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 Raymond E. Phillips

The Physical Exam

An Innovative Approach
in the Age of Imaging

123
The Physical Exam
Raymond E. Phillips

The Physical Exam

An Innovative Approach in the Age
of Imaging
Raymond E. Phillips, MD, FACP
Department of Medicine
Westchester Medical Center
New York Medical College
Kent Lakes, New York
USA

ISBN 978-3-319-63846-1    ISBN 978-3-319-63847-8 (eBook)

https://doi.org/10.1007/978-3-319-63847-8

Library of Congress Control Number: 2017959570

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
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Printed on acid-free paper

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Preface

This book invites the clinician to take a fresh look at the “routine” physical
examination. The approach taken here is intended for those who have already
learned the fundamentals and are interested in adapting a more efficient
approach to this time-honored discipline. While technological advances pro-
vide astonishing diagnostic information even in the most remote parts of the
body, they have not diminished the value of a careful “hands-on”
examination.
To modernize the physical examination, the clinician can adopt a system-
atic sequence and focus that may prove more productive than the methods
taught in the pre-imaging era. At the same time, the regional approach devel-
oped here – rather than the serial (head-to-foot) approach – provides a keen
opportunity to observe the astonishing interactions of anatomy and physiol-
ogy. These interactions, furthermore, are sometimes the basis for symptoms
that can be challenging diagnostically. For just such situations, an insightful
physical examination can reveal relevant information that is beyond the scope
of the digital image.
Presented here is a step-by-step sequence of the physical examination,
mindful of the balance between being comprehensive and rapid while at the
same time stressing accuracy. This approach emphasizes the signs that reveal
how well an organ system is functioning and helps to sort out interrelated
problems. Abnormal findings are organized descriptively and presented in
regions where they are most likely to appear. With continued applications of
these guidelines, the clinician will gain further confidence in the direct assess-
ment of a patient. These skills, applied efficiently, are considered a critical
supplement to imaging, not as an obsolete procedure required for medical
records. Indeed, the severity of an organ failure, its interrelationship with
other organs, and the identification of coexisting problems are within the spe-
cial realm of the physical examination. It is hoped that this approach to the
routine physical examination will help the clinician achieve this balance
while, at the same time, adding to the satisfaction of practicing medicine.
Here, I am honored to acknowledge those who have reviewed portions of
this manuscript and contributed to its development. These are Kristina
H. Petersen, PhD (biochemistry); Daniel C. Doyle, DMD (mouth); John
L. Phillips, MD, FACS (genitourinary system, abdomen); and Giang Nguyen,
DPM (podiatry). Joanie G. Sheeran, PhD, meticulously reviewed the entire
script for matters of language. Wendy P. Kahn, MEd, provided special guid-
ance in writing some of the more challenging sections. There is no way to

v
vi Preface

thank individually the hundreds of residents, other healthcare professionals,

and medical students with whom I have had the privilege of working over the
years and who have shared in the concepts and details that serve as the sub-
stance of this book.
The majority of illustrations in this book were drawn by Paul E. Kmiotek.
Figures of the shoulder and various hernias are those of Alex Bievenour.
Sophie D. Phillips contributed illustrations of lesions that affect the face. In
addition, the W. B. Saunders Company kindly released other images from my
authored books in cardiology and vascular medicine. The staff experts at the
computer center of Mahopac Library were graciously helpful throughout the
preparation of this book. The Health Science Library at New York Medical
College has been an invaluable resource since its beginning.
I must also express my appreciation to Michael F. Griffin, the develop-
mental editor of Springer Medicine, for his keen attention to the details in this
production. Richard Lansing, editorial director of Clinical Medicine at
Springer, provided early encouragement that continued along the way.

