Pulmonology — MCQs

A 67-year-old woman presents with increasing shortness of breath on exertion. She has no prior cardiac or pulmonary history and reports no symptoms of chest discomfort, cough, sputum production, orthopnea, or peripheral edema. Her physical examination, including vital signs, cardiac, and pulmonary examinations, is completely normal. Her CXR, ECG, and CBC are also normal. Pulmonary function tests reveal a reduction in the ratio of FEV1/FVC with no reversibility upon administration of inhaled salbutamol. What is the most likely diagnosis?

Q167Medium

Which of the following conditions can cause a transudative pleural effusion?

Q168Medium

A 53-year-old man presents with progressive shortness of breath of insidious onset. He denies cough, sputum, or chest discomfort. His past medical history includes well-controlled hypertension and type 2 diabetes. He is a lifetime non-smoker and has no history of occupational exposure. Pulmonary function tests reveal a restrictive defect, and high-resolution CT suggests pulmonary fibrosis. What is the most likely role of transbronchial biopsy in evaluating this patient?

Q169Easy

A patient with bronchial asthma is prescribed 2 puffs from a metered dose inhaler of budesonide. Which of the following actions should be avoided when using the inhaler?

Q170Medium

A 38-year-old man presents with progressive shortness of breath and cough. He denies fever, chills, or purulent sputum production. Physical examination reveals decreased breath sounds with hyperresonant upper lung fields, more prominent on the right. Arterial blood gases on room air show: pH 7.35; PCO2 38 mm Hg; PO2 78 mm Hg. Spirometry results are: FVC 1.72 L (70% of predicted); FEV1 1.34 L (60% of predicted); FEV1/FVC ratio 76%; TLC 4.1 L (100% of predicted); TLC by helium dilution 3.4 L (71%); DLCO 70% of predicted. There is no bronchodilator response. What is the next management option?

Pulmonology Indian Medical PG Practice Questions and MCQs

Question 161: Which of the following cannot be a solitary nodule in the lung?

A. Tuberculoma
B. Neurofibroma
C. Bronchogenic carcinoma
D. Lymphoma (Correct Answer)

Explanation: ### Explanation **Concept Overview** A **Solitary Pulmonary Nodule (SPN)** is defined as a single, discrete pulmonary opacity less than 3 cm in diameter, surrounded by lung parenchyma, without associated atelectasis or lymphadenopathy. The distinction between benign and malignant causes is a frequent high-yield topic in NEET-PG. **Why Lymphoma is the Correct Answer** Pulmonary involvement in **Lymphoma** (both Hodgkin and Non-Hodgkin) typically presents as **multiple nodules**, diffuse interstitial infiltrates, or bulky mediastinal/hilar lymphadenopathy. While it can involve the lung parenchyma, it almost never presents as a truly "solitary" peripheral nodule without associated nodal involvement. Therefore, it is classically excluded from the differential diagnosis of an SPN. **Analysis of Other Options** * **Tuberculoma (Option A):** This is one of the most common benign causes of an SPN in India. It represents a healed or persistent focus of tuberculosis, often showing "popcorn" or speckled calcification. * **Neurofibroma (Option B):** While rare, neurogenic tumors can present as solitary peripheral nodules, especially if they arise from the intercostal nerves. * **Bronchogenic Carcinoma (Option C):** This is the most critical malignant cause of an SPN. Adenocarcinoma, in particular, frequently presents as a peripheral solitary nodule. **NEET-PG High-Yield Pearls** * **Size Matters:** A lesion >3 cm is termed a "lung mass" and has a much higher probability of malignancy. * **Calcification Patterns:** Benign nodules often show central, diffuse, or popcorn calcification. Eccentric or stippled calcification suggests malignancy. * **Hamartoma:** The most common benign lung tumor; often presents as an SPN with "popcorn" calcification. * **Doubling Time:** Malignant nodules typically double in volume between 20 to 400 days. Stability for >2 years strongly suggests a benign etiology.

Question 162: What are the diagnostic criteria for acute respiratory distress syndrome?

