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Grand Rounds Presentation

Transcript: Patient, Mr. I.P, week 6 clinical placement Admitted to Medical Floor after undergoing a frontal twist drill craniostomy to relieve a subdural hematoma caused by fall-related injury with direct impact to the head. NURSING INTERVENTIONS INTERCONNECTIONS Place pt. bed in lowest possible position and use a floor pad at side of bed. (Doenges et al., 2016) R/T insufficient fluid intake, dysuria, incontinence AEB urinary retention, urinary tract infection, catheterization Provide pt. with frequent teaching of the consequences of falling, and importance of safety. measures red blood cell, count, white blood cell count, and platelet count. A low red blood cell count indicates significant blood loss. captures image of the brain and depicts bleeding around the brain, confirms the presence of the subdural hematoma. b | Twist drill craniostomy showing a single twist drill hole created over the thickest portion of the hematoma with a minimally invasive hollow screw in place. a | Burr hole craniostomy with subdural drain. Figure shows two burr holes created with a perforator. GRIEVING ACUTE CONFUSION Medications List Visual impairment R/T macular degeneration Has eye glasses- often forgets to put on No hearing impairment Cognition fluctuates throughout the day Disoriented to date/time; oriented to person/event 'Pleasantly confused' Some word-finding difficulties Dx dementia 2010 Risk for Falls CT Image of Chronic Subdural Hematoma Reduce clutter in pt. room by putting shoes under bed, and ensuring clear path from bed to door/commode. Foley catheter (emptied: 0700hr 800cc, 1900hr 500cc) with 'leg bag' Often forgets about catheter and complains of having to urinate Small type 1 BM found in bed 0730hr Urinary retention prior to hospitalization Wears incontinence briefs at all times Typically uses commode for bowel movements Priority problem: Using proper mobility device will improve balance and gait reducing likelihood of falling. Lowering the bed and providing a floor pad will decreass the severity of injury if pt. were to fall out of bed. Sex: Male Age group: 80-90 Diagnoses: Chronic subdural hematoma, benign prostatic hyperplasia, dementia, urinary retention, COPD, UTI (ESBL E. Coli) Vitals (2/13/17 0800hr): BP 114/60 T 36.6 C R 18/min R.A HR 88 bpm O2 Sat 96% Concept Map RISK FOR FALLS Health Perception- Management c | Minicraniotomy with subdural drain. This procedure is usually reserved for recurrent CSDH with extensive organization and membrane formation, or primary evacuation of a CSDH that has a substantial acute component. tests the patients' mental status by observing quality of speech, level of consciousness, Glasgow Coma Scale score, orientation to time, place and person, memory, and attention span as well as nerve functioning. DIAGNOSTIC TESTS Advair Diskus (fluticasone, salmeterol)- inhaled corticosteroid and bronchodilator; opens airways for gas exchange Allopurinol (Zyloprim)- xanthine oxidase inhibitor decreases high uric acid levels to treat gout and kidney stones Clotrimazole (Canesten)- anti-fungal cream to treat candidiasis yeast infection Dutasteride (Avodart)- to treat benign prostatic hyperplasia (enlarged protate) PEG 3350 prn- osmotic laxative draws large amount of water into to colon to evacuate stool Risperidone prn- antipsychotic medication administered prn to manage behaviours such as aggression Tamsulosin- for urinary retention- relaxes muscles of the bladder neck to ease passage of urine Tiotropium Bromide (Spiriva)- anticholinergic bronchodilator Regular diet- requires set up and cuing to eat a meal or will not eat Allergy to Codeine Upper and lower full dentures Insufficient fluid consumption- 400 mL over 12 hours Urinary Tract Infection (ESBL+) History of GI Bleeds Abdominal assessment findings: audible normal bowel sounds in all 4 quadrants (02/13/17 1140hr) April 10, 2017 Amanda Hill, SPN2 Common treatment options for Subdural Hematoma http://emedicine.medscape.com/article/344482-overview#a2 R/T loss of spouse, anticipatory loss of friends, anticipatory loss of current home, movement to LTC AEB altered sleep pattern, pt. expression of distress regarding moving and loss of spouse Living at retirement home in Arthur, ON prior to hospitalization Verbalized he is sad to be leaving his friends at the home and moving to LTC post hospital discharge Reports his family lives within 10 minutes of him Married for over 50 years to his late wife One biological son with wife, and two step-children from wife's previous marriage Six granddaughters, two grandsons, 18 great-grandchildren Career Hx of truck driving and volunteer fire fighting Recovering from twist drill craniostomy, on contact isolation precautions Proud to discuss his large family, especially his two granddaughters that are nurses Social, talkative, and enjoys reminiscing about Hx of travel with wife and family Expresses loneliness resulting from current loss of wife and current hospitalization and isolation Expressed feelings of sadness

