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► Med Misc 06 > Rotation Gouge > Flashcards

Rotation Gouge Flashcards

1
Q

Sebulex

A

An OTC medicated shampoo for dandruff

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2
Q

Carmol HC

A

A topical combination moisturizer that uses urea and hydrocortisone

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3
Q

Lamasil

A

Terbenafine

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4
Q

What is the MOA of terbenafine

A

Inhibits squalene epoxidase and therefore reduces fungal cell membrane ergosterol synthesis

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5
Q

What is the indication for terbenafine

A

Antifungal for onychomychosis

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6
Q

What is the mechanism of Naftin

A

Topical antibiotic that inhibits the fungal squalene epoxidase reducing fungal cell membrane ergosterol synthesis

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7
Q

Dovinex

A

Calcipotriene

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8
Q

What is the MOA of calcipotriene

A

Used for the treatment of psoriasis

Exact mechanism is unknown; binds to vitamin D receptors inducing cell differentiation and inhibiting cell proliferation

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9
Q

Clobex

A

Clobetasol topical

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10
Q

What are the indications for clobex

A

Psoriasis and dermatoses that are steroid responsive

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11
Q

Olux

A

Clobetasol topical

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12
Q

Nizoral

A

Ketoconazole

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13
Q

What are the indications for ketoconazole

A

Tinea versicolor
Seborheric dermatitis
tinea capitis adjunct

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14
Q

What are Dennie Morgan folds

A

A fold or line in the skin below the lower eyelid caused by edema in atopic dermatitis

A diagnostic marker for allergy

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15
Q

What birth control pills can be used for a means of treating acne

A

Yaz and Yasmin

Drosperinone component is potassium sparing antiadrenergic (suppresses FSH & LH)

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16
Q

What additional labs need to be ordered for patients starting yaz or Yasmin?

A

Electrolytes for potassium at drug initiation and again at 30 days

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17
Q

Duac

A

Clinicamycin and benzoyl peroxide

Indicated for acne

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18
Q

Retin- A micro

A

Tretinoin topical

Indicated for acne vulgaris

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19
Q

What is the mechanism for topical retinoids

A

Binds to retinoic acid receptors, stimulating epethelial cell turnover

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20
Q

What is the shorthand “UD” stand for?

A

As directed

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21
Q

What is the most common etiology for acne In A jawline distribution

A

Hormonal

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22
Q

Discuss demadex folicularum and d. Brevis

A

A species of the face mite

Usually found in greater numbers around the cheeks, nose, eye brows, eye lashes and forehead

D. Brevis is shorter and has a pointier tale when compared to folicularum.

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23
Q

Pityriasis alba

A

Common in pediatrics and is a loss of melanocyte density

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24
Q

Tinea versicolor

A

Discoloration of the skin due to (malassezia furfur) pityrosporum ovaleand p. biculare

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25
Q

Vitiligo

A

Autoimmune response that causes hypo pigmentation

Two types a and b
A- symmetrical
B- asymmetrical

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26
Q

Desonate

A

Desonide topical (class VI steroid)

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27
Q

Nevus hypo pigmentation

A

Nevus with inadequate or dysfunctional melanocytes

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28
Q

Ephilides

A

Freckle

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29
Q

Lentigo

A

Liver spots (sun spots)

Increases in number and prevalence with age

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30
Q

Skin tag

A

Acrochordon

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31
Q

Stucco keratosis

A

Referred to as barnacles

Common, nearly inconspicuous papular warty lesions occurring in the lower legs especially around the Achilles’ tendon.

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32
Q

Prurigo nodularis

A

Uncommon disease

Nodular form of lichen simplex

Intractable pruritis

Nodules are typically 1-2 cm

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33
Q

Generalize the Fitzpatrick skin scale

A

Type I blue eyed celts with high susceptibility for skin cancer

Type VI African American with low susceptibility for skin cancer

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34
Q

Mucosis fungiodes

A

Most common type of cutaneous T cell lymphoma

Typical affects skin but May progress internally

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35
Q

Onychodystrophy

A

Nail pitting and onycholysis

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36
Q

Nail pitting associated with psoriasis is most commonly associated with what additional characteristic

A

Psoriatic arthritis: 90% of patients with psoriatic arthritis have nail changes

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37
Q

Trachyonychia

A

Psoriatic nails that appear as if they have been scraped with sand paper

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38
Q

What nail features are associated with psoriasis

A

Nail pitting
Trachyonchia
Onycholysis
Subungal hyperkeratosis

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39
Q

What are the treatment options for systemic psoriasis

A
  1. Phototherapy: nbUVB or PUVA
  2. Oral meds: Methotrexate, acetretin, cyclosporine
  3. Biologics: alefacept, TNF-a inhibitors
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40
Q

Alefacept

A

Immune modulator that works by inhibiting T cells

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41
Q

What are the types of psoriasis?

