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fam med

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Question
Answer
what are the 6 stages of behavior change   precontemplation, contemplation, determination, action, maintenance, relapse  
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3 MC causes of dyspepsia   GERD, PUD, fxnl dyspepsia (diagnose after upper endoscopy, etc are all nml)  
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alarm symptoms in dyspepsia   age>55 w new onset of sympt, FMH of upper GI cancer, wgt loss, bleeding, worsening dysphagia, odynophagia, anemia, persistent vomitting  
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remember to ask abt NSAID use in dyspepsia    
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mgmt GERD   PPI, if taking NSAID need to stop (I guess don't need PPI)  
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if dyspepsia but not GERD or NSAID, how manage?   can do empiric PPI or H2 antagonist; **(best) H Pylori test/treat; endoscopy  
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lifestyle changes for GERD& dyspepsia   just avoid trigger foods if only dyspepsia, if GERD: wgt loss, elevating head of bed, avoiding spicy and large meals and meals before bed  
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triple tx for H Pylori   PPI, clarithromycin, amox (flagyl if allergic to PCN)  
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on female w UTI sympt be sure to ask abt   gyne symptoms (discharge, pelvic pain) and even menstrual history; sympt suggestive of pyelo (F/C, N/V, back pain)  
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serious UTI type diseases want to consider/ r/o   renal cell or bladder cancer, pyelo, PID, nephrolithiasis  
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ppl at risk for complicated UTI (ie pyelo)   fxnl or anatomic abnlty of urinary tract incl polycystic kidney dz, nephrolithiasis, neurogenic bladder, preg, DM or immunosupp, recent urinary tract procedure or catheter  
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lifestyle changes for UTI   liquids, urinate s/p sex, drink cranberry juice, wipe front to back s/p BM  
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MC bugs for UTI in female   E Coli, then Staph Sapro  
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tx for uncomplicated UTI in women   3d Bactrim or Cipro sufficient, if recurrent may used 5-10d and ensure infxn clears  
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what cxns or serious URI don't want to miss   meningitis, brain abscess, orbital cellulitis  
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imaging/w/u for URI/sinusitis   none, could order sinus XR or CT, but not usu helpful, sinus cx could be considered if resistant to tx  
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tx URI/sinusitis   if just viral use nasal saline spray, can give nasal decongestant (pseudoephed, oxymetazoline 3-5d), if sinusitis amox  
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if allergic component URI how tx   loratadine (claritin), fexofenadine (allegra)  
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mild persistent asthma symptoms and use of inhaler   daytime symptoms (using b2) >2x/wk, nighttime 3-4/mo, FEV1 >80% and FEV1/FVC nml (same as intermittent)  
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levels of asthma   intermittent, mild persistent, moderate persistent, severe persistent  
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moderate persistent asthma symptoms and use of inhaler   daytime symptoms (using b2) everyday, nighttime sympt >1x/wk, FEV1 60-80% and FEV1/FVC reduced by 5%  
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severe persistent asthma symptoms and use of inhaler   daytime symptoms (using b2) throughout the day, nighttime sympt every night, FEV1 <60% and FEV1/FVC reduced by >5%  
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well controlled asthma   sympt <2x/wk and nighttime <2x/mo, no interference nml activity, FEV1 >80% of best (can f/u 6mos)  
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not well controlled asthma   sympt >2x/wk and nighttime >2x/mo, some limitation nml activity, FEV1 60-80% of best (add tx and f/u 2-6wks)  
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poor controlled asthma   sympt throughout the day, nighttime sympt almost every night, using b2 mltpl times/day, FEV<60%, for tx consider short term oral steroids and f/u 2wks  
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SE of b2   tachycardia, tremor, hypoK, paradoxical bronchospasm  
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SE ipratropium   antichol, ie dry mouth, nervous, can have anaphylactic rxn, angioedema  
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SE mast cell stabilizer (cromolyn)   throat irritation/dry throat, bronchospasm, anaphylaxis  
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SE theophylline   N/V, HA, insomnia, irritability. Serious SE: arrhythmias, sz  
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SE leukotriene modifiers   various incl HA, flu like/URI, GI sympt. Serious SE incl angioedema, anaphylaxis  
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mech of action theophylline   prevents breakdown of cAMP and cGMP for sm mscl relax and bronchodilation, also inhibits inflamm mediators  
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key adv/disadv theophylline   cost is advantage; disadv incl SE and need to monitor levels  
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comorbidities/triggers asthma   allergens, GERD, allergic rhinitis, smoke exposure, obesity and OSA  
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components to developing therapeutic relationship   develop atmosphere of trust, connect on non-medical topic, learn abt family contextual things related to dz, offer to partner w pt, show empathy, etc  