A. PaO2/FiO2 ratio is < 200 mmHg
B. PaO2/FiO2 ratio is < 300 mmHg (Correct Answer)
C. PaO2/FiO2 ratio is < 400 mmHg
D. PaO2/FiO2 ratio is < 100 mmHg

Explanation: The diagnostic criteria for **Acute Respiratory Distress Syndrome (ARDS)** are defined by the **Berlin Criteria (2012)** [1]. To diagnose ARDS, a patient must meet four specific requirements: 1. **Timing:** Acute onset within 1 week of a known clinical insult or new/worsening respiratory symptoms [1]. 2. **Chest Imaging:** Bilateral opacities not fully explained by effusions, collapse, or nodules [1]. 3. **Origin of Edema:** Respiratory failure not fully explained by heart failure or fluid overload (requires objective assessment like echocardiography if no risk factor is present) [1]. 4. **Oxygenation:** A **PaO2/FiO2 ratio < 300 mmHg** with a minimum PEEP of 5 cmH2O [1]. **Analysis of Options:** * **Option B (Correct):** The threshold for diagnosing ARDS starts at a PaO2/FiO2 ratio of **< 300 mmHg**. This represents the "Mild" category of the disease. * **Option A & D:** These represent the thresholds for **Moderate (< 200 mmHg)** and **Severe (< 100 mmHg)** ARDS, respectively. While they fall under the umbrella of ARDS, they are sub-classifications rather than the entry diagnostic criterion. * **Option C:** A ratio of < 400 mmHg is considered abnormal but does not meet the formal Berlin definition for ARDS. **High-Yield NEET-PG Pearls:** * **PCWP:** Under the old American-European Consensus (AECC) criteria, a Pulmonary Capillary Wedge Pressure (PCWP) < 18 mmHg was required. The Berlin criteria **removed** the mandatory PCWP measurement. * **Management:** The mainstay of treatment is **Low Tidal Volume Ventilation (6 mL/kg of predicted body weight)** to prevent volutrauma. * **Prone Positioning:** Recommended for severe ARDS (PaO2/FiO2 < 150) to improve V/Q matching.

Question 163: What is the best management option in a patient with COPD presenting with low SpO2 at rest?

A. Smoking cessation
B. Bronchodilators
C. Low-flow oxygen therapy (Correct Answer)
D. Mucolytics

Explanation: The primary goal in managing a patient with COPD and resting hypoxemia (SpO2 < 88-90% or PaO2 < 55-60 mmHg) is to correct the oxygen deficit and prevent complications like pulmonary hypertension and cor pulmonale [1]. **1. Why Low-flow Oxygen Therapy is Correct:** Long-term oxygen therapy (LTOT) is one of the few interventions in COPD proven to **improve survival** [1], [3]. In patients with resting hypoxemia, low-flow oxygen (usually via nasal cannula at 1-2 L/min) aims to maintain SpO2 between 88-92%. It reduces the work of breathing and decreases secondary polycythemia [1]. **2. Why Other Options are Incorrect:** * **Smoking Cessation (A):** While this is the most effective intervention to slow the rate of decline in FEV1, it does not provide immediate correction for acute or chronic resting hypoxemia [2]. * **Bronchodilators (B):** These are the mainstay for symptomatic relief and reducing exacerbations [2]. However, they do not significantly improve oxygenation in patients with established resting hypoxemia or improve mortality. * **Mucolytics (C):** These may help reduce the frequency of exacerbations in patients with chronic bronchitis but have no role in managing hypoxemia. **High-Yield Clinical Pearls for NEET-PG:** * **Mortality Benefit in COPD:** Only two interventions are proven to reduce mortality: **Smoking cessation** and **Long-term Oxygen Therapy (LTOT)** (used >15 hours/day) [1], [3]. * **Indications for LTOT:** 1. PaO2 ≤ 55 mmHg or SpO2 ≤ 88%. 2. PaO2 56–59 mmHg if there is evidence of cor pulmonale, congestive heart failure, or polycythemia (Hematocrit > 55%) [1]. * **Target SpO2:** In COPD, always aim for **88-92%** to avoid suppressing the hypoxic respiratory drive, which could lead to CO2 retention (hypercapnia).

Question 164: What is the DOC in allergic bronchopulmonary aspergillosis (ABPA)?

