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211 Cards in this Set
- Front
- Back
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70-80% of clear cell renal cell carcinomas are associated with mutations of which gene?
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VHL gene on chromosome 3p; mutation leads to VEGF proliferation and angiogenesis
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Type 1 papillary renal cell carcinoma is associated with mutations of which gene?
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Met oncogene on chromosome 7
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What is an oncocytoma? What will you see histologically?
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Benign lesion that may seem like renal cell carcinoma on a radiograph
Will see dense eosinophilia and a "spoke wheel" vascular pattern |
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Which kidney malignancy is associated with the Sickle Cell Trait?
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Medullary Renal Cancer
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What symptoms comprise the Grawitz Triad?
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1. Hematuria
2. Flank pain 3. Palpable mass |
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What is Stauffer syndrome? With what is it associated with?
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Hepatic dysfunction NOT due to metastasis.
Is associated with renal cell carcinoma |
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What paraneoplastic syndromes are associated with renal cell carcinoma?
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Hypercalcemia, erythrocytosis, Stauffer syndrome
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Immunotherapy will only work for which type of renal cell carcinoma?
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Clear cell renal cell carcinoma
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Is Sorafenib a multikinase inhibitor, or a tyrosine kinase inhibitor?
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Multikinase inhibitor
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Is Sunitinib a multikinase inhibitor, or a tyrosine kinase inhibitor?
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Tyrosine kinase inhibitor
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Where is the most common site for a transitional cell carcinoma?
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Bladder
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What are five (5) risk factors for bladder cancer?
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1. Cigarette smoking
2. Aniline dyes 3. Arylalkamines (rubber/plastic) 4. Cyclophosphamide 5. Schistosomiasis |
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With what stage does bladder cancer become detrusor muscle invasive?
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Stage 2 and beyond
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For a stage 1 bladder cancer, what kind of vaccine might you recommened?
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BCG vaccine (a Tb vaccine); it causes an inflammatory response that may kill tumor cells
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Which urothelioma has a greater chance of cure: bladder or renal pelvis/ureter?
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Bladder
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What type of carcinoma would you use Finasteride with, and how does it help?
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Use with prostate cancer; it inhibits type 2 5-alpha reductase
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What is Brachytherapy?
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Inserting radioactive seeds into the prostate
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When would you NOT use GNRH agonists to treat prostate cancer?
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If the cancer has metastasized
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What is the most curable solid malignancy in males?
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Testicular cancer
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What is the most common malignancy in young males (15-35 yrs old)?
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Testicular cancer
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Type 2 papillary renal cell carcinoma is associated with what condition, and in which demographic?
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Leiomyomatosis in young women
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What four (4) symptoms might you see with bladder cancer?
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1. Urinary frequency
2. Abdominal pain 3. Dysuria 4. PAINLESS hematuria |
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What is the gold standard treatment for urothelioma of the renal pelvis/ureter?
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Nephroureterectomy with bladder cuff excision
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Which nodes MUST you examine in the case of testicular cancer?
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Supraclavicular nodes (may indicate testicular cancer metastasis)
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What is the description of the metastasis you might see with testicular cancer? Where are the common places of metastasis?
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"Cannon ball metastasis"
Commonly metastasizes to the LUNGS and RETROPERITONEAL lymph nodes |
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What is the most common presentation for testicular cancer?
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PAINLESS enlargement!
If you have pain, that might indicate a hemorrhage into the tumor |
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What is the lifetime risk of kidney stones in males? In females?
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Males = 12%
Females = 6% |
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Which US region has the highest prevalence of kidney stones?
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Southeastern US
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How does vitamin C lead to an occurrence of kidney stones?
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Metabolism of vitamin C can yield oxalate
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Which protease inhibitor for HIV treatment causes kidney stone formation?
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Indinavir!
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What is the clinical presentation of kidney stones?
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1. Hematuria
2. Flank pain 3. Lower UT symptoms (dysuria, frequency, urgency) |
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What are four (4) common compositions of kidney stones?
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1. Calcium oxalate/phosphate
2. Uric acid 3. Struvite 4. Cystine |
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How does ALKALINIZATION help treat kidney stones?
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The pKa's of urate and cystine dictate their solubility
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How does alpha-blockade help treat kidney stones?
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Reduces the contraction of the distal ureter to help expulsion
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What is the gold standard minimally invasive surgical procedure for BPH?
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TURP: Transurethral resection
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What is Dietl's Crisis, and with what condition might you see it in?
