Mixed acid-base disorders US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Mixed acid-base disorders. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Mixed acid-base disorders US Medical PG Question 1: A 17-year-old male presents to your office complaining of polyuria, polydipsia, and unintentional weight loss of 12 pounds over the past 3 months. On physical examination, the patient is tachypneic with labored breathing. Which of the following electrolyte abnormalities would you most likely observe in this patient?
- A. Hypophosphatemia
- B. Hypermagnesemia
- C. Hyperkalemia
- D. Hyponatremia (Correct Answer)
- E. Hyperphosphatemia
Mixed acid-base disorders Explanation: ***Hyponatremia***
- This patient's symptoms of polyuria, polydipsia, and weight loss, along with **tachypnea and labored breathing**, are highly suggestive of **diabetic ketoacidosis (DKA)**.
- **Hyponatremia** is the **most consistently observed** electrolyte abnormality in DKA, present in nearly all cases at initial presentation.
- This is typically **pseudohyponatremia** caused by the osmotic effect of severe hyperglycemia—glucose pulls water into the extracellular space, diluting the measured sodium concentration.
- The **corrected sodium** can be calculated using: Corrected Na = Measured Na + 0.016 × (Glucose - 100), which typically reveals a more normal sodium level.
- True hyponatremia from sodium loss via **osmotic diuresis** can also occur but is usually masked by the dilutional effect.
*Hyperkalemia*
- While serum potassium may appear normal or even elevated initially due to **transcellular shifts** (acidosis causes potassium to move from intracellular to extracellular space in exchange for hydrogen ions), this is not the most consistently observed abnormality.
- **Total body potassium is always depleted** in DKA due to osmotic diuresis and vomiting.
- Many patients present with normal or even low potassium levels despite acidosis.
- Potassium levels require careful monitoring during treatment as insulin therapy drives potassium back into cells, potentially causing life-threatening hypokalemia.
*Hypophosphatemia*
- While **phosphate levels** can fluctuate in DKA due to osmotic diuresis, initial presentation often involves normal or even elevated phosphate levels due to cellular shifts.
- Significant **hypophosphatemia** is more typically observed during treatment as insulin drives phosphate back into the cells, similar to potassium.
*Hypermagnesemia*
- **Hypermagnesemia** is uncommon in DKA and is usually associated with impaired renal excretion or excessive magnesium intake.
- The symptoms described do not point towards magnesium imbalance.
*Hyperphosphatemia*
- Although cellular shifts can initially raise serum phosphate, sustained **hyperphosphatemia** is not a characteristic or common electrolyte abnormality seen in the acute presentation of DKA.
- More typically, total body phosphate is depleted due to **osmotic diuresis**.
Mixed acid-base disorders US Medical PG Question 2: A 65-year-old man is brought to the emergency department from his home. He is unresponsive. His son requested a wellness check because he had not heard from his father in 2 weeks. He reports that his father was sounding depressed during a telephone call. The paramedics found a suicide note and a half-empty bottle of antifreeze near the patient. The medical history includes hypertension and hyperlipidemia. The vital signs include: blood pressure 120/80 mm Hg, respiratory rate 25/min, heart rate 95/min, and temperature 37.0°C (98.5°F). He is admitted to the hospital. What do you expect the blood gas analysis to show?
- A. Non-anion gap metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Anion gap metabolic acidosis (Correct Answer)
- E. Mixed acid-base disorder
Mixed acid-base disorders Explanation: ***Anion gap metabolic acidosis***
- The patient's history of **antifreeze ingestion** indicates likely exposure to **ethylene glycol**, which is metabolized into toxic acids (glycolic and oxalic acid).
- These accumulating acids lead to an **increased anion gap metabolic acidosis**.
*Non-anion gap metabolic acidosis*
- This type of acidosis typically results from **bicarbonate loss** (e.g., severe diarrhea) or **excessive chloride intake**, which is not indicated by the antifreeze ingestion.
- It involves a normal anion gap because other unmeasured anions do not accumulate.
*Metabolic alkalosis*
- This imbalance is characterized by an **increase in bicarbonate** or a significant loss of acid, often due to vomiting or diuretic use.
- Antifreeze poisoning directly leads to acid accumulation, precisely the opposite of metabolic alkalosis.
