Download Running head: FITE COMPREHENSIVE CLINICAL CASE STUDY

Running head: FITE COMPREHENSIVE CLINICAL CASE STUDY
Comprehensive Clinical Case Study
Leah Fite
Wright State University-Miami Valley
College of Nursing and Health
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FITE COMPREHENSIVE CLINICAL CASE STUDY
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Comprehensive Clinical Case Study
History and Physical
Patient Information
Name: V.C., Age: 65, Race: Caucasian, Gender: Male
Source
Patient and wife, both reliable sources
Chief Complaint
“My husband awoke not knowing who I was and was unable to speak. He started
hyperventilating and fell to his knees with nausea. So I called the squad.”
History of Present Illness
V.C. is a 65 year old male who presented to the emergency department after he
experienced what his wife described as an “amnesiac moment.” He was unable to speak and did
not recognize her. He then became dyspneic and nauseous. The patient has no recollection of
the event up until arriving in the emergency department. He does report that he experienced a
similar event about a year ago while vacuuming the floor. He knew the names of his wife and
children, but didn’t remember who they were. At that point he lied down for a nap, and when he
awoke, he felt better. He went to the emergency department at that time, where they told him he
had a moment of amnesia, and no further testing was done. Both episodes have been unrelated
to time or activity. He complains of increasing fatigue over the past two years, but remains
active, walking two miles daily. He denies chest pain, palpitations, swelling of the feet, or any
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other associated symptoms other than dyspnea and nausea with both episodes. The patient feels
that this episode was more “severe” than the last.
Medical History
Hypertension
Surgical History
Right knee ACL repair x3
Bilateral lasik surgery
Family History
Maternal grandmother “died” of diabetes. Father with positive history of throat cancer,
mother with history of multiple myeloma, and brother died at 58 from lung cancer. No other
significant family history.
Social History
Patient is married with two children; one grown and one still in grade school. He is a
previous smoker, with a 30 pack year history, who quit 30 years ago. He denies illicit drug use,
but admits to drinking one fifth of alcohol weekly. He also drinks one pot of coffee per day. He
engages in regular physical activity, walking two miles daily with no associated shortness of
breath, chest pain, or claudication. He is up to date on all vaccines and wears his seatbelt
regularly.
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Allergies
Aspirin-rash/hives
Home Medications
Losartan/HCTZ 50/12.5mg daily
Multivitamin
Current Medications
Losartan 50mg daily
Hydrochlorothiazide 12.5mg daily
Colace 100mg daily
Review of Systems
General:
Denies fever, weight gain/loss. Admits to increased fatigue over the past 2
years
Skin/Hair/Nails:
Admits history of benign skin cancer which he had removed. Denies
dermatitis, rash/itching, non-healing wounds, sores, or abcess.
HEENT:
Denies loss of hearing, tinnitus/vertigo, earaches, sinus problems, nose
bleeds, blurred vision, double vision, light sensitivity, glaucoma, or cataracts
Neck:
Denies swollen glands, difficulty swallowing, or neck pain
FITE COMPREHENSIVE CLINICAL CASE STUDY
Chest:
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Admits shortness of breath with these episodes, and sleep apnea. Denies
shortness of breath with regular activity, frequent/chronic cough, asthma,
COPD, wheezing, tuberculosis
CV:
Denies chest pain, palpitations, syncope, or feet swelling
GI:
Admits to intense nausea associated with these episodes. Has occasional
heart burn. Denies abdominal pain, vomiting, diarrhea, blood in stool, or
difficulty swallowing
GU:
Denies urinary incontinence, urinary frequency or hesitancy, denies kidney
stones, prostate problems, blood in urine, or bladder infections
M/S:
Admits to arthritis in R hand. Denies joint pain or swelling, gait problems
Neuro:
Admits to episodes of confusion and amnesia with these episodes. Admits to
problems with speech during episodes. Denies headache, weakness,
numbness, seizures, lightheadedness, falling, prior stroke or head injury
Psychosocial:
Denies depression, anxiety, or panic attacks
Physical Exam
Vitals:
BP 117/78 mmHg; HR 78 bpm; RR 18bpm; Temp 97.9 F; SpO2 99% on room
air
General:
No apparent distress. Appears stated age. Pleasant and cooperative
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Skin/Hair/Nails: Pink and warm; appropriate for ethnicity. No rashes, lesions, or scars. Nails
smooth without clubbing or cyanosis. Hair thinning with normal age
progression.