A

Based on their morphology

  1. Plaque
  2. Gutate
  3. Inverse
  4. Pustular
  5. Erythrodermic
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42
Q

What are the types of rosacea

A
  1. Erythematotelangectetic
  2. Papulopustule (no comedones)
  3. Phymatous
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43
Q

Why should you not use strong steroids on the face

A

Induce steroid rosacea: eruption of papular around the mouth.

If a pt has a perioral dermatitis that looks like rosacea, ask about topical steroid use.

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44
Q

What are the diagnostic criteria for lupus

A

Mnemonic DOPAMINE RASH

D: discoid lupus 
O: oral ulcers
P: photosensitivity
A: arthritis
M: malar rash
I: immunologic criteria (ANA)
N: neurological changes
E: increased ESR

R: renal disease
A: ANA +
S: serositis
H: hematologic disease

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45
Q

What is the primary symptom of atopic dermatitis

A

Itch

It’s the itch that rashes

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46
Q

What are the side effects of oral isoretinoin

A 
Birth defects
Dry eyes
Dry lips
Nose bleeds
Hypertriglyceridemia
Myalgias and elevated CK
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47
Q

What are the types of melanoma

A 
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Amelanotic
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48
Q

Actinic purpura

A

Senile bruising

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49
Q

Actinic cheilitis

A

AK’s on the lips

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50
Q

What will the histopathology show for muluscum contagiosum

A

Henderson Patterson bodies

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51
Q

What medications are fungistatic

A

Imidazoles

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52
Q

What medications are fungicidal

A

Allylamines, benzylamines

Terbenafine
Butenafine
Cyclopirox

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53
Q

What is the topical treatment for candida infections

A

Nystatin ointment

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54
Q

What is the most common dermatological complaint of school aged children?

A

Tinea capitis

Caused by trichophyton tonsurans

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55
Q

What are the two types of contact dermatitis

A

Irritant contact dermatitis (ICD)

Allergic contact dermatitis (ACD)

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56
Q

What is erysipelas

A

Superficial cellulitis with marked dermal lymphatic involvement

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57
Q

What is the hallmark lesion of leukocytoclastic vasculitis (small vessel vasculitis)

A

Palpable purpura

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58
Q

What is asteototic dermatitis

A

Xerotic eczema

More common in the elderly during the winter with multiple hot showers.

Pruritis is resolved with prolonged baths, but returns shortly after

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59
Q

What is lipodermatosclerosis

A

Subcutaneous fat is replaced by fibrosis that eventually impedes venous and lymphatic flow leading to edema above the fibrosis

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60
Q

What topical therapies can be used to inhibit keratinocytes proliferation

A

Tar
Vitamin D analog
Tazarotene

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61
Q

What is a furuncle

A

Boil

An acute, round, tender, circumscribed, perifollicular abscess that generally ends in central suppurations

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62
Q

What is a carbuncle

A

A coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles

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63
Q

What is echthyma

A

An ulcerative form of impetigo in which the lesions extend through the epidermis and deep into the dermis

Consist of punched out ulcers

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64
Q

What is necrotizing fasciitis

A

Life treating infection of the fascia just above the muscle layer. Rapidly expanding dusky, edematous red plaque with blue discoloration.