Kent Lakes, NY, USA R.E. Phillips

Contents

Part I Patient Sitting, Facing Examiner

1 Introduction������������������������������������������������������������������������������������    3
2 First Impression ����������������������������������������������������������������������������    9
3 Hand������������������������������������������������������������������������������������������������   11
4 Wrist������������������������������������������������������������������������������������������������   33
5 The One-Minute Physical Examination��������������������������������������   37
6 Forearm������������������������������������������������������������������������������������������   39
7 Elbow����������������������������������������������������������������������������������������������   43
8 Vital Signs ��������������������������������������������������������������������������������������   47
9 Shoulder������������������������������������������������������������������������������������������   59
10 Neck������������������������������������������������������������������������������������������������   67
11 Face��������������������������������������������������������������������������������������������������   73
12 Eye ��������������������������������������������������������������������������������������������������   97
13 Ear �������������������������������������������������������������������������������������������������� 119
14 Nose ������������������������������������������������������������������������������������������������ 127
15 Mouth���������������������������������������������������������������������������������������������� 133
16 The One-Minute Cranial Nerve Examination���������������������������� 143

Part II Patient Sitting with Legs on Table at 90° from Examiner

17 Chest������������������������������������������������������������������������������������������������ 149
18 Heart������������������������������������������������������������������������������������������������ 159

vii
viii Contents

Part III Patient Lying in 30°, Semi-supine Position

19 Neck: Semi-supine�������������������������������������������������������������������������� 171

20 Abdomen���������������������������������������������������������������������������������������� 179
21 Leg: Supine Position���������������������������������������������������������������������� 201

Part IV Patient Sitting, Again Facing Examiner

22 Leg: Sitting Position���������������������������������������������������������������������� 207

23 Knee������������������������������������������������������������������������������������������������ 227
24 Foot�������������������������������������������������������������������������������������������������� 237

Part V Patient Standing

25 Standing������������������������������������������������������������������������������������������ 247
26 Gait�������������������������������������������������������������������������������������������������� 259

Part VI Male Standing, Female Supine

27 Genitourinary System�������������������������������������������������������������������� 269

Part VII The Diabetic Foot

28 Appendix: The Clinician’s Guide to Examination

of the Diabetic Foot������������������������������������������������������������������������ 287

Index�������������������������������������������������������������������������������������������������������� 319
 Part I
Patient Sitting, Facing Examiner
 Introduction
1

The physical examination continues to be a core reliably define diseases. The incorporation of lab-
skill of the clinician. At a time of overuse of and oratory blood studies, the x-ray, and the electro-
overreliance on technological advances and on cardiogram so rapidly filled in the diagnostic
the checklist culture of the electronic medical uncertainty that they – to some extent – super-
record, there remains an essential medical and seded the laying on of “educated” hands and ears.
medicolegal value in the efficient bedside patient Now in the early twenty-first century, clinicians
examination. The sequence and highlights of the enjoy the additional diagnostic perspective of
guidelines presented here emphasize a systematic highly detailed imaging, serology, cytology, and
approach that is thorough, rapid, and – to a rea- laparoscopy. These advances have proven so
sonable extent – precise. They are meant for colossal that we have come to depend upon them
healthcare professionals who have accomplished for decision-making, sometimes to a fault.
the basic principles of the physical examination The CT scan, MRI, organ system function
(Fig. 1.1). testing, and serological analyses – however
Physicians in the later nineteenth and early spectacular and refined – cannot tell us all of the
twentieth centuries became highly skilled in diag- most critical information in a patient’s evalua-
nostic acumen on the physical examination, the tion. Fundamentally, they do not reveal how sick
only method to obtain objective pathophysiologi- a patient is! Evaluating abnormalities in skin
cal information on their patient. The percussion of color and texture, pulsatile vascular dynamics,
the chest and their description of cardiac murmurs mobility, sensations, and language, to name a
became an art form; conclusions based on occult few, are still important. These observations are
findings attained a kind of prestige among peers within the realm of the physical examination.
and learners. Yet, even that skill level could not Overlooking such signs in the initial encounter

Fig. 1.1 Seesaw (Image courtesy Paul. E. Kmiotek)

