PRITE EXAM (2024/2025) - Questions and Answers (Complete Solutions) Amnesia preceded by epigastric sensation and fear are associated with electrical
... [Show More] abnormality where? Temporal lobe Memory loss pattern in dissociative amnesia Memory loss occurs for a discrete period of time Amnesia characterized by loss of memory of events that occur after onset of etiologic condition or agent Anterograde What psychoactive drug produces amnesia? Alcohol Brain Lesions ... Visual problem in pituitary tumor compressing optic chiasm Bitemporal Hemianopsia 32 y/o pt 1-month history of worsening headaches, episodic mood swings and occasional hallucinations with visual, tactile and auditory content. CT head reveals tumor where: Temporal lobe Syndrome characterized by fluent speech, preserved comprehension, inability to repeat, w/o associated signs. Location of lesion in the brain? Supramarginal gyrus or insula Acute onset of hemiballismus of LUE & LLE. MRI is most likely to show lesion located where? Subthalamic nucleus Left sided hemi-neglect is associated with lesion located where? Right Parietal Lobe 60M right-handed, getting lost, only writes on right half of paper. Where is lesion Right parietal Which hormone secreted in functional pituitary adenoma: Prolactin CT & MRI show ventriculomegaly are out of proportion to sulcal atrophy. This is suggestive of what diagnosis? Normal Pressure Hydrocephalus 5 y/o with 4 month history of morning HA, vomiting, and recent problems with gait, falls, and diplopia Medulloblastoma 20 y/o with 1 yr of bitemporal headaches, polydipsia, polyuria, bulimia. For 2 months emotional outburst aggressive and transient confusion neuro exam normal. What will MRI of brain show? Hypothalamic tumor Previously pleasant mom becomes profane and irresponsible over 6 months: Frontal lobe Unilateral hearing loss with vertigo, unsteadiness with falls and headaches, mild facial weakness and ipsilateral limb ataxia is most commonly associated with tumors in what locations: Cerebellopontine angle Catatonia ... 52 y/o with h/o unipolar depression is brought to ED with a first episode of catatonia. Patient is on no meds, UDS is neg. Further w/u should initially focus on what factor? Metabolic disorders Which term describes state of immobility that is constantly maintained? Cataplexy Ability of catatonic pt to hold same position Catalepsy CVA ... Chronic Afib develops aphasia and R hemiparesis at noon. ER exam notes weakness of R extremities and severe dysfluent aphasia, but CT at 1:30 PM has no acute lesion. Most appropriate treatment: TPA Young adult gained 70 lbs in last year c/o daily severe headaches sometimes assoc with graying out of vision. Papilledema present. CT and MRI brain no abnormalities but ventricles smaller than usual. Goal of treatment in this case: Prevent blindness Patient with hypertension develops vertigo, nausea, vomiting, hiccups, left sided face numbness, nystagmus, hoarseness, ataxia of the limbs, staggering gait, and is falling to the left. Dx? Lateral medullary stroke Rapid onset of right facial weakness, left limb weakness, diplopia Brain Stem Infarction Transient symptom associated with carotid stenosis: Monocular blindness 62 y/o M w DM is not making sense, saying "thar szing is phrumper zu stalking". Normal intonation but no one in the family can understand it. He verbally responds to questions with similar utterances but fails to successfully execute any instruction. Wernicke's aphasia 58 y/o M h/o HTN, cig smoking and sudden inability to speak. Face drooping on R and dragging R leg. In ER examined within 40 mins of onset: Aphasic, unable to understand or repeat verbal commands. Unintelligable sounds for speech. Alert but appeared frustrated. R hemiplegia with arm and face weaker than leg. CT head showed no hemorrhage. Pathology type and area: Thromboembolic stroke L MCA (middle cerebral artery) Abulia refers to impairment in ability to: Spontaneously move and speak Sudden-onset left hemiparesis with deviation of eyes to the right Right putaminal hemorrhage Sudden onset vertigo/nausea, hoarseness/dysphagia, right sided face numbness, diminished gag reflex on right, decreased pinprick and temp sensation on left Right medullary infarction 65 y/o diabetic presents to ED c/o acute L sided weakness, deviation of gaze to R, L hemiplegia and hemisensory deficit, and L homonymous hemianopsia. 