Adam Blatner, M.D.

(Revised September 15, 2006)   For related articles, see  The Art of Case Formulation, on Diagnosis in Psychiatry ,
        The "Real" Diagnostic Variables  ,   Factors in Human Development , and others among my papers..

(For those who have read my recent article on this topic in the Arts in Psychotherapy, 30 (3), 131-135 (September, 2003) or for its earlier appearance in  Resident & Staff Physician, 39(2), 97-103, February, 1993, please note that this webpage offers a fair amount of elaboration and further areas to explore, described in the appendices at the bottom of this article and may be accessed quickly by clicking on the links:)
    Appendix A: Elements to Include in the History of the Present Episode

    Appendix B: Reconstructing the Client's Story

    Appendix C: Other Variables in Diagnosis

    Appendix D: Notes on the Process of Diagnosis and Formulation

    Appendix E: Writing Reports

The Art of Case Presentation

When seeking a consultation, one of the ways to make the best use of your time together is to present the case to the consultant in a clear and succinct fashion. There is an art to this. Effective case presentation is also needed for communicating with other professionals in order to provide more comprehensive care. An additional benefit in learning this skill is that more than most things you can do, presenting clearly and to the point gives the impression of professional competence. So, whether it is on the phone to a referring colleague, in written form in a report, on rounds in a clinic or hospital, in individual or group supervision, peer-group review, preparing treatment plans, or in other settings, the art of case presentation is a ubiquitous challenge. (Further comments on preparing a written report are noted below in Appendix E)

(This website paper is an expanded version of a paper I had published in 1993 in the professional journal, Resident & Staff Physician, and is oriented primarily to the sub-field of psychotherapy.)

The length and completeness of a given presentation varies depending on the context. For example, in a setting where each case is given only a few minutes' attention, the presentation should be distilled to less than a minute or two, just enough to orient the people present as to the identity and key features of the patient being described, along with the most relevant issues of the moment. In a setting where a more leisurely review of the pathogenesis or course of treatment is indicated, a correspondingly more comprehensive presentation is appropriate. Clinicians should learn to present any given case at three levels: in encapsulated form (less than a minute or so), briefly (five minutes), and at length (taking about twenty

Take some time before the presentation to become more clear in what your purpose is in making this presentation. What questions do you want the consultants to answer, or what essential information do you want to communicate to the audience. Recognize that your audience in most cases does not need to know "everything" about the client, but rather is seeking to generate an internal picture of the situation being presented. Beware of "dumping" all sorts of impressions and explanations and expecting your audience to be able to piece it all together--it only overloads them. Ideally, imagine yourself in their role and recognize the basic facts that you need to know just to become oriented to the problem.

Consider, for example, the first thing to present: Your purpose in this communication. Are you just presenting to supervisors in order to let them know who and what you are dealing with? Do you want help with making the diagnosis? Is the diagnosis clear, but you want some help with general approaches to therapy? If you have already begun an approach, are you wanting some feedback or suggestions about specific tactics or techniques in using that approach? This specificity is relevant because what you present initially should not include a lot of information that is peripheral if not irrelevant to the purpose of your presentation.

Editing Your Presentation

In professional training, there is a standard order of categories in history taking, the order having evolved so that those listening to a presentation can remain oriented and think most effectively along with the person speaking or writing. However, that order need not be absolutely adhered to, especially after the presentation moves beyond that beginning phase. (Early in training, the point of the order also has a pedagogic purpose, to ensure that the student remembers the various categories and enquired about them. Later on, though, with experience, you can and indeed must begin to focus more on the most relevant  lines of enquiry.) For example, if you're presenting a case about a teenager with drug abuse and delinquency, and you find that he had been quite healthy and did well at home, school, and with peers until around the age of 12, you might not bother going into a detailed history of this boy's early childhood development, because there are so many other more relevant issues to address. On the other hand, a child who has a complex problem of dysfunctional social interactions from an early age should have the milestones of development presented soon after the description of the presenting problem, because that is quite relevant to the differential diagnosis.