HEENT:
Head normocephalic; EOMI; No nystagmus. Pupils 3mm, equally round and
reactive to light. Nasal mucosa pink and moist, no exudates. Throat without
lesions. Oral mucosa pink and moist without errythema. Good dentition
Neck:
Neck supple, trachea midline. No palpable lymphadenophathy. No rigidity.
Brisk upstroke on bilateral carotid pulses
Chest:
Normal respiratory effort, symmetric without use of accessory muscles. Lungs
CTA bilaterally; no rhonchi, wheezes, or crackles. Resonant percussion in all
lung fields. No tactile fremitus noted.
Cardiac:
Regular rate. PMI at 5th ICS, MCL. Grade III systolic murmur at right sternal
border, which radiates to the carotids. S1 with no audible S2. No thrills,
heaves or lifts. No JVD. No peripheral edema noted. 2+ palpable pulses
noted bilateral radial, femoral, dorsalis pedis; 1+ bilateral posterior tibial
pulses.
Breasts:
N/A
GI:
Abdomen soft, rounded, nontender. Bowel sounds heard equally x4 quadrants.
Tympanic percussion over epigastrum. No hepatosplenomegaly. No palpable
masses
GU/Rectal:
Voiding per urinal; clear, yellow urine
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Musculoskeletal: Strength 5/5 throughout with good muscle tone in all extremities. No
tenderness or erythema noted on hands, elbows, knees, ankles.
Neuro:
Alert and oriented x4. Appropriate speech and good memory recall other than
the events of the episode.
Laboratory Findings
Table 1. Complete Blood Count and Renal Panel
Complete
Blood
Count
(CBC)
WBC
Results
Normal Values Renal
Panel
Results
Normal
Values
9.1K cells/mL
Sodium
140 mEq/L
RBC
Potassium
3.4 mEq/L
Hemoglobin
5.51M
cells/mL
15.4 g/dL
3.6-10.5K
cells/mL
4.4-5.8M
cells/mL
13.5-16.5 g/dL
Chloride
102 mEq/L
Hematocrit
46%
40-50%
23 mEq/L
MCV
MCH
MCHC
RDW
Platelet
84 fL
28 pg
33
13.6%
246 K/uL
82-97 fL
27-33 pg
32-36 g/dL
<15.3%
140-375 K/uL
Carbon
Dioxide
BUN
Creatinine
Glucose
Anion Gap
135-145
mEq/L
3.6-5.1
mEq/L
101-111
mEq/L
24-36 mEq/L
17 mg/dL
1.0 mg/dL
154 mg/dL
20 mEq/L
8-26 mg/dL
0.5-1.2 mg/dL
74-99 mg/dL
6-18 mEq/L
Cardiac
Enzymes
CPK
Results
134 IU/L
Normal
Values
0-200 IU/L
CK-MB
Troponin
2.7 ng/mL
0.01 ng/mL
<6.1 ng/mL
<0.05 ng/mL
Table 2. PT/INR and Cardiac Enzymes
PT/INR
Results
PT
12.2 seconds
INR
PTT
1.2
26.4 seconds
Normal
Values
9.0-11.4
seconds
0.8-1.2
23-32.5
seconds
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Other laboratory studies performed on this patient include ethanol level, drug toxicology
screen, and urinalysis. No ethanol or illicit drugs were detected. Urinalysis was clear, and
negative for abnormal findings, with a urine specific gravity of 1.013.
