ACP Case Study (2) - 1

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Advanced Clinical Practice

NUR339

7th Semester

Bachelor of Nursing

School of Nursing

The Maldives National University

Case Study - Acute Myocardial Infarction

Hawwa Shaifa Musthafa


S072853
s072853@student.mnu.edu.mv
Table of Contents

Introduction................................................................................................................................3

Clinical Presentation and History...............................................................................................4

Diagnosis....................................................................................................................................4

Electrocardiogram......................................................................................................................5

Cardiac Biomarkers....................................................................................................................5

Coronary Angiogram with Percutaneous Coronary Intervention..............................................6

Causes and Risk Factors.............................................................................................................6

Pharmacological Treatment........................................................................................................7

Nursing Care Plan......................................................................................................................9

Conclusion................................................................................................................................14

Reference..................................................................................................................................15
Case Study - Acute Myocardial Infarction
Introduction
It was narrated in Sahih Buhari that the Prophet (peace be upon him) said, "There are

two blessings which many people do not appreciate: Health and free time" (Bukhari, n.d.,

Book 81, Hadith 1). Health is an important virtue in a person’s life that must be always cared

for. However, the fact that publications by the Ministry of Health (2020) reported most deaths

in the Maldivian communities as a cause of cardiovascular diseases (CVDs) enlightened on

how health has been neglected today. The document detailed the finding stating that a total of

59% of cardiovascular disease caused deaths composed of males when compared to the

remaining 41% of females. Given the importance of health and statistics of institutions

hinting on the deteriorating level of health in communities, the present case study is going to

unravel the case of a patient with ST segment elevation myocardial infarction. According to

the World Health Organization (2016) ST segment elevated myocardial infarction (STEMI)

is a type of cardiac arrest which occurs when the blood supply to the heart by the artery is

partially or completed occluded and as a result the heart muscles become ischemic, or

necrosis occur.

This is a case study about a 32-year-old male Rajkumari Santhosh (name changed for

confidentiality) who came to ADK ER with symptoms of myocardial infraction. After seeing

elevations in ECG and positive cardiac biomarkers patient was sent to Cath lab to perform a

coronary angiography and percutaneous coronary intervention. Patient was shifted to CCU

for further monitoring Moreover, as per any case study, the outline of this assignment has

been formulated to address clinical topics of the specific case such as. nursing assessment of

the patient, the diagnosis of his primary illness, myocardial infraction by using diagnostic

criteria, along with the causes/ risk factors contributing to myocardial infarction.

Additionally, medical management including pharmacological and non-pharmacological

treatment, a nursing care plan related to the main complaints of the patient, and a concept
map in relation to the pateint. To sum up the analysis, the case study will summarise the most

prominent takeaways from the whole case study to provide a brief and concise conclusion

along with recommendations to fill the gaps identified in practice on the study which was

conducted on the case.

Nursing Assessment

History
Azaan is a married man with no children, he was a smoker but quitted 2 years ago he

also mentioned that in July 2022 he was prescribed cholesterol medicine (Crestat 10mg HS

(only at night)) but after some time he stopped taking it. He had no past surgical history, but

both of his parents have hypertension. On top of that he mentioned that his grandfather

passed away after suffering from a heart attack. Azaan presented to the Emergency room of

ADK with a history of chest pain since last night (8/5/24) and was radiating to his shoulder

and left arm. He took some medication (paracetamol 650mg) for pain relief hence it subsided.

According to him pain started to increase at 1am and he finds difficulty in breathing.

Physical Assessment

The main goal of performing the physical assessment was determining the overall

health and signs that may complicate the patient’s diagnosis and treatment. By focusing on

cardiovascular changes a physical examination was done Vitals were recorded Blood

pressure: 100/80 mmhg, pulse rate: 125 bpm, respiratory rate 30, temperature 37.2 and Spo2

at 87%. A cardiovascular physical examination begins with inspection this can be achieved

by assessing skin colour and perfusion for both central and peripheral cyanosis and pallor

especially on the palms, conjunctiva, or inner lower lip in darker-skinned patients. It is also

important to check for Jugular Vein Distension (JVD), jugular vein distension indicates right

side heart failure and sometimes pulmonary edema (Claire et al., 2021). Inspect the

precordium for deformities, scars, or abnormal pulsations. Note the presence and type of
edema, assessing the depth and rebound time. Look for signs of Deep Vein Thrombosis

