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4th year OSCE > Management of common conditions > Flashcards

Management of common conditions Flashcards

1
Q

Cluster headache:

Investigations:
Management:
Prophylaxis:

A

Ix. Most will have neuroimaging - MRI
Mx. Acute = 100% oxygen + SC Triptan
Prophylaxis = Verapamil

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2
Q

Migraine (ACUTE)

Investigations:
Management:

A

Oral triptan and NSAID or
Oral triptan and paracetamol

For younger people try nasal triptan
If these measures are ineffective give non-oral dose of metoclopramide or prolchlorperazine

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3
Q

Migraine (prophylaxis)

Management:
If treatment averse or resistant:

A

Propranolol
Topiramate (not to to be given in women of child-bearing age)

or 10 sessions fo acupuncture of 6 weeks

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4
Q

Trigeminal neuralgia

Mx:

A

Carbamazepine
Failure to respond to therapy = referral to neurology

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5
Q

Meningitis
Mx:

A

If meningococcal disease is suspected: IM Benzyl penicillin

If no indication for delaying LP (rash, increased ICP, bleeding risk)
IV blood and cultures
IV antibiotics (>50 years = Cefotaxime + Amoxicillin)
consider IV dexamethasone

CT scan not normally indicated

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6
Q

Meningitis bloods
Ix.

A

Bloods (FBCs, UEs, glucose, clotting profile, lactate, CRP)

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7
Q

Meningitis contact prophylaxis (last 7 days)

A

Ciprofloxacin or Rifampicin
Not needed if found to be pneumococcal cause

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8
Q

SAH
Investigation:
Management:

A

Non contrast CT scan
If symptoms occurse < 6 hours ago, NO LP
If > 6 hours, do LP
If confirmed, referral to neurosurgery and neuroradiology (coiling)

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9
Q

SAH complication treatment:

A

Vasospasm - Nimodipine

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10
Q

Idiopathic increased ICP:

A

Weight loss
Diuretics - acetozolamide

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11
Q

Intracranial venous thrombosis treatment:

Investigation:
Management:

A

MRI venography = gold standard
Anti-coagulation - LMWH

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12
Q

Temporal arteritis

Ix.
Mx.

A

Inflammatory markers (ESR increased), CRP)
Temoral artery biopsy
CK normal

High dose steroids
If visual loss: IV hydrocortisone
Urgent ophthalmology review

Failure to respond to therapy should prompt consideration of alternative diagnosis

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13
Q

What should be co-prescribed with long term steroids

A

Bone protection - bisphosphonates

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14
Q

Glaucoma (acute - closed angle)
Ix.
Mx.

A

Ix. Tonometry and gonioscopy (slit lamp)
URGENT referral
Eye drops: direct parasympathomimetic (pilocarpine) plus timolol
IV acetazolamide

Definitive treatment:
Laser iridotomy

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15
Q

Glaucoma (open angle)
Ix.
Mx.

A

Ix.
Perimetry (visual fields)
Slit lamp (optic nerve damage)
Tonometry
Corneal thickness measurement
Gonioscopy

Mx.
1) prostaglandin analogue (PGA) eyedrop Latanoprost
2) beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop

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16
Q

Vestibular neuronitis

A

Buccal or IM prochlorperazine (rapid relied)
Short course prochlorperazine or antihistamine
Vestibular rehabilitation exercises for chronic Sx.

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17
Q

Labyrinthitis (similar to vestibular neuronitis but with hearing impairment) Mx.

A

usually self-limiting Prochlorperazine

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18
Q

Meniere’s disease Mx.

A

ENT assessment required to confirm the diagnosis

acute attacks: buccal or IM prochlorperazine. Admission is sometimes required
Prevention: betahistine and vestibular rehabilitation exercises may be of benefit

Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved

Usually self resolves in 5-10 years

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19
Q

Vestibular schwannoma

A

Ix. MRI cerebellopontine angle
Mx. Surgery

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20
Q

Stroke
Ix.
Mx.

A

Ix.
Mx. Aspirin 300mg if a haemorrhagic stroke has been excluded
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours),

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21
Q

Stroke - secondary prevention

A

Clopidogrel
if CI, Aspirin + dipyridamole

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22
Q

Aortic stenosis (symptomatic or valvular gradient >40 mmHg)

A

Valve replacement
TAVR or balloon valvuloplasty

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23
Q

Parkinson’s diagnosis

A

Usually clinical but may use SPECT scan to differentiate between that an essential tremor

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24
Q

Epilepsy Ix.