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Acute hydronephrosis with flank pain
May see it in UPJ obstruction |
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What is a retrocaval ureter? Its presentation is similar to what other condition?
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A congenital abnormality in which the RIGHT ureter passes POSTERIOR to the vena cava
Similar presentation to UPJ obstruction |
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What is the clinical presentation (4 signs) of a UPJ obstruction?
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1. Dietl's Crisis
2. Hematuria 3. UTI w/ fever 4. Abdominal mass |
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Melanocytes originate from where?
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Neural crest
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Where are Langerhan's Cells derived from?
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Bone marrow; are a type of macrophage/dendritic cell
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What is the mutation in Epidermolytic Hyperkeratosis? What layer of epidermis is affected?
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Mutation in keratins 1 and 10
The stratum SPINULOSUM is affected, not the basal layer |
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Which layer is involucrin located in?
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Stratum Spinulosum
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Which layer are loricrin and profilaggrin located in?
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Mainly in stratum granulosum and corneum
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Which disorder of cornification is associated with an extreme odor? What is the cause of this odor?
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Epidermolytic hyperkeratosis. The odor is caused by bacterial colonization.
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Which disorder of cornification is associated with a cardboard-like appearance, erosions, and blisters?
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Epidermolytic hyperkeratosis.
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What is the defect in Harlequin Ichthyosis?
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Caused by a block in profilaggrin processing
Also associated with a defect in lipid synthesis |
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What is the general clinical presentation in Harlequin Ichthyosis?
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A general SCALING of the skin; the skin moves as one giant plate and cracks, is almost universally fatal
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What keratins are affected in Pachyonychia Congenita?
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Keratins 16 and 17, which are preferentially expressed in nails, mouth, palms, soles of feet
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Which disorder of cornification presents with wedge-shaped thickening of nails?
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Pachyonychia Congenita
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Mutilating Palmar-Plantar Hyperkeratosis is associated with a defect in what?
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Loricrin
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Mutilating Palmar-Planter Hyperkeratosis is associated with what sensory deficit?
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Deafness
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Which disorder of cornification presents with constricting bands and auto-amputation of fingers?
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Mutilating Palmar-Plantar Hyperkeratosis
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What mutation causes KID syndrome? What type of infections does it make you susceptible to?
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A mutation in the connexin gene
Increase in C. albicans infections |
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What are the four (4) signs of KID syndrome?
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1. Keratitis
2. Icthyosis 3. Deafness 4. Ocular issues |
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What type of keratinocytes does HPV target?
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Basal keratinocytes; this makes it difficult to remove
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Which organism, that infects skin, has evolved mechanisms to evade immune surveillance?
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HPV!
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Verruca usually indicates a failure in what?
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Failure of the cytotoxic cellular response
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Which virus exhibits retrograde transport to the DRG after infecting mucosal surfaces?
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Herpes Simplex Virus
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Is psoriasis more common in the extensor or flexor regions?
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EXTENSOR - elbows, knees, trunk
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What is Koebner's Phenomenon?
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Development of psoriasis in areas of TRAUMA
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What is Auspitz's Sign?
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Mechanical scraping of the silvery scale causes small blood droplets to appear
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What is the most common co-morbidity with psoriasis?
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Psoriatic ARTHRITIS
It is a spondyloarthropathy!! HLA-B27 what |
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What is dactylitis? With what condition is it associated with?
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Inflammation of an ENTIRE finger or toe.
Associated with psoriatic arthritis |
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What are the three (3) characteristics of psoriatic arthritis?
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1. Arthritis
2. Dactylitis 3. Enthesitis Look for BAD NAIL INVOLVEMENT to clue you in for PA |
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What cells play a role in the initiation and maintenance of psoriasis? How do they do so?
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TH1 cells.
They secrete cytokines that stimulates keratinocyte hyperproliferation (TNF-alpha, IL-2) |
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What cells play a role in eczema (atopic dermatitis type)?
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TH2 cells
Secrete cytokines such as IL-4, IL-5, IL-10 |
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The TH1 response to leprosy causes what type of leprosy?
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Tuberculoid leprosy - cell mediated immunity
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The TH2 response to leprosy causes what type of leprosy?
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Lepromatous leprosy - antibody response
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What are three types of biologic agents (proteins w/ pharmacologic activity)?
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1. Recombinant human cytokines
2. Monoclonal antibodies 3. Molecular fusion receptor proteins |
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What are three (3) treatments for Psoriasis? How do they work?