Anesthesia of the skin is the characteristic finding

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65
Q

What is cellulitis

A

Bacterial infection of the dermis

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66
Q

Cimex lectularius

A

Bed bugs

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67
Q

What leads to tissue destruction with a brown recluse spider bite

A

Sphingomyelenase D

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68
Q

Compound W

A

An over the counter wart removing agent that has an active ingredient of salicylic acid

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69
Q

What medications are associated with SJS/TEN

A

SATAN

Sulfa antibiotics
Allopurinol
Tetracyclines
Anticonvulsants
NSAIDs
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70
Q

What is a sclerosing agent that can be used for spider angiomas

A

glycerine

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71
Q

What is the treatment for keloids

A
  • inject smaller keloids on the face with 2.5 mg/ml kenolog
  • inject keoloids on the scalp with 10 mg/ml kenolog.
  • inject large keloids with 20-40 mg/ml kenolog
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72
Q

Elidel

A

pimecrolimus

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73
Q

What is the indication for elidel

A

atopic dermatitis

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74
Q

What is the mechanism for elidel

A

inhibits T lymphocyte activation

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75
Q

What is paronychia

A

a nail disease that is often a tender fungal or bacterial infection of the hand or foot where the nail and the skin meet at the side or base of a finger or toe nail

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76
Q

What are the classification levels of retinoids

A

From Strongest to Weakest

  • isotretinoin
  • tazorotene
  • tretinioin
  • adapalene
  • retinaldehyde
  • retinol
  • retinyl palmitate
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77
Q

What are the classification levels of topical steroids

A 
I - Clobetasol 0.05%
II - Fluocinonide 0.05%
III- Triamcinolone ointment 0.1%
IV - Triamcinolone cream 0.1%
V - Triamcinolone lotion 0.1%
VI - Fluocinolone acetonide 0.01%
VII - desonide 0.05%
VII - Hydrocortisone 1 %
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78
Q

Retin-A

A

tretinoin

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79
Q

Retin-A Micro

A

tretinoin

80
Q

Renova

A

tretinoin

81
Q

tazorac

A

tazorotene

82
Q

accutaine

A

isotretinoin

83
Q

What is sebhorreic dermatitis

A

a common chronic inflammatory papulosquamous disease. Proposed that pityrosporum yeast is the cause

84
Q

What is soriatane

A

acetretin (retinoid)

85
Q

What is the treatment options for lichen planus

A

acetretin
cyclosporin
griseofulfin

86
Q

Sarna

A

camphor/menthol topical

87
Q

When is sarna indicated

A

generalized itching

88
Q

What complication may arise if you use a topical retinoid with a benzyl peroxide?

A

benzoyl peroxide will oxidize the retinoid and will cause skin irritation

89
Q

What are the common side effects of oral retinoids

A 
xerosis
cheilitis
elevated liver enzymes
hypertirglyceridemia
mood changes
depression
Head ache associated with pseudotumor
90
Q

What is the general approach for treating acne

A

based on the severity of disease

91
Q

What is the treatment for mild comedones

A

topical retinoid

+/- topical benzoyl peroxide

92
Q

What is the treatment for mild papular pustular acne

A

topical retinoid
topical antibiotic
topical benzyl peroxide

93
Q

what is the treatment for moderate papular pustular acne

A

oral antibiotics
topical retinoids
topical benzoyl peroxide

94
Q

What is the treatment for moderate nodular without scarring acne

A

oral antibiotics
topical retinoid
topical benzoyl peroxide

95
Q

What is the treatment for sever acne or the presence of scaring from acne

A

oral retinoids (acutaine)

96
Q

What distribution of acne is consider hormonal cause for women

A

jaw line distribution

97
Q

What can be used for the treatment of hormonal induced acne in women

A

OCP

  • Yaz
  • Yasmin
  • Orthotricyclen

Spiranolactone

98
Q

What is poikiloderma

A
  • A skin condition that consists of areas of hyper pigmentation, hypo pigmentation, teleangectasisas and atrophy.
  • Commonly associated with sun damaged areas
  • most frequently seen on the chest and neck
99
Q

What is tine incognito

A

a fungal infection of the skin that is caused or hidden by the use of a topical immunosuppresant

100
Q

What is is seborrhoeic dermatitis

A
  • inflammatory skin disorder of the face, scalp and torso (T-area)
  • typically presents with flaky, itching and red skin
  • true mechanism is unknown
101
Q

What is the treatment for seborhoeic dermatitis

A
  • ketoconazole shampoo

- topical steroids

102
Q

What is keratosis pilaris

A

common, autosomal dominant genetic skin condition manifested by the appearance of rough slightly red bumps on the skin of the arms and shoulders primarily.