Your audience is consciously or unconsciously involved in constructing a differential diagnosis as they listen to your presentation. (Differential diagnosis in simple terms means: What else could be going on?) Try to make it as easy as possible for them. Except in situations where you are required to follow a fixed format, exercise your own judgment in ordering your facts so that your listeners can get oriented and come to the correct diagnostic conclusions quickly. Even if the process of getting to the correct diagnosis presented a detective mystery for you, it isn't appropriate for you to drag your listeners through all the blind alleys, false leads, and misinterpreted clues which are part of most diagnostic work-ups. Just help them to think along with you, especially in the direction of the questions you are posing.

Psychiatric case presentation involves many different frames of reference--medical (neurophysicological, general medical) factors, psycho-somatic interactions, family dynamics, the patient's educational level, cultural expectations, economic influences, issues of life style, etc. Depending on the purpose of the presentation or the particulars of each individual case, you'll want to emphasize certain categories and might put others more in the

The Purposes of a Case Presentation

Your presentation may involve any number of possible purposes: You may want some help in re-evaluating the diagnosis or formulation of the problem or in developing a comprehensive treatment plan. Perhaps you'll need to fine tune your therapy, seeking some guidance regarding a particular issue, impasse, or sensitive event in treatment. Suggestions about more specific tactical maneuvers require, first, a clear understanding of the patient's dynamics, especially the events in the course of treatment. Questions regarding the initiation or adjustment of medication, the advisability of other types of diagnostic tests, suggestions regarding the utilization of other social agencies, and consultations with other specialists should be stated at the outset of the presentation so the audience can keep these issues in mind.

Perhaps your purpose is didactic, to demonstrate to students or colleagues some particularly interesting diagnostic features, psychological dynamics, or therapeutic technique. Then you'll want to focus on those facts which are relevant to your point and eliminate other information which might be relevant to an exploration of other aspects of the case.

In treatment rounds, your briefer presentations should be aimed at specific goals, such as the adjustment of some policy or privilege in the treatment milieu, to alert staff to some change in the patient's circumstances, or current developments in family or group therapy.

One of the more important purposes of a case summary is transferring the care of a case to a new therapist, referring to another agency or hospital, or returning a referred case to the primary care physician. Again, you should remember to role reverse with the recipients of the information and emphasize the data those people would especially need in their role. A psychiatrist taking on the care of one of your patients would want to know any changes in diagnosis, reasons for the change, changes in medication (specifying dosages and schedules), and medicines which were tried and found relatively unhelpful, as well as the side effects of various drugs.

Beginning The Presentation

A key technique is to package three or four sentences at the very outset with three components: purpose of the presentation, identifying data (ID), and chief complaint (CC). Although you should write these as separate items when they are to be read, such as when following an official clinic or hospital format, these three elements may be interwoven in oral presentation. For example, "John Doe is a six-year-old boy who is being presented for a reconsideration of his diagnosis. He was transferred here from Redland Hospital in Anytown, Texas, two months ago with a diagnosis of childhood schizophrenia, but what we've been observing are behaviors such as excessive clinging, low frustration tolerance, retreat into tearfulness and pouting, along with a clear ability to relate in an immature fashion to peers and staff."

(The examples in this paper tend to address in particular the kinds of cases dealt with in child psychiatry, although most of the principles apply also to general psychiatry, psychological evaluations, family casework, psychosomatic medicine, psychotherapy in general, and related endeavors.)

The point is to orient the audience to what will be discussed. Time and again I've been in conferences where cases were presented without including one (and sometimes any!) of these three elements; instead, the speakers began with circumstantial descriptions of the events leading up to the referral or of the family background and early history. There weren't even indications as to why or how that data fits in with the case. I think the audience should be permitted to interrupt in such cases and request the relevant introductory information.

The purpose of the presentation can be compressed into and mixed with some of the other elements. The identifying data contain a few fixed and several variable components. The identified patient's full name, age, and sex are basic. (In large case conferences, it may be judicious to simply use the patient's initials or the first name and the last initial. It's not always necessary that everyone knows the patient's name.) Then, depending on the context and purpose, include the following items if they're relevant:

(In some traditional training programs, race was routinely included as an element in identifying data at the outset. However, I think we should challenge this. In psychiatry, there are few if any reasons to mention race at the outset; it's an act of consciousness-raising to omit it at this point. If it is relevant, insert this piece of information into the context in which it has meaning.