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1. Raptiva - blocks LFA1/ICAM1 co-stimulation
2. Amevive - binds CD2 to block co-stimulation 3. TNF antagonists |
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Vitamin D synthesis is a result of UVA or UVB?
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UVB
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Which penetrates skin further - UVA or UVB?
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UVA
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What are characteristics of photo-aged skin?
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Wrinkles, laxity, uneven pigmentation, brown spots, leathery appearance
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What determines skin color?
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The efficiency of transfer of melanosomes
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What is a key enzyme in melanin production, and what is its key cofactor?
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Tyrosinase; Copper
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What is albinism? What are concurrent symptoms with albinism?
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An ABSENCE of melanocytes
Vision, hearing, mental problems (think neural crest) |
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Do ppl with darker skin have higher or lower levels of vitamin D production?
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LOWER per dose of UVB
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What is the phenotype of Piebaldism? Is it AD or AR? What is the causative mutation?
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Non-progressive hypopigmentation (disorder of melanocyte development)
Autosomal-dominant mutation of KIT |
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What is the causative mutation of Waardenburg's Syndrome?
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Mutations in genes for melanocyte MIGRATION - PAX3, MITF, SOX10
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Besides achromia of the skin/hair, what are other symptoms of Waardenburg's Syndrome?
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Deafness, heterochromia irides
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What is the cause of Menkes Syndrome? What is the phenotype?
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Copper deficiency
Pigmentary dilution |
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What is the cause of vitiligo?
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AUTOIMMUNE disease that causes loss of melanocytes
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What other conditions is vitiligo associated with?
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Other autoimmune conditions: Hashimoto's thyroiditis, Addison's disease, pernicious anemia, diabetes mellitus
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In reference to carcinogenesis, what does UVB induce?
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Thymine dimers
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What is a UVA-induced photoproduct?
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8-Hydroxyguanosine
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Where are common places for melanoma in Caucasian males?
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Trunk, especially UPPER BACK
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Where are common places for melanoma in females?
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LOWER LEGS, back
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Where are common places for melanoma in Blacks and Asians?
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Plantar foot, subungal, mucosal sites
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Which keratins are located in the basal layer?
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Keratins 5 and 14
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Which keratins are located in the spinulosum layer?
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Keratins 1 and 10
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What is the function of Bullous Pemphigoid Antigen 1 and 2?
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Anchors the hemidesmosome; they are HD anchoring filaments
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Where is laminin located? With what number collagen does it interact with?
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Lamina densa of the basal lamina
Interacts with type 4 collagen in the basal lamina |
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Where is type 7 collagen located? What function does it serve there?
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Located in the sublamina densa
Serves as anchoring fibrils |
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What is the molecular cause of pemphigus? What molecular structure is affected in pemphigus?
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Inhibition of desmogleins via IgG antibodies
Desmoglein is part of the DESMOSOME |
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What is the most common symptom in pemphigus?
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Oral lesions; only 10-15% will present with cutaneous lesions
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What type of blisters do you see with pemphigus? Where is the blistering occuring?
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Will see FLACCID blisters
Blisters occur just ABOVE the basal layer |
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What will you see in a direct immunofluorescence of pemphigus?
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A "chicken-wire" pattern - will stain the keratinocytes in stratum spinulosum/granulosum
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How do you treat pemphigus?
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Steroids, cyclosporin
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What is the most common autoimmune subepidermal blistering disease?
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Bullous Pemphigoid
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What type of blisters do you see with bullous pemphigoid? Where is the blistering occuring?
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Will see TENSE blisters
Blisters occur in the lamina lucida |
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Does bullous pemphigoid usually occur in the young or the elderly?
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Elderly
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What will you see histologically w/ bullous pemphigoid?
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A clean break b/w the epidermis and the dermis
This space will accumulate fluid and eosinophils |
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Where on the body does bullous pemphigoid spare?
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The face
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What is the autoantibody target in bullous pemphigoid?
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The hemidesmosome
Specifically BP Antigen 2/Collagen 12 |
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An immunofluorescence of bullous pemphigoid will show what?
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A linear staining band of IgG and C3 deposits on the basement membrane zone
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What is the autoantibody target in epidermolysis bullosa acquisita?
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Auto IgG is directed against anchoring fibril collagen type 7
IgG deposits in the upper dermis, beneath the lamina densa |
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Can you use immunofluorescence to diagnose EB aquisita? What might be useful in diagnosis?
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May see a linear band with IF, but that is not enough.
Need to use EM to see deposits of Ab for a diagnosis |
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What are the clinical features of EB aquisita?