A. Prednisolone (Correct Answer)
B. IV Amphotercin B
C. IV Pheniramine maleate
D. Fluconazole

Explanation: **Explanation:** **Allergic Bronchopulmonary Aspergillosis (ABPA)** is a complex hypersensitivity reaction (Type I, III, and IV) to *Aspergillus fumigatus* colonizing the airways, typically seen in patients with asthma or cystic fibrosis. **1. Why Prednisolone is the Correct Answer:** The primary pathology in ABPA is not an active invasive infection, but an **exaggerated immune response** to fungal antigens. Therefore, the **Drug of Choice (DOC) is Oral Corticosteroids (Prednisolone)**. Steroids work by suppressing the inflammatory response, reducing eosinophilia, and decreasing IgE levels, thereby preventing the progression to bronchiectasis and pulmonary fibrosis [1]. **2. Why the Other Options are Incorrect:** * **IV Amphotericin B:** This is a potent antifungal used for *invasive* aspergillosis. In ABPA, the fungus is colonizing, not invading tissue; hence, systemic toxic antifungals are not first-line. * **IV Pheniramine Maleate:** This is an antihistamine used for acute allergic reactions (like urticaria). It has no role in managing the complex T-cell mediated airway inflammation of ABPA. * **Fluconazole:** *Aspergillus* species are inherently resistant to Fluconazole. If an antifungal is added to steroids (as a steroid-sparing agent), **Itraconazole** is the drug of choice, not Fluconazole. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (Rosenberg-Patterson):** Look for asthma, fleeting pulmonary opacities, **central bronchiectasis** (classic sign), elevated total serum IgE (>1000 IU/mL), and peripheral eosinophilia. * **Radiology:** "Finger-in-glove" appearance due to mucoid impaction [1]. * **Monitoring:** Treatment response is monitored by serial **Total Serum IgE levels** (a 25-50% drop indicates improvement). * **Staging:** ABPA is classified into 5 stages (Acute, Remission, Exacerbation, Corticosteroid-dependent, and Fibrotic).

Question 165: What is the most likely cause of bihilar lymphadenopathy?

A. Histoplasmosis
B. Tuberculosis
C. Sarcoidosis (Correct Answer)
D. Aspergillosis

Explanation: **Explanation:** **Sarcoidosis** is the most common cause of bilateral symmetrical hilar lymphadenopathy (BHL). It is a multisystem granulomatous disease characterized by non-caseating granulomas. In the classic Scadding staging system for Sarcoidosis, **Stage I** is defined specifically by the presence of BHL without pulmonary infiltrates. The lymphadenopathy is typically "potato-like," discrete, and symmetrical, making it the hallmark radiological finding for this condition. **Analysis of Incorrect Options:** * **Tuberculosis (TB):** While TB is a common cause of lymphadenopathy in endemic regions like India, it typically presents as **unilateral** hilar or paratracheal lymphadenopathy. Bilateral involvement is rare and usually occurs in primary TB or immunocompromised states. * **Histoplasmosis:** This fungal infection can cause hilar adenopathy, but it is more frequently **unilateral** or asymmetrical. It is also geographically restricted (e.g., Ohio/Mississippi River valleys in the US) and less common than Sarcoidosis as a cause of BHL globally. * **Aspergillosis:** This usually presents as an aspergilloma (fungus ball in a pre-existing cavity), Allergic Bronchopulmonary Aspergillosis (ABPA), or invasive disease [1]. It is not a primary cause of isolated bilateral hilar lymphadenopathy. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis for BHL:** Sarcoidosis (most common), Lymphoma (usually asymmetrical/mediastinal), Silicosis (often with "eggshell calcification"), and Coccidioidomycosis. * **Löfgren Syndrome:** A specific acute presentation of Sarcoidosis consisting of the triad: **BHL, Erythema Nodosum, and Polyarthritis/Arthralgia [1].** * **Panda Sign & Gallium-67 Scan:** Increased uptake in the lacrimal and parotid glands (Panda sign) along with BHL (Lambda sign) is highly suggestive of Sarcoidosis.