12 hrs later, pt is unconscious, L pupil enlarged and unreactive. CT will show what? R MCA infarct w/ edema and uncal herniation Pt with acute onset vertigo, what will suggest R lateral medullary infarct? R facial loss of touch + temp sensation 46 y/o M w/ double vision + pain R eye. Exam: ptosis R eyelid, inability to elevate or adduct R eye + R pupillary dilation. This is caused by: Post. Communicating artery aneurysm Aphasia w/ effortful fragmented, dysfluent, telegraphic speech, is seen in a lesion where? Post frontal lobe 39 year old with h/o of multiple miscarriages develops an acute left sided hemiparesis. Work up revels elevated anticardiolipin titers and no other risk factors for stroke. Appropriate intervention at this point is? Plasmapheresis Abnormal elevated metabolic findings associated with increased risk of stroke in patients under 50 Plasma homocysteine 73 y/o found on floor, unaware of L UE/LE. Flaccid L arm, but denies anything wrong and when asked to raise L arm raises R. When asked which arm is her L, she replies "yours." Dx? Parietal lobe CVA CT scan with occipital and intraventricular hyperintensities Parenchymal hemorrhage Which med has secondary prevention against embolic stroke in patients with Afib? Oral warfarin As opposed to strokes caused by arterial embolism or thrombosis, those caused by cerebral vein or venous sinus thrombosis are More often associated with seizures at onset Atrophy of right temporal lobe on cross section associated with occlusion of: Middle cerebral artery Loss of ability to execute previously learned motor activities (which is not the result of demonstrable weakness, ataxia or sensory loss) is associated with lesions of? Left parietal cortex 58 y/o s/p CABG - anomia for fingers and body parts, errors involving right and left, inability to write thoughts/take notes/make calculations. Fluent speech and excellent comprehension Left medial temporal stroke Visual disturbances associated with occlusion of the right posterior cerebral artery? Left homonymous hemianopsia 65 y/o with HTN collapsed. In ED is stuporous, R hemiparesis + hemisensory deficit, eyes deviate to L. CT would show intraparenchymal hemorrhage in: Left basal ganglia Higher frequency & greater severity of depression associated w/ cortical & subcortical strokes Left anterior frontal Pt with hypertension develops painless vision loss on the left eye. PE revels blindness in the left eye and afferent papillary defect on the left. MRI shows several T2 hyperintensities in the white matter periventricularly. No corpus callosum lesions. No enhancement with gadolinium. Dx? Ischemic optic neuropathy 63 y/o with new onset aphasia and R hemiparesis, 2 days ago had milder/similar symptoms that resolved in 30 minutes, yesterday had similar episode x45 minutes. Current sx started 1.5 hrs ago. CT shows no stroke or hemorrhage. Tx? Intravenous thrombolytic agents Lower facial weakness w/ relative sparing of forehead can be stroke in Internal capsule Prosopagnosia is: Inability to recognize faces 57 y/o diabetic w/ HTN c/o several episodes of visual loss "curtain falling" over his L eye, transient speech and language disturbance, and mild R hemiparesis that lasted 2 hrs. Suggests presence of what? Extracranial L internal carotid stenosis Head injury with LOC followed by lucid interval for a few hours then rapidly progressing coma. What hemorrhage? Epidural 5 days after CABG a 47 yr M is disoriented in time and place. He identifies his right and left but not that of the examiners. Can draw square and circle but not a clock. This is: Dyspraxia Pt in ED with sudden HA and collapsing, some lethargy. Exam shows rigid neck, no papilledema, no focal CN or motor signs. The initial test should be? CT Head Post stroke depression in an 80 y/o pt who is R handed is associated with cognitive impairments that Correlate with left hemispheric involvement Fluent speech with preserved comprehension but inability to repeat statements is consistent with what type of aphasia? Conduction Normal Romberg w eyes open but loses balance with eyes closed. Where is abnormality? Cerebellar vermis 65 y/o with h/o HTN, Meniere's with sudden vertigo, N/V, worse with head movement, R beating nystagmus on lateral gaze, finger to nose testing is ataxic, poor balance and dysarthria. Dx? Cerebellar infarct 66 y/o M in ED w/ sudden occipital HA, dizziness, vertigo, N/V, unable to stand, mild lethargy, slurred speech. Exam shows small reactive pupils, gaze