A

EEG after first seizure

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25
Q

Acute seizure treatment

A

IF seizures persist for 5-10 minutes - DIAZEPAM (rectally or nasally or sublingually)

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26
Q

Postural (orthostatic hypotension)

A

Fludrocortisone or midodrine

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27
Q

STEMI mx.
initial triple management for all patients in absence of contraindications

A

Aspirin
Clopidogrel
Unfractionated heparin (prior to PCI)

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28
Q

STEMI mx.

A

PCI or thrombolysis (streptokinase)

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29
Q

Which investigation should be completed following thrombolysis in MI

A

ECG 90 minutes after to check for >50% resolution

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30
Q

Acute chest pain (cardiac related) initial Ix.

A

glyceryl trinitrate
Aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
O2 - only if <94%
perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS

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31
Q

Acute chest pain (cardiac related) when to refer

A

current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission

chest pain 12-72 hours ago: refer to hospital the same-day for assessment

chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

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32
Q

Stable angina Ix.

A

If cannot be excluded on clinical assessment alone
1) CT coronary angio
2) non-invasive functional imaging (looking for reversible myocardial ischaemia - perfusion scan)
3) invasive coronary angiography

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33
Q

Viral pericarditis mx.

A

Treat underlying cause - most will be viral cause

combination of NSAIDs and COLCHICINE is now generally used for first-line for patients with acute idiopathic or viral pericarditis

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34
Q

Viral pericarditis Ix.

A

ECG - widespread ST elevation - PR depression is MOST SPECIFIC ECG marker

Transthoracic echocardiograph

Bloods - inflammatory markers, Troponin will be raised in 30% patients

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35
Q

Angina - drug management - All patients should receive ASPIRIN and STATIN

A
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36
Q

Angina Mx.

A

Asprin plus statin
GTN
CCB or BB
-> CCB/BB in combo

if ineffective:
a long-acting nitrate
ivabradine
nicorandil
ranolazine

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37
Q

PE ix.

A

CTPA (WELLS score > 4)
D-dimer (poor specificity)
ECG
Chest X-ray (to exclude other pathology)

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38
Q

PE Ix. IF PE unlikley, (Wells <4)

A

D-dimer

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39
Q

PE Ix. If wells >4 but CTPA suggests NO DVT

A

Proximal leg ultrasound

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40
Q

What should be given in the interim if PE likely (>4) and delay in getting CTPA

A

DOAC

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41
Q

How long should all patients. W/ PE be anti-coagulated for

A

At least 3 months
If ‘provoked’ i.e pt. has active disease may be stopped
If ‘unprovoked’ treatment likely to be extended to 6 months

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42
Q

PE with haemodynamic instability Mx.

A

Thrombolysis

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43
Q

Primary pneumothorax tx.
(<2cm)
(>2cm)

A

if Pt. not short of breath and rim of air <2cm - consider discharge. If breathless, aspirate
If rim of air >2cm or pt. breathless - CHEST DRAIN

44
Q

Secondary pnemothorax tx.

A

If the pt. is > 50 years old and the rim of air is > 2cm /patient is short of breath then a CHEST DRAIN should be inserted.

otherwise ASPIRATION should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours

if the pneumothorax is less than 1cm then the BTS guidelines suggest giving OXYGEN and admitting for 24 hours

45
Q

Persistent/ recurrent pneumothorax tx.

A

Video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.

46
Q

Dyspepsia mx. for those who do not meet referral criteria

A
  1. Review medications for possible causes of dyspepsia
  2. Lifestyle advice
  3. Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
47
Q

Dyspepsia who gets URGENT referral

A
  • All patients who’ve got dysphagia
  • All patients who’ve got an upper abdominal mass consistent with stomach cancer
  • Patients aged >= 55 years who’ve got weight loss, AND any of the following:
    upper abdominal pain
    reflux
    dyspepsia
48
Q

Dyspepsia who gets ROUTINE referral

A

Patients with haematemesis

Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain

49
Q

Chronic heart failure tx.

A

1) ACEi plus BB
2) Spironolactone
3) To be initiated by a specialist - Ivabradine, sacubitril-valsartan, digoxin
Hydralazine (esp. in afro-carribeans)

50
Q

Acute heart failure mx.

A

IV loop diuretics
Oxygen
Vasodilators - GTN (given if concomitant MI)

51
Q

Should regular CHF medications be stopped in acute heart failure

A

No, with the exception of BB if HR <50

52
Q

Pts. with respiratory failure from heart failure mx.

