Pediatrics Vingettes

49 terms by melwandelt

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Combo of Ashley's and my case studies

A 1-month-old girl presents to her general practitioner with a high fever that has lasted 24 hours, feeding difficulties, a moaning cry and irritability. The child has vomited repeatedly and her abdomen is distended. The baby's heart rate is 170 bpm and her respirations are 60 per minute with grunting and flaring. The baby is slightly cyanotic. Upon receiving the results of her LP the WBC of her CSF is elevated as is the protein. The CSF also shows low glucose. Physical Examination reveals altered mental status and a bulging fontanel.

Bacterial Meningitis

A neonate of approximately 36 weeks gestational age is born to a primigravida mother. Pregnancy and delivery are uncomplicated, with Apgar scores of 9 at 1 and 5 minutes. Mother's and baby's blood groups are both O+. Mother chooses to exclusively breastfeed the neonate. At 24 hours of life, the neonate is noted to be jaundiced and the total serum bilirubin is noted to be 7 mg/dL. He is discharged home later the same day with an appointment for follow-up with the pediatrician at 1 week of age. However, 48 hours later, the neonate is brought to the emergency room. History from the mother reveals that the neonate has progressively become more jaundiced, is not breastfeeding well and is lethargic. Examination also reveals evidence of moderate volume depletion and significant jaundice (including the soles). The neurologic exam is normal and total serum bilirubin is 20 mg/dL

hyperbilirubinemia

A 4-hour-old baby boy, born by vaginal delivery at 36 weeks' gestation, is noticed by his mother to be making a grunting noise when he breathes. On exam the infant is irritable, pale, and floppy. He has an increased respiratory rate (65 breaths per minute), tachycardia (170 bpm), and low blood pressure (45/25 mmHg). His temperature is 97°F (36.2°C). Blood tests reveal leukopenia, neutropenia, thrombocytopenia, and a blood glucose level of 45 mg/dL. The pregnancy had been uneventful. However, the labor was complicated by a presumed premature rupture of membranes approximately 18 hours before the delivery, and a maternal temperature of 100°F (38°C) 3 hours before delivery. Group B streptococcal carriage had not been screened for, but antibiotic prophylaxis had been given 30 minutes before delivery.

Group B Strep

A 6-month-old, previously well female infant presents in midwinter with a 3-day history of rhinorrhea, cough, and malaise. Several other school-age children in the home also have respiratory symptoms. The infant has a temperature of 101.2°F (38.5°C), respiratory rate of 70 breaths per minute, and oxygen saturation of 85% on room air. She has nasal flaring, head bobbing, and suprasternal and intercostal retractions. Auscultation reveals bilateral wheeze with prolonged expiration. The infant's work of breathing improves mildly with nasal suctioning, and her oxygenation improves with warm, humidified oxygen through nasal cannula, but there is no improvement with nebulized albuterol.

RSV bronchiolitis

A girl is born to a woman who presented in labor having had no prenatal care. The baby is preterm (35 weeks'gestation) and small for gestational age, with a low birth weight. She is irritable and feeds poorly. During the newborn check, the pediatrician notes a number of abnormalities. The babyos microcephalic, head circumference is 30 cm (<10thpercentile) and her length is 40 cm (<10th percentile). She had a systolic heart murmur consistent with a ventricular septal defect, which was later confirmed by echocardiogram. Her palpebral fissures are short (1.4 cm length,<10th percentile) and she has a thin upper lip (grade 5 in 4-digitdiagnostic code) and an indistinct (flat) philtrum, flat midface, and a small chin(micrognathia). Upon questioning the mother it is learned that she has an alcohol dependency.

Fetal alcohol syndrome is suspected.

A 6-year-old boy is brought to the surgery by his grandmother, his permanent foster caregiver. She describes him as "difficult" and says that he is now having problems in school, has poor concentration, is hyperactive, and exhibits risk-taking behavior. She has been told by his teacher that he is disruptive in class, is difficult to discipline, and is struggling with reading and numeracy. On examination, his vision is normal but he has mild sensorineural hearing loss. His grandmother says that he was a "slow developer", but that she does not know his milestones because he lived with his mother until the age of 4 years. He has had some occupational therapy in the past in an attempt to improve his fine motor skills. His mother was observed to "binge" drink and smoked cigarettes during her pregnancy, but apparently used no other medications or illicit drugs.