The Chief Complaint

The next major point is the chief complaint. This phrase is meant to indicate the patient's most obvious concern, or the concern of the main caretakers or referring agencies. It's important to be fairly concrete, in order to communicate a clear picture of the symptomatic behavior.Terms such as "aggressive" or "self-abusive," for instance, are far too general. The purpose here is to give the audience a clear sense of the nature of the problem right at the outset. Try to avoid jargon, although in some cases a classic diagnostic "label" may effectively communicate a good deal. Here are some elements you might include if they are relevant:

• The duration of the main complaints (e.g. since birth, for the previous two years, gradually for four years and then flaring up in in the two months prior to admission, etc.)

• The severity of the problem at present, and in which roles the problem is most notable--i.e., with family, peers, staff, schoolteachers, or therapist (Different complaints may be related to different roles.)

• Discrepancies in the various sources of complaint: The parents, social agencies, the courts, the school, relatives (i.e., Do the courts think one thing but the parents deny that there's any problem?)

• Obvious and definitely contributing factors, such as unusual size, talents, interests, ethnicity, medical conditions, or physical handicaps, or anything striking that has become a source of either stength or major conflict

• Glaring, major trauma, such as recent major losses through death or divorce, catastrophic illness, sexual or physical abuse, etc.

• Major unusual elements in the history, such as being raised in extreme poverty, having parents who are unable or unwilling to come for therapy, or some other social factor

• The presence or absence of a treatment alliance, voluntary or involuntary status, and degree of insight (i.e., Does the patient think s/he has a problem and that this is the appropriate place to deal with it?)

Another example: "Jane Smith is a fifteen-year-old girl who has been at this center for eight months. She was admitted because of drug use--marijuana and occasionally PCP, and associated stealing to buy drugs. There may have been some sexual activity, although Jane has denied it. Although she has improved since coming here, especially in her schoolwork, she continues to be alienated from her peers, avoiding contact and being somewhat surly."

Focusing On The Main Points

Following the introduction, the presenter should address the issues relating to the purpose of the presentation. During the presentation, the consultants or audience may be engaging in the process of differential diagnosis, as mentioned before; the key question is, "What is really going on, what else could be causing these phenomena, and what other factors might be relevant?" The most obvious and common alternatives should be addressed fairly early in the presentation of the "history of the present episode" (HPE).

A helpful technique is to make brief transitional statements which describe the forthcoming process. This helps the audience to change set and become warmed up to the next topic. For instance, one might say something like this: "I'm going to review the specifics of the history of Jane's problem, and then I'll relate these to her family dynamics and how these patterns are continued in her present relationships with her therapist and others in her milieu."

Try to clearly identify the essential beliefs and feelings of the patient which are related to the behaviors. If these are not known, guess, because the next implicit question is, how did s/he learn this pattern? Further medical, family, educational, and social history should be related to this key question. In other words, do not launch into a review of family history--especially in the distant past--without first clearly describing more of the present condition.

First, a careful review of the actual course of the various elements mentioned in the chief complaint usually reveals a wealth of important data. Which ones occurred first, and when and how did the situation worsen? (Some of the other things to include in the history of the present condition are noted in Appendix A.)

After this it makes sense to move backward in time to consider how the patient and his/her family learned these beliefs and patterns of interacting. In addition to stresses, trauma, and events which might precipitate a psychiatric disorder, consider also what experiences were missing in the patient's background, what kinds of learning were neglected or ignored. (For more ideas, see Appendix B)

By the end of an in-depth description of the patient's behavior and how it evolved, there are usually a few different possible associated conditions that might be relevant, such as specific learning disabilities, subtle handicaps, biological disorders, or other common problems. It is appropriate at this point to include any negative findings that would tend to rule out one or another of these possible differential diagnoses.

Formal case conferences deserve at least a half-hour of preparation, outlining what you are going to say ahead of time. Continue to pause and imagine what it might be like hearing this for the first time as you plan your presentation. Have you kept the material oriented to the purpose of your presentation? Can the audience follow the speaker's line of reasoning? If you were hearing this presentation, are there abstract generalizations that leave you wondering, or are there vivid examples in concrete terms so you can almost picture and begin to imagine what it might be like to be the patient or his family members?