A

CPAP

53
Q

Pneumonia investigations

A

Chest x-ray

CRP monitoring is recommend for admitted patients to help determine response to treatment

in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests

54
Q

Pneumonia - post infection counselling

A

1 week - Fever should have resolved

4 weeks - Chest pain and sputum production should have substantially reduced

6 weeks -Cough and breathlessness should have substantially reduced

3 months - Most symptoms should have resolved but fatigue may still be present

6 months - Most people will feel back to normal.

55
Q

All cases of pneumonia require what at 6 weeks

A

Repeat CXR

56
Q

Pulmonary fibrosis Ix. and tx.

A

Spirometry - restrictive pattern
impaired gas exchange: reduced transfer factor (TLCO)

Imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’) may be seen on a chest x-ray but
HIGH RESOLUTION CT SCAN is the investigation of choice and required to make a diagnosis of IPF

Prognosis is poor 3-4 years.
Anti-fibrotic medications may buy time
Oxygen and lung transplant required

57
Q

Asthma management (7)

A

1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + Leukotriene receptor antagonist
4) SABA, ICS, LABA
5) SABA +/- LTRA plus switch LABA/ICS for low dose MART
6) SABA +/- LTRA plus switch LABA/ICS for medium dose MART
7) SABA +/- LTRA plus switch LABA/ICS for high dose MART

58
Q

Acute asthma steroid dose

A

All patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least FIVE DAYS days or until the patient recovers from the attack

59
Q

Acute asthma attack recovery - when can pts. be discharged (3)

A

Stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted

60
Q

COPD stable management

A

SABA or SAMA as required

Asthmatic features?
YES - SABA PRN LABA + ICS
NO - SABA PRN LABA/LAMA

SABA, LABA, LAMA, ICS

61
Q

COPD general management

A

smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion

annual influenza vaccination

one-off pneumococcal vaccination

pulmonary rehab to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

62
Q

Initial investigations for suspected gallstones

A

Abdominal ultrasound
LFTs

63
Q

Mx. Biliary colic

A

If imaging shows gallstones and history compatible then laparoscopic cholecystectomy

64
Q

mx. Acute cholecystitis

A

Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)

65
Q

Mx. Gallbladder abscess

A

Imaging with USS +/- CT Scanning
Ideally, surgery although subtotal cholecystectomy may be needed if Calot’s triangle is hostile
In unfit patients, percutaneous drainage may be considered

66
Q

Mx. Cholangitis

A

Fluid resuscitation
Broad-spectrum intravenous antibiotics
Correct any coagulopathy
Early ERCP

67
Q

Mx. Gallstone ileus

A

Laparotomy and removal of the gallstone from small bowel

68
Q

Suspected acute appendicitis Ix.

A

Lipase
Amylase
Early ultrasound (although not required for diagnosis if lipase >3 times normal and characteristic pain)
Contrast enhanced CT scan

69
Q

Scoring systems for acute pancreatitis

A

APACHE II
Ranson
Glasgow

70
Q

Differentiating factor between gastric and duodenal ulcers

A

Gastric ulcers = WORSE with eating
Duodenal ulcers = relieved by eating

71
Q

Peptic ulcer disease (uncomplicated) - Investigations

A

H.pylori test

72
Q

Peptic ulcer disease - active bleeding Mx.

A

ABCDE approach
IV PPI
Endoscopy

If this fails, Interventional angiography or surgery

73
Q

Peptic ulcer disease - perforation Ix.

A

Erect chest x-ray

74
Q

Upper GI bleed - 2 scoring systems when is each used:

A

Glasgow blatchford - helps clinicians decide whether patient patients can be managed as outpatients or not

Rockall - after endoscopy, risk of rebleeding and mortality

75
Q

Management of NON-VARICEAL bleeding

A

NO PPIs before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although

PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
i
f further bleeding then options include repeat endoscopy, interventional radiology and surgery

76
Q

Management of VARICEAL bleeding

A

Terlipressin and prophylactic antibiotics PRIOR to endoscopy
For pts. w/ Oesophageal varices - band ligation
For pts. w/ gastric varices - injections of N-butyl-2-cyanoacrylate

Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

77
Q

Upper GI bleeding Mx.

A

Resuscitation (platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
FFP to patients who have either a fibrinogen level of less than 1 g/litre,
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding)

Endoscopy

Then splits into variceal vs. non-variceal bleeding treatment

78
Q

Loin to groin pain initial investigations

A

Urine dipstick
RFTs
FBCs, CRP
Calcium level
Clotting profile if percutaneous intervention forecasted and Blood cultures if infective cause suspected

79
Q

Renal colic Mx.

A

IM diclofenac

80
Q

Renal colic Ix.