103
Q

actinic keratosis is a precursor to what skin lesion

A

squamous cell carcinoma

104
Q

hyperhydrosis

A

excessive sweating

105
Q

Protopic ointment

A

tacrolimus topical

106
Q

What is the mechanism of protopic

A

inhibits T-lymphocyte activation and acts as an anti inflammatory

107
Q

What are the indications for protopic ointment

A

atopic dermatitis

can be used for psoriasis

108
Q

lidex

A

fluocinonide

109
Q

What are the lines of blahsko

A
  • follow a “V” shape over the back and an “S” shape over the chest, stomach and sides with wavy shapes on the head.
  • believed to trace migration of embryonic cells
110
Q

What is dermatosis papulosa nigra (DPN)

A

a condition of many small, benign skin lesions on the face generally presenting on dark skinned individuals.

  • DPN may resemble SK
111
Q

What is the leser-trelat sign

A

A sudden explosion of lesions similar to DPN (Dermatosis papulosa nigra) that is due to a growing tumor

112
Q

What is the dimple sign

A

Associated with dermatofibroma

113
Q

What is sebaceous hyperplasia

A

disorder of sebaceous glands in which they become enlarged producing yellow shiny bumps on the face
- not always associated with hair follicles

114
Q

differin

A

adapalene topical

- topical retinoid

115
Q

What is the indication for differin?

A

acne vulgaris

116
Q

What diseases should be included in your differential that has a skin rash that is unique or does not respond to therapy

A
  1. SLE

2. Sarcoidosis

117
Q

Can tagament be used for wart removal?

A

Can be used as an off label use for wart removal in peds

118
Q

What is reeds syndrome

A

multiple cutaneous leiomyomas and is associated with renal cell carcinoma

119
Q

What is madelungs disease

A
  • benign symmetric lipomatosis

- substantial fat deposits on the head, neck, and girdle

120
Q

What is dercums disease

A

painful lipomatosis
more common in females
very rare
associated with thyroid malfunction

121
Q

What is the only way to definitively treat comedones

A

retinoids, primarily oral

122
Q

What oral antibiotics can be used to treat acne

A

doxycycline
minocycline
septra

123
Q

What is idiopathic gutate hypomelanosis

A
  • very common
  • increases with age, 80% over 80
  • typical lesion is a circumscribed well demarcated symptomatic porcelain white macule
  • associated with flattening of the dermal-epidermal junction
124
Q

What can be done for patients that have developed scars from acne

A
  1. Cosmetic laser resurfacing

2. chemical peels with agents similar to glycolic acid

125
Q

What is lachydrin

A

ammonium lactate topical

126
Q

What is the mechanism of lachydrin

A

increases skin moisture and decreases epidermal keratinization

127
Q

What is erosive lichen planus

A

(ELP)

  • can occur with in the paloplantar lesion of LP particularly on the sole
  • chronic lesions are at risk of developing squamous cell carcinoma
  • more common in the 3rd - 5th decade
128
Q

Beaus lines

A

typically caused by trauma

- makes a full transverse path across the nail

129
Q

What medication can be incorporated to help minimize the side effects of steroids

A

protopics can be added to give a steroid break

130
Q

What are good indications to use a woods lamp

A

Lentiginous melanoma
melasma
vitiligo
Erythrasma

131
Q

What is erythrasma

A

a skin disease that causes brown, scaly skin patches. It is caused by the Gram-positive bacterium Corynebacterium minutissimum. It is prevalent among diabetics and the obese, and in warm climates; it is worsened by wearing occlusive clothing.

132
Q

What are the 6 P’s of lichen planus

A 
planar (flat)
purple
polygonal
pruritic
papule
plaque
133
Q

What is lichen striatus

A
  • form of LP that presents in a linear, lichenoid dermatosis
  • primarily effects children
  • lesions follow the lines of blasko
  • spontaneously resolves
134
Q

What is chondrodermatitis nodular is halicus

A

common, benign, painful condition of the helix or antihelix

135
Q

Laser therapy for scars

A
  • the brighter the red hue of the scar, the more likely the therapy would be successful
  • the laser freezes the epidermis and focus the laser at the appropriate depth at which point the hemoglobin will absorb the energy and damage the adjacent area
136
Q

Myrmecia warts

A
  • palmar plantar warts
  • round horny deep painful nodule most often on weight bearing sights
  • mosaic warts are typically asymptomatic and are also a group of warts
137
Q

What is a good treatment of plantar warts that have failed home therapy

A
  1. Cryotherapy

2. Triple Acid

138
Q

What is the technique for triple acid therapy for wart removal

A
  1. Carbolic acid
  2. Dichloracetic acid
  3. pyruvic acid
139
Q

What is a digital mucous cyst

A
  • benign ganglion cyst of the digits typically located at the DIP or in the proximal nail fold.
  • This condition is often worsened by osteoarthritis
140
Q

How much epi can be safely used in the digits

A

limit the use of epi with lidocaine in the digits to 4 cc’s. The pressure from volume is often the limiting factor.

