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mental health, substance abuse, and functional ability
Terms in this set (91)
emotional functioning mental status
cognitive functioning mental status
-is "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community."
-is relative and ongoing
what is the expected response to trauma related to a traumatic life event?
-tips the balance and causes transient dysfunction
§ For example, bereavement may lead to someone feeling down or depressed, but is an expected emotional response to a major loss and does not usually induce a major depressive episode.
§ Most grieving people feel sadness, tearfulness, loss of appetite, and insomnia; these feelings last 2 to 6 months.
§ The survivor needs social support but no medical treatment
o apparent when a person's response is much greater than the expected reaction to a traumatic life event.
o It is a clinically significant behavioral, emotional, or cognitive syndrome that is associated with significant distress (a painful symptom) or disability (impaired functioning) involving social, occupational, or key activities.
example of a mental disorder
major depression is characterized by feelings that are unrelenting or include delusional or suicidal thinking, feelings of low self-esteem or worthlessness, or loss of ability to function
o (caused by brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication, and withdrawal])
psychiatric mental illness
(in which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia]). Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Being aware of one's own existence, feelings, and thoughts and of the environment. This is the most elementary of mental status functions.
Using the voice to communicate one's thoughts and feelings. This is a basic tool of humans, and its loss has a heavy social impact on the individual.
mood and affect
Both of these elements deal with the prevailing feelings. Affect is a temporary expression of feelings or state of mind, and mood is more durable, a prolonged display of feelings that color the whole emotional life.
The awareness of the objective world in relation to the self, including person, place, and time.
The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli
The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years' worth of experiences.
Pondering a deeper meaning beyond the concrete and literal.
the way a person thinks; the logical train of thought
what the person thinks- specific ideas, beliefs, the use of words
an awareness of objects through the five sense
components of the mental status examination
-is a systematic check of emotional and cognitive functioning
-symptoms of psychiatric mental illness, especially with acute onset
o Thought processes
what are the components of the mental status examintation?
· Health history interview
· Mental health strengths
· Coping skills
when is a full mental status examination necessary?
-anxiety disorder or depression
-symptoms with acute onset
-such as memory loss or inappropriate social interaction.
o including bizarre behavior (e.g., nocturnal wandering), concentration problems, trouble with simple activities such as using the television remote, inappropriate judgment, or linguistic difficulty.
· (trauma, tumor, stroke). A mental status assessment documents any emotional or cognitive change associated with the lesion. Not recognizing these changes hinders care planning and creates problems with social readjustment.
· (the impairment of language ability secondary to brain damage). A mental status examination assesses language dysfunction and any emotional problems associated with it, such as depression or agitation.
· Symptoms with acute onset
contributions from health history
· Known illnesses: as alcohol use disorders or chronic renal disease.
· Health problems
· Medications: Current medications with side effects that may cause confusion or depression.
· Educational & behavioral level: note that factor as the normal baseline, and do not expect performance on the mental status examination to exceed it.
o social interactions
o sleep habits
o drug and alcohol use
objective data: appearance POSTURE
o Abnormal: Sitting on edge of chair or curled in bed, tense muscles, frowning, darting and watchful eyes, and restless pacing occur with anxiety and hyperthyroidism. Sitting slumped in chair, slow walk, dragging feet occur with depression and some organic brain diseases.
o Normal: posture is erect and position is relaxed
objective data: appearance BODY MOVEMENTS
§ Restless, fidgety movement or hyperkinetic appearance occurs with anxiety.
§ Apathy and psychomotor slowing occur with depression and dementia.
§ Abnormal posturing and bizarre gestures occur with schizophrenia.
§ Facial grimaces may occur with pain.
§ Involuntary tics can occur with neurologic disorders (e.g., Tourette syndrome, tardive dyskinesia
o Normal: Body movements are voluntary, deliberate, coordinated, smooth, and even.
objective data: appearance DRESS
§ Inappropriate dress can occur with organic brain syndrome.