*Respiratory acidosis*
- This occurs due to **hypoventilation** and subsequent buildup of CO2, leading to increased carbonic acid.
- While respiratory rate is elevated, the primary problem here is metabolic due to toxin ingestion, not respiratory CO2 retention.
*Mixed acid-base disorder*
- While a mixed disorder is possible in complex cases, the presentation with antifreeze poisoning is classically dominated by a **severe anion gap metabolic acidosis**.
- There is no clear indication of a separate primary respiratory or alkalotic disorder at onset to warrant a "mixed" label as the primary anticipated finding.
Mixed acid-base disorders US Medical PG Question 3: A 32-year-old man is brought to the emergency department after he was found unresponsive on the street. Upon admission, he is lethargic and cyanotic with small, symmetrical pinpoint pupils. The following vital signs were registered: blood pressure of 100/60 mm Hg, heart rate of 70/min, respiratory rate of 8/min, and a body temperature of 36.0°C (96.8°F). While being assessed and resuscitated, a sample for arterial blood gas (ABG) analysis was taken, in addition to the following biochemistry tests:
Laboratory test
Serum Na+ 138 mEq/L
Serum Cl- 101 mEq/L
Serum K+ 4.0 mEq/L
Serum creatinine (SCr) 0.58 mg/dL
Which of the following values would you most likely expect to see in this patient’s ABG results?
- A. pH: decreased, HCO3- : increased, Pco2: increased (Correct Answer)
- B. pH: increased, HCO3- : decreased, Pco2: decreased
- C. pH: decreased, HCO3- : decreased, Pco2: decreased
- D. pH: increased, HCO3- : increased, Pco2: increased
- E. pH: normal, HCO3- : increased, Pco2: increased
Mixed acid-base disorders Explanation: ***pH: decreased, HCO3- : increased, Pco2: increased***
- The patient's **depressed respiratory rate** (8/min) indicates severe hypoventilation, leading to **CO2 retention** and subsequent **respiratory acidosis** (decreased pH, increased PaCO2).
- In **acute respiratory acidosis**, the body initiates immediate buffering, causing a **mild increase in HCO3-** (approximately 1 mEq/L per 10 mmHg rise in PaCO2). Over 3-5 days, renal compensation leads to more significant HCO3- retention, but in this acute presentation, some HCO3- elevation is expected from acute buffering mechanisms.
- The **decreased pH** indicates that compensation is incomplete, which is typical in the acute setting.
*pH: increased, HCO3- : decreased, Pco2: decreased*
- This pattern is characteristic of **respiratory alkalosis** (increased pH, decreased PaCO2) with metabolic compensation (decreased HCO3-), which would occur in hyperventilation, opposite to the patient's presentation.
- The patient's **slow respiratory rate** of 8/min directly contradicts the finding of decreased PaCO2.
*pH: decreased, HCO3- : decreased, Pco2: decreased*
- This suggests a **metabolic acidosis** (decreased pH, decreased HCO3-) with respiratory compensation (decreased PaCO2), typically seen in conditions like DKA or lactic acidosis.
- Although the pH is decreased, the patient's severe bradypnea (RR 8/min) indicates increased CO2 retention, not decreased CO2.
*pH: increased, HCO3- : increased, Pco2: increased*
- This combination of findings is indicative of **metabolic alkalosis** (increased pH, increased HCO3-) with respiratory compensation (increased PaCO2).
- This is inconsistent with the patient's pinpoint pupils, cyanosis, and **severe bradypnea**, which are classic signs of opioid overdose causing respiratory depression and acidosis, not alkalosis.
*pH: normal, HCO3- : increased, Pco2: increased*
- A normal pH despite increased HCO3- and PaCO2 indicates **fully compensated respiratory acidosis**, which requires days of renal compensation to develop.
- In this **acute, severe drug overdose** with profound respiratory depression, the body would not have sufficient time to achieve full compensation, thus the pH would remain low.
Mixed acid-base disorders US Medical PG Question 4: A 17-year-old female is brought to the emergency room by her parents shortly after a suicide attempt by aspirin overdose. Which of the following acid/base changes will occur FIRST in this patient?
