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Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: My son has been having some issues with speech and development. He's 13 years old now.
Doctor: I see. Can you tell me more about his symptoms? Does he have any issues with muscle tone ... | S: The patient's mother reports that her 13-year-old son has mild to moderate speech and developmental delays and has been diagnosed with attention deficit disorder. She denies any issues with muscle tone or hypotonia. The patient also exhibits certain physical characteristics, including retrognathia, mild hyperteloris... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, what brings you in today?
Patient: Hi, my 21-month-old son has been experiencing weakness in his lower extremities and lumbar pain after a mild upper respiratory tract infection.
Doctor: I see. Did you consult any medic... | S: The patient, a 21-month-old male, presented with weakness in his lower extremities and lumbar pain following a mild upper respiratory tract infection. Initial treatment with anti-inflammatory therapy for suspected transient hips arthritis was ineffective, leading to worsening pain and inability to walk.
O: Hip ultra... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, doctor. I came here because for the past 2 months, I've been experiencing fatigue, night sweats, weight loss, loss of appetite, and mild abdominal discomfort. I don't have fever, c... | S: Patient reports experiencing fatigue, night sweats, weight loss, loss of appetite, and mild abdominal discomfort for the past 2 months. No fever, chills, cough, nausea, vomiting, itching, or urinary or bowel issues. Past medical history includes inactive sarcoidosis, hypertension, hyperlipidemia, bipolar disorder, c... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, Patient D. How are you feeling today?
Patient D: I'm feeling fine, doc, no complaints. Just here for a regular check-up.
Doctor: That's good to hear. I see that you are a 60-year-old African American male and currently ... | S: Patient D, a 60-year-old African American male, reports no current symptoms and is visiting for a routine check-up. He has a family history significant for prostate cancer, as his 62-year-old brother was diagnosed and treated with radiation.
O: Patient is currently asymptomatic. No physical examination findings or l... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you have a history of two early miscarriages and no long-term pregnancy. Can you please tell me about any symptoms you've been experiencing?
Patient: Yeah, I've been having irregular periods and noticed some ... | S: The patient, a married woman with a 7-year history of infertility, reports irregular menstruation and excessive body hair growth. She has a history of two early miscarriages, intrauterine insemination attempts, intramural myoma myomectomy, disc hernia, and peptic ulcer. She expressed concerns about her symptoms and ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello there, I heard you've been experiencing some health concerns. Can you please tell me about your history with acromegaly and any recent symptoms you've had?
Patient: Yeah, I was admitted to the hospital because I've been ... | S: The patient, a long-term sufferer of acromegaly, reports experiencing shortness of breath and dyspnea on exertion for the past 2 years, and an episode of presyncope 2 weeks ago. The patient has been treated with octreotide for approximately 20 years and has undergone stereotactic radiosurgeries twice in the past dec... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you've been referred here for further evaluations and a possible surgical operation for pancreatic head and neck carcinoma. Can you tell me about your symptoms?
Patient: Yes, I've been suffering from abdomi... | S: The patient reports a history of abdominal pain for approximately one year, worsening over the last six months, particularly postprandial and localized to the right upper abdomen. Additionally, the patient has experienced jaundice and generalized itching for the past two months. The patient denies any history of alc... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've been referred to our hospital. Can you tell me what you've been experiencing?
Patient: Hi, I've been suffering from right ankle swelling since I was 7 years old. There's no pain and no limitation of movemen... | S: The patient, who has been experiencing right ankle swelling since age 7, reports no pain or movement limitation but finds the swelling annoying. The patient has a history of intermittent high fever and bilateral knee and right ankle swelling one month prior to admission. The patient has been managing the swelling wi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you have a past history of intestinal obstruction due to sigmoid volvulus. You underwent laparotomy and detwisting sigmoidopexy, followed by elective sigmoidectomy. Can you tell me about your current symptoms... | S: The patient, with a past history of sigmoid volvulus treated with laparotomy, detwisting sigmoidopexy, and elective sigmoidectomy, presents with symptoms starting two months ago, including abdominal distension, constipation, and vomiting lasting for three days, followed by severe abdominal pain for one day. The pati... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi, I understand that you have a past medical history of asthma. Can you tell me more about your recent experience and what brought you to the emergency department?
