pancreatitis? (2)
CT, if unavailble use US
37
Tx of Duputrens contracture?
Open fasciectomy
38
Liver and Pancreas Amebic Liver Abscess Causative organism……
Entameba Histolytica Usually singe and located at upper lobe Anchovy paste fluid
39
Abdominal pain, dysentery and bloody diarrhea RUQ pain Fever and chills with travel History to endemic area vvvvvv imp common presentation
Entameba Histolytica
40
Wbcs in Entameba Histolytica
increased
41
Stool analysis in Entameba Histolytica
trophozoites
42
CT Entameba Histolytica
cystic lesions
43
TTT Entameba Histolytica
ORAL METRONIDAZOLES
44
HYDATIC CYST Causative organism Initial Inv? Best Inv?
Echinococcus granulosus US CT
45
Definitive host for HYDATIC CYST
dog Many cases are asymptomatic Abd pain, fever, and may be jaundice
46
CT presentation of HYDATIC CYST
Egg shell calcification of hepatic cyst | one big cyst with multiple daughter cysts
47
Risk for HYDATIC CYST if rutured
anaphylaxis if ruptured
48
if CT does not reveal it (HYDATIC CYST) do?
Serology
49
TTT of HYDATIC CYST
SURGERY under cover of albendazole
50
Liver malignancy | Primary shows?
Increased alpha fetoprotein | Less common than metastasis
51
CT in primary Liver malignancy
SOLITARY LESION
52
TTT of primary Liver malignancy
SURGERY, CHEMOTHERAPY, AND | INTRAHEPATIC EMBOLIZATION
53
Secondary Liver malignancy is from?
the colon | Much more common than primary
54
CT in Secondary Liver malignancy shows?
MULTIPLE SPOTS
55
HEPATIC ADENOMA is related to
OCP use Benign rare tumour Normal liver function test and alpha feto protein
56
Acute pancreatitis | Causes
Gall stones…Alcohol | Others…….trauma, infection, increase lipids TIL
57
Acute pancreatitis | Complications:
1 - Pseudocyst…..most common complications Timing …………..within weeks, Cp…………………..epigastric MASS, Fate………………..usually resolve spontaneously HAPPy PAD
58
When to drain Pseudo cyst??:
If persists more than 6 wks , size more than 6 cm, or if infected
59
How to drain Pseudo cyst?.
Endoscopic internal drainage to stomach
60
Most common early complication of Acute Pancreatitis
2 - ARF…………
61
Most common cause of acute pancreatitis
stones
62
Most common complication overall of acute pancreatitis?
pseudocyst
63
TTT of acute pancreatitis?
conservative
64
PANCREATIC CANCER Presentation
``` Sex……….usually male Age………old Most cancer causes death within 5 years Risk factors……SMOKING, DM, ALCOHOL Dull abdominal pain radiating to back Weight loss If at head…………deep jaundice Recurrent thrombophlebitis ```
65
Investigations of PANCREATIC CANCER: | Serum bilirubin
increased(direct)
66
DILATATION OF GALL BLADDER | what inv to do?
US…
67
MASS AT HEAD OF PANCREAS | BEST ( inv of choice) for Pancreatic cancer?
CT
68
TTT of Pancreatic cancer
Surgery...whipple’s operation
69
Symptomatic ttt of pancreatic cancer
stent
70
Causes of CHRONIC PANCRATITIS (2)
alcoholism…..cystic fibosis…
71
Levels of Amylase and lipase in chronic pancreatitis?
normal
72
CT of CHRONIC PANCRATITIS shows?
THE BEST …..calcification
73
TTT of CHRONIC PANCRATITIS
PANCREATIC ENZYMES REPLACEMENT
74
Nephrolithiasis Presentation
Sudden onset flank pain Colicky pain referred to the scrotum Nausea and vomiting Hematuria
75
Imaging Investigation of Nephrolithiasis: Best: In pregnancy Before surgery what imaging? Tx?
Best………… (non contrast) CT Pregnant with renal stones………ultrasound …….X-Ray Best analgesic outside the hospital………NSAIDS
76
Most kidney stones are visible
majority are radiopaque
77
MOST COMMON renal stones?