141
Q

What is finacea

A

azelaic acid topical

142
Q

What is the indication for finacea

A

mild to moderate inflamatory lesions of acne rosacea

143
Q

What is the mechanism of finacea

A

inhibits protein synthesis, exerting antibiotic effects

144
Q

What is a nevus comedonicus

A
  • rare hamartoma of the pilo-sebaceous unit
145
Q

What is the treatment for nevus comedonicus

A

topical retinoids

146
Q

What are the types of basal cell carcinoma

A

Non-Aggressive:
Nodular
Superficial

Aggressive:
Morpheoform
Sclerosing

Cystic
Micronodular
Basosquamous
Fibroepethilioma of Pinkus

147
Q

What are a few details that help to separate a basal cell carcinoma from an actinic keratosis

A

AK’s typical are never alone

AK’s are most often associated with scales

148
Q

Aside from cryotherapy and chemotherapy agents, what can be used for tx of AK’s covering a large area

A

Photo dynamic therapy (PDT)

149
Q

What is the difference between hypertrophic scars and keloids

A

Keloids typically extend beyond the margins of the lesion
Keloids are often painful
Hypertrophic scars are typically a localized over growth.

150
Q

What is the treatment for perioral dermatitis

A

antibiotics (topical)

151
Q

What is the etiology of perioroal dermatitis

A

Common with age (50’s)
associated with steroid withdrawal
associated with topical facial steroid use

152
Q

What is lichen nitiditis

A
  • Uncommon chronic eruptions consisting of multiple tiny discrete skin colored papules often arranged in large clusters.
  • considered a variant of LP
  • Most cases resolves spontaneous
153
Q

What is the treatment for lichen nitiditis

A

topical steroids and oral antihistamines

154
Q

What is a nevus sebaceous

A
  • a hamartoma that exhibits follicular sebaceous and apocrine malformations to varying degrees
  • classically a nevus or congenital malformation
  • most commonly on the scalp or face
155
Q

What is fraxel

A

non surgical tx for facial rejuvenation

156
Q

When is a bleach bath indicated

A

atopic dermatitis

157
Q

What is the assumed mechanism of a bleach bath

A

anti-inflammatory effects by inhibiting NfKb

bleach is diluted to 0.005%

158
Q

Pityriasis lichenoides chronica

A
  • papular, clonal T cell disorders that may rarely be associated with mycosis fungi odes
  • erythematous to red-brown scaly papules with an indolent course; regressing over weeks to months. - Lesions often leave a hypopigmented macule.
  • treatment resolves once triggering factor or medication has been removed. Topical steroids can be used
159
Q

What is longitudinal melanonychia

A
  • longitudinal brown to black band
  • commonly seen in dark pigmented individuals
  • Single nail may be a sign of melanoma.
160
Q

What may be the initial finding in a patient with Sjogrens disease

A

painful tears and atopic dermatitis

161
Q

What oral medication may be used as an adjunct to hyperhydrosis

A

robinol

162
Q

What oral medication can be used for the treatment of acne that is not OCP or a retinoid

A

Spiranolactone

  • start at 25-50mg qd then increase to 100 mg qd (therapeutic dose)
163
Q

Creams or Ointments: which is more pure

A

Ointments; therefore are less commonly associated with allergic reaction

  • ointments tend to be more greasy
164
Q

What is ichthyosis vulgaris

A
  • skin may appear normal at birth but most symptoms appear by 5yo
  • can affect all parts of the body including face and scalp while the bends of the arms and legs are typically spared
  • Pals are typically excessively lined
  • associated with atopic dermatitis
165
Q

What is angular cheilitis

A

Common inflammatory condition affecting the corners of the mouth or oral commisures
- treatment with lip balm or thick emollient +/- topical steroids

