Respiratory

system

Haitham N.Khalid

22/12/2020 Dr. Haitham Nabeel

 Thank you for not
sharing this
presentation

22/12/2020 Dr. Haitham Nabeel 2

OSCE stuff!
• The orders are :
A-percuss and auscultate the chest anteriorly
B-percuss and auscultate the chest posteriorly
• Percussion will test your technique and practice and
auscultation will reveal the finding.
• Examination of chest in general involves (inspection ,
palpation , percussion and auscultation)

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• Examination of respiratory system involves general
examination + chest examination
• DONOT do general examination in OSCE stations
• A mannequin with X-ray picture may be an alternative.

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 General
examination

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General examination
1-HANDS
A-clubbing :
Bronchial CA, mesothelioma
bronchiectasis , lung abscess, empyema, cystic
fibrosis
fibrosing alveolitis
NOT COPD , TB
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B-tar staining of fingers
C-yellow nail syndrome → exudative pleural effusion
D- tremors
Fine tremor : beta agonists
Flapping tremor : respiratory failure with CO2 retention.
What do you expect the pulse to be in a patient with
respiratory failure, large or small volume? Why?
Large volume, CO2 retention
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2-FACE
A-Horner syndrome:
Ipsilateral partial ptosis, miosis, anhidrosis.
Mostly due to invasion of sympathetic plexus by an apical
lung neoplasm (pancoast tumor).
Why ptosis in horner syndrome is partial?

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B-cyanosis
Central cyanosis especially in COPD and pulmonary
fibrosis.
3-NECK
A-JVP:
Raised chronically in PH as in COPD, ILD.
Raised acutley in tension pneumothorax, pulmonary
embolism, acute severe asthma.
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• SVC obstruction (thymoma, lymphoma, mediastinal
fibrosis and thrmbosis) causes an elevated non-pulsatile
JVP.
B-lymph nodes
Enlargement of scalene lymph node may be the first
evidence of metastatic lung cancer.

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4-Respiration
A-rate
Normal rate 12-18
Tachypnea if > 20
Tachypnea : any respiratory and some non-respiratory
problems.
Bradypnea: opioids, ↑ICP, hypercapnea, hypothyroidism

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B-depth :
Shallow: pain , pneumonia
Deep: metablic acidosis
C-character
Acidotic link : https://youtu.be/ebgxcj3eJLA
Cheyne-stokes Apneustic Ataxic

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D-Type :
Abdominothoracic
Thoracoabdominal
Exclusively thoracic (paradoxical)
Exclusively abdominal
E-use of accessory muscles
Characteristic of COPD patients with hyperinflated chest.

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F-noisy respiration:
Wheezes
Stridor
Hoarsness
G-accessories :
Oxygen device Face mask Non-rebreather
Venturi mask Nasal cannula CPAP
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 Examination
of chest

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Examination of chest
• Involves inspection, palpation, percussion and
auscultation.
• The order in an OSCE station will usually involve
percussion and auscultation.
• Percussion will reveal your practice.
• Auscultation will reveal the findings.
• Most common cases are asthma, copd, pulmonary
fibrosis, pneumonia, bronchiectasis, pulmonary edema.

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Inspection
1-shape
Barrel shaped chest: COPD
Pectum carinatum: severe asthma in childhood
Pectus excavatum: developmental, trauma.
2-symmetry
Symmetrical
Asymmetrical : bulging or retraction.

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3-chest movement (expansion)
Symmetrical
Asymmetrical : pathology is usually here.
4-Scars
Median sternotomy
Lateral

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5-dilated veins
SVC obstruction
6-skin lesions
Nodules
Herpes zoster

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Palpation
1-position of trachea
Normally central or slightly deviated to right
Pull the trachea Push the trachea
collapse pneumothorax
fibrosis Pleural effusion
Pneumonectomy Upper mediastinal
tumor
1-Reduction of cricosternal distance (normally 3-4
fingerbreadths) is a sign of lung hyperinflation.
2-trachea tug (fingers resting on trachea move inferiorly with
inspiration) suggest severe hyperinflation.
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2-Apex beat
Same applies here.
What causes displacement of apex beat without
displacement of trachea in a patient with normal left
ventricle?
Kyphoscolisosis, pectus excavatum.

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3-chest expansion
Qualitative : by your hands
Quantitative : by tape measure
Normal is 4-7.5 cm
If diminished on one side → pathology on that side :
effusion, collapse, pneumothorax, fibrosis,.
If diminished bilaterally : COPD, diffuse fibrosis

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Percussion
Resonant : normal
Hyperresonant : pneumothorax, emphysema
Dull : consolidation, collapse, fibrosis.
Stony dull : pleural effusion
Tympanic?

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 Percussion anteriorly and laterally in anterior exam
Percussion posteriorly and laterally in posterior exam.
Percuss over clavicles directly
Apex should always be percussed also.