§ Eccentric dress combination and bizarre makeup occur with schizophrenia or manic syndrome.
o Normal: Dress is appropriate for setting, season, age, gender, and social group. Clothing fits and is worn appropriately.
objective data: appearance GROOMING AND HYGIENE
§ Unilateral neglect (total inattention to one side of body) occurs following some strokes.
§ Inappropriate dress, poor hygiene, and lack of concern with appearance occur with depression and severe Alzheimer disease. Meticulously dressed and groomed appearance and fastidious manner may occur with obsessive-compulsive disorders.
o Normal: The person is clean and well groomed; hair is neat and clean; women have moderate or no makeup; men are shaved, or beard or mustache is well groomed. Nails are clean (although some jobs leave nails chronically dirty). Note congruence between dress/grooming and age. NOTE: A disheveled appearance in a previously well-groomed person is significant. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair; piercings; and tattoos because these sometimes reflect the person's economic status or a deliberate fashion trend (especially among adolescents).
objective data: appearance PUPILS
o Abnormal: Dilated or constricted pupils may be a sign of recent drug use. Recent anisocoria (unequal pupil size) can be the result of a brain tumor.
o Normal: note pupil size and reaction to light
objective data: behavior LEVEL OF CONSCIOUSNESS
o Abnormal: Loses track of conversation, falls asleep; Lethargic (drowsy), obtunded (confused)
o Normal: The person is awake, alert, and aware of stimuli from the environment and within the self and responds appropriately and reasonably soon to stimuli.
objective data: behavior FACIAL EXPRESSION
o Abnormal: Flat, masklike expression occurs with parkinsonism and depression
o Normal: The look is appropriate to the situation and changes appropriately with the topic. There is comfortable eye contact unless precluded by cultural norm.
objective data: behavior SPEECH
§ Judge the quality of speech by noting that the person makes laryngeal sounds effortlessly and shares conversation appropriately.
§ The pace of the conversation is moderate, and stream of talking is fluent.
§ Articulation (ability to form words) is clear and understandable.
§ Word choice is effortless and appropriate to educational level. The person completes sentences, occasionally pausing to think.
§ Dysphonia is abnormal volume, pitch
§ Monopolizes interview or is silent, secretive, or uncommunicative.
§ Slow, monotonous speech with parkinsonism or depression. Rapid-fire, pressured, and loud talking occurs with manic syndrome.
§ Dysarthria is distorted speech. Misuses words; omits letters, syllables, or words; transposes words; occurs with aphasia. Circumlocution or repetitious abnormal patterns: neologism, echolalia
§ Unduly long word-finding or failure in word search occurs with aphasia.
objective data: behavior MOOD AND AFFECT
o Normal: Judge this by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and change appropriately with topics. The person is willing to cooperate with you.
o Abnormal: Delirium, Dementia, and Depression,
objective data: cognitive functions ORIENTATION
o Normal: You can discern orientation through the course of the interview by asking about the person's address, phone number, and health history. Or ask for it directly, using tact, by saying, "Some people have trouble keeping up with the dates while in the hospital. Do you know today's date?" Assess:
§ Time: Day of week, date, year, season
§ Place: Where person lives, present location, type of building, name of city and state
§ Person: Own name, age, who examiner is
§ Many hospitalized people normally have trouble with the exact date but know the year and are fully oriented on the remaining items.
§ Disorientation occurs with delirium and dementia. Orientation is usually lost in this order: first to time, then to place, and rarely to person.
objective data: cognitive function ATTENTION SPAN
o Normal: Check the person's ability to concentrate by noting whether he or she completes a thought without wandering. Note any distractibility or difficulty attending to you. Or give a series of directions to follow and note the correct sequence of behaviors, such as, "Please take this glass of water with your left hand, drink from it, shift it to your right hand, and set it on the table." Note that attention span commonly is impaired in people who are anxious, fatigued, or drug intoxicated.