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tx for mild persistent? Moderate? Severe?   short acting b2 + low dose steroid. For moderate add long acting b2. for severe add medium dose steroid--if that doesn't control add oral steroid  
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cut offs for lipids   tChol <200, >240 is high. TG <150, >200 high. HDL 40-60 (where 60 or higher is good!). LDL >160 high  
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LDL when start tx and goals: pt with BOTH DM and CAD   start lifestyle and Rx at 70, goal <70  
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LDL when start tx and goals: pt with DM OR CAD OR 10yr risk >20%   start lifestyle at 100 and Rx at 100 or 130, goal <100  
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LDL when start tx and goals: pt with 2 RF, 10yr risk 10-20%   start lifestyle at 130 and Rx at 100 or 130, goal <130  
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LDL when start tx and goals: pt with 2 RF, 10yr risk <10%   start lifestyle at 130 and Rx at 160, goal <130  
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LDL when start tx and goals: pt with <2 RF   start lifestyle at 160 and Rx at 160 or 190, goal <160  
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RF used to calculate LDL   smoking, HTN, FMH of premature CAD  
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LDL cutoff and goal for HTN, smoker w/o FMH premature CAD   would need to calculate 10yr risk, but if >20%: start lifestyle at 130 and Rx at 100 or 130, goal <130  
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SE sulfonylureas   hypoglycemia, wgt gain, rare: hepatitis, heme abnlties  
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name types of hypolgycemics used DM2 (8, incl 4 MC)   **sulfonylureas (glyburide, glipizide), **biguanides (metformin), **thiazolidinediones (rosiglitazone, pioglitazone),**alpha glucosidase inhibitors (acarbose), meglinitinides, amylin analogs, incretin analogs, DPPV-IV inhibitors  
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key SE/cautions of metformin   GILMAR=GI, lactic acidosis, metallic taste, renal (can't use if Cr 1.5 male, 1.4 female), wgt loss  
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which hypoglycemics can cause hepatitis/hepatotoxicity   sulfonylureas, alpha glucosidase, thiazolidinediones  
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SE meglitinides   hypolgycemia, anaphylactoid, heme  
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which oral hypoglycemics have risk of hypoglycemia (4)   sulfonylureas, meglitinides, amylin analogs and incretin mimetics  
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SE thiazolidinediones (rosglitazone, pioglitazone)   fluid retention, hepatotoxicity, CHF  
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SE alpha glucosidase inhibitors   diarrhea, flatulence, bloating, rare: hypersensitivity, hepatitis  
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SE amylin analogs   N/V, anorexia, HA, interferes w absorption oral meds, avoid in gastropoeresis, **severe hypoglycemia in DM1  
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SE incretin mimetics   N/V, diarrhea, avoid in gastropoeresis or severe RF, **severe hypoglycemia in DM2 on sulfonylureas  
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which oral hypoglycemics have GI SE (4)   **biguanides (metformin), **alpha glucosidase inhibitors (acarbose), amylin analogs, incretin analogs  
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SE DPPIV inhibitors   runny nose, sore throat, HA, rare: hypersensitivity/anaphylactoid, S-J  
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MOA sulfonylureas (glyburide, glipizide)   stimulate insulin sxn  
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adv/disadv sulfonylureas (glyburide, glipizide)   cost, safety, low SE  
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MOA biguanide (metformin)   incrs insulin sensitivity, decrs liver production of glu  
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adv/disadv metformin   use in overwgt to decs wgt  
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MOA meglitinides   pancreas incrsd sxn of insulin (Same as sulfonylureas but shorter acting)  
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adv/disadv meglitinides   shorter acting than sulfonylureas (meal adjusted dosing), more effective than sulfonylureas and less likely hypoglycemia  
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MOA thiazolidinediones   enhances insulin sensitivity in mscl  
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adv/disadv thiazolidinediones   lowers insulin requirements (bc improves insulin sensitivity)  
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MOA alpha glucosidase inhibitors   inhibits intestinal alpha glucosidase  
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adv/disadv alpha glucosidase inhib   improves post-prandial hypergly, generally poorly tolerated  
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MOA amylin analogs, how given   subQ before meal for ppl on insulin. Slows gastric emptying and decrses appetite  
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adv/disadv amylin analgos   can only use in DM1 or 2 on insulin, improves postprandial hypergly, helps wgt loss, can't give gastropoeresis  
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MOA incretin mimetics   subQ before meal for DM2. Slows gastric emptying and decrses appetite, stimulates glu dependent insulin secretion  
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adv/disadv incretin mimetics   improves postprandial hypergly, helps wgt loss  
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MOA DPPIV inhibitors   incrsd insulin sxn  
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agents for HLD (5)   bile acid sequest, niacin, statins, fibric acid, ezetimibe  
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SE bile acid sequest (cholestyramine, colestipol)   GI  