Question 166: A 67-year-old woman presents with increasing shortness of breath on exertion. She has no prior cardiac or pulmonary history and reports no symptoms of chest discomfort, cough, sputum production, orthopnea, or peripheral edema. Her physical examination, including vital signs, cardiac, and pulmonary examinations, is completely normal. Her CXR, ECG, and CBC are also normal. Pulmonary function tests reveal a reduction in the ratio of FEV1/FVC with no reversibility upon administration of inhaled salbutamol. What is the most likely diagnosis?

A. COPD (Correct Answer)
B. Ankylosing spondylitis
C. Pickwickian syndrome
D. Scleroderma of the chest wall

Explanation: ### Explanation The key to solving this clinical scenario lies in the interpretation of the **Pulmonary Function Test (PFT)**. **1. Why COPD is the Correct Answer:** The patient exhibits a **reduced FEV1/FVC ratio** (typically <0.70), which is the hallmark of an **obstructive lung disease** [3]. The lack of reversibility after salbutamol administration distinguishes it from asthma [2] and points toward **COPD**. While the patient is a non-smoker with a normal physical exam and CXR, it is a high-yield fact that early or mild-to-moderate COPD often presents with a completely normal physical examination and imaging [1]. In the elderly, COPD can occur due to biomass fuel exposure or age-related lung changes, even in the absence of classic risk factors [3]. **2. Why the Other Options are Incorrect:** * **Ankylosing Spondylitis, Pickwickian Syndrome (Obesity Hypoventilation), and Scleroderma:** These conditions are all causes of **Restrictive Lung Disease**. In restrictive patterns, the FEV1 and FVC both decrease proportionately, leading to a **normal or increased FEV1/FVC ratio** [4]. * **Ankylosing Spondylitis/Scleroderma:** These involve chest wall rigidity or interstitial changes, which would not cause an obstructive ratio [4]. * **Pickwickian Syndrome:** This is associated with a high BMI and daytime hypercapnia, typically showing restriction on PFTs [4]. **Clinical Pearls for NEET-PG:** * **Gold Standard for COPD Diagnosis:** Spirometry (Post-bronchodilator FEV1/FVC < 0.7) [3]. * **Normal CXR:** Does not rule out COPD; it is often normal until significant emphysema or hyperinflation develops [1]. * **Obstructive vs. Restrictive:** * *Obstructive (FEV1/FVC ↓):* COPD, Asthma, Bronchiectasis, Cystic Fibrosis [3]. * *Restrictive (FEV1/FVC Normal/↑):* ILD, Kyphoscoliosis, Neuromuscular weakness, Obesity [4].

Question 167: Which of the following conditions can cause a transudative pleural effusion?

A. Nephrotic syndrome, Constrictive pericarditis, Pulmonary embolism (Correct Answer)
B. Rheumatoid arthritis, Pulmonary embolism
C. Nephrotic syndrome, Rheumatoid arthritis, Constrictive pericarditis
D. Nephrotic syndrome, Rheumatoid arthritis, Pulmonary embolism

Explanation: Pleural effusions are classified as either **transudative** or **exudative** based on Light’s Criteria. Transudates occur due to systemic factors that alter hydrostatic or oncotic pressure, while exudates result from local inflammatory processes that increase capillary permeability [1]. **Why Option A is Correct:** * **Nephrotic Syndrome:** Causes a decrease in plasma oncotic pressure due to significant albumin loss in urine, leading to fluid leakage into the pleural space (Transudate). * **Constrictive Pericarditis:** Increases systemic venous hydrostatic pressure, which impairs pleural fluid resorption (Transudate). * **Pulmonary Embolism (PE):** This is a "chameleon" in pulmonology. While PE most commonly causes an exudate (due to ischemia/infarction), it can also cause a transudate (due to acute right heart failure and increased hydrostatic pressure). Since it appears in the correct combination here, it is the best fit. **Why Other Options are Incorrect:** * **Rheumatoid Arthritis (Options B, C, D):** This is a classic cause of **exudative** pleural effusion. It is characterized by very low glucose levels (<30 mg/dL) and high LDH [1]. Its presence makes these options incorrect. **High-Yield NEET-PG Pearls:** 1. **Light’s Criteria:** Effusion is an **Exudate** if: * Pleural fluid protein/Serum protein ratio > 0.5 * Pleural fluid LDH/Serum LDH ratio > 0.6 * Pleural fluid LDH > 2/3rd the upper limit of normal serum LDH. 2. **Most common cause of Transudate:** Congestive Heart Failure (CHF). 3. **Most common cause of Exudate:** Parapneumonic effusion/Malignancy. 4. **Meigs' Syndrome:** Triad of benign ovarian tumor (fibroma), ascites, and pleural effusion (usually transudative).