Family and Developmental History

To promote your audience's empathy for the patient, try to maintain in your mind a kind of vivid story, starting with the present and going back to meaningful flashbacks. When you then move to the family and developmental history, replay the story again as if it were a movie. Help the consultant-audience imagine what it was like for the patient growing up. The kinds of themes to include are discussed in Appendix B. At this point, the presentation branches off into a wide variety of issues, such as styles of family interaction or positive and negative influences which lead up to the present problem. In presenting the family history, begin with a description of the parental repertoire of behavioral patterns that are relevant to what the patient learned during or just before the onset of the symptoms that are part of the chief complaint. Clarify which behaviors were probably due to lack of information and which behaviors reflected emotional conflicts or defensive patterns in the parents. Only then is it appropriate to explore the parental background--their childhoods and relations to their parents (the patient's grandparents).

(It is a common mistake in presenting a case to launch into a review of the parents' childhoods when there has been no bridge made between these and the child's behaviors. This is a pseudo- psychological cliche, implying that any disturbance of the parental background is somehow automatically reflected in the genesis of the child's disturbance. First, it ignores the fact that children are fully capable of generating their own response patterns. Second, assuming parental psycho- pathology based on their early childhood history denies any healing or compensatory strengths in the parents. It is sloppy reasoning to make these connections on a simple a priori

Remember to include the positive elements in the family and general history. These strengths and helpful influences are crucial to a holistic understanding of the case. Often, those factors that are relevant to why the patient is not more disturbed indicate clues to what might be potential channels for successful therapeutic intervention. Other relevant life experiences should be included at this point, examples of which are noted in Appendix C.

The educational history would be introduced at this point, along with any relevant general information derived from psycho-educational testing (more specific data can be included later). Relevant medical history is also included, if there are further details that are helpful but were not already mentioned in the history of the present condition. Indeed, in a briefer presentation much of the data in this section should be condensed and the most relevant highlights integrated into the history of the present condition.

Mental Status and Course of Therapy

The patient's mental status should be described, both at the time of admission to the present treatment service or the beginning of professional contact with the present therapist, and at the present time. What is included should depend on the probable diagnosis. For example, if there is a question of an organic disorder of the nervous system or a possible underlying disturbance of thought (such as is found in schizophrenia), a more conventional description of the patient's various abilities is required. On the other hand, with most behavioral problems, one would especially focus on a review of dominant attitudes, beliefs, ego strengths, defensive patterns, and the like. One could also include a description of family interaction patterns at this point, recognizing that individual psychopathology may also be viewed as being part of a functioning system. If they're contributory, the results of medical and psychological testing are then presented.

Finally, a general review of the course of therapy brings the case presentation up to the present time. Emphasize any changes in diagnosis, treatment strategies, and possible blocks in any of the forms of therapy--individual, family, group, speech, etc.

Diagnosis and Formulation

Depending on the context, it may or may not be appropriate to go through the process of  noting a formal  descriptive diagnosis according to the criteria established by the DSM-IV. In some situations, this diagnostic process is relevant, and in others, it's less relevant.

Then summarize the case, including your thoughts as to what psychodynamics are most relevant to the situation. Offering a plausible formulation is perhaps the second most professional activity at the case conference (the most professional behavior being the organized, succinct presentation itself). (Some preliminary thoughts about both diagnosis and formulation may be found in Appendix D.) Finally, offer your recommendations or plan of action. Condensing the presentation, your formulation, and recommendations in written form is a related skill discussed in Appendix E.

In summary, the process of case presentation deserves as much attention as the content. Keep in mind the purpose of your presentation and modify your material to maximize the likelihood that your audience or consultant will respond most constructively. Reverse roles (i.e., empathize) with your audience and give them the relevant data appropriate to the time and context. Try to present the data so that the audience can picture the situation and
empathize with the patient and his or her family. Remember, the goal of this exercise is cooperation--and enjoyment!

(Appendices to follow)


Blatner, A. (1993). The art of case presentation. Resident & Staff Physician, 39(2), 97-103.


Here are some other things to include in this HPE:

• What was the family constellation at the onset of the disturbance, and has it changed since then?

• What life events occurred around the time of the beginning or the exacerbation of the symptoms? Some examples might include deaths in the family or other major losses; school failures; unusually early or late puberty; medical illnesses; episodes of physical, emotional, or sexual abuse; emotionally upheavaling or frequent moves; changing family dynamics; other types of trauma; having to live with obvious emotional disturbances or illnesses in key family members, etc.