(DVT) such as unilateral warmth, redness, swelling, and pain in the calves. During palpation,

compare the rate, rhythm, and quality of peripheral pulses bilaterally (carotid, radial, brachial,

posterior tibialis, dorsalis pedis), and assess capillary refilling time. Detect any heaves or

thrills on the anterior chest wall, indicative of severe right ventricular hypertrophy. for

auscultation, listen to heart sounds at the Aortic, Pulmonic, Tricuspid, and Mitral areas (,

identifying S1 and S2 sounds, heart rate rhythm, and any extra sounds like murmurs, S3, S4,

and pleural friction rubs. Additionally, auscultate the carotid artery for bruits, which indicate

atherosclerosis. This systematic approach ensures a thorough evaluation of the cardiovascular

system. In relation to the patient no abnormal observation was seen in the patient.

Disease Condition

Pathophysiology in relation to signs and symptoms

Myocardial Infraction often begins when there is a build-up of atherosclerosis which

contains fatty acid and cholesterol causing the coronary arteries to narrow, because of this

there is reduced blood flow to the cardiac muscles causing ischemia followed by reduced

oxygen supply symptoms such as dizziness, shortness of breath and chest pain occurs. Over

the time this plaque ruptures and blood clot forms occluding the artery completely. Due to

this occlusion the blood flow to the heart is completely stopped from the coronary arteries to

the cardiac muscles. As a result of inadequate oxygen and nutrients the affected tissue or

myocardial cells occur affecting the heart’s oxygen demand and supply irreversible damage

can occur to the cardiac muscles can if blood flow is not restored (Hinkle & Cheever2018).

Causes and Risk Factors


The most crucial step in early detection, intervention, and treatment would be laying

out the risk factors associated with the disease. According to Benjamin et al. (2019) the

disease (STEMI) has several identified risk factors associated with it. These include the main

risk factor being atherosclerosis, followed by hypertension and dyslipidaemia (Libby et al.,
2011; Sarwar et al., 2010). With such broad risk factors, it emphasises how easily one can be

liable to the dangers of STEMI without proper awareness on preventing the risk factors. For

instance, there are many causes to hypertension such as stress, and other biological factors

including genetics. Furthermore, it is worth noting that the reason for atherosclerosis being

the main risk factor for STEMI is because of the nature of the occurrence. Atherosclerosis

occurs due to the accumulation and build-up of plaque in the coronary artery, which is the

main artery to the heart (Ference et al., 2021). Therefore, mitigating the risk factors of

STEMI requires the individual to adopt a healthy lifestyle that elevates all areas of health in

life. Going in depth with the present case, the patient was a previous smoker, with a family

member also being diagnosed with hypertension. These markers make the patient, Azaan, a

liable target for STEMI. It also reinforces the authenticity of the stated risk factors.

Moreover, it helps to rule out what could have been the causes for the diagnosis of Azzan

with ST-segment elevation myocardial infarction (STEMI).

Diagnosis
The global prevalence of MI in individuals < 60 years was found 3.8%. (Salari et al.,

2023), Studies done by Michaud et al. (2019) revealed the diagnosis criteria for acute

myocardial infarction divides into 4 major components which are elevated cardiac troponin

levels, ECG changes followed by evidence ischemic symptoms and identification of

thrombus in coronary angiography. Some of the signs and symptoms present in Azaan

include chest pain radiating to the neck and shoulders followed by shortness of breath and

dizziness. Chest pain is the most common symptom in myocardial infarction which can be

radiating to neck jaw or shoulder sometimes other times it can be only central to the heart the

pain is often described as squeezing or tightness in the chest other symptoms include

shortness of breath, light-headedness, nausea and vomiting (Kumar Singh & Kumar Jat,

2022). Regarding these four components, STEMI can be diagnosed by several ways including

angiography of the coronary artery and heart to identify any clots, by ischemic symptoms as
shortness of breath, by specific changes revealed in ECG reports, and elevated troponin I

from blood tests (Salari et al., 2023). In the case of Azaan, he reported to the hospital with

pain in the chest and shortness of breath. Furthermore, it is highly probable that the history of

smoking and presence of several risk factors along with blood tests led to the discovery of

STEMI.