Patient: Well, my husband found me on the couch in the mornin... | S: The patient, with a history of asthma, was found unresponsive by her husband, who initiated CPR. She reported using a nebulizer prior to the event. The patient was in pulseless electrical activity arrest and received CPR for approximately 10 minutes before EMS arrival. She was given two doses of epinephrine and achi... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I remember you had an emergency caesarean delivery at 39 weeks due to fetal distress. How have you been since then? Any postpartum complications?
Patient: Hi, Doctor. I've been doing well since the delivery. No complica... | S: The patient, a postpartum woman with a history of emergency caesarean delivery at 39 weeks due to fetal distress, reports no postpartum complications. She is currently pregnant and has been asymptomatic throughout. She underwent saline contrast sonohysterography 6 months post-caesarean, revealing a small indentation... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I wanted to talk to you about your medical history and treatment progress. You were diagnosed with infantile-onset HPP at the age of 5 months, correct?
Patient: Yes, that's right. I had recurrent pneumonia and rib fract... | S: The patient, diagnosed with infantile-onset hypophosphatasia (HPP) at 5 months, reports a history of recurrent pneumonia, rib fractures, extremity fractures, rickets, and short stature. The patient experienced bilateral subtrochanteric femoral shaft pseudofractures in 1998 and a left tibial fragility fracture in 201... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've presented to our hospital with numbness and paralysis in your left foot. Can you tell me more about these symptoms?
Patient: Yes, I've been experiencing numbness and paralysis recently, and it's been a... | S: The patient reports experiencing recent numbness and paralysis in the left foot, significantly impacting daily activities. The patient expresses concern about the symptoms and the diagnosis provided.
O: MRI revealed a tumor mass compressing the dura mater from L2-L4. PET/CT indicated multiple nodular FDG uptakes in ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I understand you're scheduled to undergo split thickness skin grafts as part of a reconstructive program following your extensive burns from a house fire 2 years ago. Is that correct?
Patient: Yes, that's right. I wa... | S: The patient, a survivor of a house fire, suffered 93% total body surface area burns with a burn index of 85. He has undergone 39 reconstructive operations over the past 2 years, including neck reconstruction using a graft from the latissimus dorsi. He reports extensive contractures and restricted motion in his right... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 3-year-old boy who was admitted to the emergency department with severe respiratory distress. Can you tell me what symptoms you were experiencing?
Patient: Yeah, I was having a really hard time breat... | S: The patient, a 3-year-old boy, presented with severe respiratory distress and difficulty breathing. He has no past medical history of chronic diseases and no family history of lung disease or smoking. The patient was unaware of a palpable mass on the right side of his neck until it was identified during the physical... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you developed heart failure due to dilated cardiomyopathy 12 years ago. Can you tell me more about your symptoms?
Patient: Yes, doctor. My heart has been feeling weak and I've had trouble catching my breath... | S: The patient, with a history of dilated cardiomyopathy leading to heart failure, reports feeling weak and having difficulty breathing. The patient has a history of ventricular fibrillation, for which a CRT-D was implanted 7 years ago, and a HeartMate II® LVAD was implanted 4 years ago as a bridge to transplantation. ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, are you the patient from the gold mining region of the União do Norte district, Peixoto de Azevedo in northern Mato Grosso?
Patient: Yes, that's me.
Doctor: What brings you here today? What symptoms have you been experi... | S: The patient, a resident from the gold mining region of União do Norte district, Peixoto de Azevedo in northern Mato Grosso, presented with fever, headache, myalgia, chest pain, dry cough, dizziness, asthenia, dyspnea, acute respiratory failure, and back pain.
O: Laboratory tests showed hemoconcentration (47.1%), thr... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello Mrs. L., I understand you consulted our Memory Clinic in 2015 for diagnostics regarding cognitive deficits and possible dementia. Can you tell me more about the symptoms you've been experiencing?
Patient: Yes, doctor. I'... | S: Mrs. L. reports a history of progressive forgetfulness beginning approximately three months prior to her initial consultation in 2015, necessitating the use of written notes for daily tasks. She denies difficulties with spatial orientation, sleep, appetite, or motivation. Mrs. L. also experiences increasing inner re... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello there! You must be the 6-year-old patient who had teeth 74 and 84 extracted due to caries. How have you been feeling since the extractions?