Ca oxalate
78
Uric acid are what kind of stones?
radiolucent | Struvite stone……….alkaline urine………proteus
79
Treatment of kidney stones
Excess rehydration and thiazide with all cases
80
ureteric stones : | First line of ttt
Ureteroscopic laser lithotripsy for stones at any level
81
Kidney stones | If less than 2 cm
ESWL
82
Kidney stones More than 2 cm
Percutaneous nephrolithotripsy
83
Staghorn stone
Open nephro- or pyelo-Lithotomy
84
Young pt complains of flank pain asking for strong analgesic first step
drug screen by urine analysis ……take sample in front of you
85
Kidney stones Recurrence rate
50% within 5 years
86
Definitive treatment of: ureteric stones : First line of ttt
Ureteroscopic laser lithotripsy for stones at any level
87
Kidney stones tx
<0.5 conservative If less than0.5 - 2 cm………ESWL More than 2 cm……… Percutaneous nephrolithotripsy Staghorn stone………………….. Open nephro- or pyelo-lithotomy
88
Indications of surgery with renal stones:
1 - obstruction and infection ….. Most absolute indication…vvvvvvvvvvvvvvvv imp 2 - too large to pass 3 - pain cannot be controlled
89
Inv that should be done before going to surgery on renal stones
X-Ray….vvvvvv imp
90
Most common cause of fever after urology procedure… | ttt
bacteremia Urosepsis Empirical antibiotics……….amoxycillin and gentamycin
91
Renal cell carcinoma presentation INV TTT
Triad of; Flank pain Hematuria Renal mass CT Biopsy……..(better to be avoided) ………..surgery ( Total Nephrectomy)…vvv imp
92
Incidental discovery of renal mass: IF OLD AGE: First step Imaging of choice for surveillence TTT of choice
……….active surveillance ………CT ………Total nephrectomy
93
When laparoscopic partial nephrectomy can be done??????
1-small tumour in one kidney (less than 4cm) 2- Cancer in both kidneys 3-only one working kidney.
94
What if metastasis of renal mass???
Total nephrectomy followed by immunotherapy
95
Young pt with renal mass , what to do?
Partial Nephrectomy Active surveillance is NOT generally recommended for young patients
96
Causes of Kidney injury
blunt trauma in the abdomen
97
Presentation of Kidney Injury: Inv… TTT
Hematuria Flank pain ……CT with contrast ……..most cases heal conservatively….imp If unstable……….laparotomy
98
Rupture of urethra HISTORY OF TRAUMA Investigation……
Blood at urethral meatus……key word Never ever insert a catheter ……retrogradeurothrography
99
Polycystic kidney disease | Two types:
Infantile………..AR………early mortality | Adult……..AD
100
Clinical picture of PKD Strong association Investigation… First……… Best TTT:
Age………usually above 50 PAINLESS HEMATURIA Hypertension Bilateral flank mass Intracranial berry aneurysm……SAH ..US …CT TTT of hypertension
101
Most common cause of death in PKD
renal failure
102
Inv of choice In PKD
CT
103
Acute prostatitis presentation Best inv… TTT……
``` Fever, chills, ++WBC Urinary urgency and dysuria Tender prostate ………..mid stream urine collection ……ANTIBIOTICS ```
104
BPH Presentation Investigation…… TTT….
``` Male usually above 50 ys Frequency Nocturia…….first symptom Hesitancy Weak stream Hypertrophy usually start at central zone PR…………smooth and firm enlargement ``` …….US………to detect hydronephrosis Alpha blocker eg: prazocin TURP Surgery
105
Complications of TURP:
UTI Bleeding (2nd common)…….important.] Clot retention and clot colic
106
TURP Syndrome:
Hyponatremia and water intoxication (TO AVOID THIS ….limit length of the procedure is limited to less than one hour,.[6] Bladder neck stenosis Urinary incontinence Retrograde ejaculation
107
PRASTATIC CANCER presentation RISK factor
Most common malignancy in men Age …….usually above 70 …..FH, increased fat in diet SAME PICTURE AS BPH
108
Type of PROSTATIC CANCER
adenocarcinoma
109
PR of PROSTATIC CANCER
hard and asymmetry
110
Complications of PROSTATIC CANCER
spread to vertebrae…….osteoblastic lesions…..back pain
111
Sequence of investigations for PRASTATIC CANCER???
