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Block 1 > Week 1 Random > Flashcards

Week 1 Random Flashcards

1
Q

Bloom’s Taxonomy

A
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2
Q

Components of Diagnosis

A

Explanation

Prognostication

Therapy

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3
Q

H & P

A

HISTORY

Chief Complain History of present illness Past medical history Surgical history Family history Social history Sexual history Review of systems Allergies Medications

PHYSICAL

Physical exam Labs Imaging and other ancillary tests Assessment/Differential Diagnosis

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4
Q

AP & CP and subcategories

A

AP

Surgical Pathology, Cytology, Hematopathology, Autopsy

CP

Clinical Chemistry, Microbiology, Blood Bank/Transfusion/ Molecular and Genetic Pathology, Hematopathology

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5
Q

Why order tests

A

Routine

Preoperative

Monitoring

Diagnostic

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6
Q

Lab categories

A

Chemistry

Urinalysis

Microbiology

Hematology

Serology (antigen interaction)

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7
Q

Reference Range vs. Optimal Range

A

Reference range – “normal” that encompasses 95% of population; specific to the equipment

Optimal (health) range – therapeutic target associated with optimal health set by us

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8
Q

Analytic Variability vs. Intraindividual variability

A

Analytic Variability – variability due to equipment

Intraindividual variability – natural biological fluctuations

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9
Q

General Chemistry (lab) / CMP

A

Aka Chem20, Profile1, Chem7 Comprehensive Metabolic Panel (CMP)

Liver, kideny, electrolytes, lipids, and glucose test

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10
Q

Liver function

A
  1. Synthesis and secretion of proteins Storage of energy (glycogen)

2 Metabolizes many drugs and toxins

  1. Transformation and Clearance (e.g. conjugation of bilirubin)
  2. Aids digestion (biliary system)
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11
Q

AST/ALT elevation

A

Hepatic injury or necrosis:

  1. viral hepatitis
  2. fatty liver
  3. toxins (including medications)
  4. strenuous exercise
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12
Q

What is the cause for uncojugated and conjugated bilirubin elevation?

A

Unconjugated: ELEVATED

  • hemolysis
  • kernicterus (destuction of baby’s blood)
  • Crigler-Najjar syndrome (deficiency of conjugating enzyme)
  • Gilbert’s disease (reduced activity of glucuronyltransferase)

Conjugated: ELEVATED

(due to obstruction)

  • hepatitis,
  • dubin-johnson syndrom (obstruction in secretion of conjugated form into bile)
  • biliary obsturction (bile cannot flow into intestine)
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13
Q

Hemoglobim breakdown

A

Hemoglobim

heam

biliverdin

bilirubin (uncoj)

bilirubin (conj)

urobilinogen

stercobiliongen

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14
Q

Albumin function

A
  1. Main agent of intravascular osmotic pressure
  2. Serves in the transport of bilirubin, hormones, and metals, vitamins, and drugs

* making 150-250mg/kg/day

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15
Q

Albumin increas and decrease

A

INCREASE:

  • Dehydration Decrease:

DECREASE (synthesis):

  • End-stage liver disease
  • intestinal malabsorption syndromes
  • protein malnutrition e.g.

DECREASE (loss):

  • nephrotic syndrome
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16
Q

Globulin function composition and test for the level

A

COMPOSITION

Serum proteins including carrier proteins

Enzymes

Complement

TEST

immunoglobulins serum electrophoresis

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17
Q

Kideny function

A

Filters 200L & removes 2L

Produces Erythropoeitin

Produces Renin

Produces Vit D

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18
Q

Kidney tests

A
  1. Blood Urea Nitrogen (BUN) – measures breakdown of proteins
  2. Creatinine – breakdown product of creatine in muscles
  3. Urinalysis (physical, chemical e.g. glucose, bilirubin, protein, leukocyte, pH, specific gravity, and microscopic examination)
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19
Q

Blood in urine symptom

A

Urinary Bladder Cancer

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20
Q

Heart tests

A
  1. Lipid Panel (possible blockage - artheroschlerosis)
  2. Beta Natriuretic Protein (released when heart stretches)
  3. Troponins (damage to muscle)
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21
Q

Brain tests

A

Lumbar puncture: protein, glucose, cell differential, culture, blood

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22
Q

Lungs tests

A

Arterial Blood Gas (ABG) pH, O2, CO2

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23
Q

Endocrine tests

A

Hemoglobin

A1c

TSH

FSH

LH

PTH

Testosterone

Estrogen *

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24
Q

Osler’s Rule

A

Correlate all abnormalities into a single plausible explanation

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25
Q

Differential diagnosis

A

A systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible. Systematically obtain information then use process of elimination

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26
Q

Progressive disclosure

A

interaction design technique often used in human computer interaction to help maintain the focus of a user’s attention by reducing clutter, confusion, and cognitive workload. This improves usability by presenting only the minimum data required for the task at hand.