© Springer International Publishing AG 2018 3

R.E. Phillips, The Physical Exam, https://doi.org/10.1007/978-3-319-63847-8_1
4 1 Introduction

can prove a serious oversight when the examiner The level of the text presupposes that the
has become overdependent upon hi-tech diag- examiner has already acquired the basic skills of
nostic methods. Identifying anomalies on the the physical examination. The organized
physical examination, in fact, guides the clini- sequence develops a rhythm and pace that can be
cian on what hi-tech tests to order or perhaps adapted to virtually every encounter. It is with
confirms that further exploration with expensive disciplined practice – just as an accomplished
tests is not necessary. musician works on scales and fingering – that the
Certainly, the immense value of modern tech- efficiency and productivity of physical examina-
nological achievements does not at all diminish tion can be realized.
the utility of the age-old discipline of the physical Meanwhile, the mindful patient, who is at a
examination. For a more personal reason, being heightened state of awareness when being exam-
able to conduct a well-organized and speedy ined, is sizing up the examiner. The patient’s
physical examination that is insightful and mean- impression of a smooth flow of the examination
ingful can provide a satisfying perspective to the may, later on, have a substantial effect on the
everyday practice of medicine. patient’s confidence and cooperation in his or her
The place of the “routine” or physical exami- own care.
nation is now in serious question [1]. Certainly Those entering the healthcare profession, hav-
there has been no proof of its value in the patient ing been exposed to massive amounts of prepara-
without symptoms (admittedly, a difficult value tory information, often find themselves
to prove). Indeed, an unexpected finding (e.g., a overwhelmed at the bedside for want of feeling
thyroid nodule) may only cause worry until an comfortable about how to proceed. Having a
additional (and expensive) battery of tests has clear idea of a logical sequence will help
ruled it benign. It is accordingly more effective – immensely. That said, the traditional “head-to-­
cost and time directed – that the physical exami- toe” method does not emphasize functional
nation be determined by specific symptoms as regions. Often neglected, for example, in the gen-
they arise. Still, an argument is made that the eral physical examination, are the hands that can
periodic physical examination provides an oppor- provide sensitive telltale signs of vital organ
tunity for the clinician and the patient to review functions, systemic illnesses, and lifestyle. Since,
all the pertinent health issues, ongoing or preven- according to this method, the feet are the last to
tative [2]. Certainly, our time-pressure mode of be examined, these anatomical workhorses are
medical practice dictates that the “laying on of routinely given less attention than, say, extraocu-
hands” must become more efficient. It is toward lar muscle function, yet the problems of the for-
this ideal that this book is directed. mer in the general clinic population are far more
The approach taken here is anatomically common than the latter.
regional, presented in a sequence that can be For purposes of these guidelines, cogent
adapted easily to individual patients. Details in details of the more commonly found clinical con-
each region can be covered rapidly and explicitly ditions in each region are denoted. It is on recog-
with acceptable accuracy. On finding an abnor- nizing an abnormality along the way that the
mality in any region, the examiner then can then examination must slow down to consider the sig-
refer to an appended description in that category nificance of such a finding. These guidelines,
for details. Abnormalities are described in the then, provide a summary of various types of find-
region where they are most likely to occur; this ings, be they spots, bumps, weakness, asymme-
regional approach does entail some repetition. try, and a host of other categories. Some rare
The sequence of the examination presented here conditions are included, mostly those that have
places the positions of the patient into those that serious implications. Examples are certain endo-
are most advantageous for the clinician while crine disorders (particularly of the thyroid and
minimizing the instructions to the patient. adrenal glands) that evolve slowly and are often
The “Little” Things 5