- A. Metabolic alkalosis
- B. Respiratory acidosis
- C. Anion gap metabolic acidosis
- D. Respiratory alkalosis (Correct Answer)
- E. Non-anion gap metabolic acidosis
Mixed acid-base disorders Explanation: ***Respiratory alkalosis***
- **Aspirin overdose** initially causes direct stimulation of the **respiratory center in the medulla**, leading to **hyperventilation**.
- This increased rate and depth of breathing blows off CO2, resulting in a primary **respiratory alkalosis**.
*Metabolic alkalosis*
- This is an unlikely primary event in aspirin overdose, which typically causes acidosis.
- While aspirin can cause electrolyte disturbances, a direct metabolic alkalosis as the *first* change is not characteristic.
*Respiratory acidosis*
- Respiratory depression, leading to respiratory acidosis, can occur in *severe* and *late-stage* aspirin overdose due to central nervous system depression.
- However, the initial effect is stimulation of respiration, causing alkalosis.
*Anion gap metabolic acidosis*
- This is a significant acid-base disturbance that *does* occur in aspirin overdose, but it develops *later*.
- Salicylates uncouple oxidative phosphorylation and impair cellular metabolism, leading to the accumulation of organic acids (e.g., lactic acid), causing a high anion gap metabolic acidosis.
*Non-anion gap metabolic acidosis*
- This type of acidosis is characterized by a preservation of the anion gap and is often associated with conditions like diarrhea or renal tubular acidosis.
- It is not the expected initial or primary acid-base disturbance in aspirin overdose.
Mixed acid-base disorders US Medical PG Question 5: A 24-year-old woman presents to the emergency department after she was found agitated and screaming for help in the middle of the street. She says she also has dizziness and tingling in the lips and hands. Her past medical history is relevant for general anxiety disorder, managed medically with paroxetine. At admission, her pulse is 125/min, respiratory rate is 25/min, and body temperature is 36.5°C (97.7°F). Physical examination is unremarkable. An arterial blood gas sample is taken. Which of the following results would you most likely expect to see in this patient?
- A. pH: increased, HCO3-: increased, Pco2: increased
- B. pH: decreased, HCO3-: decreased, Pco2: decreased
- C. pH: decreased, HCO3-: increased, Pco2: increased
- D. pH: increased, HCO3-: decreased, Pco2: decreased (Correct Answer)
- E. pH: normal, HCO3-: increased, Pco2: increased
Mixed acid-base disorders Explanation: ***pH: increased, HCO3-: decreased, Pco2: decreased***
- The patient's presentation with **agitation**, **dizziness**, **paresthesias** (tingling in lips and hands), and **tachypnea** (respiratory rate 25/min) is highly suggestive of **hyperventilation** due to an anxiety attack.
- **Hyperventilation** leads to excessive **CO2 expulsion**, causing a decrease in Pco2, which results in respiratory alkalosis (increased pH) and a compensatory decrease in HCO3-.
*pH: increased, HCO3-: increased, Pco2: increased*
- An **increased pH** coupled with **increased HCO3-** and **increased Pco2** would suggest a **metabolic alkalosis with respiratory compensation**, which is not consistent with the patient's acute hyperventilation.
- While pH is increased, the other values contradict the primary respiratory cause suggested by the symptoms.
*pH: decreased, HCO3-: decreased, Pco2: decreased*
- This profile describes **metabolic acidosis with respiratory compensation**, which would typically present with **Kussmaul breathing** and other signs of acidosis, not acute hyperventilation and agitation.
- Symptoms such as dizziness and tingling are associated with alkalosis, not acidosis.
*pH: decreased, HCO3-: increased, Pco2: increased*
- This pattern is characteristic of **respiratory acidosis with metabolic compensation**, often seen in conditions like **COPD exacerbation** or **opioid overdose** with hypoventilation.
- The patient's rapid breathing and clinical picture are not consistent with respiratory acidosis.
*pH: normal, HCO3-: increased, Pco2: increased*
- A **normal pH** with **increased HCO3-** and **increased Pco2** would indicate a **compensated metabolic alkalosis**.
- Her acute symptoms point to an uncompensated or acutely compensated respiratory disorder, not a compensated metabolic issue.