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AR 1
• The most important technique when
progressing from one auscultory site on the
thorax to another is:
(A) Top-to-bottom comparison
(B) Side-to-side comparison
(C) Posterior-to-anterior comparison
(D) Interspace-by-interspace comparison
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AR 1
• The most important technique when
progressing from one auscultory site on the
thorax to another is:
(A) Top-to-bottom comparison
(B) Side-to-side comparison
(C) Posterior-to-anterior comparison
(D) Interspace-by-interspace comparison
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Auscultation
Four observations must be made at each point of
auscultation:
1-intensity of breath sounds
2-character of breath sounds
3-added sounds
4-vocal resonance
Common pitfall: presenting the additional sounds first.

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Intensity
Should be compared bilaterally
Should involve upper, middle and lower zones.
Good or poor or diminshed air entry?
Common examples:
Good bilateral air entry
Poor bilateral air entry (copd)
diminished air entry in right lower zone (pleural
effusion)
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• Common causes of diminished breathing sounds:
pleural effusion
COPD
Pneumothorax
Collapse with obstructed bronchus
Fibrosis
Thick chest wall

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Character
Vesicular breathing sound Bronchial breathing sound
No gap between inspiration and There is a gap between them. BUT
expiration reliance on gap alone leads to mistakes.
Inspiration 2/3, expiration 1/3 Inspiration1/2, expiration 1/2
Inspiration is more harsh Expiration is more harsh
Heard normally over lung Heard normally over trachea
Common pathologies that lead to
bronchial breathing :
1-consolidation
2-collapse with patent bronchus
3-over pleural effusion
https://youtu.be/VtnMRG0ORLs https://youtu.be/WfkWMfE9VTY

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Added sounds
1-wheezes
Best heard in expiration
Due to narrowing of bronchi
Widespread polyphonic: asthma, COPD
Localized monophonic: tumor or foreign body
What is difference between wheezes and rhonchi ?
Link: https://youtu.be/T4qNgi4Vrvo

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2-Crackles (crepitations)
Opening of peripheral airways Vs. bubbling in large
airways.
Coarse crackles : https://youtu.be/aSor2XBc9K8
Fine crackles : https://youtu.be/LHqqvrm2j6g

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3-pleural friction rub
Due to pleurisy that is caused by pneumonia or
infarction.
How can you differentiate pleural rub from pericardial
rub?
Tell the patient to stop breathing
Link : https://youtu.be/KRtAqeEGq2Q?t=132

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4-Vocal resonance :
As auscultation with repeating the phrase ‫اربعة واربعين‬
Causes of increased vocal resonance: consolidation and collapse
with patent bronchus.
Causes of decreased vocal resonance: pleural effusion,
pneumothorax, collapse with obstructed bronchus.
Whispering pectoriloquy?
Aegophony?
Link for aegophony: https://youtu.be/5RqrBf242mk
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EBM

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AR 2
• To rule out a middle lobe pneumonia, you
must make sure to auscultate:
(A) Beneath the right breast
(B) Beneath the left breast
(C) Under the right axilla
(D) Under the left axilla

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AR 2
• To rule out a middle lobe pneumonia, you
must make sure to auscultate:
(A) Beneath the right breast
(B) Beneath the left breast
(C) Under the right axilla
(D) Under the left axilla

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AR 3
• Which of the following features is in favor of coarse
rather than fine crepitation?
A. If you ask the patient to cough, the crepitation would
disappear.
B. Idiopathic pulmonary fibrosis is a possible cause
particularly if it is associated with finger clubbing
C. Paroxysmal nocturnal dyspnea is an important
presentation
D. The patient is not febrile
E. It is like bubbling in thin fluid
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AR 3
• Which of the following features is in favor of coarse
rather than fine crepitation?
A. If you ask the patient to cough, the crepitation would
disappear.
B. Idiopathic pulmonary fibrosis is a possible cause
particularly if it is associated with finger clubbing
C. Paroxysmal nocturnal dyspnea is an important
presentation
D. The patient is not febrile
E. It is like bubbling in thin fluid
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 Lung
pathologies

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AR 4
• A patient with right middle lobe pneumonia (
consolidation) will have the following EXCEPT:
A. dullness on percussion.
B. reduced expansion of the lung.
C. reduced focal fremitus.
D. bronchial breath sound.
E. increased vocal resonance.

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AR 4
• A patient with right middle lobe pneumonia (
consolidation) will have the following EXCEPT:
A. dullness on percussion.
B. reduced expansion of the lung.
C. reduced focal fremitus.
D. bronchial breath sound.
E. increased vocal resonance.

