• William W. Forgey, MD

Body System Symptoms and Management - Chest and Abdomen

Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.


One of the most common reasons for a visit to a physician’s office or emergency department is a problem with the chest. Chest pain and shortness of breath can be symptoms of serious disorders and cannot be taken lightly. Fortunately, most times the chest pain is benign, generally due to muscle spasm or chest wall inflammation. It can be very difficult to evaluate, even at the emergency department. Chest problems are best evaluated by a physician, but in a remote area, try to sort out your options with the table on page 5. In case of trauma, the patient may have suffered torn muscles between the ribs or broken ribs (see page 191).


Infection of the airways in the lung (bronchitis) or infection in the air sacks of the lung (pneumonia) will cause very high fever, persistent cough that frequently produces phlegm stained with blood, and prostration of the victim. From the Non-Rx Oral Medication Module treat the fever with Percogesic, 2 tablets every 4 hours, or ibuprofen 200 mg, 2 tablets every 4 hours, and the cough with diphenhydramine 25 mg every 4 hours.

Cool the fever with a wet cloth over the forehead as needed. Do not bundle the patient with a very high fever, as this will only drive the temperature higher. The shivering cold feeling that the patient has is only proof that his thermal control mechanism is out of adjustment; trust the thermometer or the back of your hand to follow the patient’s temperature. Encourage the patient to drink fluids, as fever and coughing lead to dehydration. This causes the mucus in the bronchioles to become thick and tenacious. Force fluid to prevent this sputum from plugging up sections of the lung.

Provide antibiotic: From the Rx Oral/Topical Medication Module, give the Levaquin 500 mg daily until the fever is broken and then for an additional 4 days. Alternately give the Zithromax as directed on page 285. Or from the Rx Injectable Medication Module, you may give Rocephin, 500 mg twice daily.

Prepare a sheltered camp for the victim as best as circumstances permit. Until the fever is broken, rest is essential with or without the availability of antibiotic. Encourage the patient to eat. Even though they are very ill, people lose their appetites.


Even in very healthy young adults and teenagers, it is possible for an air cell in the lung to break for no apparent reason and fill a portion of the chest cavity with air, thus collapsing part of one lung. A minor pneumothorax will spontaneously take care of itself, with the air being reabsorbed and the lung re-expanding over 3 to 5 days. The classic sign of decreased breath sounds over the area of the collapse will be very difficult for an examiner to detect, even with a stethoscope. But listen first to one side of the chest and then the other to see if there is a difference. Part of the difficulty lies in the fact that patients with chest pain do not breathe deeply, and thus all breath sounds are decreased. Other parts of the physical exam are even more subtle. In unexplained severe chest pain in an otherwise healthy individual, pneumothorax might be the cause.

Severe pneumothorax will have to be treated by a physician or trained medic with removal of the trapped air with a large syringe or flutter valve, or by other methods currently employed in a hospital setting. If pain is severe and breathing difficult, the only choice is evacuation of the victim.

From the Non-Rx Oral Medication Module, you may give 2 Percogesic for pain every 4 hours, or 2 to 4 ibuprofen 200 mg tablets every 6 hours. This can be augmented with Atarax, 25 mg every 6 hours. It is possible for the pain to be so severe that the use of injectable Nubain or inhaled Stadol will be necessary (see page 289).

Pulmonary Embolus

A pulmonary embolus is a blood clot breaking loose from its point of origin, normally from a leg or pelvic vein, and then lodging in the lung after passing through the heart. When serious, this condition appears as shortness of breath and rapid breathing, with a dull substernal chest pain. There may be cough, bloody sputum, fever, and sharp chest pain. A pulmonary embolus can mimic pneumonia (page 63) and high-altitude pulmonary edema (page 266). It can be fatal if an embolus large enough to block off more than 50% of the lung circulation occurs at once. This condition generally resolves within a matter of days. Increased risk is found in older people who have been sitting a long time (such as on plane flights) or anyone immobilized after injury.