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SE niacin   flushing, GI, hyperuric; hepatotoxic, PUD, severe hypergly  
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SE statins   incrsd LFTs, myositis, rhabdo  
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SE fibric acid derivatives (gemfibrozil, fenofibrate)   GI, incrsd LFTs, gallstones, myositis  
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SE ezetimibe   upper respir sympt, HA, myalgia, rare hypersensitivity  
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MOA bile acid sequest   interrupts bile absorb so more cholesterol turned into bile acids in liver  
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adv/disadv bile acid sequest   usu add to statin bc SE  
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MOA niacin   decrses TG synthesis in liver and increases lipases clearing vLDL  
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adv/disadv niacin   good for incrsd TG and LDL, but SE limit use  
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MOA statin   HMG CoA reductase leading to decrsd cholesterol synthesis in liver  
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adv/disadv statin   effective and limited SE  
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MOA fibric acid   binds PPAR  
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adv/disadv fibric acid   use for high TG  
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MOA ezetimibe   inhibits cholesterol absorption in small intestine  
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goals for DM for glu (fasting/postprandial), HbA1c, BP, LDL, TG   fasting glu 130, postprandial 180, BP 130/75, LDL 100, TG 150, HbA1c 7  
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cut offs for impaired glu tolerance   fasting 110-125 or 2hr postprandial 140-200  
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cut offs for dx of DM, incl HbA1c   fasting >125 or 2hr postprandial >200, or random >200 w symptoms. Need 2 readings. Or HbA1c >6.5 x2.  
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ranges for HTN, preHTN   preHTN 120-139/80-89; HTN I: 140-159/90-99; HTN II 160/100  
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8 meds for HTN   diuretics, bb, ccb, ACEI, ARB, alpha1 antagonists, alpha2 agonists, direct vasodilators  
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SE BB   FARSHILD: fatigue, asthma, reynauds/impaired peripheral circulation, sex dysfxn, halluc, insomnia, lipid…bradycardia, mask hypoglycemia  
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SE diuretics   depends on specific, but hypoK, hypoMg, hyperuric, shortterm incrs cholesterol and glu  
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SE CCBs   HA, flushing, peripheral edema, gingival hyperplasia, constipation, bardycardia/arrhythmias, CHF (ie verapamil ChOPPd Liver: constip, heart block, prolactin, potassium)  
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SE ACEI   CAPTOPRIL: cough, angioedema, potassium, taste, preg, rash, liver toxicity  
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SE ARB   angioedema (less than ACEI), hyperK  
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SE alpha1 blockers   orthostatic hypotension  
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SE a2 agonist   antichol, ie sedataion, dry mouth, bradycardia, rebound HTN  
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SE vasodilators   HA, flushing, reflex tachycardia, lupus like  
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ex of direct vasodilators   hydralazine, NG, nitroprusside, isosorbide nitrate  
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ex of central alpha 2 agonists   methyldopa, clonidine  
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MOA alpha1 blocker   blocks post syn alpha1, leads to less NE release  
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adv/disadv direct vasodilators   difficult to control HTN, rapid control via IV, also pregnancy (hydralazine)  
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adv/disadv diuretics for HTN   CHF  
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adv/disadv bb for HTN   post MI, angina, SVT, CHF, diastolic dysfxn, migraine  
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adv/disadv ccb for HTN   angina, SVT, reynauds, diastolic dysfxn, migraine  
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adv/disadv ACEI for HTN   DM w albuminuria, CHF, postMI w systolic dysfxn, prevention progression CRF  
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adv/disadv alpha1 blockers for HTN   BPH, HLD  
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adv/disadv alpha2 agonist for HTN   clonidine can be used for rapid control HTN  
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what's BATHE model for psych visits   Background (what's happening), affect (emotl state), trbl (what trbles you most), handling, empathy  
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in prevention and screening what are the 6 major areas   CV, cancer, ID, injury/trauma, metabolic, emotl  
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screening DM starts, freq   45yo q3yrs or overwgt other RF  
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screening HLD starts, freq   35men, 45 women, q5  
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DEXA starts   65yo, 60 if high risk  
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mammography starts, freq   50-75 q2  
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colonoscopy starts, freq   50yo q10, or 10yrs before earliest/40yo high risk  
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ASA given to   45-79men and 55-79yo women for DM and hi risk CVD  
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pap smear starts, freq   21-30 q2; 30-65 q3  
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pelvic starts, freq   20-40 q3; annual >40  
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