Patient: Hi, doctor! Yeah, that's me. Hmm, I've been okay, but I've had some tro... | S: The 6-year-old patient reports difficulty chewing food following the extraction of teeth 74 and 84 due to caries. The patient has a history of difficulty in mastication.
O: Clinical examination and model analysis show no space loss post-extraction of teeth 74 and 84. The patient's general condition is stable.
A: The... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that you're currently 9 weeks pregnant through intracytoplasmic sperm injection (ICSI). Can you tell me about your medical history?
Patient: Yes, I had one previous pregnancy with a normal delivery. I also ... | S: The patient, a 28-week pregnant woman via intracytoplasmic sperm injection (ICSI), reports a history of one normal delivery and asthma. She has no history of blood cell transfusion or medication, except for cephem during ICSI. She is concerned about her recent diagnosis of acute macrocytic anemia.
O: Initial blood t... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been having blurred vision in my left eye for a while now.
Doctor: I see. Do you have any past medical history or trauma history related to this issue?
Patient: No, I don't ha... | S: The patient reports experiencing blurred vision in the left eye for an unspecified duration. The patient denies any relevant past medical or trauma history.
O: Initial ocular examination revealed a best corrected visual acuity (BCVA) of 0 logMAR in the right eye and Hand motion in the left eye. Intraocular pressures... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you're a 12-year-old female experiencing some persistent pain. Can you tell me more about it?
Patient: Yeah, I've been having this lower back pain and it's been going on for like 4 months. It also feels lik... | S: A 12-year-old female patient reports persistent lower back pain radiating down both legs for approximately 4 months.
O: MRI of the lumbar spine showed an enhancing intradural, extramedullary lesion with adjacent dura thickening at L2. Post-surgical histology confirmed mesenchymal chondrosarcoma, characterized by ro... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've been referred to our Paediatric Endocrinology Center due to short stature. Can you tell me a bit about your family's medical history?
Patient: Yes, I'm the first son of two children. I have a healthy s... | S: The patient, a young male, presents with concerns about short stature. He reports a history of aortic coarctation correction at age 5 and ongoing treatment for arterial hypertension with enalapril. His familial target height is on the 3rd to 10th percentile. He describes his growth as initially within the 10th to 25... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I'm your doctor. I understand you have no history of disease or medication. Can you tell me more about your lifestyle, such as your weight, smoking, and alcohol habits?
Patient: Hi, Doctor. Well, I'm slightly obese, and... | S: The patient, a current smoker with over 50 pack-years and moderate alcohol consumption, presented with sudden onset hemoptysis and headache. He has a history of hypertension diagnosed at a regional hospital where his systolic blood pressure was recorded at 240 mmHg and diastolic at 110 mmHg. He reports being slightl... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see you've presented with a one-month history of chest pain. Have you had any recent surgery or trauma that might be related to this?
Patient: No, there's been no surgery or trauma.
Doctor: Alright, let's start by per... | S: The patient presented with a one-month history of chest pain. No recent surgery or trauma was reported. The patient experienced episodes of hypotension and a severe episode of hemorrhagic shock and cardiac arrest postoperatively.
O: A thoracic CT scan revealed an ovoid soft tissue mass in the left posterior costophr... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, doctor. I've been having some pain in the back of my chest after I slipped on ice.
Doctor: I'm sorry to hear that. Have you had any prior risk factors for coronary artery disease?
... | S: The patient, a previously healthy individual, presented with pain in the back of the chest following a slip on ice. Two weeks post-initial evaluation, the patient reported new symptoms of dyspnea and dizziness.
O: Initial tests showed a hemoglobin level of 8.7 g/dL and a CT scan revealed a splenic hematoma. EKG and ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I heard you were referred for a second opinion regarding your son's polyuria and polydipsia. Can you tell me more about the symptoms he's been experiencing?
Patient's mother: Sure, it started suddenly about four months ... | S: The patient, a young child, presented with symptoms of polyuria and polydipsia, consuming 3-4 liters of water daily and experiencing frequent heavy wet diapers. Symptoms started suddenly four months ago. The patient also shows decreased appetite and a recent weight loss of 1 pound. There is no prior or family histor... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that your 3-year-old boy presented to another hospital with a 5-day history of respiratory distress and retching. Can you tell me more about his symptoms?
