Download - 1 LCD Efloresensi dr. PS 2014.ppt
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dr. NM Dwi Puspawati, SpKKBag/SMF I. Kes. Kulit & KelaminFK Unud/RS Sanglah Denpasar
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The art of Diagnosis in General :
• Anamnesis
• Physical Examination
• Laboratory finding
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GENERAL HISTORY
1. Race, geograhical
!. "ocial bac#gro$nd, ethnic tradition, dietary habits
%. Past medical history : allergy to medication, asthma,ast ma&or illness or oeration
'. "ocial ( occ$ational history: tra)el abroad, hobbiesand details of the tye of *or#, s$bstances in contact
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History of present illness : d$ration, date ( site of onset,details of sread, e)ol$tion of rash ( original morhology,symtoms s$ch as itchiness, ain, b$rning sensation, n$mbness,reciitating and relie)ing factors s$ch as climate, s$nlightetc.
Past history of skin disorders : history of s$nb$rn
Faily history of skin disorders : e.g. s#in cancers and atoic
disorders+stigmata atoic
!r"#s : incl$de herbs, toical, systemic, atient initiated orhysician rescribed
SPE$IAL HISTORY
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E%A&INATION OFTHE S'IN
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1. Ade$ate ri)acy
!. Good lighting
%. -agnifying glass and transarent glass slide for diascoy
t is a good ractice if affordable to ha)e thoro$ghexamination of the *hole body esecially for ne*cons$ltation and for the elderly
Do not s#i examination of the nail, scal and oral m$co$smembrane beca$se there may be )al$able cl$es, find theatoic stigmata
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EFFLORES$EN$E :A s#in lesion is an abnormal gro*th or an area of s#in that
does not resemble the s#in s$rro$nding it /normal s#in0b&ecti)e aearance
!ETAIL !ES$RI(E! OF S'IN LESION :1.Tye of s#in lesion!.2haracteristic of lesion : colo$r, m$ltile or soliter,shae, margin, si3e, s$rface characteristics, temerat$reand smell
%.Arrangement and config$ration'.Distrib$tion
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)* Type of skin lesion :1.1. Primary lesion :•
-ac$la• Pa$le• Pla$e• 4esicle• P$st$le
1.!. "econdary lesion :• "cale
• 2r$st• 5lcer• Erosion• Excoration
• 6od$l• 5rtica• 7$la• 2yst
• Lichenification
• Atrohy• "car• 8iss$re
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!. $hara+teristi+ of skin lesion :
• 2olo$r salmon9in#, erythemato$s,
hyerigmented, s#in colo$r, yello*• -$ltile or soliter
• "hae geometric shae, o)al
• -argin sharness of edge, ill9defined
• "i3e diameter, $nctata, n$m$ler
• "$rface characteristics dome9shaed, $mbilicated,
si#e li#e• Temerat$re and smell *arm on alation, mo$syodor
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%. Arran#eent and +onfi#"ration :• Gro$ed as in dermatitis heretiformis, heressimlex• Ann$lar or arciform as in gran$loma ann$lare, tinea
circinata• Linear attern as in lichen lan$s, lichen striat$s
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,* !istri-"tion :
• symmetrical, asymmetrical• exosed area, s$n exosed area• scal region, hand• extensor asect, flexor asect
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PR-AR LE"6
Primary lesions are the first toaear and are d$e to thedisease or abnormal state
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A* &A$.LE
flat, nonalable circ$mscribed area of color changein the s#in. -ac$les are ; 19! cm in si3e.
-ac$les may be the res$lt of
/A0inflammatory )asc$lar dilation+hyeremia/70bleeding+hemorhagia+$r$ra
/20change of s#in igmentation
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A*)* Hypereia /0as+"lar dilatation1
/Latin hyer9 < o)er= 9emia < related to blood0 is atemorary s#in redness d$e to increased blood flo*. Thelesion blanch $on ress$re /diascoy0.
1. Roseola /> 1cm+nail late0!. Erytemato$s /? 1 cm0
%. Telengictasis : dilated
s$erficial blood )essels
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A purpura (Latin purpura = purple) is a small (3mm– 1 cm) purplish bruise/ violaceous color due toextravasations of blood into the tissue. t does notblanch on appl!in" the pressure.1.#etechia $ (Latin petecchia (plural = petechiae) =spot on s%in) is a small (& 3 mm)'.ibises3.cchimoses (lar"e* + 3 mm)
A*2* Heorha#ia3p"rp"ra
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A*4* $han#e of skin pi#entation
1. @yerigmentation increase of igmentationo. -elasma gra)idar$m
o. -ongolian sot
!. @yoigmentation decrease of igmentationo. Pithyriasis )ersicolor
o. Le$coderma
%. Deigmentasi no igmento. 4itiligo
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@ierigmentation
@ioigmentation
http://www.pediatrics.wisc.edu/derm/tuta/03.html
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• "mall solid ele)ation of s#in generally ; ,B cm in diameter.
