Red flags in General Practice in Medicine in Rural India

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Red Flags In GP (in Rural areas) : 

Red Flags In GP (in Rural areas) Dr.Pravin B.Oza,MD Ashirvad Hospital, Radhanpur 7/18/2009 1 Dr.Pravin B.Oza,MD ,Radhanpur

Slide 2: 

ù nm‰ i+avay ù 7/18/2009 2 Dr.Pravin B.Oza,MD ,Radhanpur

What is General Practice ? : 

What is General Practice ? Play of Defence. Save Your self,-From CPA Make a “Goal”.- Guide and treat Pts and earn money. 7/18/2009 3 Dr.Pravin B.Oza,MD ,Radhanpur

Main Goal : 

Main Goal To identify critical and non critical pts To give primary Rx in critical Pts and to refer them to Secondary Centers To guide Pts for further Rx and evaluation in non critical Pts-who are not diagnosed at GP level. 7/18/2009 4 Dr.Pravin B.Oza,MD ,Radhanpur

Widgets MUST be with GP : 

Widgets MUST be with GP Good Quality BP Apparatus- Digital Thermometer Stethoscope Portable –Handy Pulse Oxymeter 7/18/2009 5 Dr.Pravin B.Oza,MD ,Radhanpur

Widgets SHOULD be with GP : 

Widgets SHOULD be with GP Ht &Wt measurment machines Torch Hammer etc…. 7/18/2009 6 Dr.Pravin B.Oza,MD ,Radhanpur

Above all you need - : 

Above all you need - Good skill of Hx taking and Good Vision to see the RED Flags by eliciting VITAL and other SIGNS 7/18/2009 7 Dr.Pravin B.Oza,MD ,Radhanpur

Normal Vital signs : 

Normal Vital signs 7/18/2009 8 Dr.Pravin B.Oza,MD ,Radhanpur

Vital Signs : 

Vital Signs Accepted Temperature Heart rate Respiratory rate Blood pressure Suggested Nutritional status Smoking status Pulse oximetry 7/18/2009 9 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature : 

Temperature Core temperature >37 ± 0.6oC (98.6 ± 1.08oF) ± 2 SD Fever: >2 SD above the mean Oral: >37.8oC or >100oF Rectal: >38.0oC or >100.4oF Hypothermia: <35oC or <95oF. Hyperthermia: >40oC or >104oF 7/18/2009 10 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature : 

Temperature Most accurate sites Distal third of esophagus Anterior inferior quadrant of tympanic membrane Pulmonary artery 7/18/2009 11 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature : 

Temperature Mercury-in-glass thermometers (no longer available) required time Mouth = 7 minutes Rectum = 3 minutes Axilla = 10 minutes Digital thermometer are prefered 7/18/2009 12 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Oral : 

Temperature: Oral Disposable covers of electronic devices not completely effective in preventing probe contamination Right or left sublingual pocket: bad placement falsely ?by 2.7oC (4.9oF) 7/18/2009 13 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Oral : 

Temperature: Oral Measurement affected by hot or cold drinks, cold ambient air, tachypnea Measurement NOT affected by cigarette smoking, oxygen flow 7/18/2009 14 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Rectal : 

Temperature: Rectal Can cause autonomic changes in patient with recent MI Most accurate 8 cm or more from anus using indwelling thermistor Most probes only 3 to 5 cm Lag behind true core temperature changes by 4 minutes or more 7/18/2009 15 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Rectal : 

Temperature: Rectal Complications reported: rectal perforation, pneumoperitoneum, bacteremia, dysrhythmia, shock Stool freezes in hypothermic patients: probe placed in frozen stool gives false low readings 7/18/2009 16 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Ear : 

Temperature: Ear Double ear thermometry 61% sensitive / 95% specific for fever May miss ~40% of fevers Cerumen impaction ?accuracy TM perforation reported 7/18/2009 17 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Ear : 

Temperature: Ear Underestimates core temperature if ambient temperature <24.6oC (76oF) 7/18/2009 18 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Armpit : 

Temperature: Armpit Axillary = Skin Positive means positive: 98% specific Misses fever frequently: 33% sensitive 7/18/2009 19 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Other : 

Temperature: Other Assessment by touch Parents 75% accurate Physicians 70% accurate 7/18/2009 20 Dr.Pravin B.Oza,MD ,Radhanpur

Temperature: Other : 

Temperature: Other Fresh-voided urine measured immediately: accurate core temperature 7/18/2009 21 Dr.Pravin B.Oza,MD ,Radhanpur

Pulse : 