Diagnostic Findings
12 lead electrocardiogram (ECG) shows left axis deviation and left ventricular
hypertrophy as evidenced by deep S wave in V1, and tall R wave in V6. Chest radiography
(CXR) shows no acute cardiopulmonary findings, with no evidence of cardiomegaly. Computed
tomography (CT) of the head is negative for any signs of bleeding or mass. MRI of the head is
negative for ischemia. Electroencephalography illustrates dysrhythmic grade I slowing
consistent with normal age related changes. Carotid Doppler study shows mild bilateral stenosis,
less than 50%.
Differential Diagnosis
Mr. C presents with an amnesiac episode unrelated to activity with associated dyspnea.
Transient global amnesia is an event usually seen in people over the age of 50, which is
characterized by acute memory deficit, often in the setting of physical exertion or emotional
stress, in which the person is alert but confused (Seeley & Miller, 2012). Differential diagnoses
to rule out for these symptoms include transient ischemic attack, stroke, and seizure disorder.
The presence of a murmur leads to further differential diagnoses including coarctation of the
aorta and aortic stenosis.
Transient ischemic attack (TIA) is a cessation of blood flow causing neurologic
symptoms mimicking stroke that typically last less than one hour (Smith, English, & Johnston,
2012). Symptoms vary among patients, but may include hemiparesis of the face, arms, or legs,
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dysarthria, and weakness. Several etiologies contribute to TIA but most often are related to the
heart, and include atrial fibrillation, rheumatic heart disease, mitral valve disease, infective
endocarditis, or atrial septal defect (Smith et al., 2012). Atherosclerosis of the carotid arteries or
aortic arch, arterial inflammatory disorders, and hypotension may also contribute to the
development of TIA. The history of hypertension in this patient can lead to a likelihood of this
diagnosis. He reports no history of palpitations or abnormal cardiac rhythms and denies history
of rheumatic fever. He is currently afebrile, which would likely rule out the diagnosis of
infective endocarditis contributing to TIA. Echocardiogram needs to be performed to evaluate
valve function. Carotid ultrasound shows no significant blockage, and MRI is negative for areas
of ischemia, likely ruling out this diagnosis.
Hemorrhagic or ischemic stroke may be a cause of the amnesiac moments the patient is
experiencing, although this is highly unlikely. Ischemic infarct may be caused by uncontrolled
hypertension or diabetes, or thrombotic or embolic occlusion of major vessels, while
intracerebral hemorrhage causes include poorly controlled hypertension, bleeding or hematologic
disorders, high alcohol intake, or brain tumor (Aminoff & Kerchner, 2013). While symptoms
vary according to location of the stroke, and whether it is hemorrhagic or ischemic, rarely does a
patient present with only amnesiac moments. Symptoms may include hemiplegia or unilateral
weakness of the arm or leg, frank confusion, visual loss, vertigo, urinary incontinence, ataxia,
global aphasia, and drowsiness leading to stupor or coma (Aminoff & Kerchner, 2013).
Negative carotid ultrasound and MRI can rule out ischemic stroke as a cause for symptoms.
Hemorrhagic stroke is unlikely due to resolution of symptoms and negative head CT.
Seizures can be related to a variety of causes, and can be described as abnormal neuronal
firing within the brain causing transient interruption in normal cerebral function (Aminoff &
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Kerchner, 2013). Causes of seizure include genetics; structural, related to tumor or space
occupying lesion; metabolic due to drug or alcohol withdrawal, uremia, or hypoglycemia; or
unknown causes (Aminoff & Kerchner, 2013). Seizures are typically evidenced by convulsive
jerking or loss of postural tone with urinary incontinence, however, some seizures may be
manifested as dysphagia and amnesiac symptoms such as déjà vu (Aminoff & Kerchner, 2013).
The possibility that this patient presents with seizures related to alcohol withdraw due to his
drinking history is unlikely, as the patient openly discusses his drinking habits with the provider
and his wife, explaining that he has cut back on his drinking over the last few weeks. Space
occupying lesion can be ruled out due the negative head CT. Blood glucose is normal. Focal
seizure may be possible due to the presentation of symptoms, however, EEG is negative for
activity that would alert the provider to this diagnosis.