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27
Q

RCT

A

Randomized Control Trial

Prodivdes fair conclusion and blinding

Removes bias

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28
Q

Coincidence vs. Concoted incidence

A

Coincidence – unlikely event occurring by chance

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29
Q

Bayes’ Theorem

A

Allows calculation of a probability if something is correct or incorrect based on the evidence

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30
Q

Research questions should be…

Types of research questions…

A

Qualities:

Specific, answerable, novel, and relevant

Types:

descriptive, evaluative, and explanatory

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31
Q

Evidence Based Medicine practice requirement:

AAAAA

A

Asses the patient (clinicla problem)

Ask the clinical question (PICO)

Acquire the evidence (search for evidence)

Appraise the evidence (usability and closeness to truth)

Apply

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32
Q

Types of studies

A

Case series and case reports (based on chart notes)

Case control studies (base on chart notes with control notes)

Cohort studies (follow the group)

Randomized Control Studies

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33
Q

Declaration of Helsinki

A

The placebo can be only used when no alternative drugs are availible.

Patient consent.

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34
Q

Bradford-Hill Criteria for Causation

A
  1. Strength of association
  2. Consistency of different studies
  3. Specificity of association with particular disease
  4. Temoral relationship (exposure precedes disease)
  5. Biological gradient (dose-response relationship)
  6. Plausability (biological plausilibity)
  7. Coherence (consistent with what is known)
  8. Experiment reversibility
  9. Existence of analogous evidence
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35
Q

Types of imaging

A

X-Ray Fluoroscopy (X-Ray real time)

CT scan (forms sections)

MRI (joints, neural tissue, dense breast tissue no good for blood or bone)

Ultrasound (sonar, water)

Mammography (good for dense breast tissue, not good for masses of blood, better for soft tissue)

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36
Q

Sievert values

A

1 Sv 5.5% chance of cancer

10,000 mSv radiation sickness

50 mSv lowest dose for cancer

15 mSv C.T. Scan of abdomen and pelvis

2 mSv head C.T. Scan

2 mSv natural radiation/year

  1. 10 mSv cheast X-ray
  2. 01 mSv dental X-ray
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37
Q

Standard position for Chest X-ray

A

PA

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38
Q

Number of X-Rays required to visualize 3D

A

2

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39
Q

X-Ray depends on

A

Atomic number, density, and thickness

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40
Q

Types of X-Ray anodes

A

Usually – tungsten

Mammography – rhodium

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41
Q

Types of contrast media

A

High Osmolar HOCM

Low Osmolar LOCM

Iso Osmolar IOCM

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42
Q

Air-Liquid interfaces

A

Help to determine the position

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43
Q

Relationship between penetration, contrast, and voltage

A

Up penetration -> lower contrast

Up penetration -> higher voltage

Body penetration reduces dose Object

Penetration reduces contrast

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44
Q

Window setting

A

Allow adjustment and focus on a specific tissue

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45
Q

Contrasts medium

A

Barium (Ba) CT – safe unless there is a perforation

Gadolinium (Ga) MRI – changes the relaxation time; dangerous to kidney function if reduced; may cause nephrogenic systemic fibrosis (NSF)

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46
Q

Senescent

A

No division

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47
Q

Prescription abbreviations ac ; bid ; gtt ; od/s ; po ; pc ; prn ; q4h ; qd ; tid ; IV ; IM

A

ac - antre cibum - before meals

bid - bis in die - twice a day

gtt - gutta - drops

od - oculus dexter - right eye

os - oculus sinister po -

per os - by mouth

pc - post cibum - after meals

prn - Pro re nata - as needed

q3h - quaque 3 hora - every 3 hours

qd - quaque die - every day

tid - ter in die - 3 times a day IV (intravenously)

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48
Q

Prescription components

A

SUPERSCRIPTION

1) Name of practitioner including address
2) Patients name, address, age, weight, and date

INSCIRPTION

3) Drug name, strength, quantity, ect.

