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📚 assessmentmedium

A patient with metastatic breast cancer remains ambulatory but can no longer perform any housework or hobbies. She is fully independent with all ADLs, has a normal appetite, and is fully alert. What is her Palliative Performance Scale (PPS) score?

#assessment#PPS
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Card #1
Answer
PPS 70%. Rationale: The patient is Ambulatory with Reduced activity (cannot do hobby/work), but Full self-care. HPCC Exam Tip: The key differentiator between 70% and 60% is self-care. At 70%, self-care is Full. At 60%, the patient requires Occasional Assistance. Even with Extensive Disease, the highest level of function in any category usually anchors the score toward the higher percentage, but Ambulation is the primary guide.
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Card #1
2
📚 assessmentmedium

A patient with end-stage COPD spends the majority of the day sitting in a recliner. He can walk short distances to the bathroom with a walker but requires help with bathing and dressing. Intake is reduced. What is the PPS score?

#assessment#PPS
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Card #2
Answer
PPS 50%. Rationale: The patient is Mainly Sit/Lie and requires Occasional Assistance for self-care. His activity level is Unable to do any work with Extensive Disease. Clinical Pearl: PPS 50% is a major clinical milestone often used for hospice transition discussions. The patient has moved from being primarily mobile (60%) to primarily sedentary (50%). Distinguish from 40% where the patient is Mainly in Bed.
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Card #2
3
📚 assessmenthard

A patient with advanced dementia is now bedbound and requires total assistance for all ADLs and feeding. She takes only small sips of liquids and is frequently drowsy or confused. What is the most accurate PPS score?

#assessment#PPS
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Card #3
Answer
PPS 20%. Rationale: Bedbound, Total Care, Minimal Sips, and Confusion/Drowsy all align with PPS 20%. Exam Tip: To distinguish 20% from 10%, look at intake and LOC. PPS 20% involves Minimal Sips and Confusion/Drowsy, whereas PPS 10% involves Mouth care only and Coma. Both require Total Care and are Bedbound.
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Card #3
4
📚 assessmentmedium

When using the PPS to assess a patient, you find that Ambulation is Mainly in Bed, Self-Care is Total Care, and Intake is Normal. Following the Left-to-Right rule of PPS interpretation, what is the score?

#assessment#PPS
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Card #4
Answer
PPS 30%. Rationale: The PPS is read from left to right. Ambulation is the primary determinant. If a patient is Mainly in Bed, they could be 40% or 30%. However, the Self-Care category for 40% is As mainly assistance, while 30% is Total Care. Since the patient requires Total Care, the score drops to 30% despite Normal intake. HPCC Exam Strategy: Always prioritize the leftmost columns (Ambulation, Activity, Self-Care) over the rightmost (Intake, LOC).
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Card #4
5
📚 assessmenthard

A patient is able to walk around the house but requires assistance with most ADLs due to significant fatigue and weakness. They are unable to perform any household chores. Intake is normal and they are alert. What is the PPS score?

#assessment#PPS
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Card #5
Answer
PPS 60%. Rationale: The patient is Ambulatory, but the presence of Occasional Assistance for self-care and being Unable to do any work/hobby confirms 60%. Exam Tip: Distinguish 60% from 50% by looking at Ambulation. At 60%, they are still Ambulatory (can walk). At 50%, they are Mainly Sit/Lie. Assistance at 60% is usually for more complex tasks (bathing/dressing), whereas 70% is completely independent.
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Card #5
6
📚 assessmentmedium

A patient with glioblastoma is bedbound, requires total care for all needs, and is in a deep coma. They are no longer taking any oral fluids. What is the PPS score?