deviated to the R, nystagmus, w/ occasional ocular bobbing, R facial weakness, decreased R corneal reflex, truncal ataxia, b/l hyperreflexia, b/l Babinski. Dx? Cerebellar hemorrhage Motor speech paradigm activation task on fMRI - hyperactivity in right temporal lobe. Damage is where? Calcarine fissure Inability to recognize objects by touch: Astereognosis In managing acute ischemic stroke, administer this within 48 hrs of onset of stroke for beneficial effect in reducing risk of recurrent stroke, disability and death: Aspirin 70 y/o w/ attacks of "whirling sensations" w/n/v, diplopia, dysarthria, tingling of lips. Occurs several times daily for 1 minute, severe that pt collapses and is immobilized when symptoms start. No residual s/s, no tinnitus, hearing impairment, ALOC or association with any particular activity. Dx? Vertebrobasilar insufficiency Component of type A behavior most reliable risk factor for CAD Hostility 70 y/o F sudden onset paralysis R foot and leg. R arm and hand lightly affected. No aphasia or visual field deficit. Over weeks found with loss bladder control, abulia and lack of spontaneity. Which vascular area: Anterior cerebral artery (left) Complications of a cerebellar hemorrhage? Acute hydrocephalus Delirium ... Multifocal myoclonus in a comatose patient indicates: Metabolic Encephalopathy 50M male w/ progressive dementia, ataxia, dysarthria, EEG w/ sharp waves Subacute Spongiform Encephalopathy 79 y/o with decreasing mental state over 3 weeks has an exaggerated startle response with violent myoclonus that is elicited by turning on the room lights, speaking loudly, or touching the patient. Myoclonic jerks occur spontaneously. Dx? Spongiform Encephalopathy Two days after bowel surgery, 53 y/o is delirious. Correctly draws a square when asked, but then continues to draw squares when asked to draw other shapes. MSE would reveal: Perseveration 75 y/o F is 8 days s/p total hip replacement and has delirium. Her diazepam and doxepin were discontinued just prior to surgery. She is getting meperidine for pain, diphenhydramine for sleep and a renewed prescription for doxepin. Her confusion is likely due to: medication toxicity, diazepam WDRL, electrolyte imbalance, atypical depression, UTI. Medication toxicity, diazepam withdrawal, electrolyte imbalance, atypical depression, or UTI. Best recommendation for pt with delirium? Minimize contact with family members or limit sleep meds to diphenhydramine, or maximize staff continuity assigned to pt? Maximize staff continuity assigned to pt Delirium in HIV patients treated with what parental agent? Low dose of a high-potency antipsychotic Mild confusion, lethargy, thirst, polydipsia Hyponatremia Cancer patient on chemo is disoriented and agitated. Afebrile VSS. Neg neuro exam. Poor attention, cog impairment. Held for observation. CT neg, EEG diffuse slowing. Treat with: Haldol A 70 y/o +HIV heroin abuser is treated with Lopinavir and Ritonavir and fluoxetine for MDD. Hep C was dx and treated 2 months ago. Since then pt is more irritable, insomnia, and diarrhea. Why? Drug-drug interaction A consult is requested for an inpatient on a medical ward who is agitated and hallucinating. Pt appears to be flushed and hot with dry skin, mydriasis, a rapid pulse and diminished bowel sounds. What is your first recommendation? Discontinue anticholinergic drugs 52 y/o w/ depression and HTN, severe headaches, "not himself" x 10 days. Poor eye contact, inattentive, picking at clothes, muttering, nodding off Delirium Suggests delirium rather than dementia Clouding of consciousness Dementia ... 65 y/o M 6 months confusion episodes, disorientation, visual hallucinations of children playing in his room. Hallucinated images are fully formed, colorful, vivid and pt has little insight into their nature. No AH. Wife says he is normal between episodes. Exam: Normal language, memory, mod diff with trails test, mild diff with serial subtractions, mild symmetric rigidity and bradykinesia. Brain MRI unremarkable. CSF, routine labs and UDS normal. Diagnosis: Lewy body dementia Dementing illness with limb and axial rigidity tremor, fluctuations in cognitive function, confusion states, hallucinosis and other symptoms of psychosis. Dx? Diffuse lewy body disease 70 y/o woman has dementia, abnormal proprioception, and dysesthesia. Lab studies reveal macrocytic anemia most likely caused by a deficiency of Vitamin B12 74F PI, suspicious, poor ADL's