Alcohol-related neurodevelopmental disorder (ARND) is suspected.

A 3-month-old previously healthy infant is found apneic and cyanotic. The baby's parents feel the infant has slept longer than usual, and the infant remains apneic when picked up. The mother calls emergency medical services (EMS) and begins CPR. When EMS arrives, the baby is still apneic, pulseless, and asystolic. EMS personnel initiate pediatric advanced life support protocols en route to the hospital without return of spontaneous circulation. Forty-five minutes after initial resuscitative measures began, the baby remains asystolic and further resuscitative measures are discontinued. Questioning of the parents reveals that the baby was healthy that morning, fed well during the day, and had no sick contacts. The baby was taking no medications and the parents deny access to medications. The baby had been growing and developing normally. The parents report typically placing the baby in the prone position for sleeping, as the baby seemed more comfortable and slept better in that position. Both parents are smokers and the mother admits to smoking, on average, just over 10 cigarettes a day during the pregnancy.

SIDS

A 24-month-old girl presents with swelling of the hands and feet. The child lives in rural sub-Saharan Africa, where she eats a predominantly maize-based diet with her family with very little protein. She was weaned off the breast 2 months earlier when her mother had another child. She has had a reduced appetite for 10 days and has become more lethargic and irritable over the last 5 days, with bilateral swelling noted on the dorsum of the feet. There is no history of hematuria, fever, or chronic medical illnesses. On examination, she has pitting edema of the feet bilaterally. With sustained, firm pressure, the imprint of the examiner's thumb is seen and an 8-mm depression is created. She has a dry, flaky rash on the lower extremities, which consists of hyperpigmented patches that flake off to reveal hypopigmented patches with small ulcerations. Her abdomen is distended. Urine is negative for protein.

Kwashiorkor

A 3 year old girl has an unusual gait. She has bowed legs, thick wrists, and dental caries. Her weight (8 kg) and height (72.5 cm) are below the 3rd percentiles for her age. Her diet consists predominantly of breastfeeding 5 times daily. The patient was born and resides in the northeastern US with her parents after an unremarkable prenatal, delivery, and postnatal course. Her mother admits to using sunscreen on the child everyday. Laboratory studies reveal elevated total alkaline phosphatase and elevated intact parathyroid hormone level. The 25-hydroxyvitamin D level is decreased. Plain radiographs of the patient's knees and wrists demonstrate osseous changes including metaphyseal cupping and flaring, epiphyseal irregularities, and widening of the physeal plates. Upon physical exam it is noted that she has craniotabes, which give her skull a "ping pong Ball" feeling. She also displays the "rachitic rosary" or enlarged costochondral junctions. Her spine shows a slight kyphoscoliosis.

rickets

A 2-month-old male infant, previously healthy, presents to the emergency room with a seizure and difficulty breathing noted by his father. Mother went to work, and left the infant with her husband and infant's 3-year-old sibling. Father states that he put the infant down for a nap and found him 1 hour later having a seizure. Emergency medical technicians found the infant pale and bradycardic, and intubated the child at the scene. In the community hospital, lorazepam was given to control ongoing seizure activity. Physical exam is unremarkable except for the neurologic exam, which reveals brisk reflexes and Glasgow Coma Scale of 10/15. Ophthalmologic exam reveals bilateral multilayer retinal hemorrhages.

Shaken baby syndrome

A mother in a small village in rural Pakistan brings an 18-month-old boy to the local clinic. The main concern is weakness in his left leg. Approximately 2 weeks ago he had fever and diarrhea that resolved without treatment within a week. The child has not received any immunizations due to parental concerns about vaccines and infertility. In particular, when the WHO has coordinated poliomyelitis eradication campaigns, they have allowed vaccinators into their home to immunize their female children but not their son. The village has outdoor sanitation and limited running water.