Coarctation of the aorta may be causing the current symptoms the patient is experiencing,
and is associated with a heart murmur. A narrowing of the aortic arch occurs in coarctation of
the aorta as a result of hypertension, with greater than 50% of cases having bicuspid aortic valve
(Bashore et al., 2012). Hypertension is usually greater in the upper extremities than the lower
extremities, with decreased femoral pulsations, and midsystolic murmur heart over the left
interscapular area, with left ventricular hypertrophy evident on ECG (Child & Aboulhosn, 2012).
Dilated ascending aorta and left subclavian artery on the left mediastinal border is evident on
CXR, while echocardiogram can identify the area of coarctation and should be obtained.
Although this diagnosis may be present in adulthood, it is usually detected and repaired in
childhood. Ruling out this diagnosis warrants echocardiography studies, but is doubtful based on
clinical and diagnostic findings.
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Clinical findings of decreased S2 and systolic murmur which radiates to the carotids,
along with ECG suggesting left ventricular hypertrophy, are highly suggestive of aortic stenosis
in this patient. Systolic murmur with radiation to the carotids has a sensitivity of 73% and
specificity of 91% for accurately detecting aortic stenosis with bedside assessment (Etchells et
al., 1998). The amnesiac moments the patient has experienced could be related to bradycardia,
or maneuvers that increase afterload, which decrease volume and contribute to decreased
cerebral blood flow. Calcification of the valve secondary to vascular atherosclerosis or
congenital heart disease such as bicuspid aortic valve is the primary cause of aortic stenosis, and
is associated with increased risk of MI and death in patients greater than 65 years of age (O’Gara
& Loscalzo, 2012). Echocardiogram is needed for definitive diagnosis in this patient, but aortic
stenosis is highly probable. Diagnosis of severe aortic stenosis is made when the patient is
symptomatic and the echocardiogram reveals an aortic valve area (AVA) of less than one cm2,
the aortic peak velocity of greater than four m/s, and a mean flow gradient greater than forty
mmHg (Nishimura et al., 2014).
Diagnostic Tests/Rationale
Electrocardiogram (ECG)
ECG is an inexpensive, non-invasive test that can assess the electrical activity within the
heart, presence of coronary ischemia, and cardiac chamber enlargement that can be a useful tool
in the evaluation of patients with murmur. Absence of arrhythmias, prior myocardial infarction
(MI), active ischemia, ventricular hypertrophy, or atrial enlargement can provide exclusion
criteria for diagnosis. The incidence of prior MI or left ventricular hypertrophy should prompt
further testing for definitive diagnosis. Left ventricular hypertrophy and existence of a murmur
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is indicative of valvular disease, however, there are no ECG findings that are specific or sensitive
for diagnosis of exact valve disease.
Chest Radiography (CXR)
CXR can provide information regarding the location, shape, and size of the heart, but is
generally nonspecific when identifying valve disease. Aortic stenosis may cause hypertrophy
which may be seen on the frontal view as a rounding of the apex, or a dilated ascending aorta
may also be seen (O’Gara & Loscalzo, 2012). Calcification of the aortic valve may be seen on
lateral view CXR, but the degree of calcification cannot be determined, and warrants further
testing (O’Gara & Loscalzo, 2012).
Dual Source Computed Tomography (DSCT)
DSCT is a noninvasive test that can provide high quality images within the cardiac
structure (Li et al., 2009). Accurate evaluation of ejection fraction, AVA, and aortic root
dimensions can be accomplished through DSCT. DSCT also evaluates valve anatomy for
severity of stenosis, and can identify other valvular lesions or masses. This test is costly, and not
available in many facilities, therefore rarely used for the assessment and diagnosis of aortic
stenosis. DSCT has a 91% sensitivity and 100% specificity for correctly identifying patients with
aortic stenosis (Li et al., 2009).