#assessment#PPS
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Card #6
Answer
PPS 10%. Rationale: The defining features of PPS 10% are Bedbound, Total Care, Mouth care only (no intake), and Coma. This represents the final stage of the scale before death (0%). Clinical Pearl: PPS 10% is a critical indicator for the nurse to initiate final hours/imminent death protocols and support the family in the active dying phase.
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Card #6
7
📚 assessmentmedium

A patient with Stage IV renal cell carcinoma is Mainly in Bed but is able to assist slightly with their own sponge bath and can use a urinal independently. They can no longer do any work. What is the PPS score?

#assessment#PPS
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Card #7
Answer
PPS 40%. Rationale: The patient is Mainly in Bed with Extensive Disease and requires Mainly Assistance for self-care. The fact that they can participate in some self-care (using a urinal, assisting with a bath) prevents a score of 30%, which requires Total Care. HPCC Tip: 40% is often the threshold where prognosis is measured in weeks rather than months.
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Card #7
8
📚 assessmenthard

A patient with ALS is bedbound and requires total care. He remains fully alert and is able to swallow a pureed diet with significantly reduced intake. What is the PPS score?

#assessment#PPS
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Card #8
Answer
PPS 30%. Rationale: Despite being Full in the Level of Consciousness (LOC) column, the patient is Bedbound and requires Total Care, which anchors the score at 30%. Rationale: The leftmost columns (Ambulation and Self-Care) carry more weight in the calculation than the rightmost (LOC). In neurodegenerative diseases like ALS, LOC often remains Full even when the PPS is 30% or 20%.
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Card #8
9
📚 assessmenthard

Which PPS level is the highest at which a patient is first described as having Extensive Disease and being Unable to do any work?

#assessment#PPS
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Card #9
Answer
PPS 50%. Rationale: According to the PPS v2 tool, 60% is defined as Significant disease and Reduced activity. The transition to Extensive disease and Unable to do any work occurs at the 50% level. This is a high-yield exam fact because it marks the transition to a more advanced disease state where the focus shifts heavily toward palliative symptom management and away from functional maintenance.
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Card #9
10
📚 assessmenthard

In a 2026 palliative care setting, a patient's PPS score drops from 60% to 40% over a 4-week period. What is the most important clinical implication for the CHPN to communicate to the interdisciplinary team?

#assessment#PPS
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Card #10
Answer
The rapid decline (20% drop in 1 month) is a strong prognostic indicator of shortened survival and suggests the need for a hospice eligibility reassessment. Rationale: While single PPS scores are helpful, the velocity of decline is more predictive of mortality. A drop to 40% or below is statistically associated with a higher risk of death within weeks. HPCC focuses on the nurse's role in identifying these trends to facilitate timely goals-of-care conversations and hospice referrals.
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Card #10
11
📚 assessmentmedium

A patient requires assistance with bathing and dressing but remains continent of bowel and bladder. According to the FAST scale, which stage is this patient currently in?

#assessment#dementia#FAST
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Card #11
Answer
FAST Stage 6 (Moderately Severe Dementia). Stage 6 is subdivided: 6a (Improperly putting on clothes), 6b (Unable to bathe properly), 6c (Unable to handle mechanics of toileting), 6d (Urinary incontinence), 6e (Fecal incontinence). Since the patient is continent, they are at 6b. Exam Tip: HPCC often tests the sequence of 6a-6e. Incontinence marks the end of Stage 6, while dressing/bathing deficits occur earlier.\n\nClinical Pearl: Stage 6 represents the loss of basic ADLs while Stage 5 is the loss of IADLs and clothing selection.
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Card #11
12
📚 assessmenthard

To meet Medicare Local Coverage Determination (LCD) for hospice with a primary diagnosis of Alzheimer's, what is the minimum FAST stage required, and what additional clinical finding must be present?

#assessment#hospice#eligibility
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Card #12
Answer
Minimum FAST Stage 7c. Additionally, the patient must have one or more specific complications in the past 12 months: aspiration pneumonia, pyelonephritis/UTI, septicemia, decubitus ulcers (Stage 3-4), or persistent fever after antibiotics. Clinical Pearl: FAST 7c means the patient cannot walk without assistance. LCD requires functional decline and nutritional impairment (e.g., >10% weight loss or albumin <2.5). HPCC exams frequently link FAST stages to hospice eligibility and the rule of 7s.
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Card #12
13
📚 assessmenthard

A hospice patient with dementia has lost the ability to sit up independently and can no longer smile. Which specific sub-stage of the FAST scale does this represent?