Polio

A 17-month-old previously healthy but unimmunized child develops fever, malaise, and upper respiratory symptoms, including cough, runny nose, and conjunctivitis, that worsen over several days in March. The fever increases gradually up to 103°F to 104°F (39°C to 40°C) over several days and the cough worsens. Photophobia is present. Whitish lesions on erythematous buccal mucosa opposite the lower molars are visible at this time. Two days later, an erythematous, maculopapular rash appears on the head and spreads from head to toe over the next 3 days as the fever dissapates. The rash is nonpuritic. The rash takes on a brownish coloration and confluent appearance over the next few days. The fever resolves on the third day of the rash, which persists for about a week as does the cough.

Measles aka rubeola

A female infant is born to a 22-year old primigravidas mother at approximately 38 weeks' gestation following an uncomplicated pregnancy. At birth the baby has mild hepatosplenomegaly. The baby develops numerous purplish firm non-blanching skin nodules and scattered petechiae within 24 hours of birth. It is noted that the child has a grade 3 continuous murmur audible at the left infraclavicular area. The child also has cataracts and an abnormal newborn hearing test. The baby's mother immigrated from Liberia during the sixth month of her pregnancy; she cannot recall having been immunized in childhood.

Congenital Rubella (german measles)

A 6-year-old boy presents with fever, headache and a diffuse, pruritic, vesicular rash, which is most prominent on the face and chest. He has had generalized malaise and low grade fever for a few days prior to presentation. He developed high fever and a rash in the last 48 hours. Physical examination demonstrates a temperature of 102°F (38.9°C) and heart rate of 140 beats/min. He has a few scattered vesicular lesions in his oropharynx and his lung fields are clear. The lesions are prominent on the face and chest but all extremities are also involved. In some areas the lesions are crusted while in others they appear newly formed. He has no nuchal rigidity or other meningeal signs.

Varicella

A previously healthy and developmentally normal 18-month-old boy presents to the emergency room by ambulance after his parents witnessed a seizure. The parents report the boy had a mild febrile illness with mild upper respiratory symptoms and they treated him with acetaminophen and ibuprofen at home. Upon his fever spiking to 104.2 the child then began to have frequent jerking movements of all limbs and turned an "awful shade of grey". The parents called 911, and an acetaminophen suppository was administered during transport to the emergency room. The rectal temperature was 103.1°F (39.5°C) upon arriving at the hospital. The jerking stopped after approximately 5 minutes. Afterward, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurologic status. .

Febrile seizure

A 13-year-old boy was admitted with intermittent high-grade fevers and headache of 2 weeks' duration. He complained of retro-orbital headache, neck stiffness, photophobia, nausea with projectile vomiting, and chills and rigors with fever, mainly in the late evenings. He also had backache for the past 5 days and about 3.6 kg weight loss in 2 weeks. The patient had hamsters as pets, and his friend had recently acquired a new kitten. On examination, he had a fever of 101.9°F (39°C), along with mild tachycardia (pulse rate of 110 bpm). He also had tenderness over his back in the thoracolumbar paraspinal area, but he did not have point tenderness over the vertebrae. A malar rash was present and dermographism was noticed on his skin.

Cat Scratch Fever

A 16-year-old boy with a history of seizures was seen with a 1-day history of fever, rhinorrhea, and fatigue. He was treated with amoxicillin/clavulanate for presumed sinusitis but admitted later that day after a tonic-clonic seizure. A paronychia was noted on the right middle finger; this was drained and he was discharged on dicloxacillin. Three days later he was readmitted with fever and right-middle-finger and axillary pain. On examination his temperature was 101.5°F (38.5°C), pulse was 116 bpm,respiratory rate was 24 breaths per minute, and blood pressure was 122/76 mmHg. A large, tender, palpable node in the right axilla was found. The patient had recently been rabbit-hunting and had mosquito bites, but there was no known tick exposure.

Tularemia

A 5-year-old boy is brought to the ER with redness and swelling around his eye that has been present for 1 day. His right eyelid is red, tender to touch, and swollen. It will not open fully and he has a slightly decreased confrontational visual field in the right eye superiorly. He is afebrile and vital signs are normal. He denies any decrease in vision or double vision and his examination is significant for best-corrected vision of 20/25(right eye) and 20/20 (left eye). He has full motility of both eyes, has no afferent pupillary defect, and has eye pressures of 16 mmHg (right eye) and 18mmHg (left eye). His conjunctiva and sclera are within healthy limits and the anterior chamber is deep and quiet. Fundus findings are normal in the right eye and the rest of his examination is within healthy limits. No masses are palpable.