The only medication in the suggested Off-Grid Medical Kit that would be of any help is ibuprofen, 200 mg given 4 times daily. Stronger doses of this product (up to 800 mg given 4 times daily) or additional pain medication can be given to help with the discomfort. The use of Plavix from the Rx Cardiac Medication Module is not supported by the literature, but giving a loading dose of 300 mg, and then 75 mg daily, is a possible field technique. Due to the uncertainty of the diagnosis, treat with an antibiotic such as Zithromax, as described on page 285, or Levaquin, 500 mg once daily, until the pain and/or fever resolves, and then continue for an additional 4 days. This would not help a pulmonary embolus, but it would properly treat pneumonia.


Even for professionals with years of clinical experience and unlimited laboratory and X-ray facilities, abdominal pain can be a diagnostic dilemma. How serious is it? Should evacuation start, or can it be waited out or safely treated off the grid? Or what treatment protocol can be followed when there is no grid?

Abdominal Pain

Any abdominal pain that lasts longer than 24 hours is a cause for concern, and professional help should be sought if possible. Diagnosis will be determined from the history (type and severity of pain, location, radiation, when it started), as well as certain aspects of the physical examination and the clinical course that develops. Some of these aspects are summarized in Table 3-6 and in the discussion that follows.

A burning sensation in the middle of the upper part of the abdomen (mid-epigastrium) is probably gastritis, or stomach irritation. If allowed to persist, this can develop into an ulcer, a crater eaten into the stomach or duodenal wall. In the latter case the pain may be most notable in the right upper quadrant. For some reason, ulcers will occasionally feel better if you press against them with your hand. This supposedly was why Napoleon is seen with his hand inside his jacket in his favorite pose—he was pressing against his abdomen to relieve the pain of an ulcer.

Severe, persistent mid-epigastric pain that is also frequently burning in nature can be pancreatitis, an inflammation of the pancreas. This is a serious problem but rare. Alcohol consumption can cause pancreatitis, as well as gastritis and ulcer formation. Avoid alcohol if pain in this area develops. In fact, any food that seems to increase the symptoms should be avoided. Reflux of stomach acid up the esophagus, caused by a hiatal hernia—protrusion of a part of the stomach through a hole in the diaphragm through which the esophagus passes—will cause the same symptoms. The reflux also causes the burning pain to radiate up the center of the chest.

Treatment for all of the above is aggressive antacid therapy. These conditions can be made worse by eating spicy food, tomato products, and other foods high in acid content. Milk may temporarily help the burning of an ulcer or gastritis but may increase the burning sensation later. Avoid any medications containing aspirin and ibuprofen. Acid suppression medication such as Tagamet, Zantac, Pepcid, Axid, Prevacid, Nexium, AcipHex, Dexilant, and Prilosec help greatly, and anyone with a history of these disorders should consider adding such items to the medical kit. There is a concern that these medications can make the user more vulnerable to traveler’s diarrhea, cholera, and other infectious disease from which a normal or high stomach acid level might otherwise provide some protection. A safer medication for persons afflicted with heartburn not responsive to antacids, who must travel in a third-world situation, would be Carafate taken 1 gram 4 times daily. This is a prescription medication.

Mild nausea may be associated with the above problems, but intense nausea could indicate gastroenteritis, food poisoning (generally these also cause significant diarrhea), hepatitis, or gall bladder disorder.

Gall Bladder Problems and Appendicitis

Nausea associated with pain in the right upper quadrant of the abdomen may be from a gall bladder problem. No burning is associated with gall bladder pain, and this discomfort is typically made worse by eating and sometimes even by smelling greasy foods. While drinking cream or milk would initially help the pain of gastritis or an ulcer, it causes an immediate increase in symptoms if the gall bladder is involved. Treatment is avoidance of fatty foods. Nausea and vomiting can be treated as indicated on page 70. Treat for pain as described on page 31.

The onset of fever is an important indication of infection of the blocked gall bladder. This is a surgical emergency. Treat with the strongest antibiotic available. If the Rx Injectable Medication Module is available, give Rocephin, 500 mg, 2 doses, IM immediately; repeat with 2 doses every 12 hours. Lacking that medication, give Levaquin, 500 mg, daily. Continue to treat the pain and nausea as required for relief. Offer as much fluid as the patient can tolerate.

Gall bladder disease is more common in overweight people over the age of 30. It is also more common in women.