Electrocardiogram
Technology has boosted the medical industry to another level, helping doctors and

nurses more efficient care to patients. Regarding the current case study, one of the most

significant pieces of equipment throughout the study is the repeated mentioning of the

electrocardiogram (ECG). This equipment becomes a significant stone in diagnosing and

intervening the diagnosis of STEMI and other related diseases. It is important to take an 12-

lead ECG within 10 minutes of a patient reporting substantial pain on the chest area (Hinkle

& Cheever, 2018). ECG can show several types of changes, such as T-wave inversion, ST-

segment elevation, and abnormal Q waves In a case of STEMI, the ST segment is elevated 1

mm above the isoelectric line, measured 0.06 to 0.08 seconds after the QRS complex at the J

point, hence, leading to the diagnosis of STEMI (Hinkle & Cheever, 2018). In relation to the

patient the ECG revealed elevation in lead III and AVF suspecting an inferior myocardial

infarction and a blockage in the right coronary artery (RCA).

Cardiac Biomarkers
One of the most useful tests to determine any cardiac damage or to confirm the

diagnosis for myocardial infarction is checking troponin level of the patient. Blood tests

reveal that Troponin I increase in 4 to 6 hours, peaks at 12 hours, and returns to base level in

3 to 10 days, where troponin-T stays elevated for 12 to 48 hours and falls to base in 10 days

unlike Troponin I. Another test to determine cardiac damage is CK-MB even though it
usually elevates 6 to 12 hours, troponins show elevation in most AMI cases within 2 to 3

hours of arrival. (Morton & Fontaine, 2018). In relation to the patient Azaan’s cardiac

biomarkers are elevated which confirmed the diagnosis of acute myocardial infarction.

Investigations Normal Patient

Troponin I 0-0.04 mg/dL 7.90mg/dL

CK <180 mg/dL 390 mg/dL

CKMB <25 mg/dL 62.5 mg/dL

INR < 1.1 0.99 mg/dL

HDL >40 mg/dL 30 mg/dL

LDL <100 mg/dL 327 mg/dL

Triglycerides <150 mg/dL 268 mg/dL

Coronary Angiogram with Percutaneous Coronary Intervention


A coronary angiogram with percutaneous coronary intervention was performed on the

patient. On Angiogram it was revealed that there is blockage in the right coronary artery just

as suspected from ECG and was 95% blocked hence PCI was performed to RCA via the right

femoral artery. The angiogram, as explained previously in the case study, refers to the

observation of blood clots in the coronary artery to the heart. Such an observation can help to

intervene on a diagnosis for treatment in a short period of time. Percutaneous coronary

intervention is an intervention strategy where surgeons use a stent to keep open a narrowed

blood vessel to increase blood flow using a catheter insertion (Knuuti et al., 2020).

Echocardiography
Echocardiography is a crucial tool used in medical field while diagnosing and

assessing patients with myocardial infarction, it can detect regional wall motion abnormalities

caused by ischemia almost immediately after onset, at the same time it can also assesses right

ventricle infarction and provides valuable findings (Thygesen et al., 2018). Additionally, it

identifies some of the complications arise mechanically during MI such as pericarditis,

pericardial effusion, and cardiac tamponade (Tsega et al., 2023). In relation to the patient an

urgent echocardiography was done since elevation was seen in the inferior side of the heart as

right coronary also supplies blood to both right atrium and right ventricle, hence the

echocardiography was done to rule out any wall abnormalities due to reduced blood flow to

the inferior side, but the echocardiography report was normal.

Medical Management

Non- pharmacological Management

As people say, prevention is better than cure. It is important for patients recovering

from myocardial infarction to adopt a healthy lifestyle, including smoking cessation, regular

physical activity, and following a healthy diet rich in vegetables, fruits, fish, and whole grains

while reducing the intake of red meat, butter, and full-fat dairy products. (Qian et al., 2024).

exercise-based cardiac rehabilitation, initiated early and tailored to the individual, has been

shown to positively impact disability, quality of life, and reduce morbidity and mortality in

both post-MI and other cardiovascular condition patients (Gomes et al., 2019). Additionally,

intensive management of atherosclerosis risk factors, such as controlling blood pressure,

diabetes, and hyperlipidaemia, is essential in the treatment and ongoing care of these patients

(Yadav et al., 2022). By implementing these non-pharmacological interventions, individuals

recovering from myocardial infarction can improve their prognosis, enhance their quality of

life, and reduce the risk of recurrent cardiovascular events.