#assessment#dementia#FAST
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Card #13
Answer
FAST Stage 7e. Sequence of Stage 7: 7a (Speech limited to ~6 words), 7b (Single intelligible word), 7c (Ambulatory ability lost), 7d (Ability to sit up lost), 7e (Ability to smile lost), 7f (Ability to hold head up lost). Strategy: HPCC tests the downward progression. Inability to smile (7e) is a late-stage marker often seen near end-of-life. Remember: 7c (walking) is the threshold for hospice, but 7d-7f tracks progression toward death.
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Card #13
14
📚 assessmentmedium

A patient can no longer manage complex tasks like finances or planning a dinner party but can still perform basic ADLs and live at home with minimal support. Identify the FAST stage.

#assessment#dementia#FAST
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Card #14
Answer
FAST Stage 4 (Mild Dementia). This stage involves decreased ability to perform complex tasks (IADLs). Stage 5 (Moderate Dementia) begins when the patient can no longer survive without some assistance and specifically struggles with choosing proper clothing for the weather/occasion. Distinction: Stage 4 = IADL deficit; Stage 5 = Early ADL deficit (clothing choice). For the CHPN exam, Stage 4/5 patients are rarely hospice-eligible without a secondary terminal diagnosis.
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Card #14
15
📚 assessmentmedium

In the progression of Stage 6 dementia, which functional deficit typically occurs immediately BEFORE the onset of urinary incontinence?

#assessment#dementia#FAST
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Card #15
Answer
FAST Stage 6c: Inability to handle the mechanics of toileting (e.g., forgetting to flush, wiping improperly, or adjusting clothing). Sequence: 6a (Dressing) -> 6b (Bathing) -> 6c (Toileting mechanics) -> 6d (Urinary incontinence) -> 6e (Fecal incontinence). Exam Strategy: Note that mechanics of toileting (6c) fails before biological control (6d/6e) is lost. This distinction is high-yield for determining the exact level of care needed.
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Card #15
16
📚 assessmenthard

An Alzheimer's patient is FAST 7a. They have lost 12% of body weight in 6 months and have a Stage 3 pressure injury. Do they meet the structural requirements for hospice eligibility for dementia?

#assessment#hospice#eligibility
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Card #16
Answer
No. While they meet the nutritional (weight loss >10%) and co-morbidity (Stage 3 ulcer) criteria, they do not meet the FAST stage requirement. Hospice LCD typically requires FAST Stage 7c or beyond (loss of ambulation). 7a (speech limited) is insufficient for the primary diagnosis of dementia hospice entry, regardless of other factors. Exam Tip: Many students miss this because they see the complications and assume eligibility, but the FAST 7c requirement is strict.
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Card #16
17
📚 assessmentmedium

A caregiver reports the patient needs help selecting clothes appropriate for the season but can still bathe and dress themselves once the clothes are laid out. What FAST stage is this?

#assessment#dementia#FAST
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Card #17
Answer
FAST Stage 5 (Moderate Dementia). The hallmark of Stage 5 is the inability to choose proper clothing (e.g., wearing a heavy coat in summer). This is the transition point where the patient can no longer survive without assistance. They may still be able to physically bathe/dress (Stage 6 tasks) once the decision-making step is handled. HPCC emphasizes this stage as the loss of independence marker.
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Card #17
18
📚 assessmenthard

A patient's speech is limited to Yes, No, and Thank you, used repeatedly throughout the day. Which FAST stage does this represent?