Pick's disease Safest heterocyclic antidepressant for a 78 y/o with depression, agitation and dementia is: Nortriptyline What cognitive enhancers is an NMDA receptor antagonist? Memantine Neuronal damage from excitotoxicity secondary to glutamate sensitivity. Treat with: Memantine 75 y/o with mild intermittent forgetfulness, hallucinations, delusions, confusion. Frequent falls and dizziness when getting out of bed. BP laying down 135/90, standing 100/55. BL limb and axial rigidity without tremor. Dx? Lewy Body disease Detection of 2 Apolien e4 alleles is useful in dx dementia b/c Increases probability of dx of Alzheimers Neurofibrillary tangles in Alzheimer's are composed of: Hyperphosphorylated tau proteins 80 y/o Alzheimer's with increasingly combative behavior. Family wants to keep at home. Give what med? Haldol Dementia characterized by personality change, attention deficits, impulsivity, affect lability, indifference, perseveration, loss of executive function. Assoc with dysfunction in what area of the brain? Frontal lobe Alzheimer's disease risk - Apolipoprotein E phenotype ɛ4ɛ4 Binswanger disease has pseudobulbar state, gait disorder, AND: Dementia An 80yo pt with Alzheimer's is brought in for increasingly combative behavior. Daughter would like to keep the pt at home if possible. What interventions would be most helpful in this situation? Assessing for caregiver burnout Which meds have best results for treating agitation in dementia? Anti-psychotics Clock drawing test is quickly administered and sensitive screen for which d/o? Alzheimer's Amyloid precursor protein in Alzheimer's Disease Most common cause of dementia: Alzheimer's disease Individuals over 40yo with Down's syndrome frequently develops: Alzheimer's What baseline labs should be taken before starting tacrine? ALT and AST (baseline and f/u) Known risk factors for dementia: Age, family hx, female, Down Syndrome Neuronal enzyme that is the target of drugs to treat Alzheimer's i.e. galantamine and rivastigmine Acetyl cholinesterase Seizures ... 19 yr old woman has bouts of motor agitation, often followed by intense, seemingly meaningless writing; also mood lability, tactile & olfactory hallucinations. During the interview, patient abruptly stops paying attention and begins rapidly pacing around the room. What should be the next step? Wait 15 mins, then obtain prolactin level Which procedure confirms the diagnosis of non-epileptic seizures? Video telemetry or EEG between episodes? Video telemetry (CL: Should be more accurately called EEG Video telemetry) Antiepileptic for juvenile myoclonic epilepsy Valproic Acid Complex partial seizures are differentiated from simple partial seizures by: Simple seizures have no loss of consciousness but have altered responsiveness to outside stimuli. Convulsive episode with leftward eye deviation, tonic contracture of left side. Postictally, eyes deviate to right w/ hemiparesis of left side Seizure focus right frontal region 28 female w/ HA, hyperventilates, asynchronous tonic-clonic sz, no LOC during Sz Psychogenic Seizure In young pt w/ epilepsy, tx depression w/ Prozac Lack of prolactin elevation after szs suggests what kind of szs: Non-epileptic 32 y/o with partial complex seizures refractory to treatment, picture of MRI shown. (picture) Mesial temporal sclerosis Drug-addicted healthcare professional experiences seizure that is not a withdrawal phenomenon. Cause? Meperidine What is the diagnostic value of transient paresis or aphasia after a seizure? Localizes the focus of seizure Complex partial epilepsy aura has what symptom? Lip smacking Head & eyes deviate to right and right arm extends immediately before a generalized tonic-clonic seizure Left cerebral hemisphere Gustatory special sensory seizures (auras) localize where? Insular cortex First sz with focal onset and second generalization in a 58 y/o patient is most likely the consequence of what? Glioblastoma multiforme 10 y/o child freq episodes brief lapses of consciousness without premonitory sxs. Lasts 2-10 seconds, followed by immediate and full resumption of consciousness without awareness of what has happened. These ictal episodes most likely caused by what kind szs: Absence EEG ... 