ascribed to other conditions (such as aging) yet While these conditions may seem only too self-­
can have dire consequences when missed evident, some are easily compromised in the rush
diagnostically. from patient to patient. No apology is given for
Concerning the “annual” or “routine” physical going over them once again.
examination not prompted by a symptom or spe- Preparation for the physical examination
cial concern, an argument has been made that should habitually include hand washing (or an
there is little point in using time and resources in alternative), maximum lighting, proper access,
what will almost certainly be a nonproductive useful tools, and an appropriate sense of confi-
effort. Emphasis instead should be on the patient dence. Also, the care given to preparing for the
history and the impact of social issues. examination may provide the most obvious facets
Furthermore, there is concern about some find- of the encounter by which the patient judges the
ings that are not “medically significant” may lead clinician. These simple interventions convey an
to unwarranted worry and expensive follow-up impression that the examination will be well
testing. Others point out that the “routine” physi- thought out and performed in an earnest – not a
cal examination may disclose no meaningful perfunctory – manner. A brief description of each
information but at least the “laying on of hands” follows.
establishes a special bond with the patient in a
setting conducive to discussing on-going medical
issues. Addressing all is the position that the cli- Hygiene
nician incorporates experience and good judg-
ment into the everyday gathering of information Patients expect doctors to examine them with
and decisions made on a patient’s behalf. freshly cleaned hands and well-trimmed nails. A
To restate the position taken here, the clinician vigorous scrub with soap and water is optimal.
can gather a substantial amount of information on An antiseptic rinse is effective only in copi-
the health of the person examined, and this can be ous amounts and then only if well-scrubbed
obtained in a very short time. With continued prac- into the whole hand. A quick dab not covering
tice of an organized and concentrated approach, the entire hand may do little good. Furthermore,
efficiency can only increase. It is when there is a microorganisms resistant to the chemical
significant finding (a sizable mole, possible club- cleanser are being recognized with ever-
bing of the finger tips, increased warmth of a joint, increasing frequency.
a minor tremor, etc.) that the clinician must slow Gloves may be preferred; they are mandatory
down to evaluate the finding in more detail. In when “open” lesions are encountered. For pur-
addition, it is only after extensive experience that poses of the general physical examination, “non-­
the most effective clinician can detect subtle but sterile” gloves taken directly from the box are
meaningful differences that separate normal from adequate. When touched on the “working” outer
abnormal (color, texture, power, etc.). On the per- surface with the unwashed hand – a common
sonal side, the clinician can appreciate enough dif- observation – they merely provide an illusion of
ferences in every patient to make a well-organized proper hygiene. The examiner must take care to
and highly focused routine physical examination touch only the cuff with a bare hand in the same
an interesting accomplishment. way that he or she would don sterile gloves in the
operating room.
Of course, every “external” item touched dur-
The “Little” Things ing the examination further compromises the
microorganism barrier. It is recommended, when
We begin with a reminder of ideal conditions for feasible, that the personal stethoscope or other
the physical examination that were taught and diagnostic tools should be cleaned with an alco-
emphasized on beginning medical training. hol wipe in full view of the patient. Indeed, it is
6 1 Introduction

well documented that the uncleaned stethoscope always stands directly in front of the patient to
carries multiple drug-resistant Staphylococcus prevent his or her stepping down. It is just as
aureus (MRSA) from patient to patient [3]. important that the bed be lowered fully when the
Where a gown is required, the examiner is encounter has been completed.
well-advised to wear it fully robed and tied. The
patient’s impression of a gown hurriedly put half-
­on may reflect the patient’s impression of the Tools
quality of the encounter.
The minimal tools that a general clinician should
have on hand for virtually every examination
Lighting include: a flashlight (the pocket-sized disposable
ones are quite serviceable), blood pressure cuff,
The physical examination in inadequate light stethoscope, tongue blade, percussion hammer,
seriously compromises its reliability. Turning on vibratory fork, and measuring tape. A small “fanny
all available lights, pulling aside curtains, and pack,” available at stores for outdoor activities, is
fully opening window shades seem too funda- invaluable for keeping these items close at hand.
mental to need mentioning. Yet, examinations The otoscopic and ophthalmic examinations
performed in the poorly lighted areas are all too are often too important to skip for wont of easily
commonplace on a busy clinical service. available equipment. At least, every general clini-
Appropriate lighting is particularly important cal service should have both instruments within
in regard to color of the skin and sclera. For reach. The circumstances may dictate that the
example, incandescent light emphasizes icterus, patient examination be completed in a room
whereas neon lighting lessens its intensity. The where this equipment is available.
combination of these two sources, available in
“plant grow lights,” can provide the nearly “white
light” that is optimal and cost-effective. Attitude