Pulse Blood flows through vessels at 0.5 m/sec Pressure waves move at 3 to 5 m/sec Thus pulse is a pressure wave Palpated HR approximates actual HR within 2% 7/18/2009 22 Dr.Pravin B.Oza,MD ,Radhanpur

Pulse : 

Pulse Palpate at brachial artery: can appreciate pulse contour and amplitude Routine measurement of pulse amplitude not reproducible without instrumentation 7/18/2009 23 Dr.Pravin B.Oza,MD ,Radhanpur

Pulse : 

Pulse New norms being proposed: Bradycardia <50 beats/min Tachycardia >90 beats/min High temperature without tachycardia: drug fever, typhoid fever, central neurogenic fever 7/18/2009 24 Dr.Pravin B.Oza,MD ,Radhanpur

Respiratory Rate: Kids : 

Respiratory Rate: Kids Infants: if RR >60, ~80% hypoxic 7/18/2009 25 Dr.Pravin B.Oza,MD ,Radhanpur

Respiratory Rate: Kids : 

Respiratory Rate: Kids Prehospital respiratory rate <10 / min or >29/min associated with major injury in 73% Rate by stethoscope higher than if obtained by observation by up to 2.6 breaths / minute 7/18/2009 26 Dr.Pravin B.Oza,MD ,Radhanpur

Pulse Oximetry (SpO2) : 

Pulse Oximetry (SpO2) Patient having seizure: most accurate SpO2 is earlobe AJCC article: 62% of clinicians think that SpO2 provides information about ventilatory status 7/18/2009 27 Dr.Pravin B.Oza,MD ,Radhanpur

Pulse Oximetry (SpO2) : 

Pulse Oximetry (SpO2) Anemia: fewer hemoglobin molecules easier to saturate ? SpO2 may be high, but total oxygen content will be low Polycythemia: more hemoglobin molecules difficult to saturate ? "hypoxemia" when oxygen content may be normal 7/18/2009 28 Dr.Pravin B.Oza,MD ,Radhanpur

Blood Pressure : 

Blood Pressure Palpated systolic blood pressures underestimates manometric values by nearly 30% ATLS no longer teaches palpation Carotid ? SBP 60-70 mm Hg Femoral ? SBP 70-80 mm Hg Radial pulse ? SBP >80 mm Hg 7/18/2009 29 Dr.Pravin B.Oza,MD ,Radhanpur

Blood Pressure : 

Blood Pressure Palpated systolic blood pressures underestimates manometric values by nearly 30% ATLS no longer teaches palpation Carotid ? SBP 60-70 mm Hg Carotid and femoral ? SBP 70-80 mm Hg Radial pulse ? SBP >80 mm Hg 7/18/2009 30 Dr.Pravin B.Oza,MD ,Radhanpur

Blood Pressure : 

Blood Pressure False low Cuff too wide Too much pressure with stethoscope head Rapid cuff deflation False high Cuff too narrow Anxiety Pain Tobacco use Exertion Unsupported arm Slow cuff inflation 7/18/2009 31 Dr.Pravin B.Oza,MD ,Radhanpur

Blood Pressure : 

Blood Pressure High pulse pressure (60 mm Hg) Anemia Exercise Hyperthyroidism A-V fistula Aortic regurgitation Patent ductus Low pulse pressure (20 mm Hg) Hypovolemia Increased peripheral vascular resistance Decreased stroke volume 7/18/2009 32 Dr.Pravin B.Oza,MD ,Radhanpur

Blood Pressure : 

Blood Pressure Ratio of pulse rate over SBP ? shock index (SI), normal range of 0.5 to 0.7. SI >0.85 to 0.90 suggests acute illness in medical patients Increase in potential for gross hemodynamic instability in a trauma patient 7/18/2009 33 Dr.Pravin B.Oza,MD ,Radhanpur

RED FLAGS : 

RED FLAGS All flags are ON CLINICAL presentations ONLY Not dependent on Lab/X-ray/USG reports THESE Flags are GUIDELINE only They may deviate after Ix 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 34

Red Flags : 

Red Flags Alterd VITALS with or without any RED Flag gives Very bad Prognosis 7/18/2009 35 Dr.Pravin B.Oza,MD ,Radhanpur

1.Fever with : 

1.Fever with Headache Vomiting Neck Regidity May suggest- Meningitis 7/18/2009 36 Dr.Pravin B.Oza,MD ,Radhanpur

2.Fever with : 

2.Fever with Bleeding gums Anaemia Leg cramps Tenderness over Muscles May Suggest Dengue and like fevers 7/18/2009 37 Dr.Pravin B.Oza,MD ,Radhanpur