3 days s/p cardiac arrest and CPR, a 73-year-old man is comatose. His eyes are open but he does not fix and follow with his eyes. Doll's eyes elicits full horizontal eye movements. His spontaneous limb movements are symmetrical. The reflexes are mildly hyperactive. The EEG shows? Burst suppression pattern 8 y/o observed to have brief episodes (seconds) of interruption of consciousness. Associated with automatism such as lip smacking. What is EEG likely to show? Burst od 3 cycles per second spike & wave activity EEG that reveals posterior alpha and anterior beta activity is most likely to have been obtained from whom? A relaxed adult with eyes closed Endocrine ... 73 y/o man w/ onset of fatigue, weight gain, constipation, cold intolerance, depressed mood. Which organic caused needs to be ruled out? Thyroid Physical finding associated with Hypothyroidism: Slow relaxation of deep tendon reflexes A 32 y/o s/p thyroidectomy presents c/o frequent panic attack, progressive cognitive inefficiency, perceptual disturbances, severe muscle cramps, and carpopedal spasm. PE shows alopecia and absent DTR. DX? Hypoparathyroidism Headaches ... 35 y/o M awakens frequently middle of night with severe headaches, which sometimes occurs nightly and lasts approx 1-2 hrs. Headaches are so severe that pt is afraid to go to sleep. Located around L eye and assoc with lacrimation, ptosis and miosis. Likely dx is: Cluster headaches In treating migraines, triptans should NOT be given to: Patients with CAD Flashing lights traveling slowly from left to right in left visual field persist 30 minutes followed by difficulty with expression and concentration that subsides after 30 minutes, followed by headache and nausea. PE and MRI are normal. Dx? Migraine w/ aura Young pt new onset headaches w/ periods of visual obscuration. Papilledema. MRI nml. Best test: Lumbar puncture 26 y/o male is awakened by early morning headaches that last 60-90 minutes. Sharp stabbing sensation in left nostril, severe retro-orbital pain, tearing of the left eye and rhinorrhea. Dx? Cluster headaches Man awakens 4am with severe HA, excruciating, lasts 1 hr, unilateral lacrimation, rhinorrhea, ptosis. No association w stress. Cluster headaches 29 y/o awakened by headaches in middle of night. Unilateral, periorbital, + lacrimation and rhinorrhea, swelling of face. Asymmetry of pupils, hyperesthesia of face Cluster headaches Huntington's Disease ... Treatment of Huntington's chorea Haloperidol 98 y/o M in ER, unconscious after choking on chicken. Pt had a progressive neuro condition presented in his early 30's w involuntary irregular movements of all extremities and face but after 15 yr course evolved into rigid, akinetic condition w diff swallowing and speaking. Also progressive dementia and full time care. After obstruction was relieved pt remained unconscious, had cardiac arrest and died. PM exam showed generalized brain atrophy. (Path picture of brain atrophy). Diagnosis: Huntington's disease Cross section of the brain picture with generalized atrophy: Huntington's disease Treatment for Huntington's disease: High potency antipsychotics Memory ... Confabulation is: Unconscious filling in of memory gaps 45 y/o with nystagmus and ataxia, short term memory loss and believes wife is possessed by demons. Most appropriate treatment? Thiamine A conscious memory that covers for another memory that is too painful to hold in the consciousness is: Screen memory Example of declarative memory Retention and recall of facts In patients with pronounced defects in recent memory, remote memory is: Often deficient on close examination even when it seems well preserved "My father was very involved in my life. I remember going to football games in the snow with him" is an example of memory associated with what part of the brain? Medial temporal lobe What is the role of the hippocampus and parahippocampal gyrus? Declarative memory (facts)
Parkinson's Disorder ... Parkinson's tx w/ levodopa. Visual hallucinations. Recommendations? Reduce dose of levodopa Implantation of deep brain stimulation electrodes is an effective tx for Parkinson's. Optimal location for electrodes? Subthalamic nucleus Gait disturbance w/ involuntary acceleration Parkinson's disease Lewy bodies visualized Parkinson's disease Gait consisting of: postural instability, festination, & truncal rigidity is seen in what condition? Parkinson's disease Motor dysfunction in Parkinson's associated with: Increased activity in subthalamic nucleus and pars interna of globus pallidus Characteristics of Parkinson's tremor Being Inhibited with Volitional Movement Spine ... New-onset back pain after shoveling - left