• Pa$les may be flat9toed, dome shaed, or sic$lar
• Pa$les may res$lt from locali3ed hyerlasia of dermal oreidermal cell$lar elements
(* PAP.LE
PL E
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alable, latea$9li#e ele)ation of s#in, $s$ally more than !cm in diameter and rarely more than B mm in height. ftenformed by a con)ergence of a$les, as in soriasis.
$* PLA5.E
Cell9defined, reddish,
scaling la$es
http://dermnetnz.org/common/image.php?path=/scaly/img/ps3.jpg
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4esicles are raised lesions less than 1 cm in diameter
that are filled *ith clear fl$id. 4esicle *alls can be sothin that the contained fl$id is easily seen. 8l$id can beacc$m$lated *ithin or belo* the eidermis.
!* 6ESI$LE
http://www.dermnet.com/image.cfm?passedArrayIndex=15&moduleID=21&moduleGroupID=307
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E (.LA /(LISTER1
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7$la /Lat. b$lla < b$bble0 is a )esicle that exceeds 1 cm in si3e
circ$mscribed, ele)ated lesion that is ? 1 cm in diameter, containingsero$s /clear0 fl$id.
E* (.LA /(LISTER1
F P.ST.LE
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s$erficial, ele)ated lesion that contains $s /$s in ablister0. P$st$les may )ary in si3e and shae. P$s is
comosed of le$#ocytes *ith or *itho$t cell$lar debris. tmay also contain bacteria or may be sterile.
F* P.ST.LE
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6od$le is a solid, ro$nd, or ellisoidal alable lesion that has a
diameter larger than ,B cm. 6od$les can in)ol)e any layer of the s#in.7ased on the anatomical comonents in)ol)ed, there are fi)e tyes ofnod$les: eidermal, eidermal9dermal, dermal, dermal9s$bdermal, ands$bc$taneo$s.
G* NO!.LE
H $YST
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An encas$lated or eithelial
lined ca)ity containing li$id orsemisolid material /fl$id, cells,and cell rod$cts0. A shericalor o)al a$le or nod$le may be a
cyst if, *hen alated, isresilient /feels li#e an eyeball0.
/A0 eidermal cysts, lined bys$amo$s eitheli$m and rod$ce#eratino$s material. /70 Pilarcysts, lined by m$ltilayeredeitheli$m
H* $YST
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Transitory, comressible a$le
or la$e of dermal edema.
The a$le or la$e is $s$allyro$nded or flat9toed, ande)anescent, disaearing *ithinho$rs. The borders of a *healare shar, b$t not stable
I* 7HEAL OR .RTI$A
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An er"ption of 8heals is tered "rti+aria and"s"ally it+hes
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, 2omedo
acne9 Telengiectasion9 7$rro* scabies
9* SPE$IAL LESION
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"E26DAR LE"6
Res$lt from the nat$rale)ol$tion of rimary lesions
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"cale acc$m$lation or abnormal shedding of horny
layer #eratin /strat$m corne$m0 in ercetiblefla#es. "cales $s$ally indicate inflammatory changeand thic#ening of the eidermis. They may be fine,*hite and sil)ery, or large and fish9li#e, as inichtyosis
A* S$ALE
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circ$mscribed area of s#in lossextending thro$gh the eidermisand at least art of the dermis/aillary0.
7asically, its a Fhole in the s#inF.5lcers $s$ally res$lt from theimairment of )asc$lar andn$trient s$ly to the s#in.
(* .L$ER
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• Dried ser$m, blood, or $s
on the s$rface of s#in.-ay be thin, delicate, andfriable or thic# andadherent.
• 2r$sts are yello*, if fromser$m= green or yello*9green
if from $s= or bro*n ordar# red if formed fromblood.
• 2r$sts that occ$r ashoney9colo$red, delicate,glistening artic$lates aretyical of 9 metigo.
$* $R.ST
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Erosion: oist +ir+"s+ri-ed sli#htly
depressed areas of skin d"e to loss of allor part of the epideris*
!* EROSION ; E%$ORATION
E
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2hronic thic#ening of the s#in along *ith increased s#inmar#ings. Res$lts from scratching or r$bbing.