3. Fever with : 

3. Fever with Altered sensorium H/O convulsions With/wthout neck regidity May S/O Encephalitis 7/18/2009 38 Dr.Pravin B.Oza,MD ,Radhanpur

4. Fever with : 

4. Fever with Weakness in limb, Progressive muscular weakness Loss of bladder /bowel control May S/O Viral- Polineuritis, GBS/ATM 7/18/2009 39 Dr.Pravin B.Oza,MD ,Radhanpur

5. Fever with : 

5. Fever with Breathlessness Unilateral Chest pain Haemoptysis With /Without DM May S/O PNEUMONIA 7/18/2009 40 Dr.Pravin B.Oza,MD ,Radhanpur

6. Fever with : 

6. Fever with Hepato spleenomegaly Peripheral multiple Lymphadenopathy Anaemia May S/O Lymphomas 7/18/2009 41 Dr.Pravin B.Oza,MD ,Radhanpur

7. Headache with : 

7. Headache with Vomiting Bradycardia Focal signs of deficit With/without convulsion. May S/O SOL in Brain ( Increased ICT ) 7/18/2009 42 Dr.Pravin B.Oza,MD ,Radhanpur

8. Headache with : 

8. Headache with Vomiting Pin point Pupil HT Hyperpyrexia Altered sensorium May S/O Pontine Haemorrhage 7/18/2009 43 Dr.Pravin B.Oza,MD ,Radhanpur

9. Headache with : 

9. Headache with Vomiting HT Neck regidity No H/O fever May S/O SAH 7/18/2009 44 Dr.Pravin B.Oza,MD ,Radhanpur

10. Headache with : 

10. Headache with Pregnancy HT Oedema legs Convulsions May S/O Eclampsia 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 45

11. Head Injury with : 

11. Head Injury with Alterd sensorium Vomiting Altered Vital Signs Always an EMMERGENCY 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 46

12. Epistaxis with : 

12. Epistaxis with Anaemia Fever Bleeding gums Purpura Hypotension May S/O Exanthematous Viral Fevers 7/18/2009 47 Dr.Pravin B.Oza,MD ,Radhanpur

13. Chest Pain : 

13. Chest Pain Itself is a Red Flag If with alterd VITALS – Has bad prognosis 7/18/2009 48 Dr.Pravin B.Oza,MD ,Radhanpur

14. Chest Pain with : 

14. Chest Pain with Vomiting Parspiration Jaw pain Epi. Pain Bil .arm pain SOB. May S/O ACS/MI/Unstable Angina 7/18/2009 49 Dr.Pravin B.Oza,MD ,Radhanpur

15. Chest Pain with : 

15. Chest Pain with Sudden onset breathlessness Unilateral chest pain Decreased air entry on same side SOB May S/O-Pneumothorex 7/18/2009 50 Dr.Pravin B.Oza,MD ,Radhanpur

16. Chest Pain with : 

16. Chest Pain with Fever Unilateral Chest Pain Haemoptysis Acute onset pain BB on auscultation May S/O Pneumonias 7/18/2009 51 Dr.Pravin B.Oza,MD ,Radhanpur

17. Chest Pain with : 

17. Chest Pain with Fever Unilateral Chest Pain Acute onset pain Breathlessness Decreased TVF on auscultation May S/O Pl.Effusion 7/18/2009 52 Dr.Pravin B.Oza,MD ,Radhanpur

18. Chest Pain with : 

18. Chest Pain with Age – Elderly,Male Clubbing Hemoptysis No fever Unilateral Chest pain May S/O CA Lung 7/18/2009 53 Dr.Pravin B.Oza,MD ,Radhanpur

19. Chest Pain with : 

19. Chest Pain with Murmurs on Auscultation Increased JVP Hepatomegaly DOE/PND Oedema legs H/O Rh Fever In past May S/O Rh Ccarditis/Valvular HD/CCF 7/18/2009 54 Dr.Pravin B.Oza,MD ,Radhanpur

20. Chest Pain with : 

20. Chest Pain with Orthopnea Bil. Creps Loud M1 H/O MI /HT before Altered SpO2 May S/O LVF 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 55

21. HT With : 

21. HT With Sudden loss of Vision/Aphasia Elderly male pt May S/O Ischemic CV Stroke 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 56

22. HT With : 

22. HT With Breathlessness Anaemia Oedema Face H/O some renal surgery May S/O CRF 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 57

23. HT With : 

23. HT With Sudden hemiplegia/Monoplegia Alterd sensorium Vomiting May S/O ICH 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 58