paraspinal muscle spasm, negative straight leg raise, reflexes symmetric, no weakness, no sensory deficit. Management: Conservative (bed rest) with NSAIDS 23 y/o CF in office for f/u appt after an ER visit 2 days earlier for sudden diplopia, R leg weakness and shaking, difficulty w/ speech which resolved after a few hours. Pt had fever 103.1 F and was tx for UTI. Current exam shows normal CN & sensory, minimal R leg weakness, brisk DTR and musculocutaneous reflexes throughout, and equivocal plantar reflex on L. R toe is downgoing. Review of hx reveals several episodes of transient neurological deficits that resolved spontaneously after a few days. Her spinal fluid is most likely to show what? ... 26 year old with sudden onset back pain. Spasms in the right paraspinal muscles in the lumbar region. Straight leg raising on the right is limited by sharp pain at 45 degrees. Ankle jerk on Left is diminished. No muscle weakness, no sensory deficit. Next step? ... 77 y/o gets numbness and aching in buttocks and thighs down to legs when walking > 100 ft. Better after sitting down. How to Dx? MRI of lumbar spine 50 y/o male with acute neck pain radiating down L arm, gait problems, urinary incontinence. What test should be ordered? MRI of C spine to r/o cord compression Patient treated conservatively with analgesics and muscle relaxants, continues to have back pain radiating to R leg, increased by coughing/sneezing. Tenderness in lumbar paravertebral area, decreased R ankle jerk, weak flexion of right foot. Next step in management: MRI lumbar spine 68 y/o pain in buttocks while walking, shooting down legs, w/ weakness and numbness. Relieved by sitting, pain persists with standing. Dx? Lumbar spinal stenosis Loss of pain and temp sensation on one side with motor paralysis and propioception on the other. Spinal syndrome is: Hemisection Brown-Sequard syndrome includes: Contralateral loss of pain and temp sensation beginning below lesion Fall from a ladder with persistent back pain and inability to void. Bilateral leg weakness, decreased pinprick in sacral and perianal area. Dx? Cauda equina compression Tardive Dyskinesia ... The single most consistently documented and significant risk factor in the epidemiology of tardive dyskinesia is? Advanced age Risk factor for TD Presence of mood disorder TD in 63 y/o w/ end stage renal failure. Culprit: Metoclopramide Which gender has a higher risk for tardive dyskinesia (TD)? Female General Neurology ... Persistent numbness n the L hand, decreased sensation in 4th/5th digits (palmar/dorsal), weak finger abduction/ adduction especially 5th digit: Ulnar nerve entrapment at the elbow Injury R upper extremity in 29 y/o M, difficulty holding pencil in R hand. Reflexes intact, weakness of opponens R thumb and adduction of 4th and 5th digits. Decreased sensation R 4th and 5th digits extending into palm of hand and ending at crease of wrist. Cause: Ulnar nerve Right neck pain, tends to rotate neck to left - touching the chin prevents deviation - prominent right SCM spasm. Tx? Treat with botulinum toxin Severe occipital HA, BL papilledema and no other abnormalities. Chronic acne treated with isotretinoin. Lumbar puncture elevated opening pressure with no cells, 62 mg/dl glucose, and 22mg/dl protein. CT is normal. Pseudotumor cerebri Internuclear ophthalmoplegia is an ocular motility disorder often seen in patients with: Multiple Sclerosis During 2nd trimester, a pregnant 38 y/o F has numbness in both hands, particularly thumb, forefinger, middle finger bilaterally. Dorsal part of hand unaffected. Arms aches in morning from shoulders to hands. Diagnosis: Median neuropathy at the wrist Mechanism of action of botulinum toxin at neuromuscular junction: Inhibition of acetylcholine from presynaptic terminals Benign intracranial HTN etiology: Hypervitaminosis A Fever, HA, seizures, confusion, stupor, and coma, evolving over several days. EEG with lateralized high-voltage sharp waves arising in the L temporal region, with slow wave complexes repeating at 2-3 second intervals. CT low-density lesion in L temporal lobe. Herpes Simplex Encephalitis Severe spasms and rigidity of limbs intermittently and later more persistent/continuous: Antiglutamic and anidecarboxylase (anti-GAD) antibodies Progressive weakness over several days - absent reflexes worse in lower extremities - slow conduction velocity, conduction block Acute inflammatory polyneuropathy [Show Less]