The possibility of appendicitis is a major concern, as it can occur in any age group, and that includes healthy individuals. It is fortunately rare. While surgery is the treatment of choice, probably as many as 70% of people not treated with surgery or antibiotics can survive this problem. The survival rate is over 80% with appropriate IV therapy. Of course, timely surgery provides 100% survival. A 2018 Finnish study confirmed the above statement; unfortunately, it also showed that within 5 years 40% of those not having surgery will have a recurrence.

The classic presentation of this illness is a vague feeling of discomfort around the umbilicus (navel).Temperature may be low grade, 99.6 to 100°F (or 37°C) at first. Within 12 hours the discomfort turns to pain and localizes in the right lower quadrant, most frequently at a point two-thirds of the way between the navel and the very top of the right pelvic bone (anterior-superior iliac crest). Ask the patient two questions: Where did you first start hurting? (Belly button.) Now where do you hurt? (Right lower quadrant as described.) Those answers mean appendicitis until it is ruled out.

It is possible but unusual to have diarrhea with appendicitis. Diarrhea usually means that the patient does not have appendicitis. I find it helpful to ask the patient to walk and watch how he does it. A person with appendicitis will walk with rather careful, short steps, bent slightly forward in pain. They certainly do not bounce off the examining table and walk down the hall to the bathroom. Anyone with springy steps most likely does not have appendicitis.

Sometimes full laboratory and X-ray facilities can do no better in making this diagnosis. The ultimate answer will come from surgical exploration. If a surgeon has doubts, he might wait, with the patient safely in a hospital or at home under close supervision. But the patient with those symptoms should certainly be taken to a surgeon as soon as possible.

In the examination of the painful abdomen, several maneuvers can indicate the seriousness of the situation. The first is to determine how guarded the area is to palpation. If the patient’s stomach is rigid to gentle pushing, this can mean that extreme tenderness and irritation of the peritoneum, or abdominal wall lining, exists. Use only gentle pushing. If there is an area of the abdomen where it does not hurt to push, apply pressure rather deeply. Now, suddenly take your hand away! If pain flares over the area of suspect tenderness, this is called referred rebound tenderness and means that the irritation has reached an advanced stage. This person should be evacuated to surgical help at once.

What can you do if you are in the deep bush, say the Back River of Canada, without the faintest hope of evacuating the patient? Move the patient as little as possible. No further prodding of the abdomen should be done, as her only hope is that the appendix will form an abscess that will be walled-off by the bodily defense mechanisms. Give no food. Provide small amounts of water, Gatorade, or fruit drinks as tolerated. With advanced disease the intestines will stop working and the patient will vomit any excess. This will obviously cause a disturbance to the gut and possibly rupture the appendix or the abscess.

Treat for pain, nausea, and with antibiotics as indicated in the section on gall bladder infection.

The abscess should form 24 to 72 hours following onset of the illness. Many surgeons would elect to open and drain this abscess as soon as the patient is brought to them. Other surgeons feel it is best to leave the patient alone at this time and allow the abscess to continue the walling-off process. They feel there is so much inflammation present that surgery only complicates the situation further. Even without surgery, within 2 to 3 weeks the patient may be able to move with minimal discomfort.

One form of therapy never to be employed when there is a suspicion of appendicitis is a laxative. The action of the laxative may cause disruption of the appendix abscess with resultant generalized peritonitis (massive abdominal infection).

It is currently thought that there is no justification for the prophylactic removal of an appendix in an individual, unless he is planning to move to a very remote area without medical help for an extended period of time and it is known from X-ray that he has a fecalith (or stone) in the colon at the mouth of the appendix. Otherwise, the possible later complications of surgical adhesions may well outweigh the “benefit” of such a procedure.


Nausea and vomiting are frequently caused by infections known as gastroenteritis. Many times these are viral, so antibiotics are of no value. These infections will usually resolve without treatment in 24 to 48 hours. Fever is seldom high but may briefly increase in some cases. Fever should not persist above 100°F (38°C) longer than 12 hours. Nausea may be treated with diphenhydramine, 25 mg every 8 hours, from the Non-Rx Oral Medication Module, or with Atarax, 25 mg every 6 hours, from the Rx Oral/Topical Medication Module. If the Rx Injectable Medication Module is available, severe nausea and vomiting may be treated with Vistaril, 25 to 50 mg every 6 hours given intramuscularly. Vomiting without diarrhea will not require the use of an antibiotic. If the vomiting is caused by severe illness, such as an ear infection, then use of an antibiotic to treat the underlying cause is justified.