Pharmacological Treatment

Below are medications given to the patient during the hospital stay
Injection Pantoprazole 40 mg twice a day

Group Proton pump inhibitor

Mechanism Works by inhibiting the enzyme namely hydrogen-potassium

of action adenosine triphosphate in the gastric parietal cells by decreasing the

gastric acid production.

Indication Gastroesophageal reflux disease (GERD), severe erosive esophagitis,

gastritis (For Azaan) (Kizior & Hodgson, 2019).

Side effects Rash, headache and diarrhoea. Patient had no side effects

Health Advise the patient to report signs such as rash, diarrhoea or headache.

education Educate the patient regarding the indication and side effects of the

medicine.

Encourage the patient to take medicine before food.

Injection Paracetamol 1g twice a day

Group Analgesics

Mechanism works by blocking the prostaglandin synthesis in central nervous system


of action and block pain impulses through peripheral action.

Indication fever and pain

Side effects Abdominal pain, flatulence, belching and vomiting Patient had no side
effects.

Health Educate the patient regarding the indication and side effects of the
education
medications.

Advise the patient not to skip any doses and to take it regularly as

prescribed by the doctor (Waller & Sampson, 2014).


Tablet Clonazepam 0.25mg twice a day

Group Benzodiazepine/ Antixylotics class

Mechanism works by depressing the nerve impulse transmission.


of action

Indication Panic attacks, anxiety disorders and seizure disorders. In related to Azaan
given for anxiety and restless behaviour.

Side effects confusion, blurred vision, weakness, and irritation. Patient had no side
effects.

Health Educate the patient regarding the indication and side effects of the
education medications, advise the patient not to skip any doses and to take it regularly
as prescribed by the doctor (Basit, 2023).

Syrup Duphalac 15ml once a day

Group Lactulose

Mechanism used to relieve constipation and reduce straining during bowel movements.
of action In the colon, lactulose is metabolized by bacteria into acids, increasing
osmotic pressure and drawing water into the bowel, which softens stools
and makes them easier to pass. This action reduces the need for straining,
helping alleviate discomfort associated with hard stools and constipation.

Indication To avoid constipation so that he can avoid straining while passing stool,
straining can increase myocardial workload.

Side effects rash, anaemia and jaundice. Patient had no side effects

Health Teach the patient the use and how the medicine works, educate the patient
education
regarding the side effects and advise to report them (Skidmore-Roth, 2024).

Tablet Ecosprin (loading dose 300mg) 75mg once a day

Group Antiplatelet
Mechanism irreversibly inhibits COX-1 in platelets, leading to decreased synthesis
of action of thromboxane A2, a potent promoter of platelet aggregation. This
antiplatelet effect reduces the risk of clot formation, which is particularly
beneficial in preventing myocardial infarctions.

Indication chest pain, strokes and prevent formation of blood clots in blood vessels.

Side effects gastric irritation, bleeding nausea and heartburn Patient had no side
effects.

Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it

regularly as prescribed by the doctor (Kizior et al., 2016).

Tablet Ticagrelor (loading dose 180mg) 90mg twice a day

Group P2Y12 platelet aggregation inhibitor

Mechanism By blocking the P2Y12 receptor, ticagrelor prevents adenosine


of action diphosphate ADP from binding to it. This inhibition reduces the
activation of the GPIIb/IIIa receptor complex, which is essential for
platelets to form a clot. ticagrelor effectively reduces platelet
aggregation, decreasing the likelihood of clot formation.

Indication unstable angina NSTEMI, STEMI, and patients undergoing


percutaneous coronary intervention (PCI).

Side effects Atrial fibrillation, bleeding, fatigue, and hypertension. Patient had no
side effects.

Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it

regularly (Skidmore-Roth, 2015).