SUBSCRIPTION

4) Directions
5) Refil times
6) Label
7) Specify if brand and not generic is desired
8) Signature of practitioner

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49
Q

Categories of drugs

A

Over-the-Counter

Legend Drugs (prescription)

Controlled Substances (Principal or secondary site of action is the Central Nervous System generally)

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50
Q

Classification of controlled substances

A

Schedule I: no currently accepted medical use and may lead to serious dependence

Schedule II: accepted medical use; may lead to severe dependence; may not be refilled; must be filled within 14 days (nv); do note fill before/dispense until; handwrited only; separate sheet

Schedule III: Moderate to low physical dependence and possible high psychological dependence; 6 refill

Schedule IV: Low dependence; 6 refill

Schedule V: Limited dependence liability

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51
Q

Requirements for prescribing controlled substances

A

DEA number

Registered with specific state

Visible proof of registration

Legitimate medical purpose

Cannot self-prescribe Schedule II-IV

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52
Q

Bio-equivalents Therapeutic Equivalents

A

Bio-equivalents – the same chemical property of a generic drug

Therapeutic Equivalents – the same effect of the drug

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53
Q

FDA Recall drugs classes

A

Class I – Severe health consequence

Class II – cause temporary or medically reversible adverse health

Class III – is not likely to cause adverse health

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54
Q

FDA Category Use in Pregnancy

A

Category A – fail to demonstrate a risk to the fetus

Category B

Category C – Drugs should be given only if the potential benefit justifies the potential risk to the fetus

Category D – There is positive evidence of human fetal risk

Category X – the risk of the use of the drug in pregnant women clearly outweighs any possible benefit

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55
Q

Human mitochondrial genome

A

16.5 kb mtDNA encodes

13 proteins 22 tRNAs, and 2 rRNAs

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56
Q

4P’s

A

Predictive

Preventative

Personalized

Participatory

57
Q

SSLPs

A

simple sequence length polymorphisms (SSLPs): tandem repeat sequences that display length variations.

1) minisatellites, also known as variable number tandem repeats (VNTRs)
2) microsatellites or simple tandem repeats (STRs)

58
Q

Pol α Pol β Pol γ Pol δ Pol ε

A

Pol α - Primase activity; Initiates DNA synthesis; No Proof

Pol β - DNA Repair; No Proof

Pol γ - Replicates mitochondrial DNA; Proof

Pol δ - Elongates Okazaki fragments; Proof

Pol ε - Leading strand synthesis & DNA Repair; Proof

59
Q

Herpes 1 vs 2

A

Herpes simplex 1 is a DNA virus that causes cold sores.

Herpes simplex 2 causes most genital herpes infections.

60
Q

Levels of Maternal Serum Alpha-Fetoprotein

A

HIGH:

Dating error, Neural Tube defects, Twins, Abdominal Wall defect, Fetal demise, Low Birth Weight

LOW:

Fetal demise, Dating error, Lack of pregnancy, Molar Pregnancy, Trisomy

61
Q

When and why are Heel stick blood draws done

A

Newborns before discharge and at 10-14 days, to test for

Metabolic Disorders(phenylketonuria)

Endocrine Disorders(Hypothroidism)

Hematological Disorders (Sickle Cell) Cystic fibrosis

62
Q

Breast Quadrants

A

UIQ, UOQ, LIQ, LOQ

63
Q

Lipid Panel

A

Cholesterol

Triglycerides

HDL

Cholest/HDL Ratio

LDL

64
Q

Quadruple aim

A

Triple Aim (Better patient experience, better patient outcome, lower cost)

+ physician experience

65
Q

Mutations causes

A

Endogenous

  • attack by reactive oxygen species
  • replication errors

Exogenous

  • UV and ionizing radiation including x-rays and gamma rays, plant toxins
  • Man-made mutagenic chemicals that act as DNA intercalating agents, cancer chemotherapy and radiotherapy
  • Viruses
66
Q

Functions of blood

A

Gases-O2,

CO2 Nutrients,

electrolytes,

waste Hormones,

cell signals (cytokines)