#assessment#dementia#FAST
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Card #18
Answer
FAST Stage 7a. Stage 7a is defined as speech limited to approximately a half-dozen (6) intelligible words or fewer in an average day. Stage 7b is defined as the loss of all intelligible vocabulary except for a single intelligible word (e.g., Yes or Okay) used repeatedly. Documentation Tip: Be precise with word counts as these are key for hospice recertification. If the patient has 3-5 consistent words, they are 7a.
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Card #18
19
📚 assessmentmedium

Which tool is often preferred over the MMSE in hospice for tracking end-stage dementia decline, and why?

#assessment#dementia#FAST
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Card #19
Answer
The FAST scale is preferred because it tracks functional decline through the final stages of life (7a-7f), whereas the MMSE has a floor effect. By the time a patient is hospice-eligible, they usually score 0-5 on the MMSE, making it impossible to measure further decline. The FAST scale allows nurses to document continued progression (e.g., moving from 7c to 7d) which supports ongoing hospice eligibility and recertification.
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Card #19
20
📚 assessmenthard

A patient with Frontotemporal Dementia (FTD) maintains the ability to walk but has total aphasia. Why might the FAST scale be an unreliable prognostic tool here?

#assessment#dementia#FAST
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Card #20
Answer
The FAST scale was specifically developed for Alzheimer's Type Dementia, which follows a predictable, ordinal pattern of functional loss (reverse development). Non-Alzheimer's dementias (FTD, Lewy Body, Vascular) often do not follow this sequence; a patient might lose speech (7a) while remaining fully ambulatory (Stage 5/6). For CHPN, remember FAST is the Gold Standard for Alzheimer's but has significant limitations in other types where deficits are non-sequential.
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Card #20
21
📚 assessmentmedium

A patient with metastatic lung cancer is ambulatory and capable of all self-care but is unable to carry out any work activities. They are up and about more than 50% of waking hours. What is their ECOG Performance Status?

#assessment#scales
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Card #21
Answer
ECOG 2. Rationale: ECOG 0 is fully active; ECOG 1 is restricted in strenuous activity but ambulatory; ECOG 2 is Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours. This is a critical threshold; patients falling to ECOG 2 or higher often experience a shift in goals of care toward palliation. HPCC Tip: Distinguish ECOG 2 from 3 by the 50% of waking hours rule.
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Card #21
22
📚 assessmentmedium

A hospice patient requires frequent medical care and significant assistance with activities of daily living (ADLs). They are unable to care for themselves. Which Karnofsky Performance Status (KPS) score best represents this patient?

#assessment#scales
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Card #22
Answer
KPS 50. Rationale: KPS 50 indicates the patient Requires considerable assistance and frequent medical care. KPS 60 requires occasional assistance but is able to care for most of his needs. KPS 40 is Disabled; requires special care and assistance. Clinical Pearl: KPS 50% is a common benchmark used in Medicare Local Coverage Determinations (LCDs) to support hospice eligibility for various non-cancer diagnoses.
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Card #22
23
📚 assessmenthard

A nurse assesses a patient who spends 7 hours of a 12-hour daytime period in bed or a chair. The patient is capable of only limited self-care. Applying the ECOG scale, which grade is most appropriate?

#assessment#scales
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Card #23
Answer
ECOG 3. Rationale: ECOG 3 is defined as Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. Since 7 hours is more than 50% of the 12-hour waking period, ECOG 3 is correct. ECOG 2 would be less than 50% of waking hours spent in bed. This distinction is high-yield for the CHPN exam as it often determines eligibility for aggressive palliative treatments versus comfort-focused care.
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Card #23
24
📚 assessmentmedium

A palliative care patient can care for themselves but is unable to carry on normal activity or do active work. Which KPS score is assigned?