§ Digression from initial thought. Irrelevant replies to questions. Easily distracted; "stimulus bound" (i.e., any new stimulus quickly draws attention).
§ Confusion, negativism
objective data: cognitive function RECENT MEMORY
o Normal: Recent Memory: Assess recent memory in the context of the interview by the 24-hour diet recall or by asking the time the person arrived at the agency. Ask questions you can corroborate. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss.
o Abnormal: Recent memory deficit occurs with delirium, dementia, amnestic syndrome, or Korsakoff syndrome in chronic alcoholism
o The Four Unrelated Words Test
four unrelated words test
§ Abnormal: People with Alzheimer dementia score a zero- or one-word recall. Impaired new learning ability also occurs with anxiety (because of inattention and distractibility) and depression (because of lack of effort mobilized to remember). (NEW WORD TEST)
§ This tests the person's ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than does the recall of personal or historic events. It also avoids the danger of unverifiable material.
· Say to the person: "I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them." To be sure the person has understood, have the person repeat the words. Pick four words with semantic and phonetic diversity:
1. Brown; fun
2. Honesty; carrot
3. Tulip; ankle
4. Eyedropper; loyalty
· After 5 minutes, ask for the recall of the four words. To test the duration of memory, ask for a recall at 10 minutes and at 30 minutes. The normal response for people younger than 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay
testing for person with aphasia: word comprehension
§ Word comprehension: Point to articles in the room, parts of the body, or articles from pockets and ask the person to name them.
· Abnormal: Aphasia is the loss of the ability to speak or write coherently or to understand speech or writing as a result of a stroke or brain damage
testing for person with aphasia: reading
Ask the person to read available print. Be aware that reading is related to educational level. Use caution that you are not testing literacy. Ensure that the person has reading glasses if needed, and use a large-print item if possible.
testing for person with aphasia: writing
§ Ask the person to make up and write a sentence describing the weather or their job. Note coherence, spelling, and parts of speech (the sentence should have a subject and a verb).
Abnormal: Reading and writing are important in planning health teaching and rehabilitation. Agraphia (inability to communicate through
objective data: cognitive functions REMOTE MEMORY
o Abnormal: Remote memory is lost when the cortical storage area for that memory is damaged (e.g., Alzheimer dementia or any disease that damages the cerebral cortex
o Normal: Remote memory: In the context of the interview, ask the person verifiable past events (e.g., ask to describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person).
thought process: judgement
o Ask yourself, "Does this person make sense? Can I follow what the person is saying?" The way a person thinks should be logical, goal directed, coherent, and relevant. The person should complete a thought.
o Abnormal: Illogical, unrealistic thought processes. Digression from initial thought. Ideas run together. Evidence of blocking (person stops in middle of thought)
thought process: thought consent
o What the person says should be consistent and logical.
o Abnormal: obsessions and compulsions
thought process: perceptions
o The person should be consistently aware of reality. The perceptions should be congruent with yours. Ask the following questions:
§ How do people treat you?
§ Do other people talk about you?
§ Do you feel as if you are being watched, followed, or controlled?
§ Is your imagination very active?
§ Have you heard your name when alone?
o Abnormal: illusion and hallucinations
§ Auditory and visual hallucinations occur with psychiatric and organic brain disease and psychedelic drugs.
§ Tactile hallucinations occur with alcohol withdrawal
screening for suicidal thought: assess for any possible risk of physical harm
-Begin with more general questions. If you hear affirmative answers, continue with more specific questions
-· have the person sign a contract that contains a plan not to act on suicidal thoughts if they happen again. The plan should contain the names and numbers of people the patient can call if suicidal ideations occur.