Grand Rounds Presentation

Transcript: Physical Assessment History of Present Illness Last visit with Ms. "E" VS Stable Labs: patient refuses phlebotomy sticks for lab values Discharge to boyfriend's home per pt. request Continue Methadone outpatient in Watts Abscess D/C IV Vanco Rx: PO Bactrim UTI Urine Culture + E. Coli D/C IV Vancomycin Rx: PO Cipro Wound care education Fu in clinic 3-4 days for symptoms check and to establish primary care Abscess Management Active Diagnoses Abscess of right hip PICC line Surgery Consult for I & D Vancomycin IV Thorazine PO Drug abuse Methadone Acute UTI Bactrim PO Repeat UA Urine Cx Gentamicin IV Acute pain Norco PO only NO IV pain meds Morphine sulfate sub Q Acute hypokalemia Potassium PO Acute hyponatremia NS Bolus IVFs Cardiovascular BP 103 Respiratory Clubbing of nails Integumentary R hip: 20 x 15 erythematous lesion blanching warmer fluctuant mass No necrosis No crepitus L hip: multiple older lesions Thank You! HPI Continued Report Labs Blood Cultures Lactate Renal Function CK to rule out Rhabdomyolysis Diagnostics Ultrasound distinguishes cellulitis vs abscess Lymph node enlargement and lymphatic streaking confirm cellulitis Dx Management Antibiotics **MRSA** PO Bactrim, doxycycline, Linezolid IV Vanco, Daptomycin, Linezolid, Clindamycin IVFs I&D surgery Ellipitical incision Loop drainage technique O2 CVP monitoring Loose packing Past Medical History Taj Price-Gibson California State University, Los Angeles Ms. "E" 37 y.o. Caucasian Female English Speaking Single No children Admitted to WMMC ED CC: Right hip abscess Admission date: 4/16/17 CC: Abscess LOS: 3 days Day 1: April 16 Day 2: April 17 Day 3: April 18 April 16, 2017 CC: R hip Abscess x 1 week w/ non radiating pain To WMMC ED Constitutional + Diffuse body aches x 1 week + Fatigue x 1 week + Subjective fever x 1 week + Chills + Diaphoresis + weakness + diffuse pain + throbbing pain to abscess site non radiating 8/10 - no exudate or leakage + Severe withdrawal + heroin use 2 hours ago ENT + Nasal congestion + Sore throat Respiratory + Sputum production + Cough Pus accumulation within tissue of body Furuncle or Carbuncle Cellulitis Signs & Symptoms Warmth Redness Pain Swelling Fluctuant fluid Purulent odor or pus drainage Sub Q Air Associated Cellulitis Etiology Staph Aureus Chronic: E. Coli** Risk factors IVDA& Chemical irritants PMH IVDA heroin & methadone 40 cc/day or 2 “packs”/ day Methadone clinic last time 3 mos ago Endocarditis ECHO ORDERED PSH Appendectomy Cholcystectomy Hysterectomy Allergies Penicillin Toradol Home Medications: None Cardiovascular + Palpitations Gastrointestinal + Nausea GU + Dysuria + Polyuria Lymphatics + Swollen lymph glands MS + Joint pain + Muscle pain + Claudication + Decreased ROM Integumentary + Rashes + Needle tracks in bilateral upper extremities + L hip multiple old abscesses or indurations non infected + R hip multiple abscesses redness, warmth Psychiatric +Anxiety +Depression What is an Abscess? Continuity of Care History The Patient CC: Abscess Surgery Consult Ruled out Necortizing fasciitis, DVT & osteomylitis Recommendation: I&D R hip & bilateral buttocks Rx: PO Doxycycline CV EKG - Endocarditis hx ECHO - Ruled out Endocarditis GU Dysuria & pyuria UA Orange color Turbid appearance Moderate leukocyte esterase Blood Rx: PO Bactrim Blood Cx’s Lab Values WBC 15.3 Hct 29.8 Na 128 K 3.0 Day 2 Grand Rounds Presentation Abscess Day 1 Day 3 Med Surge Awaiting Urine Cx Continue IV Vanco & Gent Increase Methadone to 80 Discharge Planning Case Management Consult Wound care 62 ECG bpm