E* LI$HENIFI$ATION
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Paer9thin, *rin#led s#in
*ith easily )isible )essels.Res$lts from loss ofeidermis, dermis or both."een in aged, some b$rns,and longterm $se of highlyotent toicalcorticosteroids.
/A0 Dermal atrohymanifests as a deressionin the s#in. /70 Eidermal
atrohy manifests as thinalmost transarent s#in=may not retain normal s#inlines
F* ATROPHY
G $ R
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Relacement of normal
tiss$e by fibro$s connecti)etiss$e at the site of in&$ryto the dermis. "cars may behyertrohic, atrohic,sclerotic or hard d$e tocollagen roliferation.
/A0 @yertrohic or /70atrohic scar
G* S$AR
@yertrohicscar
H FI .RE /RHAGA!E1
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A fiss$re is linear clea)age of s#in *hich extendsinto the dermis.
H* FISS.RE /RHAGA!E1
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"@APE, ARRA6GE-E6T
A6D 268G5RAT6
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Annular = Ring shaped
Granulomaannulare,tineacorporis,erythemaannulare centrifugum
Numular/discoid = Coin
shaped with uniformmorphology from theedges to the center.
Nummular eczema,
plaue!typepsoriasis,discoid lupus
"olycyclic = formed fromcoalesing circle
#rti$aria,su%acutecutaneus
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Arcuate = arc shape,result from incomplateformation of an annular
lesion
#rti$aria,su%acutecutaneus lupuseritematosus
&inear = straight line
'ca%ies %urrow,
poison i(y dermatitis,lichen nitidus, lichenplanus)lesi multipel
Reticular = net!li$e &i(edo reticularis
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'erpiginous = sna$e!li$eCutaneus lar(amigrans
*argetoid = target!li$e +rytema multiforme
horled = li$e mar%elca$e
-ncontinentia pigment
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Irregularldistri!uted
"erpeti#$rmis
%esi$ns lustered t$gether'e.g. herpes simple()
Sattered
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D"TR75T6 8 "6
LE"6
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E%A&INATION OF
THE HAIR
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• valuate hair -uantit! and -ualit! its len"th* densit!* colour and texture
• Loo% for associated s%in conditions*especiall! those aectin" the scalp
• air loss associated 0ith excessive
sheddin"
positive air pull test
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A #2LL 4
• 5rasp a loc% of hairs to determine if an!can be extracted 0ith 6rm pull
• 7ormall! 8,' telo"en hairs can be
extracted$ these are hairs in the restin"phase* identi6ed usin" ma"ni6cation b! arounded bulb at the proximal end
• An elon"ated or tapered end indicates
ana"en hair ("ro0in" phase). Ana"en hairsextracted b! the "entle hair pull test arepatholo"ic.
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*hinned $r a!sent hair
• hinnin" hair or baldin" (alopecia) ma! be localised ordiuse.
• Localised alopecia ma! aect a sin"le or multiple areas.
• valuate $
1. ound/oval* 9moth,eaten: or linear bald patches
'. 4hort hairs$ these ma! be tapered at the tip (normalre,"ro0th)* 9exclamation mar%: (hairs tapered nearscalp)* bro%en,o* sin"ed or cut
3. 7e"ative or positive hair pull test;. 4carrin" (cicatricial alopecia) i.e. no follicles* or non,
scarrin" alopecia (follicular ori6ces present)
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Localised alopecia areata4carrin" alopecia
Locali>ed alopecia
ufted folliculitis
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?iuse alopecia
?iuse alopecia is most often due to pattern baldin"*and more
prominent over the vertex of the scalp
Pattern !alding'male)
Pattern !alding'#emale)
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Salp s+in
• valuate the appearance of the scalp oil! or dr!
• Loo% for locali>ed lesions and in@ammator! s%indiseases.
• valuate$1. ?iuse* patch! or perifollicular er!thema
'. ?iuse* patch! or follicular @a%in" or scalin"
3. ollicular or non,follicular papules* erosions or
pustules;. 7its (louse e"" cases)
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pit!riasis amiantacea #erifollicular er!thema$frontal 6brosin" alopecia
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(essi-e hair
• xcessive hair ma! be due to localised or diuseh!pertrichosis or in 0omen* hirsutism* 0hichrefers to an adult male pattern of hair "ro0th.
• !pertrichosis describes localised or diuseexcessive hair on face* arms* le"s or trun%. t ma!be due to increase in lanu"o (soft* 6ne and blond)
or terminal hair.