-A precise suicide plan to take place in the next 24 to 48 hours using a lethal method constitutes high risk.
what are the important clues and warning signs of suicide?
o Prior suicide attempts
o Depression, hopelessness
o Firearms in the home
o Family history of suicide
o Family violence, including physical or sexual abuse
o Verbal suicide messages (defeat, failure, worthlessness, loss, giving up, desire to kill self)
o Death themes in art, jokes, writing, behaviors
o Saying goodbye (giving away prized possessions)
mini-mental state exam
o is a test of the cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a three-stage command). It requires paper and pencil; the person must be able to write and have no vision impairment. The MMSE is copyrighted and available for purchase from Psychological Assessment Resources, Inc.
o is used with caution in people with low education, who may have problems copying intersecting pentagons, spelling "world" backward, or performing serial 7s. The MMSE also lacks sensitivity for mild cognitive impairment
-· Standard set of 11 questions and requires only 5-10 minutes to administer
-concentrates only on cognitive function not on mood, thought processes, or executive functions
what is the scoring of the mini-mental status exam
o The maximum score on the test is 30; people with normal mental status average 27. Scores between 24 and 30 indicate no cognitive impairment.
o Scores that occur with dementia and delirium are classified as follows: 18-23 = mild cognitive impairment; 0-7 = severe cognitive impairment.
mini-cog status exam
-cognitive impairment in otherwise healthy older adults.
- takes only 3 to 5 minutes to administer.
-is not influenced by educational level or health literacy of the patient and can be used in a variety of settings, including the hospital
-consists of a 3-item recall test and a clock-drawing test
-A score of <3 is indicative of dementia although some cognitive impairment cannot be ruled out with scores of 3, 4, or 5
-§ A person with no cognitive impairment or dementia can recall all three words and draw a complete, round, closed clock circle, with all face numbers present and in correct position and sequence and with the hour and minute hands indicating the time you requested.
developmental competence: infant and children
o "Behavioral Checklist"
-covers behavioral, cognitive, and psychosocial development and examines how the child is coping with his or her environment
-the Denver II screening test gives you a chance to interact directly with the young child to assess mental status. The Denver II is designed to detect developmental delays in infants and preschoolers within four functions: gross motor, language, fine motor-adaptive, and personal-social skills.
-listen for signs of irritability in the child (i.e., overreacting to a stimulus, leading to excitability or anger). This is expected in a child who is ill with a medical condition
developmental competence: adolescents
o follow the same A-B-C-T guidelines as described for the adult. Keep your beginning questions open ended (i.e., "How are things at school? At home? How about friends—anyone close?"). Then you can ask more specific questions: "Do you feel any extra stress or anxiety at school? At home? With friends? How about your parents—do they think you act worried or anxious?"
§ Anxiety disorders are common in the teen years and are associated with GAD, social phobia, ADHD, PTSD
developmental competence: aging adults
o Check sensory status
. Confusion is common in aging people and is easily misdiagnosed.
o can have deleterious effects after the acute episode, including increased risk of mortality, prolonged cognitive impairment (lasting up to a year), and physical impairment.
-is an acute confusional change or loss of consciousness and perceptual disturbance; it may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and it is usually resolved when the underlying cause is treated.
dementia is a gradual, progressive process, causing decreased cognitive function even though the person is fully conscious and awake; it is not reversible
documentation for normal mental status: appearance
Person's posture is erect, with no involuntary body movements. Dress and grooming are appropriate for season and setting.
documentation for normal mental status: behavior
· Person is alert, with appropriate facial expression and fluent, understandable speech. Affect and verbal responses are appropriate.
documentation for normal mental status: cognitive functions
Oriented to time, person, place. Able to attend cooperatively with examiner. Recent and remote memory intact. Can recall four unrelated words at 5-, 10-, and 30-minute testing intervals. Future plans include returning home and to local university once individual therapy is established and medication is adjusted.
documentation for normal mental status: thought processes
Perceptions and thought processes are logical and coherent. No suicidal ideation. Score on Mini-Mental State Examination is 28
what is considered low-to-moderate amounts of alcohol?
less than or equal too 2 for men and less than or equal to 1 for women
what is considered heavy drinking?