1st step………PSA | 2nd step…….transrectal US
112
TTT for Prastatic Cancer :
Very old patient and not fit for surgery……….WATCHFUL WAITING Guidelines of prostate cancer ttt
113
Treatment of choice if of Prostate Cancer if: FOCAL LOCALLY ADVANCED METASTATIC RECURRENT
Focal ……………..radical prostatectomy Locally advanced……radiation Metastatic………androgen ablation Recurrent………..hormonal therapy
114
According to Gleason score: Less than/equal to 6 ... Less than/equal to 7... Less than/equal 8-10...
Less than or equal to 6…………active surveillance or radical prostatectomy 7 ……………radical prostatectomy or Radation 8-10………..androgen ablation
115
According to PSA: | If less than 10
If less than 10 ……….active surveillance
116
Screening for Prostatic cancer
Not recommended | Done by PR and PSA
117
What if the patient asked for prostate screening???
First step……..Counseling | Second step………Do it
118
DD multiple myeloma VS prostatic cancer?? | both of them
old age male with back pain
119
Multiple myeloma will display
hypercalcemia……vvv imp
120
Prostate cancer will display
normal or high calcium | So…..if old male with back pain and normal calcium NEVER CHOSE MM
121
VARICOLCELE primary. .. secondary. ..
Primary……….usually at left side | Secondary……….due to malignancy
122
Clinical picture of VARICOLCELE ``` Age... Type of Pain... Examination... Complication... Investigation TX ```
Age………..young Asymptomatic or dragging pain EXAMINATION……….bag of worm sensation Complication……..hypofertility , and thrombosis Investigation………semen analysis and doppler TTT…………CONSERVATIVE SURGERY WITH SEMEN ABNORMALITY
123
1ry Varicecole Young/Old Patient? Gradual/Sudden onset Empty/Full Scrotum? Inv?
1ry……..young patient gradual onset empty on elevation of scrotum inv………US
124
2ry Varicecole Young/Old Patient? Gradual/Sudden onset Empty/Full Scrotum? Inv?
2ry……..old patient sudden onset does not empty inv………CT
125
``` Hydrocele What is it? Complication? CP? Investigation? TX? ```
``` Collection of serous fluid in procesus vaginalis Primary or secondary CP……..PAINLESS scrotal swelling Complication……..infection, hge, Investigation………….transillumination US TTT ASPIRATION OR SURGERY ```
126
HYDROCELE IN PEDIATRICS TEST TTT
TEST………TRANSILLUMINATION (POSITIVE) US NEVER TO TTT ANY INFANT BEFORE FIRST YEAR ………………REASSURE THE MOTHER ADULTS; Usually secondary TTT…….ASPIRATION PLICATION OF TUNICA ALBUGINEA
127
Acute epididymo - orchitis ``` Age...? Most Common Causative Organism? Sexually Active young less than 35 =? Investigation? Treatment? ```
Age …………middle age Most common Causative organism……E-COLI Sexually active young less than 35………chlamydia Fever, pain, swelling, redness Elevation of testis does decrease pain Investigation………..urine analysis and culture TREATMENT ……………….antibiotics eg; cefotriaxone
128
Epididymal cyst and spermatocele | Cp:
Painless small scrotal swelling
129
Epididymal cyst and spermatocele Exam:
Purely scrotal swelling…… you can get above it
130
Epididymal cyst and spermatocele Site
above and behind the testis | Cystic and translucent
131
Epididymal cyst and spermatocele TTT:
Small….. no ttt…………review after 3-6 months | Large,,,,surgery……transscrotal
132
Additional notes:*** Delete?*******
Translucent lesions in the scrotum……hydrocele and epididymal cyst Spermatocele……radio opaque
133
How to deal with epididymal cyst in sequence??? | First step
First step………examination
134
Second step of dealing with an epididymal cyst
Second step………US
135
Third step of dealing with an epididymal cyst
Third step…………tumour markers
136
Fourth step of dealing with an epididymal cyst
Fourth step………review after 3-6 months
137
If u decide to ttt an epdidymal cyst
transscrotal approach
138
Torsion of testis Age? Predisposing Factor?
Age……………5-15 | Predisposing factor………….transverse lying
139
Clinical picture of torsion of testis Complication..?
``` History of trauma Sudden severe pain at the testis Swelling, pain and redness Nausea and vomiting and may be shock Elevation of the testis doesnot relieve the pain Complication…………..gangrene ```
140
TTT… of torsion of testis
URGENT SURGERY……..LESS THAN 6 HOURS
141
Undescended testis | CLINICAL PICTURE
Empty scrotum
142
Complications of Undescended testis
Sterility Trauma Torsion Malignancy
143
Association of undescended testis
.indirect inguinal hernia
144
TTT
SURGERY IS A MUST BEFORE FIRST YEAR
145
TESTICULAR CANCER Age ? Symptoms?