Question 168: A 53-year-old man presents with progressive shortness of breath of insidious onset. He denies cough, sputum, or chest discomfort. His past medical history includes well-controlled hypertension and type 2 diabetes. He is a lifetime non-smoker and has no history of occupational exposure. Pulmonary function tests reveal a restrictive defect, and high-resolution CT suggests pulmonary fibrosis. What is the most likely role of transbronchial biopsy in evaluating this patient?

A. To assess disease severity
B. To assess possible bronchiolar narrowing
C. To diagnose specific causes of interstitial lung disease (Correct Answer)
D. To determine the degree of inflammation

Explanation: ### Explanation The patient presents with a classic clinical picture of **Interstitial Lung Disease (ILD)**: progressive dyspnea, restrictive defect on PFTs, and fibrosis on HRCT [1]. **Why Option C is Correct:** The primary role of a **Transbronchial Lung Biopsy (TBB)** in the evaluation of ILD is to identify specific etiologies that have a characteristic histological pattern or distribution. While HRCT is highly sensitive, TBB is particularly useful for diagnosing conditions like **sarcoidosis, hypersensitivity pneumonitis, or lymphangitic carcinomatosis**, where the pathology is peribronchial or granulomatous. However, it is important to note that TBB has a low yield for diagnosing Idiopathic Pulmonary Fibrosis (IPF) because the small tissue samples cannot reliably demonstrate the "patchy" nature of Usual Interstitial Pneumonia (UIP). **Why Other Options are Incorrect:** * **Option A & D:** Biopsy is a static assessment of a small tissue area. It is **not** used to assess disease severity or the overall degree of inflammation; these are better evaluated through clinical symptoms, PFTs (DLCO/FVC), and imaging. * **Option B:** Bronchiolar narrowing is typically assessed via physiological testing (PFTs showing obstructive patterns) or specific HRCT findings (mosaic attenuation/air trapping), not by TBB. **NEET-PG High-Yield Pearls:** * **Gold Standard for ILD Diagnosis:** HRCT is the initial investigation of choice [1]. * **Surgical Lung Biopsy (SLB):** If HRCT is non-diagnostic for IPF/UIP, SLB is the gold standard for definitive diagnosis, as it provides larger tissue samples compared to TBB. In very frail patients, SLB is often inappropriate, and diagnosis relies on HRCT alone [2]. * **Cryobiopsy:** An emerging technique that provides larger, higher-quality samples than traditional TBB with fewer artifacts. * **Classic HRCT finding in IPF:** Subpleural, basal-predominant reticular opacities with **honeycombing** [1].

Question 169: A patient with bronchial asthma is prescribed 2 puffs from a metered dose inhaler of budesonide. Which of the following actions should be avoided when using the inhaler?

A. Shake the inhaler well before use.
B. Clean the inhaler after every use. (Correct Answer)
C. Wait for 1 minute between puffs.
D. Rinse the mouth after every use.

Explanation: ### Explanation **Correct Option: B. Clean the inhaler after every use.** **Why it is the correct answer:** While hygiene is important, cleaning a Metered Dose Inhaler (MDI) after **every** single use is unnecessary and can be counterproductive. Most manufacturers recommend cleaning the plastic actuator (the sleeve) only **once a week** with warm running water to prevent medication buildup that might block the spray. Frequent washing can lead to moisture retention in the nozzle, potentially interfering with the drug delivery mechanism. **Analysis of Incorrect Options:** * **A. Shake the inhaler well before use:** This is a mandatory step for MDIs. Most MDIs are suspensions; shaking ensures the active drug (Budesonide) and the propellant are mixed thoroughly to deliver an accurate dose. * **C. Wait for 1 minute between puffs:** When two puffs are prescribed, a gap of 30–60 seconds is recommended. This allows the valve to refill and the propellant to stabilize, ensuring the second puff contains the full therapeutic dose. * **D. Rinse the mouth after every use:** This is a critical step for **Inhaled Corticosteroids (ICS)** like Budesonide [1]. Rinsing the mouth and spitting helps prevent local side effects such as **Oropharyngeal Candidiasis (Oral Thrush)** and dysphonia caused by drug deposition in the throat. **High-Yield Clinical Pearls for NEET-PG:** 1. **MDI Technique:** The most common error in MDI use is poor **hand-breath coordination**. Using a **spacer** device is the best way to overcome this and increase lung deposition [2]. 2. **ICS Side Effects:** Systemic absorption of ICS is minimal, but long-term high doses can rarely lead to cataracts or decreased bone density. Local effects (thrush) are much more common [1]. 3. **Dry Powder Inhalers (DPIs):** Unlike MDIs, DPIs (e.g., Rotahalers) should **not** be shaken and require a deep, rapid forceful inhalation rather than the slow, steady breath used for MDIs.