Orbital Cellulitis

A 9-year-old girl presents with a 12-day history of purulent nasal drainage and nasal congestion, and reports a history of fever, myalgia, "annoying" nighttime cough and facial pressure. She is otherwise healthy. After 5 days of illness, the patient's symptoms started to improve; however, they have worsened in the last few days, despite the use of over-the-counter medications. Physical exam shows edematous mucosa of the inferior turbinate. There is also thick mucus in the nasal cavity. Nasal endoscopy demonstrates purulent drainage and a small polyp in the ostiomeatal complex. The adenoids are small and erythematous and halitosis is noted. Transillumination of the maxillary sinus showed fluid within the sinus.

Sinusitis

An 18-month-old toddler presents with 1 week of rhinorrhea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, pulling on her ear and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks.

Acute Otitis media

A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical exam the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualized due to the swelling. The concha and the pinna look normal. Neck exam fails to reveal any lymphadenopathy.

Otitis Externa

A 7-year-old girl presents with abrupt onset of fever, nausea, vomiting, and sore throat. The child denies cough, rhinorrhea, or nasal congestion. On physical exam, oral temperature is 101°F (38.5°C) and there is an exudative pharyngitis, with enlarged cervical lymph nodes. A rapid antigen test is positive for group A Streptococcus(GAS).

Pharyngitis (Strep Throat)

A 6-year-old previously healthy boy presents with acute onset of fever of 102°F (39°C), severe throat pain that is exacerbated by swallowing, slight cough, hoarseness, rhinorrhea, headache, conjunctivitis and malaise. On examination his tonsils are symmetrically enlarged and red, with purulent exudate. He has multiple enlarged, painful anterior neck lymph nodes, but no other lymphadenopathy and no splenomegaly. He has no difficulty breathing.

Viral Tonsillitis

A 2-year-old boy presents with a 3-day history of malaise, dysphagia, halitosis and a d fever that ranges between 103 and 105. In the last 24 hours he has complained of a sore mouth and refuses to eat. He has been well until this illness, and there are no other symptoms. All other family members are well. On examination, he has a temperature of 103°F. There are several yellow lesions in the anterior portion of his mouth and small oval vesicles on his tongue and gingiva.

Herpetic Gingivostomatitis

A 5-year-old boy presents with a 3-day history of malaise and a mild fever. In the last 24 hours he has complained of a sore mouth and developed vesicles on his hands and feet. He has been well until this illness, and there are no other symptoms. All other family members are well. On examination, he has a temperature of 99.6°F (37.6°C). There are several yellow lesions in the posterior pharynx and small oval vesicles with an erythematous base on the palms.

Coxsakie (Herpangina)

A previously healthy 6-month-old infant presents with a 4-day history of recurrent sudden-onset high fever in the range of 102°F to104°F (39°C to 40°C), peaking in the early evening. His mother states that he seemed well despite the fever and upon physical exam you have no clinical findings. Today, his fever resolved but he just developed a rash consisting of 2- to 5-mm red macules on his trunk and proximal extremities.

Roseola

A 6-year-old child presents to the clinic in February with bright red macules on his cheeks, circumolar pallor and a lacy, reticular eruption on his extremities and torso. He has not had a noteable fever. His mother reports that last week he did have symptoms of a mild cold. Other than the exanthem, the child appears healthy.

Fifth disease

A 16-year-old female high school student presents with complaints of fever, sore throat, and fatigue. She started feeling sick 1 week ago. Her symptoms are gradually getting worse, and she has difficulty swallowing. She has had a fever every day, and she could hardly get out of bed this morning. She does not remember being exposed to anybody with a similar illness recently. On physical examination she is febrile and looks sick. Enlarged cervical lymph nodes, exudative pharyngitis with soft palate petechiae and faint erythematous macular rash on the trunk and arms are found.