≥15 drinks per week for men and ≥8 drinks per week for women
what can heavy drinking lead too?
increases the risks for chronic diseases such as hypertension, heart disease, and stroke; the cancers listed earlier plus liver and colorectal cancer; mental illness such as depression and anxiety; learning and memory dysfunction; social issues such as family problems and unemployment; and certainly alcohol dependence or alcoholism.
alcoholism is the major cause of what disease?
how many drinks is considered binge drinking?
≥5 drinks per occasion for men and ≥4 drinks per occasion for women
what can binge drinking lead too?
increases the risk for injuries (motor vehicle accidents, falls, drownings, burns); violence (sexual assault, homicide, suicide); alcohol poisoning, which is a medical emergency; and risky sexual behaviors (unprotected sex or sex with multiple partners), which increases risk for sexually transmitted diseases and unintended pregnancy.
how does alcohol effect the cardiovascular system?
o consuming more than 1 or 2 drinks of alcohol a day is associated with hypertension.
o arterial plaque buildup; baroreceptor reflex changes; body fluid changes through the renin-angiotensin-aldosterone system; and activation of the sympathetic nervous system, which constricts blood vessels and increases contractility.
o ingestion of >2 drinks/day and especially >3 drinks/day increases the risk for all types of stroke. Heavy daily drinking (>5 drinks/day) increases the risk of heart failure and cardiomyopathy.
o Finally, alcohol drinking is positively associated with risk for atrial fibrillation (AF), the most common cardiac arrhythmia. Consuming 15 to 21 drinks/week increases the risk of AF by 14% and >21 drinks/week increases risk by 39%.
what is the diagnostic criteria for alcoholism
alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period:
(1) Alcohol is often taken in larger amounts or over a longer period than was intended.
(2) There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
(3) A great deal of time is spent in activities necessary to obtain alcohol, use it, or recover from its effects.
(4) Craving or a strong desire or urge to use alcohol.
(5) Recurrent alcohol use results in a failure to fulfill major role obligations at work, school, or home.
(6) Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
(7) Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
(8) Recurrent alcohol use in situations in which it is physically hazardous.
(9) Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
(10) Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
(b) A markedly diminished effect with continued use of the same amount of alcohol
(11) Withdrawal, as manifested by either of the following
(a) The characteristic withdrawal syndrome for alcohol
(b) Alcohol (or a closely related substance such as a benzodiazepine) taken to relieve or avoid withdrawal symptoms
who many symptoms are present with mild alcoholism?
who many symptoms are present with moderate alcoholism?
who many symptoms are present with severe alcoholism?
6 or more
developmental competence: pregnant women
· No amount of alcohol is safe for pregnant women
· No illicit drugs are safe for pregnant women
· Potential adverse consequences to fetus are well known
· All contemplating pregnancy or pregnant
o Screened for alcohol use
o Abstinence recommended
developmental competence: aging adult
o Use decreases with age
o Risks increase with age
o Liver metabolism: body water, and kidney function are decreased, which increases the bioavailability of alcohol in the blood for longer periods.
o kidney functioning decrease
o Less tissue mass: body water, and kidney function are decreased, which increases the bioavailability of alcohol in the blood for longer periods.
o Multiple medications: benzodiazepines, antidepressants, antihypertensives, pain relievers, aspirin
o Increases risk of falls
o Gastrointestinal problems
subjective data: substance abuse
-intoxicated or going through withdrawals
-· Sober, most willing and able to give reliable data
-ask about alcohol use (how many drinks they have a week/day/month)
-use of illicit substances
-advise and assist (brief intervention)
what does AUDIT questionnaire used for?
helps detect both less severe alcohol problems (hazardous and harmful drinking) and alcohol abuse and dependence disorders.
o Alcohol consumption
o Drinking behavior
o Adverse consequences
o covers three domains: alcohol consumption (questions 1 to 3); drinking behavior or dependence (questions 4 to 6); and adverse consequences from alcohol (questions 7 to 10). Record the score at the end of each line and total; the maximum total is 40.