Mixed acid-base disorders US Medical PG Question 6: A 47-year-old woman presents to the emergency department with ongoing dyspnea and confusion for 2 hours. She has a history of psychosis and alcohol abuse. She has smoked 1 pack per day for 25 years. She is agitated and confused. Her blood pressure is 165/95 mm Hg; pulse 110/min; respirations 35/min; and temperature, 36.7°C (98.1°F). The pulmonary examination shows tachypnea and mild generalized wheezing. Auscultation of the heart shows no abnormal sounds. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 138 mEq/L
CI- 100 mEq/L
Arterial blood gas analysis on room air
pH 7.37
pCO2 21 mm Hg
pO2 88 mm Hg
HCO3- 12 mEq/L
Which of the following best explains these findings?
- A. Alcoholic ketoacidosis
- B. Hyperventilation syndrome
- C. Severe chronic obstructive pulmonary disease
- D. Salicylate intoxication (Correct Answer)
- E. Vomiting
Mixed acid-base disorders Explanation: ***Salicylate intoxication***
- The patient's presentation with **agitation, confusion, tachypnea, and wheezing** is consistent with acute salicylate poisoning.
- The **ABG shows a mixed acid-base disturbance**, with a primary respiratory alkalosis (low pCO2 due to hyperventilation) and a partially compensated metabolic acidosis (low HCO3- and a normal pH, suggesting an underlying acidosis). The calculated anion gap in this case is 138 - (100 + 12) = 26, indicating a **high anion gap metabolic acidosis**, which is characteristic of salicylate toxicity.
*Alcoholic ketoacidosis*
- While alcoholic ketoacidosis presents with a **high anion gap metabolic acidosis**, it typically does not cause the prominent **respiratory alkalosis** seen here.
- Patients are usually **hypoglycemic** or euglycemic and may have a history of recent heavy alcohol intake followed by decreased oral intake, but the respiratory symptoms are not as pronounced.
*Hyperventilation syndrome*
- This condition presents with **respiratory alkalosis** (low pCO2 and elevated pH), but it does not cause a **high anion gap metabolic acidosis** with a low bicarbonate.
- Symptoms like agitation and dyspnea can be present, but the **ABG findings are inconsistent** with pure hyperventilation syndrome.
*Severe chronic obstructive pulmonary disease*
- Patients with severe COPD typically have **chronic respiratory acidosis** (elevated pCO2 and low pH), which is the opposite of the ventilatory pattern seen in this patient.
- While they can present with dyspnea and wheezing, the **ABG results rule out** an acute exacerbation of COPD as the primary cause of this presentation.
*Vomiting*
- Chronic or severe vomiting typically leads to **metabolic alkalosis** (elevated pH and high bicarbonate) due to loss of gastric acid, often accompanied by hypokalemia.
- The patient's **low bicarbonate and metabolic acidosis are inconsistent** with vomiting as the primary cause of her acid-base disturbance.
Mixed acid-base disorders US Medical PG Question 7: A 50-year-old woman presents to the ED 6 hours after ingesting three bottles of baby aspirin. She complains of nausea, vomiting, dizziness, and tinnitus. Her blood pressure is 135/80 mmHg, pulse is 110/min, respirations are 32/min, temperature is 100.1 deg F (37.8 deg C), and oxygen saturation is 99% on room air. Arterial blood gas at room air shows, PCO2 11 mmHg, and PO2 129 mmHg. Blood salicylate level is 55 mg/dL. Management should involve which of the following acid-base principles?
- A. Serum neutralization, urine alkalization
- B. Serum alkalization, urine alkalization (Correct Answer)
- C. Serum neutralization, urine acidification
- D. Serum acidification, urine acidification
- E. Serum acidification, urine alkalization
Mixed acid-base disorders Explanation: ***Serum alkalization, urine alkalization***
- Managing **aspirin overdose** involves **aggressive serum alkalization** to promote the shift of salicylic acid from the cells into the bloodstream, where it remains ionized and cannot freely diffuse into the CNS. This also reduces its toxicity by increasing the proportion of the ionized form.
- Subsequently, **urine alkalization** with **sodium bicarbonate** is used to trap the ionized salicylate in the renal tubules, preventing reabsorption and enhancing its excretion.
*Serum neutralization, urine alkalization*
- This option is flawed because the goal is not to "neutralize" the serum pH to a neutral 7.0 but rather to raise it above normal towards an alkaline state (typically pH 7.45-7.55) to enhance salicylate elimination.