Grand Rounds Presentation

Transcript: Alfred Mathew Grand Rounds Presentation James Zhao MD HPI HPI The patient is a 30 year old male with no relevant past medical history, presenting after a motor vehicular accident with an emergent cricothyrotomy placed. He presents with several severe lacerations to the face. The patient is stabilized in the utmb OR. More recently, the patient is recovering and is able to shake yes or no to questions. The patient is a welder was past ocular history of far sightedness and early signs of cataracts. Other past medical history, ocular history, family history, and social history is currently unknown. Only a brief history was taken due to patient's mental status. History History Medications taken for severe automobile injuries include: -Albuterol 20-100 mcg -Esomeprazole 40 mg -Fentanyl 250 mL -Levetiracetam 100mg/mL -Lidocaine 1% -Piperacillin 3.375 gram/50 mL The patient has no known allergies. Medications Meds/Allergies Pupils: OD: dark: 3 mm light: 1 mm rAPD: no OS: dark: 3mm light: 1 mm rAPD: no Intraocular Pressure: soft to palpation, low pressure Motility OD: full OS: -2 restriction to left gaze Forced adduction OS with restriction to left gaze Negative oculocardiac reflex during EOM and forced abductions Anterior Exam and Fundus Exam was could not be conducted Visual EXAM Visual Exam Ocular Movements Normal Ocular Movements TIME Doctor's Name Patient CT Differential Differential A tumor in the orbit of a 62-year-old man compresses a structure that runs through both the superior orbital fissure and the common tendinous ring. Which of the following structures is most likely damaged? A-Frontal Nerve B-Lacrimal Nerve C-Trochlear Nerve D-Abducens Nerve E-Ophthalmic Vein OKAP Question OKAP D Answer Is this a nerve or a muscular issue? How can you tell? Differential Differential List -Muscle entrapment (Lateral Rectus) -Cranial Nerve VI Defect -Cranial Nerve III Defect -Duane Syndrome Type 1 -Duane Radial Ray Syndrome -Blowout Fracture Differential List List History History/Pathophysiology NOW 1957 1844 2015 Orbital floor fractures Originally described in 1844 by Dr. MacKenzie in Paris The term blow-out fracture was coined around 1957 by Dr. Smith The lateral rectus muscle is innervated by the abducens nerve and controls movement of eye away from the midline (abduction) An entrapment of the muscle would prevent the leftward or rightward gaze of the left or right eye respectively. Very commonly seen in trauma patients Treatments Treatments Conservative Treatments -Smoothing of bony contour -Reduction in Orbital Content Herniation -Spontaneous Improvement Surgical Repair Research Article Young et al -Compares conservative treatment with surgical repair in patient cohort -Conclusions showed the treatments were equally as effective, with reduced side effects from the conservative approach -Possible issues include the small sample size