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Marked skin fragility, progressive hair loss, loss of nails, autoamputation of digits
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What are the three (3) types of epidermolysis bullosa?
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1. EB Simplex
2. Junctional EB 3. Dystrophic EB |
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What is the abnormality in EB simplex? Where are the blisters located?
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Abnormal keratin 5 and 14 in the basal cells causes fractures; an autosomal dominant disorder
Blisters localized to the hands/feet, where there is mechanical shearing |
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Where are the blisters in Junctional EB? Is Junctional EB autosomal dominant or recessive?
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Blisters through the lamina lucida
An autosomal RECESSIVE disorder |
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What is the abnormality in Dystrophic EB?
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Decreased/absent collagen 7 (dermal anchoring fibrils) causes fracturing below BM zone
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Is Dystrophic EB autosomal dominant or recessive? Its presentation is similar to what other bullous disease?
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An autosomal DOMINANT disorder
Similar in presentation to EB aquisita - skin fragility, nail loss, autoamputation of digits |
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How do drugs cause toxic epidermal necrolysis (TEN) ?
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Drugs may induce keratinocyte FAS ligand to become lytic
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What are three (3) types of drugs that are associated with TEN?
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1. Anticonvulsants
2. Anti-seizure meds 3. Sulfa drugs |
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What is a requirement for a condition to be considered TEN?
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MUST have oral/mucus membrane involvement
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What type of bullae do you see in TEN?
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FLACCID bullae
Will see detachment of sheets of skin |
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What percentage of skin is involved before you diagnose the condition as TEN?
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30%
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How do you calculate Sensitivity?
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TP / (TP+FN)
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How do you calculate Specificity?
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TN / (TN+FP)
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How do you calculate Positive Predictive Value?
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TP / (TP+FP)
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What are four (4) clinical insults that are involved in the Systemic Inflammatory Response Syndrome?
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1. Temp > 38C or < 36C
2. Heart rate > 90bpm 3. Resp. Rate > 20 bpm, or PaCO2 < 32 mmHg 4. WBC > 12000/mm3, < 4000/mm3, or a left shift |
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How do you differentiate b/c septic shock and sepsis-induced hypotension?
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Administer fluids; if blood pressure increases, it is NOT septic shock and it is rather sepsis-induced hypotension
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What would you use to treat septic shock, but not sepsis-induced hypotension?
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Pressors
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What causes the "warm" in warm shock?
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Decreased vascular resistance causes vasodilation; skin becomes warm and flushed
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What causes the "cold" in cold shock?
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Injury to the tight junctions leads to fluid loss and hypovolemic shock
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How do you treat compensated septic shock?
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Use vasoconstrictors (NE, dopamine, vasopressin) only, since blood pressure is preserved
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How do you treat uncompensated shock?
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Use an inotropic agent + alpha-agonist to control vasodilation and increase cardiac output
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What are three (3) characteristics of the febrile response?
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1. Cytokine-mediated rise in core temperature
2. Generation of acute-phase reactants 3. Activation of numerous systems (physiologic, endocrinologic, immunologic) |
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Where are three (3) places you can measure the core body temperature?
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1. Aortic blood
2. Esophageal 3. Tympanic membrane |
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What are the five (5) temperature sensors of the body?
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1. Skin
2. Deep chest and abdomen 3. Spinal cord 4. CNS 5. Hypothalamus |
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What are the four (4) endogenous pyrogens that I keep on forgetting?
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1. Ciliary neurotropic factor
2. Oncostatin M 3. Cardiotropin-1 4. Leukemic inhibitory factor |
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How do pyrogens increase body temperature? What actually crosses the BBB?
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Pyrogens bind to preoptic anterior hypothalamus and activate phospholipase A2
PGE2 crosses the BBB to activate thermosensitive neurons |
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What is DECREASED in the febrile state (3 things)
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1. TSH
2. ADH 3. Sweating |
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What infections (4) do NOT cause the febrile response in the elderly?
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1. Bacteremia
2. Meningitis 3. Endocarditis 4. Pneumonia |
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How do COX inhibitors work?
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Blocks the synthesis of PGE2
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How do corticosteroids work as antipyretics?
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Inhibits phospholipase A2; blocks mRNA transcription of pyrogenic cytokines
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What temperature is considered the critical thermal max?
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41.6 - 42.0 C
i.e. 106.9 - 107.6 F |
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How much should the pulse rise per 1C increase in body temp?