Patients expect and in general appreciate a care-

Access fully conducted examination, especially during
the initial encounter. Here the clinician’s attitude
Clinicians put themselves at disadvantage when is important.
bedside paraphernalia clutter easy access. In the When the examiner begins with an apology,
hospital, chairs, mobile tables, and other imped- adding that he or she is going to do a “quick
ing objects should be moved out of the way. physical if you don’t mind,” the words may
Turning off the “audio” control of radio and tele- diminish the quality and the authority of the
vision eliminates a powerful distraction and con- encounter in the perception of the patient. Even
veys the impression that the clinician intends to in follow-up examinations of a shortened nature,
concentrate on the examination. it is preferred to state in an assertive way that a
The typical hospital bed is generally kept low few areas (or systems) “should be examined
to allow the patient to step easily onto the floor; again.” After all, the patient is there to be exam-
the position is not meant to facilitate the exami- ined, and the doctor is there to examine the
nation. The level should be raised to a height that patient. It is the succession of examiners check-
allows the examiner to easily bend and reach the ing an “interesting finding,” as happens in the
opposite sides of the body. In this elevated posi- teaching hospital setting, that patients can under-
tion, however, it is imperative that the clinician standably develop some objection. Of course,
The ABCs 7

any necessary aspect of the examination that may tain normal mental faculties. Only if there has
produce some degree of patient discomfort emerged a suspicion of thought derangement will
deserves both explanation beforehand and assur- a need for formal mental status examination be
ance of it being performed as gently as possible. indicated. It is on completion of the physical
examination that “thank-you” would be appropri-
ate and appreciated.
“Privacy”

The busy practitioner can easily overlook our The ABCs

commitment to preserving patient privacy of both
information and body exposure. Be assured that Before proceeding, three principles deserve con-
the patient does not overlook it. sideration throughout the physical examination:
Clinicians must be fully cognizant of the need symmetry, direction, and sequence.
for a chaperone – documented by name in the
chart – when examining patients of a different
gender. It is good practice to have another Symmetry
observer present with any patient whose gender
orientation is an issue. First of all, people are generally symmetrical. As
the examination progresses, it is critically impor-
tant to compare each observation or function with
Listening its contralateral analogue. Keeping this in mind
throughout the examination will be helpful in
Letting a patient describe a “chief complaint” for identifying abnormalities not producing symp-
a minute or two (or longer) without interruption toms. Sometimes asymmetry becomes a key fac-
can be highly rewarding in the search for what tor in defining or at least leading to a diagnosis.
really concerns the patient. Only then should the Facial appearance, pupil and tendon reflexes, joint
interviewer begin the incisive questioning. The enlargement, strength, skeletal imbalances, and
period of listening provides the clinician with an prostatic enlargement are but a few examples.
opportunity to “reconstruct” the salient features of Evaluating symmetry is where accuracy is
the history, rambling or fragmented as the patient’s highly challenging. For optimal evaluation of
version may be, into a coherent and concise form. symmetry in most regions, the physical orienta-
It has been well established that physicians tion of patient to examiner is crucial. It is the rea-
tend to interrupt the initial explanation by the son for this presentation begins with the patient
patient within seconds, often jotting down each sitting and facing the clinician.
answer as the interview proceeds rather than
waiting until a rather comprehensive concept of
the presenting problem can be formulated [4]. Direction
Computer entry at the bedside seems to have
exaggerated this disconcerting tendency. It is most helpful to develop a rigorous habit of
In essence, the physical examination begins examining symmetrical details in a consistent direc-
with the interview. The clinician has had an tion: right to left (or, if preferred, left to right). While
opportunity to notice capacity of the patient’s not infallible, this simple practice is invaluable for
attention, cognizance of details, memory, coher- performing an organized physical examination
ence, and speech. Questions about home, family, and – equally utilitarian – for remembering on
and occupation are generally sufficient to ascer- which side a notable or even minor finding occurs.
8 1 Introduction