Immune response

Inflammatory response

Clotting

Acid buffering

67
Q

Complete Blood Count test results

A
  1. RBC (quantity of blood) (count/uL) expressed in 10^6
  2. Hgb (concentration of hemoglobin) – Hemoglobin (spectronomny) in g/dL; O2 carrying capacity
  3. Hct (concentration of blood) – Hematocrit % of blood cells (HCT = RBC (cells/L) x MCV (L/cell))
  4. MCV (size of blood) – Mean corpuscular volume (fL) measured by counter plotted on historgram
  5. RDW – Red cell distribution width (standard deviation)
  6. Plt (count/uL)
  7. WBC =white blood cells=leukocytes=white cells count/mL
  8. WBC (count/uL)
68
Q

RBC (erythorcyte) Hormone that simulates? How many cells are made per day? Lifespan of RBCs?

A

EPO

2-3 trillion

120 days

69
Q

H/H

A

Hematocrit / Hemoglobin

70
Q

Types of blood cells

A

Blood stem cells

Myeloid stem cell RBC (early Reticulocyte) Platelest

Myeloblast -> all WBCs except Lymphocyte Neutrophilic stab=band cell (early Neutrophil)

Lymphoid stem cell -> Lymphoblast B, T Lymphocyte and NK

Neutrophil = “polys” = “segs”

71
Q

Effects on RBCs sizes

A

Lack B12 = large

Lack Iron = small

72
Q

Risk of occurence vs. reoccurence

A

occurence = Depends on population frequencies of the disorder and the rate of spontaneous mutations

recurrence = the probability that a genetic disorder that has occurred in a family will recur in another member in the same or in future generations

73
Q

Ka vs. Kd

A

Association constant = [P·L]/([P][L]) (affinity) Dissociation constant = ([P][L])/[P·L]

74
Q

Michaelis Menten Equation

A

v = Vmax·[S]/(KM + [S])

where

Vmax = [E]tot·k3

and

KM = (k2 + k3)/k1

75
Q

Lineweaver Burk Plot

A

The enzyme with the highest “specificity” or “preference” for catalyzing a reaction is the enzyme with the highest specificty

v = Vmax·[S]/(Km + [S]) 1/v

Km/(Vmax[S]) + 1/Vmax y

1/Vmax x = 1/Km slopeKm/Vmax

76
Q

Enzyme types: Oxidoreductases Transferases Hydrolases Lyases Isomerases Ligases

A

Oxidoreductases – e- transfer

Transferases – group transfer

Hydrolases – hydrolysis reaction

Lyases – addition of groups to double bonds or formation of double bonds by removal of groups

Isomerases - transfer of groups within molecules

Ligases - formation of C-C, C-S, C-O, and C-N bonds by condensation coupled with ATP

77
Q

Enzyme Specificity

A

Vmax/KM

78
Q

Irreversible Inhibitors

Competitive Inhibition

Non-Competitive Inhibition

Uncompetitive Inhibition

A

Irreversible Inhibitors – Vmax DOWN; Km unaffected (Removing the concentration of the enzyme)

Competitive Inhibition – Km UP; Vmax unaffected (Always can out compete the enzyme)

Non-Competitive Inhibition – Vmax DOWN; Km unaffected (alternative reactions)

Uncompetitive Inhibition – Vmax DOWN; Km DOWN (Even enzyme is saturated, rate will be slower; Km substrate binds more readily)

79
Q

Anemia diagnosis

A

MCV and RDW

80
Q

Repair systems and causes for activations

A

BaseER – X-Ray, radicals, alkylating agents, spontaneous reaction

NucleotideER - UV; polycyclic aromatic hydrocarbons

RecR/NHEJ - IR, UV-light; X-rays; anti-tumor agents

MismatchR - replication errors

81
Q

Radiolucent

A

allow radiation to pass more freely

82
Q

Positive contrast vs. Negative contrast examples

A

Barium (high density) vs. Air (low density)

83
Q

Object penetration reduces what? Body penetration reduces what?

A

Object penetration reduces the contrast Body penetration reduces the dose

84
Q

Brest mammography CC (craniocaudal) MLO (mediolateral oblique)

A

squeezed top-bottom squeezed left-right

85
Q

Genome composition

A

1/2 Transposons (SINES, LINES, and retrovir like)

1/3 Genes (1.5% exons, introns)

1/4 Repeats, other?