Question 170: A 38-year-old man presents with progressive shortness of breath and cough. He denies fever, chills, or purulent sputum production. Physical examination reveals decreased breath sounds with hyperresonant upper lung fields, more prominent on the right. Arterial blood gases on room air show: pH 7.35; PCO2 38 mm Hg; PO2 78 mm Hg. Spirometry results are: FVC 1.72 L (70% of predicted); FEV1 1.34 L (60% of predicted); FEV1/FVC ratio 76%; TLC 4.1 L (100% of predicted); TLC by helium dilution 3.4 L (71%); DLCO 70% of predicted. There is no bronchodilator response. What is the next management option?

A. Place a chest tube urgently
B. Increase bronchodilator dosage and frequency
C. Start chest physical therapy
D. Perform CT scan of the chest (Correct Answer)

Explanation: ### Explanation The clinical presentation and pulmonary function tests (PFTs) point toward **Bullous Lung Disease**, likely a large solitary bulla. **1. Why Option D is Correct:** The key to this question lies in the **discrepancy between the Total Lung Capacity (TLC) measurements**. * **TLC by Plethysmography (implied 4.1L/100%):** Measures the total volume of gas in the chest. * **TLC by Helium Dilution (3.4L/71%):** Only measures gas in communication with the airways. The significant difference (4.1L vs 3.4L) indicates a large volume of "trapped gas" that does not communicate with the bronchial tree—a classic sign of a **large bulla**. The hyperresonance and decreased breath sounds further support this. A **CT scan of the chest** is the gold standard to confirm the diagnosis, assess the size of the bulla, and differentiate it from a pneumothorax before any surgical intervention (bullectomy). **2. Why Other Options are Incorrect:** * **Option A:** While hyperresonance and dyspnea suggest pneumothorax, the patient is hemodynamically stable with near-normal ABGs. Placing a chest tube into a large bulla (misdiagnosed as pneumothorax) can create a persistent bronchopleural fistula. * **Option B:** The FEV1/FVC ratio is 76% (non-obstructive) and there is no bronchodilator response, making asthma or COPD exacerbation unlikely [1]. * **Option C:** Chest physiotherapy is used for secretion clearance (e.g., bronchiectasis); it does not address the anatomical issue of a bulla. **Clinical Pearls for NEET-PG:** * **Vanishing Lung Syndrome:** Also known as Type 1 Bullous Disease; characterized by large bullae involving at least one-third of a hemithorax. * **PFT Hallmark:** A "Volume Gap" where TLC (Plethysmography) > TLC (Gas Dilution) signifies non-communicating air spaces (bullae). * **Surgical Indication:** Bullectomy is generally considered if the bulla occupies >30-50% of the hemithorax or causes significant complications.

Practice by Chapter

Obstructive Airway Diseases (Asthma, COPD)

Practice Questions

Interstitial Lung Diseases

Practice Questions

Pulmonary Infections

Practice Questions

Pulmonary Vascular Diseases

Practice Questions

Pleural Diseases

Practice Questions

Sleep-Disordered Breathing

Practice Questions

Respiratory Failure

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Mediastinal Disorders

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Occupational Lung Diseases

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Pulmonary Function Testing

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Bronchiectasis and Cystic Fibrosis

Practice Questions

Lung Cancer Approach

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