Using a consistent direction does not mean, for

example, examining the right eye and then the left The Essentials
but rather examining the right lids and then the left; The “Essentials” text boxes within this
observing the right palpebral fissure, then the left; book are meant to highlight those specific
checking the right pupil, then the left; and so on. features that should cross the mind of the
What may seem cumbersome and slow is neither clinician when he or she moves through
once sufficiently integrated into one’s practice. each region. As such, the discipline forms a
mental checklist. These foci of attention
are listed in box form at the beginning of
Sequence each region. They will become second
nature with practice.
These guidelines present a sequence for perform- When features on the checklist are found
ing the “routine” physical examination. This normal, one can quickly move on to subse-
region-based outline presupposes that the patient quent regions outlined in the protocol. When
is not critically ill or disabled and can follow basic any feature is abnormal and considered sig-
requests. It maximizes the examiner’s access to nificant, a quick reference is provided that
the various regions while keeping time-­consuming expand categories of abnormalities.
instructions to the patient for changing position to [Brackets around a subject indicate that
a minimum. Furthermore, this approach to the it needs to be examined only if those sub-
physical examination begins at the periphery jects listed above it turn out to be
rather than the center, emphasizing how organ abnormal.]
systems are working, not what the sound like.
There are times when a practiced sequence as
expounded here should be modified. For example,
finding hot and sweating palms on tremulous
References
hands at the initial phase of the encounter brings
into sharp focus the possibility of hyperthyroid- 1. Mehrotra A, Prochazha A. Improving value in health
ism. The findings may logically prompt the clini- care – against the annual physical. N Engl J Med.
cian to straightaway check for all the usual signs of 2015;373(16):1485–7.
2 Goroll AH. Toward trusting therapeutic relation-
hyperthyroidism: tachycardia, bounding arterial ships – in favor of the annual physical. N Eng J Med.
pulse, thyroid enlargement and bruit, and lid lag 2015;373(16):1487–9.
along with leading questions pertaining to history. 3. Longtin Y, Schenider A, et al. Contamination of stetho-
Having satisfied a thorough search for corroborat- scopes and physician’s hands after a physical examina-
tion. Mayo Clin Proc. 2014;89(3):291–9.
ing clues while they are uppermost in mind, he or 4. Groopman J. How doctors think. Houghton Mifflin:
she could then return to continue from where the Boston; 2007.
sequential format had been interrupted.
 First Impression
2

Ideally, the sitting patient faces the examiner medical evaluation. Indeed, some clinicians may
directly on the edge of bed or examining table. find some discomfort in the “medical face-off,”
(Of course, a patient may be too ill or injured to even for the several seconds suggested.
allow this position with tolerable comfort.) Also This initial full facial look tells the patient that
raising the hospital bed to eye-to-eye level pro- the clinician means to perform more than a per-
vides an enormous advantage. With the bed ele- functory examination. For the clinician, an objec-
vated, the examiner must always stand directly in tive observation offers more. Of course, it
front of the patient to prevent his or her stepping provides obvious indications of age, sex, ethnic-
down. ity, and well-being (although always with a wide
margin of uncertainty). Basic emotional states
are said to be expressed by a facial “universal
Essentials
language”. A smile, a frown, or a myriad of other
The healthy face
facial expressions provides a level of nonverbal
Eye-to-eye contact
communication of feelings. We are familiar with
Sense of mood
the look of surprise, the grimace of pain, and the
Pitfalls
wincing on being touched in a tender place. The
tense look of anxiety or fear needs no descrip-
tion. A vacant stare, the semblance of fatigue, or
With this perspective, take 5 s to look care- an unsmiling, melancholy expression tells us
fully into the face of the patient in silence. This something. Added to the mix are personalities
simple beginning – although not at first easy to ranging from the immobile stoic to the fidgeting.
do – enhances the encounter in a powerful and The inability of the patient (excepting small chil-
positive manner. Almost always, the patient will dren) to look you directly in the eyes for these
make eye contact. This point is important. It is a seconds may reflect exceptional anxiety, a psy-
moment to assess the patient’s alertness, ability chiatric disorder, or mind-altering drug effect.
to focus, and general amenability for being exam- Yet, the examiner must be careful to avoid over-
ined. Further, this advantage – even for these few generalizing, embellishing stereotypic impressions,
seconds – establishes a connection between and misinterpreting expressions observed. Facial
patient and examiner that is meaningful. It con- expressions – intentional or not – are far too com-
veys the impression that a well-concentrated plex to be of diagnostic quality. How complex
evaluation is about to begin. are they? A reference book for writers, “Word
Our everyday experience of “reading faces” is Finder” published in 1951, cites 775 descriptive
very different from the riveting objectivity of a adjectives under “face” [1].

© Springer International Publishing AG 2018 9

R.E. Phillips, The Physical Exam, https://doi.org/10.1007/978-3-319-63847-8_2
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