24. Breathlessness with : 

24. Breathlessness with Acute chest pain- Unilateral BB Fever Hypotension Kn H/O Br Asthma/COPD May S/O PNEUMONIA (Sec.Inf) 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 59

25. Breathlessness with : 

25. Breathlessness with Acute chest pain- Unilateral BB Hypotension Kn H/O Br Asthma/COPD No Fever Drcreased AE on same side May S/O PNEUMOTHOREX 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 60

26. Breathlessness with : 

26. Breathlessness with Cyanosis Hypotension Decreased SpO2 H/O COPD May S/O Acute Resp.Failure 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 61

27. Breathlessness with : 

27. Breathlessness with Enlarged Thyroid Exopthalmos HT/Murmurs May S/O Thyroid crisis 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 62

28. Breathlessness with : 

28. Breathlessness with Haemoptysis Hypotension Anaemia Clubbing May S/O CA Lung 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 63

29. Abdominal Pain with : 

29. Abdominal Pain with Vomiting Absolute constipation Distension of abdomen ±Guarding /Regidity May S/O Intestinal Obstruction 7/18/2009 64 Dr.Pravin B.Oza,MD ,Radhanpur

30. Abdominal Pain with : 

30. Abdominal Pain with Vomiting Distension of abdomen ±Guarding /Regidity Loss of Dullness in RHQ May S/O Perforation of Hollow Viscus 7/18/2009 65 Dr.Pravin B.Oza,MD ,Radhanpur

31. Abdominal Pain with : 

31. Abdominal Pain with Age 50 or more Palapble lump in abdomen H/O Hemetemesis/Malena Anaemia H/O GERD,Belching,Heart burn May S/O Malignant mass lesion 7/18/2009 66 Dr.Pravin B.Oza,MD ,Radhanpur

32. Abdominal Pain with : 

32. Abdominal Pain with Vomiting Distension of abdomen ±Guarding /Regidity Presence of irreducible Hernia Tenderness over Hernia May S/O Strangulated Hernia with Int. Obstruction 7/18/2009 67 Dr.Pravin B.Oza,MD ,Radhanpur

33. Abdominal Pain with : 

33. Abdominal Pain with Fever Vomiting Guarding + Regidity Distension of Abdomen May S/O Peritonitis 7/18/2009 68 Dr.Pravin B.Oza,MD ,Radhanpur

34. Abdominal Pain with : 

34. Abdominal Pain with Fever Hepatomegaly Pain at Rt lower chest Increased level of Dullness in Rt Lower Chest May S/O Liver abscess 7/18/2009 69 Dr.Pravin B.Oza,MD ,Radhanpur

35. Abdominal Pain with : 

35. Abdominal Pain with Vomiting Jaundice Pruritus Pale stool RHQ /Epi.tenderness May S/O Obstructive Jaundice 7/18/2009 70 Dr.Pravin B.Oza,MD ,Radhanpur

36. Abdominal Pain with : 

36. Abdominal Pain with Obstructive Jaundice signs + If age –Elderly- CA Pancrease If age Young adult- Gall stone disease. 7/18/2009 71 Dr.Pravin B.Oza,MD ,Radhanpur

37. Abdominal Pain with : 

37. Abdominal Pain with Hemetemesis Malena Distension of abdomen Spleenomegaly H/O Alcoholism May S.O- Portal HT + Esophageal Varices Bleeding 7/18/2009 72 Dr.Pravin B.Oza,MD ,Radhanpur

38. Abdominal Pain with : 

38. Abdominal Pain with Vomiting Acute unilateral testicular Swelling Young age-Male Redness over Scrotum May S/O Torsion Testes 7/18/2009 73 Dr.Pravin B.Oza,MD ,Radhanpur

39. Abdominal Pain with : 

39. Abdominal Pain with H/O Trauma –Blunt Sudden Anaemia Postural Hypotension May S/O Hemoperitoneum 7/18/2009 74 Dr.Pravin B.Oza,MD ,Radhanpur

40. Abdominal Pain with : 

40. Abdominal Pain with Young Female H/O some OBG Procedure Anaemia Fever Tender Hypogastrium Hot temp in P/V., P/R. May S/O Pelvic Abscess 7/18/2009 75 Dr.Pravin B.Oza,MD ,Radhanpur

41. Abdominal Pain with : 

41. Abdominal Pain with Young Female Amenorrhoea Sudden onset lower abdominal pain Postural Hypotension May S/O Ruptured Ectopic Pregnancy 7/18/2009 76 Dr.Pravin B.Oza,MD ,Radhanpur