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Lung pathologies
• Common lung pathologies are :
1-pleural effusion
2-consolidation
3-collapse
4-pneumothorax

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Pleural effusion

Inspection ↓ chest movement

Palpation Trachea pushed to other side
Reduced chest expansion
Percussion Stony dullness
Auscultation Breathing sound reduced or absent
Vocal resonance reduced or absent

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Consolidation

Inspection ↓ chest movement

Palpation Trachea same position
Percussion Normal or dull
Auscultation Bronchial breathing sound
Vocal resonance increased
Aegophony and whispering pectorilquoy
Pleural friction rub
Crepitations in resolution phase

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 Collapse

collapse With patent bronchus With obstructed

bronchus
Inspection Reduced chest expansion Reduced chest expansion
Palpation Trachea shifted to lesion Trachea shifted to lesion
percussion Dull dull

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 Pneumothorax

Inspection ↓ chest movement

Bulging of affected side
Palpation Trachea pushed to other side
Reduced chest expansion
Percussion Hyperresonance
Auscultation Breathing sound reduced or absent
Vocal resonance reduced or absent
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Quiz
A patient with diminished breathing sounds on right
side, diminshed vocal resonance and trachea shifted to
left, what will you examine to distinguish pneumothorax
from pleural effusion?
Percussion
A patient with dull percussion note, bronchial breathing
and increased vocal resonance. How to distinguish
collapse from consolidation?
Tracheal position
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AR 5
• The patient has an undiagnosed tumor in the
middle lobe of the right lung, causing atelectasis,
as suggested by
(A) Low-pitched grating sound heard during
inspiration and expiration
(B) Hyperresonance in the right middle lobe
(C) Diminished or absent breath sounds in the
right middle lobe
(D) An ammonia-like odor on the patient’s breath
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AR 5
• The patient has an undiagnosed tumor in the
middle lobe of the right lung, causing atelectasis,
as suggested by
(A) Low-pitched grating sound heard during
inspiration and expiration
(B) Hyperresonance in the right middle lobe
(C) Diminished or absent breath sounds in the
right middle lobe
(D) An ammonia-like odor on the patient’s breath
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AR 6
• A patient presents with an area of dullness to
percussion and breath sounds that are
decreased to absent, suggesting the following
diagnosis:
(A) Pneumothorax
(B) Asthma
(C) Pleural effusion
(D) COPD (emphysema
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AR 6
• A patient presents with an area of dullness to
percussion and breath sounds that are
decreased to absent, suggesting the following
diagnosis:
(A) Pneumothorax
(B) Asthma
(C) Pleural effusion
(D) COPD (emphysema
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 Common
Respiratory
conditions

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Common respiratory conditions
• Common respiratory conditions during OSCE exam are:
1-Asthma
2-COPD
3-pulmonary fibrosis
4-pneumonia

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Asthma
Face Agitated or drowsiness
Central cyanosis
pulse rapid
Chest Intercostal recession
Hyperinflated chest
Wheezes
Link for a presentation https://youtu.be/7oTfvJff7go

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COPD
Face Plethoric , why?
Central cyanosis
Tripod position
Neck Accessory muscles
JVP elevated
Hands Tar staining
legs Ankle swelling?
Chest Barrel chest
Diminished breathing sounds
wheezes
Link for a presentation https://youtu.be/f5ydW0hnMcg
https://youtu.be/KRtAqeEGq2Q?t=111

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Pulmonary fibrosis
Face Central cyanosis
hands clubbing
Legs Ankle swelling
chest Reduced chest expansion
fine late inspiratory crackles
Link https://youtu.be/KRtAqeEGq2Q?t=70

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Pneumonia
General Fever
Confused
Tachycardia
tachypnea
Face cyanosis
chest Signs of consolidation
https://youtu.be/KRtAqeEGq2Q?t=70 Link

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AR 7
• A 60 year old heavy smoker man presented
with sudden onset of shortness of breath
and right sided chest pain. On examination
of the chest you expect to find:

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AR 7
A. Limited chest examination, hyper-resonant percussion note and
diminished breathing sounds and vocal resonance with expiratory
wheezes on both sides
B. Limited chest examination, dull percussion note, bronchial
breathing sounds and increased vocal resonance on both sides
C. Limited chest examination, dull percussion note and diminished
breathing sounds and vocal resonance on the right side
D. Limited chest examination, hyper-resonant percussion note and
diminished breathing sounds and vocal resonance on the right side
E. Limited chest examination, dull percussion note, bronchial
breathing sounds and increased vocal resonance on the right side

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AR 7
A. Limited chest examination, hyper-resonant percussion note and
diminished breathing sounds and vocal resonance with expiratory
wheezes on both sides
B. Limited chest examination, dull percussion note, bronchial
breathing sounds and increased vocal resonance on both sides
C. Limited chest examination, dull percussion note and diminished
breathing sounds and vocal resonance on the right side
D. Limited chest examination, hyper-resonant percussion note and
diminished breathing sounds and vocal resonance on the right side
E. Limited chest examination, dull percussion note, bronchial
breathing sounds and increased vocal resonance on the right side