Young male 20-30 years Painless enlargement of testis Loss of testicular sensation Spread……….lung and paraaortic LN
146
TYPES of Testicular Cancer
SEMINOMA………GOOD PROGNOSIS | Non seminoma……bad prognosis
147
Tumor Markers | AFP
Increase with non seminoma | always normal with seminoma
148
Tumor Markers | B-HCG
Choriocarcinoma 100% | SEMINOMA 10%
149
Investigation for testicular Cancer What to use for metastasis Can you do a needle Biopsy
US……BEST CT chest………for metastasis NEVER to do needle biopsy…….spread of cancer
150
TTT of SEMINOMA…
.RADIOSENSITIVE | SURGERY
151
TTT of NON SEMINOMA
CHEMO AND SURGERY
152
If metastasis TTT
chemo and surgery
153
Any young male with painless enlargement of testes is _____________ until proven otherwise
Any young male with painless enlargement of testes is CANCER TESTIS until proven otherwise
154
Hematuria Types: Macroscopic: Common sources
Bladder Cancer (painless) urethra Kidney(Polycystic Kidney) Prostate Painful Hematuria………… stones , infection or Kidney Infarction
155
Investigations (hematuria)
IV Urography
156
Pseudo Hematuria
Foods, Drugs , Porphyrins, Free Hemoglobin. Myoglobin
157
Most common cause of painless hematuria
bladder cancer
158
Best inv for the bladder
cystoscopy and biopsy
159
Second most common cause of painless hematuria
cancer kidney
160
Best inv for the kidney
CT
161
Most common cause of painful hematuria
stones
162
Inv of choice for the stone
CT without contrast
163
If immigrant + painful hematuria
shistosomiasis
164
If immigrant + painless hematuria
cancer bladder
165
1st inv in hematuria
urine culture and sensitivity
166
If normal(1st inv of hematuria)
.US
167
Inv of choice for painless hematuria
cystoscopy
168
Inv of choice for cancer kidney
CT
169
Inv of choice for renal stones
CT KUB
170
Inv of choice for renal stones in PKD
US KUB
171
Carcinoid syndrome | products:
Vasoactive substance (serotonin, histamine)
172
C/P of carcinoid syndrome
Flushing , diarrhea , wheezes Serotonin induce fibrosis for tricuspid , pulmonary Abdominal Pain
173
Carcinoid tumor | Sites :
1-Appendix……………most common site | 2-terminal ileum
174
Carcinoid tumor | Investigation:
24 hour urine 5-HIAA
175
Carcinoid tumor | Treatment :
1- octreotide | 2- < 2cm Reassure > 2cm hemicolectomy + 5FU(chemotherapy
176
Inflammatory Bowl Disease | C/P:
Fever , Diarrhea , WT , Abdominal pain , Bleeding
177
ulcerative colitis Lead to Colon Cancer after _ - __ years
ulcerative colitis Lead to Colon Cancer after 8-10 years
178
Ulcerative Colitis Treatment : Outpatient? Admission?
Outpatient mild Attack | Admission severe Attack
179
Medical treatment for Ulcerative Colitis
Sulfasalazine main stay TTT | Corticosteroid
180
Immunosuppressive Drugs : (ulterative colitis)
Azathioprine -Cyclosporin Surgery if fail medical TTT
181
Crohn’s | Most common cause of perianal fistula
abscess
182
Most common cause of multiple or recurrent anal fistulae
crohn’s
183
Cause of low lying fistula
Crohn’s
184
TTT of anal fissure with Crohn’s
infliximab
185
Coeliac Disease ( Gluten Sensitive Enteropathy ) most common age
Any age ( children 9-18 months)
186
Causes of Coeliac Disease
genetic
187
C/P of Coeliac Disease:
Previously healthy infant FTT ( wasting buttocks ) + fatigue -Malabsorption Steatorrhea + abdominal distension - Iron and Folate Deficiency Anemia
188
Investigations of Coeliac Disease : | Golden Standerd?
Duodenal Biopsy golden standard…..atrophic villi IG Antiendomysial AB IGA Transglutamines IGA Antigliadin for screening
189
Complications of Coeliac Disease : Most feared? Skin?