86
Q

Site specific recombination types:

  • DNA only
  • Retrovilar-like retrotransposons
  • Nonretroviral retrotransposons
A

DNA only

  • short inverted repeats
  • cut and paste

Retroviral-like retrotransposons

  • Long terminal repeats
  • Reverse transcriptase and integrase

Nonretroviral retrotransposons

  • Poly A at 3’ end of an RNA intermediate
  • Reverse transcriptase and endonuclease
87
Q

PICO

A

P: Patient or population (age, sex, race)
I: Intervention (exposure, diagnostic test, therapy)
C: Comparison group (nothing, placebo, another intervention)
O: Outcome of interest (clinical effect or intervention)

88
Q

Four basic gene elements

A

Promoter, coding, intervening, structural (untranscribed and 3’ and 5’ UTR)

89
Q

Radioucent material from most to least

A

Air, Fat, Water/tissues, Spongy, Bone, Compact Bone

90
Q

Antibiotics acting on Topoisomerase

A

EUKYAROTES

Irinotecan

Act on: Human topoisomerase I

Uses: Colon, ovarian, small cell lung cancers

Etoposide

Act on: Human topoisomerase II (prevents ligation)

Testicular cancer

Doxorubicin

Act on: Human topoisomerase II (intercalating agent; stabilize topo II on DNA)

A variety of cancers

BACTERIA

Ciprofloxacin

Act on: Bacterial DNA gyrase (topoII)

Use: Gm(-) infections, COPD

91
Q

Jaundice

A

A medical condition with yellowing of the skin or whites of the eyes

92
Q

Kernicterus

A

Hyperbilirubinemia during the neonatal period describes the history of nearly all individuals who suffer from kernicterus. It is thought that the blood–brain barrier is not fully functional in neonates and therefore bilirubin is able to cross the barrier.

93
Q

Gilbert’s disease

A

The cause of this hyperbilirubinemia is the reduced activity of the enzyme glucuronyltransferase, which conjugates bilirubin and a few other lipophilic molecules.

94
Q

Kwashiorkor

A

Is a form of severe protein–energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. Sufficient calorie intake, but with insufficient protein consumption, distinguishes it from marasmus. Kwashiorkor cases occur in areas of famine or poor food supply.

95
Q

Nephrotic syndrome

A

It is characterized by an increase in permeability of the capillary walls of the glomerulus leading to the presence of high levels of protein passing from the blood into the urine low levels of protein in the blood.

96
Q

Atherosclerosis

A

Artery wall thickens as a result of invasion and accumulation of white blood cells and remnants of dead cells, including cholesterol and triglycerides, eventually calcium and other crystallized materials, within the outer-most and oldest plaque.

97
Q

Nephrogenic systemic fibrosis (NSF)

A

Renal failure due to exposure to gadolinium

98
Q

Heart hypertrophy

A

Increase in volume of the heart

99
Q

Hemothorax

A

Is a type of pleural effusion in which blood accumulates in the pleural cavity.

100
Q

Appendicitis

A

is an inflammation of the appendix; left untreated will burst and spill infections materials into the abdominal cavity

101
Q

Fibroid

A

are non-cancerous growth that develop in or just outside a woman’s uterus. Uterine fibroid develop from normal uterus muscle cells that start growing abnormally. As the cells grow, they form a benign tumor.

102
Q

Pelvic inflammatory disease

A

is an infection of female reproductive organs; PID is one of the most serious complications of a sexually transmitted disease

103
Q

Peritonitis

A

is an inflammation of the peritoneum the tissue that lines the inner wall of the abdomen; left untreated can result in sepsis; severe abdominal pain worsened by any movement

104
Q

Ovarian torsion

A

refers to the rotation of the ovary to such a degree as to occlude the ovarian artery and/or vein

105
Q

Endometriosis

A

Happens when tissue normally found inside the uterus grows in other parts of the body; it may attach to the ovaries, fallopian tubes, the exterior of the uterus, the bowel, or other internal parts.