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15bpm per 1C increase
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What does fever do to calcium levels?
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Hypercalcemia due to an increase in bone resorption
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What causes neuroleptic malignant syndrome? What would this syndrome cause?
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Too much dopamine antagonism due to neuroleptic/antipsychotic drugs
Syndrome will cause hyperthermia |
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What are some drug causes of hyperthermia?
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1. Beta-blockers (leads to unopposed alpha stimulation)
2. Anti-cholinergics 3. Sympathomimetics 4. Salicylate toxicity |
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Which will cause a high grade fever, atelectasis (collapsed lung) or pneumonia?
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Pneumonia
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Which will cause a high grade fever, acute cholecystitis or cholangitis?
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Cholangitis
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Which will cause a high grade fever, acute pancreatitis or an infected pseudocyst?
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Infected pseudocyst
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What is a common cause of the double quotidian fever?
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Miliary tuberculosis
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What are the only two infections that can cause a temperature greater than 106F?
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1. Malaria
2. Small pox |
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What kind of heart rate will you see in central fever?
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Relative bradycardia; the febrile response is not activated, so you don't have beta agonism via catecholamines
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What kind of drugs commonly cause malignant hyperthermia?
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General anesthetics
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What type of tumors cause fever?
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Tumor cells involved in the reticular activating system
Tumor cells that secrete interleukins Tumors involving macrophage-like cells |
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Which solid tumors (4) cause fever?
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Renal cell carcinoma, hepatoma, ovarian carcinoma, osteosarcoma
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What are some events that would trigger DKA?
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1. Failure to take meds
2. Infection (mucormycosis) 3. Emesis 4. Other forms of stress |
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Which two drugs cause fever as a side effect?
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1. Amphotericin B (shake and bake)
2. Bleomycin |
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What is the cause of death in DKA?
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OVER-correction of fluids/glucose/electrolytes
Hypoglycemia from treatment may starve brain cells |
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What is the physiologic explanation for the pseudohyperkalemia in DKA?
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Acidotic conditions will drive K+ out of cells
(Insulin drives K+ back into cells) |
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How would you calculate the amount of pseudo-hyponatremia in a DKA patient?
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Na+ is reduced by 1.6 mEq/L for every 100 mg/dL the glucose level is above 100 mg/dL
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How would you calculate the pseudohyperkalemia in DKA?
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Serum K+ will be increased by 0.6 mEq/L for every 0.1 decrease in pH
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What are 4 counter-regulatory hormones released in DKA, and what is the result of each?
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1. Catecholamines --> ketone formation, lipolysis, glycogenolysis
2. Glucagon --> gluconeogenesis from lipolysis, ketone formation 3. Cortisol --> gluconeogenesis from muscle 4. Growth Hormone --> lipolysis, antagonism of insulin |
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What is the result of released cortisol in DKA?
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Gluconeogenesis from muscle
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What is the result of released catecholamines in DKA?
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Ketone formation, lipolysis, glycogenolysis
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What is the result of released glucagon in DKA?
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Ketone formation, gluconeogenesis from lipolysis, glycogenolysis
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What is the result of released growth hormone in DKA?
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Lipolysis, antagonism of insulin
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What causes the early symptoms of DKA?
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Hyperglycemia, muscle breakdown and dehydration
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What are the early symptoms of DKA?
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1. Polydipsia, polyphagia, polyuria
2. Visual changes 3. Weight loss/weakness |
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What causes the later symptoms of DKA?
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Acidosis, ketonemia, hyperosmolarity
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What are the later symptoms of DKA?
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1. Acetone breath
2. Abdominal pain 3. Kussmaul hyperpnea 4. Altered mental status |
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What causes the terminal symptoms of DKA?
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Hypokalemia
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What are the terminal symptoms of DKA?
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1. Cardiac arrhythmias
2. Muscle cramps 3. Gastric stasis/ileus |
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What are the three vitals you want to measure STAT in DKA?
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1. Glucose level in blood
2. Ketones in blood 3. Arterial blood gas to measure acidosis |
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What causes the abdominal pain in DKA?
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Acidosis causes vasoconstriction of the blood supply to the gut viscera
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How do you treat DKA (in order of importance)
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1. Fluids (BOLUS for fast result)
2. Electrolytes (K+, Mg, Phos) 3. Continuous monitoring 4. CONTINUOUS insulin (to decrease ketones, not to fix hyperglycemia) |
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What correlates to mental status in DKA?
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Serum osmolality
Normal is 285-295 mOSM/L |
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How do you calculate serum osmolality?