Nausea induced by high altitude, see page 265.

Nausea associated with jaundice, see hepatitis, pages 225–227.

Nausea from ingestion of seafood, see paralytic shellfish poisoning, page 86; scombroid poisoning, page 85; and ciguatera poisoning, page 85.

See also plant or food poisoning, page 84, and petroleum products poisoning, page 84.

Motion Sickness

Motion in any vehicle can induce nausea, hence the many etiologies of this disorder, such as sea sickness, air sickness, and the dreaded “tilt-a-whirl”-induced vomiting at the amusement park. After being exposed to motion for many days—for example, a long nautical trip or train ride—some people become nauseated when the motion suddenly stops and they are on terra firma. The natural method for preventing motion sickness is to look at a point on the horizon, thus minimizing the motion exaggeration. On a large plane, stare at a distant cloud, or if you’re stuck in a center seat, look as far forward in the plane as possible. Reading tends to increase the symptoms. Avoid alcohol and greasy foods on bouncy trips. With repeated exposure to the same sort of motion over many days, you may become adapted and experience less discomfort.

To medically prevent and treat motion sickness, a very useful medication in the Non-Rx Oral Medication Module is diphenhydramine, 25 mg taken 1 hour prior to departure and repeated every 6 hours as needed. This is not an indicated use for this medication, and treatment or prevention of nausea will not be noted on the package. But it works, although drowsiness may be a problem for some (see page 282).

Transderm Scop, a patch containing scopolamine, has been developed for prevention of motion sickness and post-operative nausea and vomiting, but it requires a prescription. Each patch may be worn behind the ear for 3 days. It is fairly expensive but very worthwhile if you are prone to this malady. There tends to be a higher frequency of side effects in elderly people with this medication, consisting of visual problems, confusion, and loss of temperature regulation. It is unlikely that this medicated patch would tolerate long periods of storage.

A valuable drug to prevent and treat motion sickness is Atarax, 25 mg every 4 hours as needed, from the Rx Oral/Topical Medication Module, or Vistaril, 25 mg IM every 4 hours as needed, from the Rx Injectable Medication Module.


Diarrhea is the expulsion of watery stool. This malady is usually self-limited but can be a threat to life, depending upon its cause and extent. Diarrhea can be the result of bowel disorders such as diverticulitis or colitis; infectious diseases such as cholera, campylobacter, shigella, or salmonella; and the presence of many other creatures hiding in contaminated food or water; it is seen rarely with appendicitis and gall bladder disease. The serious infectious disease malaria can have diarrhea as a presenting complaint. Obviously, diagnosing the cause of diarrhea can be of importance both in regard to treating and in estimating the danger to the patient.

Diverticulitis is usually found in people over the age of 40 and is generally a condition only of the elderly. Diverticula are little pouches that form on the large intestine, or colon, from a weakness that develops over time in the muscles of its wall. These are of no trouble unless they become infected. Infection causes diarrhea, fever, and painful cramping. Pain is usually located along the left side of the abdomen. It tends to be at a constant location, unlike many conditions with diarrhea where the pain migrates. Appendicitis pain is in the right lower quadrant of the abdomen (see page 67).Treatment for diverticulitis is with antibiotics such as Levaquin, 500 mg daily, or Rocephin, 500 mg given by injection twice daily.

Colitis and other inflammations of the bowel cause repeated bouts of diarrhea. At times a fever may be present. These cases are chronic, and like diverticulitis, the diagnosis must be made with CT scan using contrast or colonoscopy. If in doubt, treat with antibiotics as indicated under diverticulitis. Both conditions require specific drugs for treatment, such as the steroids included with the Rx Oral/ Topical and Injectable Medication Modules, but unless the person has a prior history of these diseases, the use of such drugs off the grid is inappropriate.

Traveler’s diarrhea is caused by infections, so prevention seems an appropriate priority. Prevention equates to staying alert. Water sources must be known to be pure or should be treated, as indicated on pages 89–94. Once dehydrated or freeze-dried food has been reconstituted, it should be stored as carefully as any fresh, unprocessed food. Certain animal products are tainted in various parts of the world, particularly at specific times of the year. Know the flora and fauna from local sources that you can utilize for survival! The primary prevention that has been classically stressed concerning food safety is “Peel it, boil it, or forget it,” but this has not been proven to be practical or even accurate. The recognized method of reducing diarrhea in travelers has been to improve the hygiene of food handlers preparing the food. Simple measures such as washing hands appropriately, using clean utensils, and reasonable food-preparation techniques apply critically when off the grid as well.