Grand Rounds Presentation

Transcript: Distal caries on S and Mesial caries on T Treatment Option 1 Pulpotomy/ SSC on tooth S -4/13/15 DO composite restoration on tooth I -4/20/15 **Change in tx plan MO composite restoration on tooth T- 4/22/15 - Permanent Dentition: teeth 3, 14, 19, 24, 25 and 30 are erupted Phase 1 Treatment option 2 Phase 2 Dental Exam SDI "The Penthouse Suite " Oral hygiene instruction Nutritional counseling Child prophy/ Fluoride Pulpotomy/ SSC on I Pulpotomy/SSC on S References Grand Rounds Thank You! Class II MO Amal- tooth T Class II MO Amal -tooth A Class II DO Amal- tooth B Class II MO Amal- tooth J Class II DO Amal- tooth L Class II MO Amal- tooth K Nitrous (for every procedure) Sealants on teeth 3, 14, 19 & 30 Treatment completed to date Oral hygiene instruction Nutritional counseling Child prophy with Fluoride Pulpotomy/SSC on S Pulpotomy/SSC on I Nitrous Several studies have found that formocresol and ferric sulfate have no significant difference in the success rate. Ferric sulfate has become the preferred choice since formocresol has some controversy of its toxicity. (Ghajari) Eruption Sequence The ideal dressing material for the radicular pulp should (1) be bactericidal, (2) be harmless to the pulp and surrounding structures, (3) promote healing of the radicular pulp, and (4) not interfere with the physiologic process of root resorption. (Casamassimo 341) SDI 5 yrs old (now 6) Ht: 4'1" Wt: 45lbs Race: Hispanic/latino LastVisit: about a year ago Primary Dentition: All present except O and P Phase 3 Class II MO Comp -tooth T Class II MO Comp- tooth A Class II DO Comp - tooth B Class II MO Comp - tooth J Class II DO Comp- tooth L Class II MO Comp- tooth K Nitrous (for every procedure Sealants on teeth 3, 14, 19 and 30 Phase 3 Chief Complaint (from mom) "She has some holes in her teeth and they are sensitive when she eats sometimes" Phase 1 Phase 2 Pulpotomy, Pulpectomy or Extraction? D1335 Code Enforcers Photos Re-eval Ortho Consult OHI Medical History Bite Wings Panoramic Casamassimo , Paul. Pediatric Dentistry: Infancy Through Adolescence, 5th Edition. Mosby, 112012. Carina Canizares SDI Any Questions? Primary teeth E, F, and N are mobile Asthma No Allergies ASA Classification II Medications: Albuterol as needed - e lungs Treatment option 2 was chosen Re-eval Ortho Consult OHI GIVE KIDS A SMILE