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2*Na + Glu/18 + BUN/3
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Can DKA be the initial presentation in diabetes mellitus?
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Yes (10% of the time)
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At which dilution should you look at serum acetone to measure ketones?
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1 : 2 dilution
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What causes the tachypnea in DKA?
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Tachycardia + acidosis...think about it
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What causes shock in DKA?
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Uncorrected dehydration
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What two (2) things will shock cause in DKA?
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1. Exacerbation of acidosis via lactic acidosis
2. Decreased GFR, which worsens hyperglycemia and causes acute tubular necrosis |
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What EKG reading would alert you to stop administering K+ to treat DKA?
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Peaked T-waves, which are indicative of hyperkalemia (more K+ rushing into the cell)
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When would you administer bicarbonate therapy in DKA?
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ONLY if the pH drops < 7.0
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How do you treat anaphylactic shock? Can you treat other forms of shock this way?
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Treat w/ epinephrine
Do not use it to treat other forms of shock |
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What is the etiology of hemorrhagic shock?
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Rapid blood loss
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What is the etiology of septic shock?
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Increased capillary permeability
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What is the etiology of neurogenic shock?
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Loss of sympathetic tone, probably due to spinal cord trauma
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What is the etoilogy of cardiogenic shock?
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Decreased pumping ability of the heart, which causes inadequate perfusion to tissues
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What is the etiology of anaphylactic shock?
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Type 1 hypersensitivity rxn causing systemic vasodilation and increased capillary permeability
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Which skin infection is more superficial, that of Staph or Strep?
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Staph
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Which organism infects the skin and loves to go into the lymphatics
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Strep
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Do subcutaneous arteries/veins/nerves travel above or below the fascia?
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Above
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How are the gradings for musculotendinous strains determined?
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Grade 1: partial tear, NO weakness
Grade 2: partial tear, SOME weakness Grade 3: complete tear, loss of function, palpable defect |
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What is tendinosus?
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Tendon degeneration from OVERuse
NOT an inflammatory condition! |
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What word describes a fracture in several pieces?
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"Comminuted"
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What is the normal time progression for fracture healing?
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Day 1-3: Bleeding and clot formation
Week 1: Macrophage infiltration Weeks 1-6: Clot reorganizes into a CALLOUS Months 2 - 12: Reorganization into mature bone |
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What is the time progression for ligament healing?
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Immediately - Hemorrhagic phase
1-2 weeks - Inflammatory phase 1-8 weeks - Reparative phase 4 weeks - 1 year - Remodeling phase |
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What is the healing time for the different grades of sprains?
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Grade 1: 2-4 weeks
Grade 2: 4-6 weeks Grade 3: 2-3 months |
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What 3 risk factors give the highest risk for melanoma?
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1. Changing nevus
2. Familial melanoma w/ dysplastic nevi 3. > 50 nevi that are > 2mm |
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What happens to the ratio of collagen 3 and 1 in photoaging?
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Increase in the 3/1 ratio
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If pemphigus is a paraneoplastic lesion, what is the underlying malignancy?
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Signifies a lymphoreticular malignancy
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What is Nikolsky's sign?
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The movement of the entire epidermis with little lateral pressure
Seen in TEN |
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What is the most common patient profile of bladder cancer?
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Caucasian, older, male
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What can give a false positive in a screen for beta-HCG to test for choriocarcinoma?
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Hypogonadism, marijuana
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What can give a false positive in a screen for alpha-fetoprotein to test for yolk sac tumor?
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Hepatoma, hepatitis, cirrhosis
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What symptom is common in many genitourinary lesions, but does not occur in BPH?
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Dysuria!
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Which calculi are radio-opaque?
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Stones made up of calcium
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Which calculi are radio-transparent?
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Stones made up of urate...b/c they are complexed w/ SODIUM
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Which calculi indicates an infection?
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Struvite stones, which are made up of phosphate+Mg+Ca
Due to the presence of ammonia |
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What would a calculi composed of cystine indicate?
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The patient has difficulties reabsorbing amino acids at the proximal tubule
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How big does a calculi have to be before you consider surgical removal?
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> 5mm
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Which drugs are sympathomimetic?
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1. Cocaine
2. Amphetamines 3. PCP 4. LSD |
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Which drugs are cholinergic?
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1. Organophosphates
2. Pilocarpine |
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Which drugs are CNS depressants?
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1. Inhalents
2. GHB 3. Opiates/narcotics 4. Ketamine |