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lsewhere
• A complete examination inspection of terminalhair of the e!ebro0s* e!elashes* beard* axilla Bpubic area
• n adolescents
note sta"e of pubertaldevelopment (anner "ro0th charts)
• #remature pubarche appearance of pubic hair0ithout other si"ns of pubert! $
, & C !ears in bo!s, & D !ears in 0hite "irls
, & E !ears in blac% "irls
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E%A&INATION OF THENAILS
I t d ti
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Intr$duti$n
7ails are a specialisedform
of stratum corneumand are
made predominantl! of%eratin. heir primar!
functions are forprotection*
scratchin" and pic%in"up
small obFects.
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xamination of the nails evaluate $
• Abnormalities of nail plate surface
•7ail plate discolouration• Abnormalities of the cuticle and nail fold
• Abnormalities of nail shape
• Gomplete loss of nails
• Lesions around nails
!n$rmalities $# the nail plate
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!n$rmalities $# the nail platesur#ae
7ail plate abnormalities are often due to
in@ammator! conditions aectin" the matrix or
nail bed. 4peci6c dia"noses ma! be made from
characteristic appearances* 0hich are "enerall!
self,explanator!
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PI**IN
c>ema* psoriasis* Alopesia
areata
*RNS0RS RIDIN
#soriasis* trauma* acute
s!stemic illness
%1NI*UDIN%
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%1NI*UDIN% RIDIN 2%1NI*UDIN% SP%I**IN
A"in"* trauma* lichen planus*
psoriasis
%1NI*UDIN%R110
G!st or tumour of matrix*
rauma
1nh$grph$sis 'thi+
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1nh$grph$sis 'thi+hard ur-ed nail plate)
A"ein"* #soriasis* rauma
Nail plate thinning
Lichen #lanus* trauma
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Nail platerum!ling
#soriasis*Hn!chom!cosis
Distal lamellar
splitting3 !rittlenails
Iater/deter"entdama"e* 7ail
polish removers* raumaticremoval or
arti6cial nails
R$ugh nailsLichen planus* 0ent! 7ail?!stroph!
Dis$l$urati$n $# nails
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Dis$l$urati$n $# nails
4ell$w Jello0 nail s!ndrome*
Hn!chom!cosis* #soriasis
4tainin" from nail enamel
white $r ell$w distall
#soriasis* dermatitis*lichen planus* 7ailinfection
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reen
nfection
Br$wn $r !la+
4tainin"* ?ru"s nfection*
elanoc!tic naevus*elanoma acial
5utile and nail #$ld
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a!n$rmalitiesRagged utiles &
telangietases
rauma$ han" nailGonnective tissue disease
Distal digital in#arts
asculitis
Di t l ! l
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Distal su!ungualhper+erat$sis
#soriasis* Hn!chom!cosis*
7or0e"ian scabies
Par$nhia
%esi$ns ar$und nails
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%esi$ns ar$und nails
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E%A&INATION OF THE&.$OSA
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xamination of the mucosa $
1.ucosa oral
'.ucosa "enetalia
(aminati$n $# mu$sa $ral
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• Hbserve the color B its consistenc!
• he presence or absence of saliva in the @oor of mouth• he ton"ueKs appearance distinct on the dorsal*
ventral and lateral aspect
• he dentition and 0hether there are "rossl! cariousteeth
• he use of removable prosthesis
• Hbserve $ lesion* ulcer
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Dis$rder $# the $ral mu$sa
ranul$mat$sa 5heilitisFissured t$ngue
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Dis$rder $# the $ral mu$sa
e$graphi t$ngue"air t$ngue
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Dis$rder $# the $ral mu$sa
Mu$eler$si$n $n lips, t$ngue
and palate
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Dis$rder $# the $ral mu$sa
Kap$si sar$maphth$us uler
(aminati$n $# mu$sa
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genitalia
Lesion of the ucosa "enitalia ma! be an! of thefollo0in" $
• 7ormal variant
• anifestations of 4?
•?ermatoses that ma! be "enerali>ed or found at extra,"enital site but that have a predilection for the"enitalia
• ?ermatoses that are spesi6c to the "enitalia
7 l i
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7ormal variant
Pearl penile papulesSe!ae$us gland
pr$minene
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Mani#estati$n $# S*D
Ul+us durum
"erpes genitalis
Dermat$ses with a
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Dermat$ses with apredileti$n #$r the genitalia
Ps$riasis%ihen planus
P i i l d
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Primar genital dermat$ses
%ihen sler$sus
S6uam$us ellarin$ma
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