Parent: Yes, he was struggling to breathe and kept retchin... | S: The patient, a 3-year-old boy, presented with a 5-day history of respiratory distress and retching. The parent reported that the child was struggling to breathe and was visibly distressed.
O: Initial chest X-ray revealed a left-sided tension pneumothorax with mediastinal shift and suspected bowel loops in the left l... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there! I see that you are a 52-year-old female with no significant past medical history. What brings you here today?
Patient: Hi, Doctor. I've been experiencing some left lower quadrant abdominal pain lately.
Doctor: I'm so... | S: A 52-year-old female presents with left lower quadrant abdominal pain. She has no significant past medical history and no family history of gastrointestinal or ovarian cancer. Her brother had lung cancer, her paternal grandmother had bilateral synchronous breast cancer, and her grandfather had prostate cancer.
O: Ph... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi, I see that you've been referred to our department because of several weeks of symptoms like chills, fever, malaise, fatigue, and recurrent tumble despite antibiotic therapy. Can you tell me more about it?
Patient: Yes, I w... | S: The patient reports persistent symptoms of chills, fever, malaise, fatigue, and recurrent tumble despite antibiotic therapy. The patient had a gastrectomy, lymphadenectomy, and esophageal stent placement three months ago due to gastric carcinoma. The patient was previously treated with amoxicillin and later switched... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were diagnosed with SLE three years ago. Can you tell me about the symptoms you've experienced so far?
Patient: Yeah, I've had skin lesions, alopecia, and my tests showed I was ANA positive.
Doctor: I see... | S: The patient, diagnosed with Systemic Lupus Erythematosus (SLE) three years ago, reports experiencing skin lesions, alopecia, and being ANA positive. Recently, the patient was admitted for lupus nephritis, presenting with nephrotic range proteinuria, dysmorphic hematuria, and a positive direct Coombs test. Subsequent... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you were admitted to the hospital on December 2, 2020, due to being anxious and easily frightened for 3 months, with psychomotor retardation and urinary incontinence for half a month. Can you tell me more abo... | S: The patient, a 34-year-old female, reports persistent anxiety and fearfulness without a clear trigger, lasting for 3 months. She describes increased sensitivity, crying episodes, and a fear of leaving the house. Additionally, she mentions psychomotor retardation and urinary incontinence starting half a month ago. Sh... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi there, I'm Dr. Smith. I understand your 8-month-old female infant had a coronary reimplantation at age 3 months for ALCAPA. How has she been since the surgery?
Patient's parent: She seemed to be doing better at first, but l... | S: The patient, an 8-month-old female infant, had a coronary reimplantation at 3 months for ALCAPA. Recently, she has been experiencing trouble breathing and poor growth. The parent reports initial improvement post-surgery, but deterioration in symptoms lately.
O: Physical examination indicates congestive heart failure... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand you are a 42-year-old nulliparous woman with a history of infertility and recurrent catamenial pneumothorax. You've been referred to our emergency department due to right-sided chest pain and mild dyspnea w... | S: The patient is a 42-year-old nulliparous woman presenting with right-sided chest pain and mild dyspnea, which started within 48 hours of the onset of her menses. She reports a history of recurrent catamenial pneumothorax, with two previous episodes, the last occurring six months ago. She denies any history of endome... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've been admitted with a seven-day history of persistent fever and chills, along with painful swelling of the right shoulder and pharyngitis. Can you tell me more about that?
Patient: Yes, I've had these s... | S: Patient presents with a seven-day history of persistent fever and chills, painful swelling of the right shoulder, and pharyngitis. Reports discomfort and pain associated with these symptoms. Denies recent dental treatment, surgery, or drug abuse. No significant past cardiac history.
O: Vital signs include blood pres... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you've been referred to our clinic for further management after having a Whipple procedure done elsewhere for chronic pancreatitis. Can you tell me about your symptoms?
Patient: Yes, I have been experiencing ... | S: The patient reports intermittent severe epigastric pain radiating to the back, affecting daily activities. History of chronic pancreatitis and a recent Whipple procedure with findings of multifocal PanIN-3 and high-grade dysplasia, but negative surgical margins. The patient has a history of chronic narcotic dependen... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I came to your institution because I have this nevus on my left lumbosacral region. It's been there since I was born, but about a year ago, this new lesion appeared on top of it an... | S: The patient reports a rapidly growing lesion on top of a congenital nevus in the left lumbosacral region, present since birth but changed about a year ago. The lesion has changed color, exhibits irregular edges, sometimes bleeds, and causes pain.