Mono

You are examining a newly born infant. She is 7.6 lbs, bright pink and crying. Her 5 minute APGAR was 9. Her head seems large for her body and she is fully flexed. Is this baby full term, preemie, SGA or LGA?

Full term

You are examining an neonate in the nursery. He is very skinny. He is fully flexed and screaming. His head seems large for his body. His mother admits to using cocaine during pregnancy. Is this child full term, preemie, SGA or LGA?

SGA

You are examining a neonate in the nursery. This child is in the 90th percentile for weight. Her head is large for her body and she is fully flexed. Her mom is a diabetic. Shortly after the umbilical cord was clamped the baby seized. How is this baby's size classified?

LGA

A 6 week old presents to your office with ruddy skin that resembles a tomato. What is the most likely cause of this discoloration?

Polycythemia

A newborn has green staining on its fingers and toes. What is the most likely cause for this?

Meconium staining

A 4 day old newborn arrives in the ER and appears grey and unstable. The baby had 99% pulse ox upon discharge from the nursery. On examination, the baby has good brachial pulses but femoral pulses cannot be palpated. What is the likely inciting event that led to this presentation?

The pt's patent ductus arteriosus likley closed at home and blood flow to her lower extremies is compromised due to obstruction. This can be a result of a coarctation of the aorta.

A newborn in the nursery has come down with jaundice His direct bilirubin is elevated. A Coomb's test of the infant's blood is positive. The infant has type A blood and his mother is type O. What is the Dx?

ABO incompatibilty. It is rare. The mom will ALWAYS have O and the kid will ALWAYS be A or B.

A 4 day old come to the office with jaundice. Upon taking blood it is determined that her DIRECT bilirubin is elevated. What are possible dx for this condition?

1. Sepsis
2. TORCH
3. ABO/Rh incompatibilty
4. Cystic Fibrosis

A 2 day old appears jaundiced in the nursery. His total serum bilirubin has risen from 4 yesterday to 12 today. What is the course of treatment for this infant?

He should be placed under the UV lights. Usu jaundice will clear up within 7 days.

During the delivery of her child a mother's membranes broke 24 hours before the baby was delivered. Upon birth the baby appeared helthy and had an APGAR score of 9 at 5 mins. Her respiration rate was 45/min and her HR was 130 bpm. Should this child be worked up for sepsis? If so what is the workup and treatment?

Yes, all babies born 24 hours or more after the membranes rupture are septic until proven otherwise. The sepsis w/u is:
1. CBC
2. Blood, Urine and CSF cultures
3. Lumbar puncture
4. ESR
5. CRP
6. immunoassay for bacterial antigens.
**The treatment is IV ABx.

The nurse in the newborn nursery calls you at 3am to come see a newborn who is grunting, flaring and showing retractions. The baby was born 6 hours ago at 35 weeks and her breathing was normal at birth. You get to the nursery an upon examination you notice decreased breath sounds bilaterally. The CXR you ordered shows a ground glass appearance. What is the Dx? What is the etiology?

The dx is Respiratory Distress Syndrome (RDS). It is caused by a lack of surfactant whih causes progressive atelectasis.

A baby in the nursery has noted tachypnea. The baby was born via C-Section 2 hours ago. The baby's birth weight was >90th percentile. The baby's mother is a diabetic. The CXR shows hyperinflation and increased infiltrate. What is the Dx? How does it resolve?

Transient Tacypnea (Wet lung/Big Fat Baby), believed to be caused by inefficient reabsorption of fetal lung fluid, usu resolves itself in 24 hours.;

A 4 year old boy with gastroenteritis presents to the ER with severe vomitting and diarrhea. He is tachycardic, hypotensive and irritable. His eyes look mildly sunken in and his skin is cool and pale to the touch. He has not urinated all day and his mucous membranes appear dry. He weighs 23kg.
1. What level of Dehydration is he?
2. How much mait. fluids does he require?
3. What Is his deficit?
4. How would you administer these fluids?