• How have significant others responded to the "identified patient's" behavior? (i.e., spouses, employers, family members, teachers, or significant others). Or what might they have been going through that might have added stress or even significantly "caused" the patient's reaction?

• If significant others were seeking to cope with the patient's behavior, what responses were helpful, what were ineffective, and what made the behavior worse?

• Note if there was a likelihood of the patient being exposed to the modeling of bossy, angry, disrespectful, anxious, depressed, or similar types of behaviors by significant others.

• Indicate any data that would give a clue to what the patient's beliefs were which motivated the symptomatic behavior.


There are a number of variables to consider in the process of developing a deeper understanding of a client's situation. This is the original or essential meaning of the term "diagnosis," and not simply the categorization process of "descriptive diagnosis." One strategy for understanding a patient is that of reconstructing the patient's life as if it were a story. Indeed, allow part of your mind to identify with the patient. This is an exercise in empathy. Imagine yourself as the patient, even as other parts of you shift points of view, like a director attending to the needs of the cameraman, the other actors, the audience, etc. The idea of a story carries the sense of continuity and significance, so that historical events are understood in the context of what has been experienced previously and how this affected the future.

Thus, in reconstructing this story, and in attempting to maintain a fairly vivid unfolding image in your mind, begin in the present moment and move backward and forward in time, as if you were replaying flashbacks of the patient's significant memories. Include, if relevant, the following themes:

• Intra-uterine experiences--what the impact would have been if the patient could have sensed the emotional context of its pre-birth existence. How might s/he have interpreted his mother's anxiety, isolation, resentment, depression, etc.?

• Birth and neonatal experiences--not only regarding possible neurological damage, but more importantly, what might have happened to the early bonding experience? Was the infant able to experience physical closeness or was she kept in an incubator? What kind of feeding and nurturing experience did the mother-infant dyad have? Was mother given adequate support? Were the medical care and education adequate?

• Early and mid-infancy--were there opportunities for play, relaxed and pleasant feeding, physical closeness, stimulating toys, and, in later months, some degree of exploration? What temperamental qualities were manifested early, and was the mother able to cope with them? Again, what kind of support was mother given during this important phase? For the child, was it a pleasant or insecure world?

• Toddler phase--were there adequate opportunities to build autonomy? Was the family overprotective, invasive, anxious, neglectful, harsh, or impatient? This is an especially important phase about which to elicit history from parents.

• Early childhood--what early patterns of interaction were being established? How was discipline handled? Were there adequate opportunities to socialize with other children, be exposed to other adults, and have some degree of consistency?

At this point, the process of reconstruction then branches off into a wide variety of issues, such as styles of family interaction or positive and negative influences which lead up to the present problem.

Remember to include the positive elements in the family and general history. These strengths and helpful influences are crucial to a holistic understanding of the case. Often, those factors that are relevant to why the patient is not more disturbed indicate clues to what might be potential channels for successful therapeutic intervention.


*See especially my paper on this website on the "real" diagnostic variables!

Other relevant life experiences to be considered during the reconstructive process include the following:

• Relationships with siblings, place in family (birth order), and probable dynamic interactions regarding rivalries, mutual helpfulness, etc.

• Peer group experiences in school, camp, neighborhood

• Religion, how it was handled, what reactions there were, and its continuance as a source of strength or conflict

• Moves, the challenge of getting resettled, and the success of efforts to make new friends

• Access to activities, geographical or other types of isolation, exposure to "bad" neighborhoods, etc.

• Access to free play and special activities which helped develop talents or interests

• Levels of success and examples of achievement (this is the best single indicator of overall ego strength)

• Other experiences at school, college, etc.

• Medical history--significant illnesses, disabilities, or other aspects of physical health that may have affected the client's development

Adam Blatner, M.D.

Diagnosis in the original root meaning of the term means to know-through, to understand. Applying a diagnostic label often does not communicate any depth of understanding, but it does indicate in a very general way what kind of problem is being addressed. Practically, it's necessary to have a diagnosis for insurance and statistical purposes, as well as for general professional communications. At present, putting on this label is primarily a descriptive process which does not suggest the nature of the etiology of the disorder. As imperfect as it may seem, the process of developing a somewhat valid and reliable diagnostic system has been going on for a century; the most recent effort, the American Psychiatric Association's Diagnostic and Statistical Manual, Revised Edition (1994), DSM-IV, is a definite improvement over its predecessors. Nevertheless, there are significant problems associated with the whole enterprise of psychiatric diagnosis, so recognize that this categorization system is still far from perfect (Kutchins & Kirk, 1997; Caplan, 1995). Nevertheless, it is important for a clinician to learn to use it to describe the major manifestations of the patient's behavior.