- While urine alkalization is correct, the idea of serum neutralization is incorrect and could lead to inadequate treatment.
*Serum neutralization, urine acidification*
- This approach is entirely incorrect for **salicylate toxicity** as **acidifying the urine** would promote the reabsorption of salicylic acid from the renal tubules, worsening toxicity.
- Serum neutralization, as mentioned, is not the correct term or goal for managing **aspirin overdose**.
*Serum acidification, urine acidification*
- This strategy would be **dangerous** in the context of **salicylate overdose** as it would significantly increase the proportion of **non-ionized salicylic acid**, allowing it to more readily cross cell membranes, including the blood-brain barrier, thereby increasing systemic and central nervous system toxicity.
- It would also drastically reduce elimination.
*Serum acidification, urine alkalization*
- **Serum acidification** is contraindicated in **salicylate poisoning** as it drives salicylate into the tissues, exacerbating its toxicity, particularly in the central nervous system.
- While urine alkalization is correct for enhancing elimination, combining it with serum acidification would counteract its benefits and worsen patient outcomes.
Mixed acid-base disorders US Medical PG Question 8: A 27-year-old man presents to the emergency department with his family because of abdominal pain, excessive urination, and drowsiness since the day before. He has had type 1 diabetes mellitus for 2 years. He ran out of insulin 2 days ago. The vital signs at admission include: temperature 36.8°C (98.2°F), blood pressure 102/69 mm Hg, and pulse 121/min. On physical examination, he is lethargic and his breathing is rapid and deep. There is a mild generalized abdominal tenderness without rebound tenderness or guarding. His serum glucose is 480 mg/dL. Arterial blood gas of this patient will most likely show which of the following?
- A. ↑ pH, ↑ bicarbonate, and normal pCO2
- B. ↓ pH, ↓ bicarbonate and ↑ anion gap (Correct Answer)
- C. ↑ pH, normal bicarbonate and ↓ pCO2
- D. ↓ pH, ↓ bicarbonate and normal anion gap
- E. ↓ pH, normal bicarbonate and ↑ pCO2
Mixed acid-base disorders Explanation: ***↓ pH, ↓ bicarbonate and ↑ anion gap***
- The patient's symptoms (abdominal pain, excessive urination, drowsiness, rapid and deep breathing, hyperglycemia) and history of Type 1 diabetes with missed insulin are highly suggestive of **diabetic ketoacidosis (DKA)**.
- DKA is characterized by **metabolic acidosis** due to the accumulation of ketone bodies, leading to a **decreased pH**, consumption of bicarbonate and thus a **decreased bicarbonate level**, and an **increased anion gap**.
*↑ pH, ↑ bicarbonate, and normal pCO2*
- This pattern suggests a **metabolic alkalosis**, which is inconsistent with the patient's presentation of DKA.
- Metabolic alkalosis is typically seen in conditions like severe vomiting or diuretic use, not uncontrolled diabetes.
*↑ pH, normal bicarbonate and ↓ pCO2*
- This profile describes **respiratory alkalosis**, often caused by primary hyperventilation.
- While the patient has rapid and deep breathing (Kussmaul respiration), this is a compensatory mechanism for metabolic acidosis, not a primary respiratory alkalosis.
*↓ pH, ↓ bicarbonate and normal anion gap*
- This indicates a **normal anion gap metabolic acidosis**, also known as hyperchloremic acidosis.
- This is typically seen in conditions like renal tubular acidosis or severe diarrhea, where bicarbonate is lost or chloride is retained, which is not the case for DKA.
*↓ pH, normal bicarbonate and ↑ pCO2*
- This presentation indicates **respiratory acidosis**, which is caused by hypoventilation and retention of CO2.
- The patient's rapid and deep breathing (Kussmaul breathing) is a compensatory mechanism to blow off CO2 and would decrease pCO2, not increase it.
Mixed acid-base disorders US Medical PG Question 9: A 60-year-old homeless man presents to the emergency department with an altered mental status. He is not answering questions. His past medical history is unknown. A venous blood gas is drawn demonstrating the following.