Grand Rounds Presentation

Transcript: Clarkson University Class of 2019 Christina Vogel-Rosbrook, PA-S2 Life Is Like a Box of Chocolates Patient Info 69 y/o CM presents to ER CC: "constipated for three days" Differential Differential Diagnosis Appendicitis Abdominal Hernia Diverticulitis Crohn Disease Ulcerative Colitis Perforation Ileus Irritable Bowel Syndrome Large Bowel Obstruction Spontaneous Bacterial Peritonitis Toxic Megacolon Volvulus Ogilvie Syndrome Multiple Sclerosis Lupus Scleroderma Amyloidosis Spinal Cord Injury Parkinson Disease Neuropathy Hypothyroidism Colon Cancer Medication-Induced Hypercalcemia Anal Fissure Fecal Impaction Renal Insufficiency Achalasia Portal Hypertension Cholelithiasis Cholecystitis Celiac Disease Liver Cirrhosis Alcoholic Fatty Liver Disease Non-Alcoholic Fatty Liver Disease Hyperparathyroidism Uremia HPI HPI: Pt reported to ER after 3 days of constipation. Insidious onset of abdominal distention beginning last fall worsened over the past 3-4 days. Associated symptoms include SOB, decreased appetite, severe abdominal distention, and weight fluctuation. He reported first time occurrence. Sxs worsened with time; nothing improved sxs. Medications Medications Neurontin (Gabapentin) - 300 mg PO TID Lipitor (Atorvastatin Calcium) - 40 mg PO daily Synthroid (Levothyroxine) - 175 mcg PO daily Flomax (Tamsulosin) - 0.4 mg PO daily Medical marijuana - for PTSD Intolerance/ Allergies Simvastatin - Headache Pollen Allergy - Congestion. PMH & PSH Past Medical History Frozen Shoulder - Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Post Traumatic Stress Disorder Past Surgical History FH & SH Family History Father 50's y/o. Helicopter accident. Mother 60's. Alcoholism. Brother HTN. Sister Unknown. Sister Alive and well. Sister Alive and well. Daughter 37 y/o. Alive and well. Daughter 34 y/o. Alive and well. Daughter 32 y/o. Alive and well. Daughter 28y/o. Alive and well. Denies family history of liver cancer, cirrhosis, hepatitis, pancreatic cancer, crohn's disease, ulcerative colitis, congestive heart failure. Vietnam Veteran and Retired plumber. Married. Lives with wife, two wolves. Former tobacco and alcohol use. Stopped smoking and drinking about 10 years ago. Registered NYS medicinal marijuana. Denies cocaine or heroin use. Diet: Regular. Exercise: Active with projects around house. Leisure: Enjoys cooking, fixing motorcycles, spending time with family. Safety: Drives with seatbelt. Social History Review of Systems ROS General: +poor appetite, fatigue. No fever, chills. Skin: No open wounds, rashes, lesions, ecchymosis. Head: No headache, trauma, pain. Eyes: No vision changes, blurred vision, photophobia. Ears: No hearing changes, vertigo, tinnitus. Nose: No rhinorrhea, changes in smell, epistaxis. Throat: No dysphagia, sore throat, hoarseness. Neck: No nuchal rigidity, stiffness, lumps. Cardiovascular: No palpitations, chest pain, chest wall pain, orthopnea. Pulmonary: +Dyspnea. No cough, hemoptysis, pleuritic chest pain. Gastrointestinal: +Abdominal distention, diffuse abdominal pain, constipation, early satiety, passing flatus. No nausea, vomiting, diarrhea, hematochezia, melena. Genitourinary: +Rentention. No dysuria, hematuria, frequency, incontinence. Musculoskeletal: +Left leg pain. No arthralgia, muscle atrophy, myalgia. Neuro: No weakness, numbness, confusion, change in speech. Vascular: +Mild leg edema bilaterally. No increased vascularity, claudication. Endocrine: No heat/ cold intolerance, diaphoresis, polyuria, polydipsia. Psychiatric: No feeling of depression, anxiety, memory loss, harmful thoughts. ROS Physical Exam Exam Vital Signs Blood Pressure - 135/67 Pulse - 72 Temperature - 97.7 degrees Farenheit Respirations - 18 Oxygen Saturation - 96% Room Air Vital Signs Physical Exam Physical Exam General: Skin: Head: Eyes: Ears: Nose: Throat: Neck: Pulmonary: Cardio: Abdomen: Extremities: Msculoskeletal: Neuro: Endocrine: Psych: Tests Labs CBC, CMP, other chemistries Blood Cultures Urinalysis Coagulation Serology Labs CBC, CMP CBC, CMP 13.2 16.2 38.7 285 129 4.6 94 4 113 0.6 29 MCV - 83.2 MCH - 28.4 MCHC - 34.1 RDW - 13.7 MPV - 8.4 Neutorphil% - 84 Lymph% - 7.7 Mono% - 6.8 Eos% - 0.6 Baso% - 0.3 Lactic Acid - 1.0 Calcium Adj for Alb - 11.7 Mag - 1.70 Total Bili - 0.5 AST - 31 ALT - 25 Alk Phos - 89 LDH - 164 Total PRO - 6.8 Albumin - 3.8 Lipase - 57 C-Reactive Protein - 9.11 Other CHEM Other CHEM Lipase - 57 TSH - 24.700 T4 - 10.8 TBG Color - Yellow Clarity - Clear pH - 8.0 Specific Gravity - 1.028 Ketones - Negative Blood - Negative Nitrite - Negative Bilirubin - Negative Urobilinogen - 1.0 Leukocyte Esterase - Negative Total PRO - Negative Urinalysis UA Serology Serology Imaging Imaging EKG EKG Chest X-Ray No Acute Disease. Abdominal CT with contrast "Large 10 cm liver lesion with subhepatic space extension into the small bowel mesentery with changes of perotineal carcinomatosis identified with omental caking and studding as well as ascites. I am concerned about primary cholangiocarcinoma of the