42. Bach Pain with : 

42. Bach Pain with Acute onset Loss of Bladder – Bowel Control,Acute Constipation Parasthesis-Numbness in lower limbs No Fever H/O Some Physical Strain May S/O Cauda Equina with Acute Disc Herniation 7/18/2009 77 Dr.Pravin B.Oza,MD ,Radhanpur

43. Insect bite With : 

43. Insect bite With Wheezing in R/S SOB / ± Coughing Postural Hypotension Vomiting May S/O Anaphylaxis due to stinge bite 7/18/2009 78 Dr.Pravin B.Oza,MD ,Radhanpur

44. Snake Bite with : 

44. Snake Bite with Ptosis SOB, Alterd SpO2 Dysarthria- Slurred speech May S/O Neurotoxicity of Venum 7/18/2009 79 Dr.Pravin B.Oza,MD ,Radhanpur

45. Scorpion Bite With : 

45. Scorpion Bite With Age below 5 yrs Severe perspiration Breathlessness,Creps in Bil Lungs Severe creps in lungs at base/whole lungs Severe Tachypnoea,Tachycardia,Irregular Pulse May S/O Pul.Oedema- Cardiotoxicity of Venom 7/18/2009 80 Dr.Pravin B.Oza,MD ,Radhanpur

46. Diabetic Pt with : 

46. Diabetic Pt with Sudden Unconciousness Perspiration Tachycardia Cold clammy skin Normal breathing May S/O Hypolycemia 7/18/2009 81 Dr.Pravin B.Oza,MD ,Radhanpur

47. Diabetic Pt with : 

47. Diabetic Pt with Sudden Unconciousness Laboured breathing Ketotic smell from nose Severe dehydration May S/O DKA 7/18/2009 82 Dr.Pravin B.Oza,MD ,Radhanpur

48. Leg pain with : 

48. Leg pain with Unilateral acute onset pain Severe burning pain Cold – clammy affected limb Absent peripheral pulsation in same limb If late – May have Ch/O Gangrene May S/o Acute Thrombo-embolic Ischemia of PVD 7/18/2009 83 Dr.Pravin B.Oza,MD ,Radhanpur

49. Cellulitis with : 

49. Cellulitis with Fever Crackeling sound on palpation at local site Hypotension May S/O GAS -Gangrene 7/18/2009 84 Dr.Pravin B.Oza,MD ,Radhanpur

50. AGE with : 

50. AGE with Hypotension Dehydration Cold Clammy Skin May S/O Gram-Negative Shock 7/18/2009 85 Dr.Pravin B.Oza,MD ,Radhanpur

51. Convulsion with : 

51. Convulsion with Hydrophobia Irritability No Fever Altered sensorium May S/O Rabbies 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 86

52. Convulsion with : 

52. Convulsion with HT Vomiting Altered sensorium No neck regidity May S/O HT Encephelitis 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 87

53. Convulsions with : 

53. Convulsions with Altered sensorium Jaundice Foetor Hepaticus Flap tremors May S/O Hepatic Encephalopathy 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 88

54. Dysphagia with : 

54. Dysphagia with Stridor Breathlessness Cough HOV May S/O CA Larynx 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 89

55. FB in nose : 

55. FB in nose Paed, Pt Bleeding from nose DO NOT Try TO REMOVE –IT is Dangerous 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 90

56. FB Ingested : 

56. FB Ingested Sharp Object Vomiting Hemetemesis EMMERGENCY Round Objest-Nothing to Worry-W/W 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 91

57. FB Aspirated : 

57. FB Aspirated Always EMMERGENCY 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 92

58. Bleeding P/V with : 

58. Bleeding P/V with Pregnancy Hypotension Anaemia Hypogastric pain May S/O Threatened – Missed Abortion 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 93

59. Bleeding P/V with : 

59. Bleeding P/V with H/O Abortion H/O SB delivery Gum bleeding Echymosis Hypotension May S/O DIC 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 94

60. Bleeding P/R with : 

60. Bleeding P/R with Long H/O resistant diarrhoea Colicky pain in abdomen Anaemia Young , Females May S/O Ulcerative colitis 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 95

61. Poisoning with : 

61. Poisoning with Altered vitals including bad respiration Altered SpO2 Cyanosis Hypotension Is a BIG Red Flag For GP…. 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 96

So- Have a look to all Reg flags : 

So- Have a look to all Reg flags And REMEMBER to Refer Pts on RIGHT time – RIGHT place- & to RIGHT consultant. 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 97

AND : 

AND ENJOY -- “THE Dinner” 7/18/2009 Dr.Pravin B.Oza,MD ,Radhanpur 98

Thank You! : 

Thank You! 7/18/2009 99 Dr.Pravin B.Oza,MD ,Radhanpur

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