Diarrhea is diagnosed when an individual has 2 or 3 times the number of customary bowel movements for that individual. These stools can be either soft, meaning that they will take the shape of a container, or watery, meaning that they can be poured. By definition at least one associated symptom of fever, chills, abdominal cramps, nausea, or vomiting must be present. This will generally mean 4 unformed stools in a day or 3 unformed stools in an 8-hour period accompanied by at least one other symptom listed above.

While the disease is generally self-limiting, lasting 2 to 3 days, this illness can result in chronic bowel problems in many patients. Initially, as many as 75% of people will have abdominal pain and cramps, 50% will have nausea, and 25% will have vomiting and fever. An acute onset of watery diarrhea usually means that an enterotoxigenic E. coli is the cause, but shigellosis will also first present in this manner. Symptoms of bloody diarrhea or mucoid stools are frequently seen with invasive pathogens such as shigella, campylobacter, or salmonella. The presence of chronic diarrhea with malabsorption and gas indicates possible giardia. Rotavirus disease starts with vomiting in 80% of cases.

In a study of US students in Mexico, the cause of diarrhea was found to be enterotoxigenic E. coli 40%; enteroadherent E. coli 5%; Giardia lamblia and Entamoeba histolytica 2%; rotavirus 10%; aeromonas 1%; shigella 15%; salmonella 7%; campylobacter 3%; and unknown 17%. Studies of traveler’s diarrhea show different frequencies from the above in various other locations of the world, but the cause is always due to infection.

Various medications have been shown effective in preventing traveler’s diarrhea, but experts discourage their use due to cost, exposing people to drug side effects, and the possible development of resistant germs due to antibiotic overuse. Pepto-Bismol, 2 ounces (4 tablespoons) or 2 tablets taken 4 times daily, can prevent this problem. Ugh! About 8 aspirin tablets worth of salicylate are in that quantity of Pepto-Bismol. Prevention with antibiotics is effective, although not usually indicated. Prevention of diarrhea-causing illness is best accomplished in a survival situation with good hygiene.

Treating diarrhea with Pepto-Bismol requires 2 tablespoons every 30 minutes for 8 doses. As most diarrhea in developing countries is from bacterial causes, the use of antibiotics can be very effective. A single dose of the antibiotic Levaquin, 500 mg, can eliminate diarrhea instantly. Loperamide, 2 mg, from the Non-Rx Oral Medication Module, may not be required if you have access to Levaquin. A dose of loperamide may be given simultaneously with the Levaquin. When using loperamide, give 2 tablets at once, followed by 1 tablet after each loose stool, with a maximum adult dose of 8 tablets per day. One tablet of the pain medication Norco 10/325 can also stop diarrhea, but it would be best to use the loperamide and/or Levaquin if they are available. In parts of the world where Levaquin is losing its effectiveness, such as the Indian subcontinent, Southeast Asia, and Africa, Zithromax is a better choice. Since diarrhea in North America is seldom caused by bacteria, antibiotics should be used there only after stool cultures.


One of the popular wilderness medical texts has instructions on how to break up a fecal impaction digitally, that is, using your finger to break up a hard stool stuck in the rectum. Don’t let it get that far. In healthy young adults (especially teenagers), there may be a reluctance to defecate due to the unusual surroundings, lack of a toilet, and perhaps swarms of insects or freezing cold. It is the group leader’s responsibility to make sure that a trip member does not fecal hoard by failing to defecate in a reasonable length of time. Certainly, one should be concerned after 3 days without a bowel movement.

To prevent this problem, I always include a stewed fruit at breakfast on menus. The use of hot and cold food and water in the morning will frequently wake up the “gastric-colic reflex” and get things moving perfectly well.