-Intestinal Lymphoma…….MOST FEARED COMPLICATION | Skin………..dermatitis herpetiformis
190
association (coeliac disease)
Type 1 DM , IGA deficiency , Autoimmune Thyroiditis , Dermatitis herpitiformis,Osteoporosis
191
Management of Coeliac Disease :
Gluten free diet vitamin replacement , Pneumococcal Vaccine Dapsone ……..for dermatitis herpetiformis
192
Acute gastric dilatation | CAUSES:
Post operative Fractures Septicemia,
193
Acute gastric dilatation cp:
Hiccough, vomiting and upper abd. Pain
194
Acute gastric dilatation TTT:
MAINLY naso gastric suction | no surgery
195
Lung Abscess | Causes:
Aspiration due to Alcoholism or intubation
196
Lung Abscess C/O:
Anaerobic Bacteria | Aerobic Bacteria eg. Klebsiella in alcoholism
197
Lung Abscess C/P:
Purulent cough + Hemoptysis
198
Lung Abscess Investigations:
X-ray……..air fluid level
199
Lung Abscess Treatment : Antibiotic? If not improved?
Physiotherapy Antibiotic,,,,,,,,main TTT……….. clindamycin If not improved……..transpleural drainage….vvvvimp
200
Empyema | Cause…
Lung infections…..most common cause
201
Empyema Symptoms :
Fever, cough, shortness of breath, and pleurisy.
202
Empyema Inv:
X-ray
203
Empyema Treatment : (2 )
1- Intravenous antibiotics…….. cephalosporins ,metronidazole and penicillins Clindamycin for patients who are allergic to penicillin. 2-chest tube If complex empyema………chest tube is a must…vvvvvvimp
204
``` Epidermoid cyst (sebaceous cyst ) C/P: ```
Firm to soft regular lump | Found in hairy skin central punctum
205
Complication of epidermoid cyst
Inflammation
206
Management fo epidermoid cyst Before puberty? Small? Trouble/Infected?
Before puberty ----- Polyposis coli Small ------ Leave it Troubling or infected ------- Surgery (under local anesthesia)
207
.commonest for acute pancreatitis | .
Gall stones…
208
commonest for chronic pancreatitis
Alcoholism…
209
Clinical presentation of acute pancreatitis
SEVERE EPIGASTRIC ABDOMINAL PAIN RADIATING TO THE BACK Nausea, vomiting, and tenderness CULLEN SIGN……..bluish discoloration around umbilicus GREY TURNER SIGN……bluish discoloration at flanks
210
In colon surgery, where do you want INR?
,<1.5
211
MC cancer post transplant?
Squamous cell
212
Aside from immobilization after surgery, what is the other risk factor for VTE?
Cardiac failure
213
2 situations where tetanus toxoid should be considered
1. unknown vacination hx | 2. less than 3 doses
214
When to give tetanus IVIG?
when wound is dirty
215
Most important sign of orbital fracture?
Diplopia
216
MC presentating symptom of ampullary carcinoma?
Obstructive jaundice
217
Pt develops acute limb ischemia and required a procedure, what to do for life?
warfarin for life
218
Presentation of chronic Pancreatitis?
Chronic epigastric abd pain Malabsorption……….diarrhea and steatorrhea Weight loss and DM
219
A pop and immediate swelling of knee, think?
ACL
220
You can get above a painless scrotal mass, suspect?
Testicular tumor
221
What to do when u suspect testicular tumor?
Color doppler
222
Organism responsible for cholecystitis?
ecoli
223
Tx of house maids knee (prepartella bursitis)
Steroid injection in prepatella bursa
224
Mortality rate of ruptured AAA?
80%
225
What to do when you suspect esophageal cancer? (3)
1. barium swallow 2. scope and biopsy 3. CT chest and abdomen
226
Pt can not lift hand above head,,,,,this is called?
Impingement syndrome (rotator cuff injury)
227
fluid replacement in burns?
4 X numbers given...eh 4 x Weight X burn area | 4 x 80kg x 15
228
MC fracture to eye
Orbital floor fracture
229
Head injury with Lucid interval, Think?
Epidural. Luci on top!
230
Pt with paradoxical breathing, how to avoid impending doom?
Intubate and ventilate
231
Pt with vascular claudication, when do you refer?
Rest Pain
232
Old male with back pain and normal/high calcium never chose...
Multiple Myeloma

AMC MCQ (14 decks)

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