Tablet crestat (loading dose 180mg) 20mg once a day

Group Antihyperlipidemic drug (Statin)

Mechanism Interferes with cholesterol biosynthesis by inhibiting the conversion of the


of action enzyme HMG-CoA to mevalonate, a precursor to cholesterol by decreasing
LDL cholesterol and plasma triglyceride levels, increases HDL
concentration.

Indication Hyperlipidaemia, dyslipidaemia

Side effects Dyspnea, nausea, dizziness and constipation Patient had no side effects

Health Educate the patient regarding the indication and side effects of the
education
medications, Advise the patient not to skip any doses and to take it regularly

as prescribed by the doctor (Skidmore-Roth, 2021).

Nursing Care Plan

Nursing Diagnosis 1: Decreased cardiac output related to Impaired myocardial

Infarction as evidenced by a report of chest pain radiating to left arm including shoulders and

shortness of breath spo2 level at 87% in room air.

Goal: With Proper nursing interventions and care, the patient's cardiac output will be normal

with normal Blood pressure and absence of shortness of breath within 24 hours.

Nursing Intervention Rationale Implementation

Assess and monitor To form baseline data and to Patient BP 100/70 mmhg, pulse

patient vital signs hourly. prevent further complications. 100 bpm, RR 24 bpm SP02 87%.

Patient is tachypnoeic.
Auscultate heart and Helps to identify S3/S4 heart Auscultated both heart and lung

lung sounds 4th hourly. sounds with muffled tones, sounds. No abnormal lung

tachycardia, irregular heart rate sounds(wheezes, crackles)Patient

(Doenges et al., 2010). is tachypnoeic.

Palpate peripheral Decreased cardiac output may Peripheral pulse is regular and

pulses. be reflected in diminished radial, strong.

popliteal, dorsalis pedis, and

post-tibial pulses (Doenges et

al., 2010).

Keep the patient in Helps to expand the lungs and Patient on Fowler's position and

fowler’s position. helps to promote venous return patient is comfortable.

and facilitate oxygen (IŞILDAK

et al., 2023).

Administer stool Helps to reduce straining during Patient receiving syrup EVA-Q

softeners as prescribed bowel movements. 15ml HS.

by the doctor.

Administer oxygen as To maintain adequate ventilation Administered 4l of oxygen via

per doctor’s order (Rengasamy et al., 2021). Nasal prongs.

Evaluation: With proper nursing interventions and care, patient BP was normal along with a

normal pulse, respiratory rate and was maintaining oxygen at Room Air within 24 hours.

Nursing Diagnosis 2: Acute pain related to MI and surgical procedure (angiography)


and PCI as evidenced by patient verbalization at a pain score of 8/10.

Goal: Proper nursing interventions and instilling care for 8 hours, patient will feel reduced

levels of pain due to intervention

Nursing intervention Rationale Implementation

Assess patient pain level Helps to identify key symptoms Assessed patient pain level,

severity, location, onset, regarding the condition which pain radiating to shoulders,

duration if the pain is may deteriorate patient’s health pain level is at 7/10.

radiating or not. further.

Put the patient on complete Reduces myocardial oxygen Patient on complete bed rest

bed rest until doctor’s order. demand to minimise the allowed to mobilise after 10

increase of tissue damage. hours.

Maintain a quiet and Mental or emotional stress may Maintained a quiet

comfortable environment to increase myocardial demand. comfortable environment for

the patient. the patient.

Monitor ECG elevations. Ischemia during angina attack Monitored ECG changes no

may cause transient ST elevation or t wave

ST-segment depression or depression found.

elevation which provide a

baseline against which to

compare later pattern changes

in diagnosing STEMI (Doenges

et al., 2010).

Administer supplemental Increases oxygen available for Administered supplemental


oxygen as per doctor’s cardiac muscles. oxygen 4L via nasal prongs.

order.

Administer analgesics as per To decrease pain level of the Administered Paracetamol 1

doctor's order. patient. gram intravenously.

Nursing Diagnosis 3: Anxiety related to deficient knowledge regarding the disease condition,

management, medication and treatment as evidenced by frequent questioning and restless

behaviour of the patient.

Goal: Adequate information regarding the disease condition, medications and treatment will

be provided decreasing the anxiety

Nursing Intervention Rationale Implementation

Assess the patient's Helps to identify areas of lack of Assessed the level of

knowledge about knowledge, misinformation and understanding of the disease

disease conditions and provide necessary information knowledge.

treatment possibilities. (Makic & Martinez-Kratz, 2023).