Grand Rounds Presentation

Transcript: Diagnostic Tests Goal Addressed Nursing Interventions & Rationales Grand Rounds Presentation By:Nellie Jordan Evaluation of my short-term goal was that the aide and physical therapist were getting my patient in the lift to get him into the chair as I was leaving the floor after my 8-hour shift. Goal was met. References: As far as the patient’s past medical and surgical history he rarely went to the doctor. The patient’s wife stated that he did not believe in going. He has been a hard working farmer his whole life and has been in great health with no past surgeries or medical problems. They did not know that he even had high blood pressure problems until this incident which correlates the CVA with his undiagnosed hypertension. Past Medical History Decadron 4mg Q12H IV Labetalol 20mg PRN IV Apresoline 20mg PRN IV Dextrose 12.5-25gm PRN IV Zofran 4mg Q6H PRN IV Sodium Chloride (0.9% NS) 1,000mL@ 125mls/HR Continuous IV CT Scan Will demonstrate ability to sit up in chair with assistance by end of my 8-hour shift. Impaired physical mobility r/t neuromuscular impairment secondary to CVA AEB left-sided weakness, difficulty turning and limited ROM. Chest X-Ray Evaluation of Goal Pharmacological Management The secondary diagnosis is hypertension, which is when the arterial walls constrict (narrow) which increases the force of the blood on the walls thus, steadily giving a high blood pressure reading above 140/90. Hypertension is confirmed when your BP is measured 1-2 wks apart and is at least 140/90 on 3 separate instances Lopressor 50mg BID P.O. Levaquin 500mg Daily P.O. Nicoderm 14mg Daily Patch Norvasc 10mg Daily P.O. Theragran-M 1 Tab Daily P.O. Colace 200mg BID P.O. Famotidine 20mg BID P.O. Glucose 15-30gm PRN Tylenol 650mg Q4H/PRN P.O. Glucagon 1mg PRN I.M. HumuLIN R S.S. PRN S.C. Secondary Diagnosis The EBP article I chose\can be applied to my patient’s care because he had met several of the criteria for which the study based their patients on. He was a drinker, never went to college therefore he had a lower level of education since he worked as a farmer and also chewed tobacco. These were all mentioned in the study along with 17% were found to have hypertension that they were never diagnosed with, which he also is a part of. The article was basically stating that preventative care is the way to go and that early compliance are key to maintaining hypertension and preventing future problems. Admission Summary The doctor is ordering the CT scans to keep an eye on the previously seen right thalamic hemorrhage and to make sure there is no new hemorrhage. The most recent results of the head CT from 2/4/15 showed no significant interval change when compared to the prior CT scans. Renal Ultrasound 1.) Perform ROM exercises (passive and active) every 2 hours. R- Increases circulation, maintains muscle tone and prevents joint contractions. 2.) Maintain proper body alignment at all times; support extremities with pillows, blankets or towel rolls. R- Prevents flexion contractures and progression of complications. 3.) Observe for complications of immobility (e.g. constipation, muscle atrophy, decubitus ulcers). R- Allows early detection and prevention of complications. A chest x-ray was ordered because the patient had been febrile. Results show mild cardiomegaly and no pulmonary edema but there is increased density seen within the lower lungs that reflects atelectasis. Primary Diagnosis Newfield, S.A, Hinz M.D, Tilley D.S., Sridaromont K.L., & Maramba P.J. (2007), Cox’s Clinical Applications of Nursing Diagnosis. (5h ed.), Philadelphia, PA: E.A. Davis Company. Ignatavicius, D & Workman, L, (2013), Medical-Surgical Nursing. (7th ed.), St. Louis, MO: Saunders, Elsevier. Gould, B.E. & Dyer, R. M., (2011), Pathophysiology for the Health Professions. (4th ed.), St. Louis, MO: Saunders, Elsevier. Rosdahl, C.B. & Kowaiski, M.T. (2011), Textbook of Basic Nursing. (10th ed.), Minneapolis, MN: Lippincott Williams & Wilkins. Mayo Clinic. (2014). Hypertension. Retrieved from http://www.mayoclinic.com WebMD. (2014). Intracerebral Hemorrhage. Retrieved from http://www.webmd.com Epocrates. (2014). Various Medications. Retrieved from https://online.epocrates.com Primary Nursing Diagnosis WBC: 12.3H To evaluate if there is an infection present, patient’s WBC was high therefore this is indicative of an infection. HGB: 13.0 Done to measure the amount of oxygen carried in the blood and can be used to evaluate anemia, patient’s HGB was within normal limits. HCT: 37.0L Ordered to monitor the patient with ongoing bleeding. Patient’s level was low which can be common with intracranial bleeds. Platelet: 213 Ordered to determine if the patient is at risk for hemorrhagic or clotting disorders, patient’s level was within normal limits. Glucose: 186H Ordered to measure amount of glucose in the patient’s blood and because he is a diabetic this is also important. His glucose level was high which would indicate he needs insulin. BUN: 22.0H Ordered to

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