106
Q

Small bowel obstruction

A

occurs when small or large intestine is partly or completely blocked

107
Q

Ectopic pregnancy

A

a pregnancy in which the fetus develops outside the uterus, typically in a Fallopian tube

108
Q

Gastroenteritis

A

or stomach flu is an inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection and causing vomiting and diarrhea

109
Q

Constipated

A

infrequent bowel movement and difficulty during defecation

110
Q

Ovarian cyst

A

are fluid-filled sacs or pockets within or on the surface of an ovary; a large cysts can cause

111
Q

Electrolytes

A

odium, Potassium, Chloride, Phosphorus, Calcium, Carbon dioxide, and Magnesium

112
Q

AST

ALT

A

aspartate transaminase–alanine transaminase ratio

OR

aspartate aminotransferase–alanine aminotransferase ratio

113
Q

LFT

A

Liver profile

114
Q

Medical Research

Evidence Based Medicine

Characteristics

A
  1. Delcaration of Helsinki
  2. Bradford-Hill criteria for causation
  3. Data collection and outcomes
  4. Sample size, power, and cuasation
115
Q

Defining characteristics of studies

A

Primary outcomes must be well defined

Secondary outcomes are common

Sample size determined based on the primary outcome

Composite outcomes can be useful

116
Q

Sample SD

Population SD

A
117
Q

What properties can be changed in beam?

A

Volatge

Anode

118
Q

Under and Over Penetration

A
119
Q

Breast Density and Composition Mammogram

A
120
Q

Breast Mammogram

A
121
Q

MRI characterstics

A

0.5-3 Tesla

Small radio frequencies

MRI constrast media are considered safer than CT media

122
Q

Evidence: Case Series and Case Reports

A

Retrospective observational studies

Determine commonalities in medical history or other associations among those affected

123
Q

Evidence: Case Control Studies

A

Retrospective observational studies of a particular diagnosis or exposure

Can establish correlations but cannot prove causation

124
Q

Evidence: Cohort Studies

A

Used when a RCT would be unreasonable or unethical.

Compare two groups of subjects over time, one having a particular condition or receiving a particular treatment, the other not

125
Q

Evidence: Randomized Controlled Studies

A

Randomly assigns subjects into treatment group or a control group to compare efficacy of a treatment, diagnosis, drug

126
Q

Over the counter Drugs characteristics

A

Deemed safe without professional guidance

Quality standards during manufacturing

Safety and effectiveness monitored by FDA

127
Q

Legend / Prescirption drugs characteristics

A

Require physician to be dispenced

Considered unsafe unless supervides by a licensed practitioner

Must be labeled “Federal law prohibits dispensing without prescription”

128
Q

Controlled Substances characteristics

A

Addictive potential for trafficing

Primary or secondary stie on CNS

Drug Enforcement Agency responsible for identifying and regulating drugs in this class

Can be OTC, legend, or unabailable

129
Q

Who is responisble for standards for drug purity in the US?

A

Non-profit organizations like USP or U.S. Pharmacopoeia

130
Q

e.g. of DNA and RNA viurs

A

Herpes (DNA) and HIV-1 (RNA)

131
Q

Purifying Selection

A

Negative Selection

132
Q

Synteny

A

Stretches of conserved gene order on chromosomes

e.g. globin genes clusters

133
Q

Acyclovir

A
134
Q

High fiedility proofreading mechanisms

A
135
Q

Inherited Syndromes with DNA Repair defect

A

MSH2, 3, 6, MLH1, PMS2 (colon cancer) = mismatch repair

Xeroderma pigmentosum (XP) (skin cancer) = nucleotide excision repair

Ataxia–telangiectasia (AT) (leukemia) = ATM protein kinease

BRCA2 (breast cancer) = homologous recombination

Fanconi anemia (leukemia) = DNA interstand cross-link repair

136
Q

Transposons

A

DNA only

short inverted repeats

cut and paste

Retroviral-like retrotransposons

Long terminal repeats

Reverse transcriptase and integrase

Nonretroviral retrotransposons

Poly A at 3’ end of an RNA intermediate

Reverse transcriptase and endonuclease

137
Q

Role of RBCs, WBCs, and platelates

A

RBC: O2/CO2 transport, acid buffer

WBCs: immune response, inflammation

Platelets: clotting

138
Q

Why there might be a little variability between RBCs?

A

Young RBCs (reticulocytes) are slightly larger.

Block 1 (25 decks)

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