Having engaged in the exercise of descriptive diagnosis, go on to the task of formulation. This is what you have been building up to from the outset. It's especially helpful if the person presenting can address the phenomena involved in terms of at least three different frames of reference or schools of thought. This helps to "flesh out" the case, so to speak; it respects the complexity and multi-dimensionality of human experience. Some of the more
comprehensive frameworks I have found especially useful include the following:

  • Individual psychodynamics, whether that be in terms of psychoanalytic, Adlerian, cognitive therapy, Transactional Analysis, etc. Characteristic "defense mechanisms" are particularly relevant.

  • Family dynamics, including communications styles, role distribution and triangulation patterns, temperamental differences, family myths, unfinished business, "secrets," etc.

  • Social factors, including economic resources, network of friends, vocational aspirations and stresses, variety of hobbies or affiliations, etc.

  • Biological factors, including temperamental inclinations, inherited vulnerabilities, neurophysiological states of arousal due to post-traumatic states, anxiety, or food allergies, or other "constitutional" contributors. Also address the self-reinforcing processes of habitual patterns of posture (as described in Bioenergetic Analysis, for example); nutrition; smoking; use of alcohol/ drugs, etc.

  • Skill development, in terms of learning theory, conditioning, range of experiences, areas of weakness and strength, etc.

The goal is to communicate a sense of the patient's humanity and his or her existential dilemmas. If the audience or consultant can begin to empathize with the patient (and family members), then useful treatment strategies often can be constructed.


Caplan, Paula J. (1995). They say you're crazy. Reading, MA: Addison-Wesley.
Kutchins, Herb, & Kirk, Stuart A. (1997). Making us crazy: DSM--the psychiatric bible and the creation of mental disorders. New York: The Free Press.


In communicating with other agencies or therapists who have treated (or will treat) the patient, a number of issues should be emphasized:

  • If diagnoses from previous treatments were changed and the reasons for the change.

  • A summary, in outline form, of key events and other major hospitalizations is especially helpful in writing about cases with a "thick chart." The courtesy and professionalism shown in doing this will impress your colleagues and increase the chances that your recommendations will be considered seriously.

  • Note specifically if medications were used and the names and the amounts. Briefly give the reasons why they were started or stopped, increased or decreased, and the duration of their use. Note if any evoked unacceptable side effects and, in short, what has and has not been effective. The point is to save the patient from going through the delay and discomfort of an unnecessary trial of medication. If medicines were either started or stopped, note which target symptoms were relieved or exacerbated.

  The principle of communicating with other agencies is the same--reverse roles and ask yourself what information you would need if you were in their place. When dealing with third party payers (such as insurance agencies or CHAMPUS), modify your formulations so that you give as little detailed personal information as possible, while still indicating the general type of disorder, why it needs to be treated intensively, and your over-all treatment

  If you are taking over a patient in a hospital or clinic, summarize the past care in outline form, especially if the patient is a re-admission. Do not expect the reader of the chart, such as the doctor on call who may be asked to intervene in an emergency regarding the patient, to be able to access the relevant and key points in the patient's background. Furthermore, in the course of treatment, repeat a succint summary of the key features (in one or two sentences) along with the current considerations, as if you were in direct phone contact with a consultant and only had a brief time to communicate the essential elements of the problem. When in doubt as to what to include, imagine that you were being asked to intervene in this case, knowing nothing about it--what would be the things you'd really need to know? (Do not assume the consultant knows any more than you do.)

This, then, is an appeal to professionals to take responsibility in exercising judgment, in daring to select the important issues and summarize them so that others can become quickly oriented to the nature of the problem. Whether writing a report to an agency or insurance company or making a progress note or transfer summary in a patient's hospital chart, remember that this is no mere fulfilling of requirements for paperwork, but vital communications that could affect the health of a living and highly vulnerable person.

And, perhaps most importantly, write legibly.

For responses, email me at

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