Venous blood gas
pH: 7.2
PaO2: 80 mmHg
PaCO2: 80 mmHg
HCO3-: 24 mEq/L
Which of the following is the most likely etiology of this patient's presentation?
- A. Heroin overdose (Correct Answer)
- B. COPD
- C. Ethylene glycol intoxication
- D. Aspirin overdose
- E. Diabetic ketoacidosis
Mixed acid-base disorders Explanation: ***Heroin overdose***
- The patient exhibits severe **respiratory depression** (high PaCO2 of 80 mmHg and altered mental status) leading to **respiratory acidosis** (pH 7.2) which is characteristic of opiate overdose.
- The **normal bicarbonate (HCO3-) of 24 mEq/L** suggests an acute, uncompensated respiratory acidosis, consistent with an acute overdose event.
*COPD*
- While patients with COPD can have high PaCO2, they typically develop **chronic respiratory acidosis** and would have a **compensated metabolic alkalosis** with elevated bicarbonate levels.
- The **normal bicarbonate** in this patient points away from a chronic respiratory condition.
*Ethylene glycol intoxication*
- Ethylene glycol intoxication causes a **high anion gap metabolic acidosis**, which would present with a **low bicarbonate level**.
- This patient's bicarbonate is normal, ruling out this etiology.
*Aspirin overdose*
- Aspirin overdose commonly causes a **mixed acid-base disturbance**, initially a **respiratory alkalosis** (due to central nervous system stimulation) and subsequently a **metabolic acidosis**.
- The patient's presentation of prominent respiratory acidosis and a normal bicarbonate level is inconsistent with aspirin overdose.
*Diabetic ketoacidosis*
- Diabetic ketoacidosis is characterized by a **high anion gap metabolic acidosis** with significantly **reduced bicarbonate levels**.
- The patient's normal bicarbonate level effectively rules out diabetic ketoacidosis.
Mixed acid-base disorders US Medical PG Question 10: A 52-year-old man with a history of Type 1 diabetes mellitus presents to the emergency room with increasing fatigue. Two days ago, he ran out of insulin and has not had time to obtain a new prescription. He denies fevers or chills. His temperature is 37.2 degrees Celsius, blood pressure 84/56 mmHg, heart rate 100/min, respiratory rate 20/min, and SpO2 97% on room air. His physical exam is otherwise within normal limits. An arterial blood gas analysis shows the following:
pH 7.25, PCO2 29, PO2 95, HCO3- 15.
Which of the following acid-base disorders is present?
- A. Respiratory alkalosis with appropriate metabolic compensation
- B. Respiratory acidosis with appropriate metabolic compensation
- C. Mixed metabolic and respiratory acidosis
- D. Metabolic acidosis with appropriate respiratory compensation (Correct Answer)
- E. Metabolic alkalosis with appropriate respiratory compensation
Mixed acid-base disorders Explanation: ***Metabolic acidosis with appropriate respiratory compensation***
- The patient's pH of 7.25 and HCO3- of 15 indicate **metabolic acidosis**, while the PCO2 of 29 indicates **respiratory compensation**.
- The compensation is **appropriate** as suggested by Winter's formula [Expected PCO2 = (1.5 x HCO3-) + 8 +/- 2; (1.5 x 15) + 8 = 30.5, which is close to 29].
*Respiratory alkalosis with appropriate metabolic compensation*
- This would involve a **pH > 7.45** and **low PCO2** with a secondary drop in HCO3-, which is not seen here.
- The patient's primary problem is a metabolic disturbance due to insulin deficiency.
*Respiratory acidosis with appropriate metabolic compensation*
- This disorder is characterized by a **low pH** and a **high PCO2**, with a secondary rise in HCO3-.
- The patient's PCO2 is low, indicating a compensatory response rather than a primary respiratory acidosis.
*Mixed metabolic and respiratory acidosis*
- A mixed disorder would show a **low pH** due to both **low HCO3-** and **high PCO2**.
- The patient's PCO2 is low, indicating a compensatory response to metabolic acidosis, not an additional respiratory acidosis.
*Metabolic alkalosis with appropriate respiratory compensation*
- This would present with a **high pH (>7.45)** and **high HCO3-**, with compensatory **elevated PCO2**.
- The patient's pH and HCO3- are low, indicating acidosis, not alkalosis.
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