#assessment#scales
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Card #24
Answer
KPS 70. Rationale: KPS 70 is defined as Cares for self; unable to carry on normal activity or do active work. KPS 80 is Normal activity with effort; some signs and symptoms of disease. KPS 60 is Requires occasional assistance but is able to care for most of his needs. Exam Strategy: Remember 70 is the tipping point where the patient is still independent in ADLs but can no longer maintain employment or heavy activity.
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Card #24
25
📚 assessmenthard

A patient with end-stage heart failure is disabled, requires special care and assistance, and is mostly bedbound but not yet requiring institutionalization or acute hospitalization. Differentiate between KPS 40 and KPS 30.

#assessment#scales
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Card #25
Answer
KPS 40: Disabled; requires special care and assistance. KPS 30: Severely disabled; hospital admission is indicated although death is not imminent. The distinction lies in the intensity of special care and the need for acute/hospital-level support. In hospice, KPS 40 patients are frequently seen at the time of initial admission, while KPS 30 often indicates a need for increased nursing visits or a higher level of care (like GIP) if symptoms are uncontrolled.
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Card #25
26
📚 assessmentmedium

A terminal patient is completely disabled, cannot carry on any self-care, and is totally confined to bed or chair. What is the ECOG score?

#assessment#scales
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Card #26
Answer
ECOG 4. Rationale: ECOG 4 is the highest level of disability before death (ECOG 5). It represents total confinement to bed/chair and inability to perform any self-care. Clinical Pearl: ECOG 4 is often associated with a prognosis of weeks or days. When documenting for the HPCC exam, ECOG 4 is a strong indicator of hospice appropriateness and the need for intensive family support for total care.
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Card #26
27
📚 assessmenthard

A hospice nurse is documenting the status of a patient who is very sick, requires active supportive treatment, and is moribund with fatal processes progressing rapidly. Contrast KPS 20 and KPS 10.

#assessment#scales
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Card #27
Answer
KPS 20: Very sick; hospital admission necessary; active supportive treatment (e.g., IV fluids, pressors) necessary. KPS 10: Moribund; fatal processes progressing rapidly. HPCC Exam Tip: KPS 10-20 scores are typically seen in the final hours to days of life. Documentation of these scores supports the transition to imminent death protocols and triggers the nurse to prioritize comfort and family presence.
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Card #27
28
📚 assessmenthard

A patient is assessed at ECOG Grade 3. What is the approximate corresponding Karnofsky Performance Status (KPS) percentage range used by the interdisciplinary team (IDT) for prognosticating?

#assessment#scales
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Card #28
Answer
KPS 30% to 40%. Rationale: Generally, the scales correlate as follows: ECOG 0 (90-100%), ECOG 1 (70-80%), ECOG 2 (50-60%), ECOG 3 (30-40%), and ECOG 4 (10-20%). These correlations are vital for IDT communication, as different clinicians may prefer one scale over the other. Most hospice agencies use KPS for Medicare documentation, while oncology-palliative clinics often use ECOG.
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Card #28
29
📚 assessmentmedium

Beyond simple assessment, what is the primary clinical significance of utilizing the KPS and ECOG scales in the palliative setting according to HPCC standards?

#assessment#scales
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Card #29
Answer
Prognostication and Treatment Planning. Rationale: Performance status is one of the most powerful predictors of survival in advanced illness. It guides decisions on whether a patient can tolerate palliative chemotherapy/radiation and helps determine the timing of hospice referrals (typically when KPS falls below 50%). On the CHPN exam, look for questions where the scale result is used to justify a change in the plan of care or to facilitate a surprise question discussion (Would I be surprised if this patient died in 6 months?).
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Card #29
30
📚 assessmenthard

A patient with COPD is restricted in physically strenuous activity but is ambulatory and able to perform light housework or office work. How is this patient classified on the ECOG scale?

#assessment#scales
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Card #30
Answer
ECOG 1. Rationale: ECOG 1 is Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work. The key differentiator from ECOG 0 (fully active) is the restriction on strenuous activity. The differentiator from ECOG 2 is the ability to still perform light work. In non-oncology hospice patients, ECOG 1 may persist for a long duration before a rapid decline.
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Card #30

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