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AR 8
• A 55 year old heavy smoker man presented
with gradually increasing shortness of breath
over the last 5 years and he is now dyspneic
on minimal exertion. On examination of the
chest you expect to find:

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AR 8
A. Normal chest expansion, dull percussion note and bronchial
breathing sounds bilaterally
B. Reduced chest expansion, dull percussion note and bronchial
breathing sounds on the left side of the chest
C. Reduced chest expansion, dull percussion note and bronchial
breathing sounds on the right side of the chest
D. Reduced chest expansion, hyperresonant percussion note and
diminished breathing sounds with prolonged expiratory phase
bilaterally
E. Reduced chest expansion, hyperresonant percussion note and
diminished breathing sounds on the right side of the chest

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AR 8
A. Normal chest expansion, dull percussion note and bronchial
breathing sounds bilaterally
B. Reduced chest expansion, dull percussion note and bronchial
breathing sounds on the left side of the chest
C. Reduced chest expansion, dull percussion note and bronchial
breathing sounds on the right side of the chest
D. Reduced chest expansion, hyperresonant percussion note and
diminished breathing sounds with prolonged expiratory phase
bilaterally
E. Reduced chest expansion, hyperresonant percussion note and
diminished breathing sounds on the right side of the chest

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Case scenario
• Examination of the anterior chest of this patient had shown barrel-shaped chest
with increased anteroposterior diameter, symmetrical reduction in expansion;
no abnormal heard sounds, dyspnoea and tachypnea with pursed lip breathing
and use of accessory muscles of respiration and drawing in of the lower
intercostal muscles with inspiration. The apex beat was difficult to be localised;
no palpable axillary lymph nodes; the trachea is centrally located with tracheal
tug; symmetrical reduction in vocal fremitus and chest expansion which was
limited to two cm difference between inspiration and expiration. The percussion
notes were hyper-resonant over anterior chest and both axillae with reduction
in both cardiac and liver dullness. There was poor air entry bilaterally; vesicular
breathing with prolonged expiratory phase; coarse late inspiratory crackles over
all the lung tissues, and symmetrically reduced vocal resonance

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Case scenario
• Examination of the anterior chest of this patient had shown barrel-shaped chest
with increased anteroposterior diameter, symmetrical reduction in expansion;
no abnormal heard sounds, dyspnoea and tachypnea with pursed lip breathing
and use of accessory muscles of respiration and drawing in of the lower
intercostal muscles with inspiration. The apex beat was difficult to be localised;
no palpable axillary lymph nodes; the trachea is centrally located with tracheal
tug; symmetrical reduction in vocal fremitus and chest expansion which was
limited to two cm difference between inspiration and expiration. The percussion
notes were hyper-resonant over anterior chest and both axillae with reduction
in both cardiac and liver dullness. There was poor air entry bilaterally; vesicular
breathing with prolonged expiratory phase; coarse late inspiratory crackles over
all the lung tissues, and symmetrically reduced vocal resonance

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Case Scenario
• Examination of the anterior chest of this patient had shown elliptical
chest shape with reduction in the expansion of the right side; no
heard sounds but there were dyspnoea and tachypnea. The apex beat
was localised to the left fifth intercostal space slightly medial to the
midclavicular line; no palpable axillary lymph nodes; the trachea is
centrally located with no tracheal tug; vocal fremitus was
asymmetrical and increased in the right middle and lower zone; chest
expansion was reduced on the right side. The percussion notes were
resonant over the left side of the chest apart from cardiac dullness
but the notes were dull in the right middle and lower zones and right
axilla. There was good air entry with vesicular breathing heard over
the left side but bronchial breathing over the right middle and lower
zones with egophony and pectoriloquy; late inspiratory crackles are
also heard over the right side of the chest. The vocal resonance was
asymmetrical and increased over the right side of the chest.

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Case Scenario
• Examination of the anterior chest of this patient had shown elliptical
chest shape with reduction in the expansion of the right side; no
heard sounds but there were dyspnoea and tachypnea. The apex beat
was localised to the left fifth intercostal space slightly medial to the
midclavicular line; no palpable axillary lymph nodes; the trachea is
centrally located with no tracheal tug; vocal fremitus was
asymmetrical and increased in the right middle and lower zone; chest
expansion was reduced on the right side. The percussion notes were
resonant over the left side of the chest apart from cardiac dullness
but the notes were dull in the right middle and lower zones and right
axilla. There was good air entry with vesicular breathing heard over
the left side but bronchial breathing over the right middle and lower
zones with egophony and pectoriloquy; late inspiratory crackles are
also heard over the right side of the chest. The vocal resonance was
asymmetrical and increased over the right side of the chest.

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Thank You!
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