§ A cut point of ≥8 points for men or ≥4 points for women, adolescents, and those older than 60 years indicates hazardous alcohol consumption
o Cut down- Annoyed- Guilty- Eye-opener
o works well in busy primary care settings because it takes less than 1 minute to complete and the 4 straightforward yes/no questions are easy for clinicians to remember. The CAGE tests for lifetime alcohol abuse and/or dependence but does not distinguish past problem drinking from active present drinking. It may not detect low but risky levels of drinking and is less effective with women and minority groups.
§ Answering "Yes" to ≥2 CAGE questions signals possible alcohol abuse and a need for further assessment.
o Tolerance- Worry- Eye-opener- Amnesia- Kut down
o are a combination of items of two other questionnaires that help identify at-risk drinking in women, especially pregnant women. Instead of the guilt question from the CAGE questionnaire, the TWEAK includes a question that measures tolerance:
§ Tolerance: How many drinks can you hold? Or how many drinks does it take to make you feel high?
§ Worry: Have close friends or relatives worried or complained about your drinking in the past year?
§ Eye-opener: Do you sometimes take a drink in the morning when you first get up?
§ Amnesia: Has a friend or family member ever told you about things you said or did that you could not remember?
§ Kut down: Do you sometimes feel the need to cut down on your drinking?
· Score 2 points each for Tolerance and Worry, 1 point each for the rest. A low-risk response is ≤1 point.
o Scoring ≥2 points = a drinking problem.
o 10 questions with yes/no responses
o emotional responses
o physical reactions to alcohol
o for older adults who report social or regular drinking of any amount of alcohol. Older adults have specific emotional responses and physical reactions to alcohol, and the 10 questions with yes/no responses address these factors. A low-risk response is zero or 1 point
§ Scoring ≥2 points indicates an alcohol problem and a need for more in-depth assessment.
what dose Serum protein, gamma glutamyl transferase (GGT) test for
o Chronic heavy drinking
o Nonalcoholic liver disease
what does the CBS test for?
o Mean corpuscular volume (MCV)-red blood cell size
o Can detect earlier drinking after long period of abstinence
Cognitive, social, physical, and emotional ability to carry out the normal activities of life.
what is functional ability changes across the lifespan influenced by?
o Developmental stage
§ Achievement of developmental milestones
o Physical health
o Psychosocial health
o Cognitive ability
o Social and cultural factors
what do the attributes of functional capacity include?
o The capacity to perform specific functional abilities
o The actual or required performance functional abilities
what do the antecedents of functional capacity include?
o Development of physiological process: neural, endocrine, musculoskeletal, and metabolic.
o Acquisition of developmental milestones and skills
what are some examples of risk recognition?
o Developmental abnormalities
o Trauma (physical or psychological)
o Disease (acute or chronic)
o Social and cultural factors
o Advanced age
o Cognitive function
o Mental health issues (especially depression)
o Comorbidities and socioeconomic factors
o Preclinical disability
· Recognition is essential for early identification of functional deficiencies
· Early identification of functional deficits is linked to health outcomes
· Relationship of functional ability to outcomes
· Comprehensive functional assessment is time-intensive and should be an interprofessional effort
o In children who have delays in developmental milestones
o In adults who have loss of functional ability, change in mental status, or multiple health conditions, or in frail elderly persons living in a community setting
functional assessment components
· Fall History
· Home environment
· Social participation
· The goal of care delivery is to maintain optimal independent function and prevent functional decline for health-related quality of life
o Reduce risk
o Early detection and screening
o Management of function activity impairment involving multidisciplinary interventions
· Well-balanced nutrition
· Regular physical activity
· Routine health checkups
· Stress management
· Regular participation in meaningful activity
· Fall prevention measures
· Avoidance of tobacco and other substances associated with abuse
interventions to manage functional impairment
· Requires a multidisciplinary approach
o Interprofessional collaborative practice
o Each health care discipline contributes to management but in differing roles
· Interventions depend on the underlying cause of impairment (e.g., visual, mobility, cognitive, mental health)
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