Echocardiography
The gold standard diagnostic tool for the evaluation of aortic stenosis is
echocardiography. Not only can echocardiography assess left ventricular dysfunction and wall
thickness, but also the degree of valve calcification and the presence of other associated valve
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diseases (Bashore et al., 2013). Two-dimensional doppler transthoracic echocardiogram (2D
echo) is favorable for its capability to estimate aortic valve gradient, and the severity of stenosis.
2D echo has a sensitivity of 74% and specificity of 67% to accurately predict AVA for severe
aortic stenosis (Kupfahl et al., 2004). Echocardiography is a portable, reliable, cost-effective test
used for the accurate diagnosis of valvular disease.
To establish etiology, confirm diagnosis, and determine severity, prognosis, and timing of
intervention, echocardiogram should be completed with the initial assessment, and is a class Ia
ACC/AHA recommendation (Nishimura et al., 2014). This patient did undergo echocardiogram
revealing severe concentric left ventricular hypertrophy with normal wall motion, and an ejection
fraction of 55%. The left atrium is mildly dilated. Mild mitral calcification with trace mitral
regurgitation. The aortic valve is severely calcified and appears bicuspid. The AVA is 0.9 cm2;
peak aortic velocity is 4.3 m/s; mean gradient is 55 mmHg. The aortic root is not well
visualized.
Cardiac Catheterization
While cardiac catheterization is not required for most patients with cardiac murmurs, it
may be beneficial for diagnosing aortic stenosis when clinical findings do not correlate with
echocardiography findings (O’Gara & Loscalzo, 2012). Left heart catheterization is an
ACC/AHA class I recommendation for patients with severe aortic stenosis at risk for coronary
artery disease, who plan to undergo aortic valve replacement (AVR) (Nishimura et al., 2014).
The sensitivity and specificity for cardiac catheterization to identify severe aortic stenosis is 78%
and 91%, respectively (Kupfahl et al., 2004). While this patient’s clinical symptoms associate
with the echocardiogram findings, cardiac catheterization is performed to rule out CAD, showing
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heavily calcified aortic valve area with minor irregularities in the major coronary arteries, but no
significant blockages. The ascending aorta is not well visualized.
Cardiac Magnetic Resonance (CMR)
CMR is another noninvasive approach for the diagnosis of severe aortic stenosis. Poor
acoustic visibility on echocardiogram or inability to cross the valve by catheterization may call
for further testing such as CMR (Kupfahl et al., 2004). In the circumstance of bicuspid aortic
valve, the importance of CMR or CT is stressed for the appropriate evaluation and measurement
of the aortic root (Svensson et al., 2013). Inability to perform CMR depends on the presence of
metallic implants or pacemaker, history of severe claustrophobia, and facility ability. CMR has a
sensitivity of 78% and specificity of 89% for the accurate detection and diagnosis of severe
aortic stenosis (Kupfahl et al., 2004).
Prioritized Plan
Currently, no medical treatment has been established for aortic stenosis. The only
effective treatment shown to improve quality of life, relieve symptoms, and increase survival in
aortic stenosis is aortic valve replacement (AVR) (Svensson et al., 2013). Cardiothoracic
surgery should be consulted in this patient, and surgical risk score and frailty index should be
calculated in order to proceed with AVR.
AVR is an ACC/AHA class Ia recommendation for any patient with severe aortic
stenosis at the onset of symptoms of lightheadedness or syncope, angina, and dyspnea (Svensson
et al., 2013). The guidelines also recommend elective aortic root replacement for any patient
with bicuspid aortic valve who’s diameter exceeds five cm (class Ia) (Svensson et al., 2013). In
patients with severe aortic stenosis presenting with aortic velocity of greater than four m/s or
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mean pressure gradient of forty mmHg or greater, plus calcified aortic valve with associated
symptoms, AVR is recommended (Nishimura et al., 2014).
A shared decision making process on the choice of valve intervention between the patient
and provider must be carried out to discuss risks regarding each valve type and patient
preference and values. Choice of mechanical or bioprosthetic valves should be discussed with
the patient, regarding the need for anticoagulation therapy and associated risks, and the durability
of each valve with the possible need for future reoperation. For patients who have an exclusion
risk for surgical AVR, and post-surgery survival rate of greater than one year, transcatheter aortic
valve replacement (TAVR) is recommended (Nishimura et al., 2014). Balloon aortic
valvuloplasty (BAV) can be used as a bridge therapy in patients with severe aortic stenosis who
are hemodynamically unstable and unable to undergo immediate AVR (Svensson et al., 2013).