O: Physical examination revealed a 6 x 4-cm erythematous tumor with ac... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that your 3.5-year-old daughter was referred to us due to her gait impairment and microcephalus. Can you tell me more about her current symptoms?
Parent: Yes, she recently had an episode where she seemed di... | S: The patient, a 3.5-year-old female, was referred for gait impairment and microcephalus. The parent reports a recent episode of disconnection from the environment, a history of isolated febrile convulsions, sleep disorders, and developmental delays primarily in motor skills. The child also exhibits behavior problems ... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, I've been experiencing blurred visual acuity and photopsias in one eye for the past few days.
Doctor: I see. Were there any symptoms before this visual issue started?
Patient: Yeah... | S: The patient reports experiencing blurred visual acuity and photopsias in one eye for the past few days, preceded by flu-like symptoms including fever and headache. The patient denies any significant medical history or recent contact with animals.
O: The patient's complete blood count (CBC) and chest and sinus X-rays... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, how can I help you today?
Patient: Hi, doctor. I'm here because I had an abdominal ultrasound for cancer screening. They found something and referred me to your hospital for examination.
Doctor: I see. Did you have any ... | S: The patient, who underwent an abdominal ultrasound for routine cancer screening without any prior symptoms, was referred for further evaluation after the discovery of a hypoechoic mass in the retroperitoneal space. The patient reports no specific complaints or symptoms prior to the ultrasound.
O: The ultrasound repo... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I understand that you have been referred to our department for a renal angiogram due to your uncontrolled hypertension despite receiving medications for the past 8 months. Can you tell me about the symptoms that led to ... | S: The patient reports severe headaches and fatigue as symptoms leading to referral for a renal angiogram due to uncontrolled hypertension despite 8 months of antihypertensive medication. The patient denies any history of smoking, alcohol consumption, diabetes, or atherosclerosis, and has no family history of these con... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hi, I'm Dr. Smith. It seems that you, your mother, and your sibling have presented with some abnormal fusions of joints. Can you describe the issues with your hands and feet?
Patient: Sure, doc. On my fingers, both my thumbs a... | S: The patient reports inability to flex fingers except for the thumbs, which are normal. Similar issues are noted in the toes, with the big toes being normal but other toes lacking creases and flexibility. The second toes on both feet are described as slightly short. The patient's elbows function normally, allowing he... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I see that you're a 19-year-old Hispanic female with a past medical history of acne, asthma, and extensive psychosocial distress but no psychiatric diagnoses. What brings you in today?
Patient: Hi, I've been having some... | S: 19-year-old Hispanic female with a history of acne, asthma, and psychosocial distress presents with recurrent episodes of lightheadedness, weakness, diaphoresis, diarrhea, and vomiting. Reports using a blood glucose monitor during episodes, with readings as low as 53 mg/dL, improving to 80 mg/dL after eating. Denies... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Hello, I'm Dr. Smith. How can I help you today?
Patient's Mother: Hi, Doctor. This is my 5-year-old son. He was born at full term, but he had a history of hypoxia after birth. Recently, he's been having developmental delays an... | S: The patient is a 5-year-old male with a history of hypoxia at birth, presenting with developmental delays and sleep disturbances. The mother reports recent findings of elevated GHB levels from a urinary organic acid analysis.
O: Genetic testing revealed a novel homozygous mutation c.800 T > G (p.V267G) in exon 5, in... |
Please convert the following medical transcript into a medical SOAP note. Transcript: Doctor: Good morning, I'm Dr. Smith. Can you tell me about your medical history?
Patient: Yes, I have poorly controlled diabetes.
Doctor: I see. What brings you to the emergency room today?
Patient: I was transported here because I st... | S: The patient, with a history of poorly controlled diabetes, presented to the emergency room with vomiting blood and disorientation. He also reported experiencing nausea and epigastralgia for the past 2 days.
O: Upon examination, the patient was in shock with concerning vital signs and did not respond well to rehydrat... |
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