Educate the patient Helps the patient to have a better Educated the patient about the

regarding disease understanding about the disease disease condition such as risk

condition. and reduce anxiety making the factors, causes and types.

patient more comfortable during

treatment and procedures (Makic

& Martinez-Kratz, 2023).

Provide authentic and Reduces fear and instils assurance Provided accurate information
correct information in treatment making the patient about the care and treatment of

about the care, relax and more comfortable while the patient.

management and about providing care.

the patient's disease.

Treat the patient in a Reduces fear and anxiety and Treated the patient in a

supportive and calm provides patients with a more supportive and a calm manner.

manner. comfortable treatment.

Administer Anti- Helps to reduce anxiety and Patient receiving clonazepam

anxiety medications. restlessness which making patient 0.25mg twice a day.

calm.

Evaluation: with proper nursing interventions and care of 24 hours patient anxiety was

decreased.

Nursing Diagnosis 4: Risk for bleeding related to surgery such as PCI and CAG along with

anticoagulation medications.

Goal: with proper nursing interventions and care, patient’s will be free from any kind of

bleeding.

Nursing Intervention Rationale Implementation

Assess vital signs Helps to identify potential Vitals are closely monitored.

especially BP and pulse bleeding factors as sometimes Blood pressure:125/76

hourly. hypotension can be a sign of mmhg, pulse 120bpm.

bleeding.

Assess for Signs and Frequent assessment for signs of No signs of bleeding present
symptoms of Bleeding. bleeding (e.g. hematomas at the in the patient observed.

surgical site, blood in urine or

stools) (Gulanick & Myers, 2022).

Monitor both haemoglobin Helps to detect early signs of Patient haemoglobin and

and haematocrit levels of bleeding (Gulanick & Myers, haematocrit level is normal.

the patient. 2022).

Administer Anticoagulants Ensures therapeutic levels are Administered anticoagulants

as Prescribed and Monitor maintained, minimising the risk of and monitoring patient

Coagulation factors. both bleeding and thrombosis. coagulation factors.

(Gulanick & Myers, 2022).

Apply Pressure to catheter Applying manual pressure on the Applied pressure while

site after removal. catheter insertion sites prevents removing the catheter for 15

bleeding and hematoma formation mins to prevent any sort of

and since patient did surgery on bleeding.

radial artery and is on medications

that can increase the risk of it

(Gulanick & Myers, 2022).

Educate the Patient on the Educating the patient such as Educated the patient

warning signs of bleeding feeling dizziness or pain or dark regarding warning signs of

and to report them. or bloody stools ensuring no bleeding.

symptoms go unnoticed.
Evaluation: patient is free from any risk of bleeding with proper nursing interventions and

care.

Recommendation

According to research done by (Candjondjo et al., 2022) STEMI-CR, a home

monitoring program for ST Elevation Myocardial Infarction (STEMI) patients, utilizes digital

tools like mobile apps and websites to deliver cardiac rehabilitation services remotely. It

enables real-time monitoring of Patient Reported Outcomes Measures (PROMs) and

biometric/electrocardiographic data, integrated into hospital records. The platform includes

exercise prescription, dietary guidance, symptom recording, and gamification features to

enhance patient engagement. By combining pharmacological and non-pharmacological

interventions, STEMI-CR aims to improve patient adherence to rehabilitation programs can

positively impact prognosis in MI management within the Maldives healthcare system also.

Here is a concept made in relation to the patient


Conclusion
Through the analysis of the case, it is evident that ST- segment elevated myocardial

infarction is a severe acute heart attack that often can be fatal. Given the statistics of the high

frequency of fatalities due to cardiovascular diseases, more awareness and modern

intervention strategies are required to reduce the high number of fatalities. Furthermore, the

case study has thoroughly analysed and provided nursing care plans developed for Azaan

along with the medications that are prescribed for treatment of STEMI. As strongly

elaborated in the assignment, the prevention and early detection of such life-threatening

diseases can mean life and death at times. Therefore, providing clear and concise information

to vulnerable populations regarding mentioned risk factors are essential to promote a

healthier community in the Maldives and other landscapes.


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