Bioprosthetic valves are more likely to be considered in patients over the age of 70 due to
the increased risk of bleeding complications, but have decreased durability inversely related to
the patient’s age (Nishimura et al., 2014). Since patients do not require anticoagulation therapy
with bioprosthetic valves, some patients may prefer to avoid the “hassle” of long term therapy
such as dietary and medication interactions, frequent laboratory monitoring, and athletic activity
restrictions (Nishimura et al., 20140. In patients already treated with anticoagulation therapy for
a pre-existing medical condition, mechanical valve is suitable. Patients less than 60 years of age
without contraindication for life-long anticoagulation therapy, may benefit from a mechanical
valve, and is an ACC/AHA class II recommendation (Nishimura et al., 2214). Studies have
shown a decrease in reoperation rate and lower mortality rate associated with mechanical valves
in patients younger than 60 (Nishimura et al., 2014). For patients between the age of 60 and 70,
FITE COMPREHENSIVE CLINICAL CASE STUDY
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either valve choice is reasonable with similar long term outcomes, and is based on patient
preference (Nishimura et al., 2014).
This patient decides to undergo bioprosthetic valve to avoid the complications and
lifestyle alteration associated with life-long therapy. Prophylactic antibiotic with gram-positive
and gram-negative coverage is recommended for any patient undergoing AVR (Svensson et al.,
2013). If mechanical valve was chosen, warfarin therapy to achieve a goal INR of 2.5-3.5 is
recommended for the prevention of thromboembolism due to abnormal flow conditions which
cause platelet activation, with frequent laboratory monitoring to ensure therapeutic dose range
(Nishimura et al., 2014). Even with bioprosthetic AVR, anticoagulation therapy should be
started and continued for the first three months post-operatively, until the valve is
endothelialized, due to the increased risk of peripheral embolism and ischemic stroke associated
with bioprosthetic valves (IIb) (Nishimura et al., 2014). Regardless of valve type, 81 mg daily
aspirin dosing is a class IIa recommendation for the further prevention of thromboembolism
(Nishimura et al., 2014).
Follow-up
Patients who have endured valve replacement are still considered to have a serious heart
disease, and routine follow-up is essential. Seven to ten days following discharge from the
hospital, the patient will follow-up with the cardiothoracic surgeon for history and physical
exam, and assessment of vital signs, wound healing, and activity tolerance post-operatively.
CXR and ECG may be performed at that time. To evaluate the outcomes of surgery and assess
valve hemodynamics, echocardiogram should be performed during this time (Nishimura et al.,
2014). Baseline post-AVR images and measurements are obtained from the echocardiogram at
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this time for comparison regarding valve compliance should problems develop in the future.
Routine follow up with a cardiologist is essential, with varying interval in visits depending on
valve type, clinical factors, and other comorbid conditions. In patients with bioprosthetic valves,
annual 2D echos should be performed for the first ten years post AVR, and is an ACC/AHA
class II recommendation (Nishimura et al., 2014). Due to the increased risk of endocarditis,
prophylactic antibiotic therapy is required for any patient with a history of AVR who undergoes
surgical, endoscopic, or dental procedures (Svensson et al., 2013).
Health Promotion Activities
Immediate post-operative health promotion activities are aimed toward infection
prevention with adequate hand washing and increased pulmonary exercises to prevent atelectasis
contributing to pneumonia. Cardiac rehabilitation is generally recommended to assist with
normal activities of daily living and reduce the risk of future problems. The patient should be
instructed on eating heart healthy items and participating in normal cardiovascular exercise to
inhibit atherosclerosis. Encouraging the patient to stay up to date on annual influenza vaccination
and every five year pneumococcal vaccination is also important for health promotion.
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