166
Q

What are the causes of angular cheilitis

A

most commonly an irritant contact dermatitis from drool or spit often seen in down syndrome and associated with atopic dermatitis

Rare causes include:

  • anemia
  • nutritional deficiency (zinc)
167
Q

What is onychomadresis

A

nail shedding may arise in severe or bullous lichen plans or acute and severe systemic illness

168
Q

What foods are associated with acne flares

A

Milk

Foods with a high glycemic index

169
Q

What is the concern for SLE patients that may be elgible for light box therapy

A

May exacerbate the SLE

170
Q

What is the treatment for granuloma anulare

A

Steroid injection
potassium iodide
light therapy
cyclosporin

often may be self limiting

171
Q

What are campbell de morgan spots

A

Cherry angiomas

172
Q

what are naevus araneous

A

spider angiomas

173
Q

What is telogen effluvium

A

temporary hair loss due to the shedding of resting or telogen hair after some shock to the system. New hair continues to grow

174
Q

What is anogen effluvium

A

hair shedding is due to the interruption of active or anagen hair growth (drugs, toxins, inflammation) such as alopecia areata

Anogen hair has a pointed or tapered tip

175
Q

What labs should e drawn for patients with alopecia areata

A

thyroid
vitamin D
Vitamin B-12
Folic acid

176
Q

Leprosy can mimic a fixed drug eruption, what additional stain should be done

A

stain for AFB

177
Q

Psoriasis is associated with an increased risk for what other pathologies

A

HTN

Stroke

178
Q

What is EAC

A

Erythema Annulare Centrificum:

-the lesion will be annular with central clearing but will often have a trailing scale.

179
Q

What is acquired keratoderma

A

Presents with thickening of the skin of the palms and soles

180
Q

What is a known trigger for gutate psoriasis

A

strep throat; be sure to get an ASO titer.

ASO > 200 is diagnostic

181
Q

What nail finding is associated with alopecia areata

A

nail pitting

more uniform than the nail pitting that is associated with psoriasis

182
Q

Grovers disease

A

Transient akantholytic dermatosis:

skin condition that affects the chest and back

  • most often in men over 50
  • presents with small red papules that may blister, crust or erode
183
Q

What is a fibrous papule

A
  • firm bump that most often appears on the nose
  • often resembles a flesh colored dermal nevus
  • it is a benign lesion, but needs to be separated from a BCC
184
Q

What is an angiokeratoma

A
  • small dark red raised papules often presenting with scale

- composed of dilated capillaries

185
Q

What is the treatment for bed bugs

A

Lesions will appear with the typical “breakfast, lunch and dinner” lesions

only treat symptomatically with topical steroids

  • replace linens and check for cracks and crevices around the bed.
186
Q

What is the set up for PDT

A

Photodynamic therapy (Blue light)

  1. Pre clean with acetone
  2. cover face with ALA kerastick
  3. Sit in light box for 16:40
  4. Avoid sun for 48 hours
187
Q

What is a short term treatment for rosacea

A

Afrin sprayed in a cotton ball then applied to the affected areas

188
Q

What is a newer treatment for rosacea

A

Mirvaso (bromonidine)

  • an alpha adrenergic agonist
189
Q

What is lichen sclerosus

A

a chronic skin disorder that most often affects the genital and perianal areas. It usually persists for years, and can cause permanent scarring.

no known cure, although most people are substantially improved and quite comfortable with treatment. The condition was previously known as lichen sclerosus et atrophic us.

More common with redundant skin over the penis of an uncircumcised man

190
Q

What does the term lichenoid signify for histopath evaluation

A

lymphocyte bands at the DEJ

191
Q

Aldera

A

Imiquimod

192
Q

Laser treatment for warts

A

pulse dye and vascular laser can be used for the treatment of warts

193
Q

EPS

A

Elastosis perforans serpiginosa (EPS) is a rare skin disorder in which abnormal elastic tissue fibre passes from the papillary dermis (inner layer of skin) to the epidermis (outer layer of skin). This is described as transepithelial elimination and results in a group of small reddish bumps

194
Q

What ingredient in eucerin and aquaphor may cause an adverse reaction

A

lanolin

195
Q

Where is lanolin derived from

A

A wax secreted by wool bearing animals

► Med Misc 06 (27 decks)

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