If the 5-day mark is approaching, especially if the patient—and the person has become a patient at about this point—is obviously uncomfortable, it will become necessary to use a laxative. From the Non-Rx Oral Medication Module, give 15 mg bisacodyl laxative tablet at bedtime. If that fails, the next morning take 2 tablets. Under winter conditions, when getting up in subzero weather might prove abominable, or under heavy insect conditions, take these tablets in the morning, rather than at bedtime, to preclude this massive inconvenience occurring in the middle of the night. Any laxative will cause abdominal cramping, depending upon how strong it is. Expect this.


Also called piles, this painful swelling is a cluster of varicose veins around the rectum. External hemorrhoids are small, rounded, purplish masses that enlarge when straining at stool. Unless a clot forms in them, they are soft and not tender. When clots form, they can become very painful, actually excruciating. Hemorrhoids are the most common cause of rectal bleeding, with blood also appearing on the toilet tissue. The condition can be very painful for about 5 days, after which the clots start to absorb, the pain decreases, and the mass regresses, leaving only small skin tags.

Provide the patient with the OTC pain medication Percogesic, 2 tablets every 4 hours. The application of heat is helpful during the acute phase. Heat a cloth in water and apply for 15 minutes 4 times a day if possible. Avoid constipation, as mentioned above in that section. If you are carrying the Rx Oral/Topical Medication Module, Topicort 0.25% ointment will provide the anti-inflammation ability of a steroid and some local pain relief.


The most common hernia in a male is the inguinal hernia, an outpouching of the intestines through a weak area in the abdominal wall located above and on either side of the groin. It is through this area that the spermatic cord connects the testes to the back of the penis. A hernia can be produced while straining or lifting, even coughing or sneezing, when the bowel pushes along the spermatic cord. There will be a sharp pain at the location of the hernia and the patient will note a bulge. This bulge may disappear when he lies on his back and relaxes (i.e., the hernia has reduced).

If the intestine in the hernia is squeezed by the abdominal wall to the point that the blood supply is cut off, the hernia is termed a strangulated hernia. This is a medical emergency, as the loop of gut in the hernia will die, turn gangrenous, and lead to a generalized peritonitis or abdominal infection (peritonitis is discussed under Gall Bladder Problems and Appendicitis, page 67). This condition is much worse than appendicitis, and death will result if it is not treated surgically.

The hernia that fails to reduce or disappear when the victim relaxes in a recumbent position is termed incarcerated. While this may turn into an emergency, it is not one at that point.

Most hernias caused by straining in adults will not strangulate. Further straining should be avoided. If lifting items is necessary, or coughing cannot be prevented, etc., the victim should protect himself from further tissue damage by pressing against the area with one hand, thus holding the hernia in reduction.

Bladder Infection

The hallmarks of bladder infection (cystitis) are the urge to urinate frequently, burning upon urination, small amounts of urine being voided with each passage, and discomfort in the suprapubic region— the lowest area of the abdomen. Frequently the victim has fever, with its attendant chills and muscle aches. In fact, people can become quite ill with a generalized infection caused by numerous bacteria entering their bloodstream. At times the urine becomes cloudy and even bloody. Cloudy urine without the above symptoms does not mean an infection is present and is frequently normal. The infection can extend to the kidney, at which time the patient also has considerable flank pain, centered at the bottom edge of the ribs along the lateral aspect of the back on the involved side (often both sides). While bladder infections are more common in women than men, they are not an uncommon problem in either sex. One suffering from recurrent infections should be thoroughly evaluated by a physician prior to having to leave the grid.

Many drugs have been developed for treating infections of the genitourinary system. Doxycycline, 100 mg, 1 tablet taken twice daily, is very effective. Levaquin, 500 mg tablet once daily, is ideal to use if the doxycycline seems ineffective. Generally, 3 days is a sufficient length of time for treatment, unless flank pain is involved, in which case provide 10 days of antibiotic. Symptoms should disappear within 24 to 48 hours, or it may mean that the bacteria are resistant to one antibiotic and the other should be substituted.

For severe infections with high fever that have not responded within 48 hours to oral antibiotic use, the injectable Rocephin, 500 mg IM given twice daily, provided in place of the oral antibiotic would be a superior choice.

Additional treatment should consist of drinking copious amounts of fluid, at least 8 quarts per day! At times this simple rinsing action may even cure cystitis, but I wouldn’t count on it. Use an antibiotic, if it is available. Percogesic or ibuprofen may be needed to treat the fever and pain that accompany such problems prior to the start of the antibiotic and during the early stages of therapy.

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