1. He is moderatly dehydrated (7-10%)
2. Since he is over 20kg use (1500mL + 20 ML/Kg for each Kg over 20) So (1500mL + (20 x 3))= 1560mL or 65 mL/hr
3. A 23kg kid = 23000 grams - at 10% dehydration you take 10% of his body weight (230og) to get deficit = 2300mL
4. In 1st 8 hrs you give 1/3 mait. and 1/2 def. (520+1150)
In next 16 hrs you give 2/3 mait. + 1/2 def (1040+1150)

A mother and father bring their 3 month old to the ER late one evening. The baby has a large contusion on his head and several linear bruises on his thighs. The parents tell you that the baby fell off the bed while they were grabbing his pajamas. They said he hit his head on the bedpost during the fall. Upon physical exam you note the head contusion, the thigh bruises as well as several older bruises on his arms, back and legs. What is your diagnosis?

Child Abuse

A 7 month old is brought to the ER for respiratory difficulty. The mother says her son began to experience trouble breathing at home a few hours ago. She denies fever, cough or other symptoms. She says the child is normally healthy and has no significant past Hx. The mother asks about the cost of the ER visit as she was just laid off from her job. Upon physical exam you find his RR is 42/min, HR is 124/min and he is lethargic. Upon fundoscopic exam you note bilateral retinal hemorrhages. His chest is clear with mild tachycardia. A chest Xray reveals multiple bilateral rib fractures that are at least 3 weeks old. A CT of the child's head shows a fresh subdural hemorrhage. What is your Dx? How should you manage this case?

The Dx is Shaken Baby and the management of the case should be to admit the kid and call the authorities.

An adopted 1 yo boy comes into the ER when his mother notes that he "broke his leg" when he slipped out of the stroller. Multiple fractures are noted on xray in both right and left legs. The baby is noted to have blue sclera and is below the 3rd percentile for length? What is the most likely diagnosis?

Osteogenesis imperfecta

A 6 yo girl is diagnosed with Chlamydia. Her mom states that she has been acting out at school. What should you suspect?

Sexual Abuse - any kid under 15 that has a STD should be assumed to be abused. CPS should be called immediately.

A 2 yo girl has a generalized tonic clonic seizure that lasts one minute when she is febrile. The child attends day care and had a very low birth weight. Her mother mentioned that her father had seizurres when he as feverish as a kid. The child recovers fully from her seizure and the source of the fever (otitis media) is confirmed. Should you put this child on seizure meds?

NO - febrile seizures are benign. Kids usu outgrow them by 5 yo.

A child presents to the ER with a fever of 102 which has been unremitting for the last 12 days. He has seen his family doctor who ruled out EBV, Strep and Bacterial causes. The doc said it was probably viral and would run its course. When the boy's fever spiked to 104 his mom brought him to you. Physical exam of the child was normal. History was unremarkable. The mother said the fever started right after they got a new turtle as a pet for the boy. Was is your suspicion for the cause of the boy's FUO? What Labs would you run to work up this child?

1. Salmonella
2. CBC, ESR, CRP, LDH, Uric Acid, Urinanalysis, Lumbar Puncture, Antinuclear antibodies (kid >12), Blood/Urine?CSF cultures, PPD, Xray of chest/sinuses/GI tract, bacterial & Viral serological tests

A 8 month old child presents to your office with irritablilty, fever, nasal congestion and he's pulling on his right ear. When you go to touch his right ear he pulls away from you. Otoscope exam shows a red TM that is bulging with a complete loss of the cone of light and obliteration of the landmarks. What is your Dx? What is your Tx?

Dx - Acute Otitis Media (purulent infxn of middle ear) Tx- *For kids over 2 yo - watchful waiting and analgesics. Give the Rx for Abx but don't fill it for 2 days. For kids *under 2 yo - ABx - either amoxocillian or augmentin

A 4 year old presents to your office with a "crackling or popping" in his ear. Sometimes he has a hard time hearing. His mother says that other thanm seasonal allergies he has been healthy. She denies any fever or irritability. The boy denies any pain. He says that his ears pop wheen he swallows, like in an airplane. Upon otoscope inspection you notice an retracted TM. What is your Dx? Tx?

Dx - Otitis Media with Effusion (non-infective inflammation accomp. by effusion) Tx - ear popper thing.

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