A

Non-contrast CT KUB (within 14 hours of admission)

81
Q

Management of renal stones < 5mm

A

Will likely pass spontaneously

82
Q

Tx. options for renal stones if not passing spontaneously

A

Shockwave lithotripsy
Ureteroscopy
Percutaneous nephrolithotomy

83
Q

Stone burden of less than 2cm in aggregate mx.

A

Lithotripsy

84
Q

Stone burden of less than 2cm in pregnant females

A

Ureteroscopy

85
Q

Complex renal calculi and staghorn calculi mx.

A

Percutaneous nephrolithotomy

86
Q

Diverticulitis ix.

A

FBC - Increased WCC
CRP raised
CXR - pneumoperitoneum??
AXR - dilated bowel lumen
CT - best modality in suspected abscess

87
Q

Diverticulitis mx.

A

Mild - oral antibiotics
Severe or if symptoms are not settling w/in 3 days - IV antibiotics w/ admission

88
Q

Pyelonephritis Ix.

A

Pts. should have MSU (mid-stream urine culture) PRIOR to commencing antibiotics

89
Q

Pyelonephritis Mx.

A

7-10 days broad spectrum antibiotics
CEPHALOSPORIN OR QUINOLONE
Consider hospital admission

90
Q

Gastroenteritis incubation periods
1-6 hrs:
12-48 hrs:
48-72 hrs:
> 7 days:

A

1-6 hrs: Staphylococcus aureus, Bacillus cereus*

12-48 hrs: Salmonella, Escherichia coli

48-72 hrs: Shigella, Campylobacter

> 7 days: Giardiasis, Amoebiasis

91
Q

Acute diarrhoea: when to send stool sample

A

Systemically unwell; needs hospital admission and/or antibiotics.

Blood or pus in the stool.

Immunocompromised.

The person has recently received antibiotics, a proton pump inhibitor (PPI) or been in hospital (specific testing for Clostridium difficile should also be requested).

Hx. foreign travel (tests for ova, cysts, and parasites should also be requested) -> amoebae, Giardia, or cryptosporidium are suspected, particularly if diarrhoea is persistent (14 days or more) or the person has travelled to an at-risk area.

There is a need to exclude infectious diarrhoea.

92
Q

UC gradings: mild, moderate, severe

A

mild: < 4 stools/day, only a small amount of blood

moderate: 4-6 stools/day, varying amounts of blood, no systemic upset

severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers

93
Q

UC (proctitis) mx.

A

Topical Mesalazine
if no response in 4 weeks, add high dose ORAL salicylate
If remission still not achieved, add ORAL or TOPICAL corticosteroid

94
Q

UC (proctosigmoiditis/left-sided colitis) Mx.

A

Topical Mesalazine
if no response in 4 weeks, add high dose ORAL salicylate or comination w/ steroid
If remission still not achieved, add ORAL corticosteroid

95
Q

UC (extensive disease) Mx.

A

Topical AND ORAL Aminosalicylate
If remission not achieved in 4 weeks - stop topical treatments and go high dose oral aminosalicylate and steroid

96
Q

UC (severe) disease Mx.

A

Should be treated in hospital
IV steroids first line

97
Q

UC - maintaining remission mx.

A

topical (rectal) aminosalicylate alone (daily or intermittent) or

an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or

an oral aminosalicylate by itself: this may not be effective as the other two options

Left sided UC - Maintenance dose of ORAL aminosalicylate

98
Q

UC if more than 2 flares/year

A

Azathioprine or mercaptopurine

99
Q

Crohns - Mx.
Acute flares:
Maintain remission:

A

GLUCOCORTICOIDS (oral, topical, IV)
5 - asa drugs are second line to this

Azathioprine (TPMT test prior to start) or mercaptopurine are used first line to maintain remission

100
Q

Thyroid disease investigations:

A

serum TSH and T4 levels

Antibody testing ->
Anti-thyroid peroxidase (anti-TPO) antibodies
TSH receptor antibodies
Thyroglobulin antibodies

Other: scintigraphy

101
Q

Thyrotoxicosis treatments:

A

propranolol: often used at the time of diagnosis to control thyrotoxic symptoms such as tremor

Carbimazole

Radioiodine treatment

102
Q

UTI female mx.

A

3 day course antibiotics (Nitro,trimetho)

Send urine culture if pt. >65 years or has haematuria

103
Q

should you treat asymptomatic bacteriuria in CATHETERISED pts.

A

NO, only if symptoms

104
Q

Asymptomatic bacteriuria

A

Aurine culture
Nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course
the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
a further urine culture should be sent following completion of treatment as a test of cure

105
Q

UTI in males Mx.

A

7 day course of nitrofurantoin/ trimethoprim

4th year OSCE (39 decks)

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