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Running head: MAJOR CASE STUDY

Major Case Study

Molly Chaffin
The University of Southern Mississippi


Patient Introduction

AB is an 84-year-old black male admitted to the emergency room of

Memorial Hospital of Gulfport (MHG) at 3:00 am on October 25, 2014 with
complaints of constipation and severe abdominal pain. AB reported that he
felt an urge to have a bowel movement but did not have any relief. He then
began experiencing intense pain in the lower portion of his abdomen. AB was
initially diagnosed with an ileus, or intestinal obstruction. Following further
examination, it was determined that AB had multiple jejunal diverticula with
perforations resulting in pneumnoperitoneum.
Upon admission, ABs temperature was within normal limits at 37.3 o C.
His heart rate (recorded at 104 beats per minute) and his respiration rate (17
breaths per minute) were also within normal limits. ABs blood pressure was
within a normal range at 103/61 mm Hg. AB weighed 109.5 kg upon
admission and reported that he is approximately 510. According to his body
mass index (BMI) of 34.6 kg/m2, AB is diagnosed with class I obesity (BMI
30.0-34.9 kg/m2). AB is 144% of his ideal body weight of 166 pounds.
AB has an extensive medical history including congestive heart failure
(CHF), type II diabetes mellitus, and cancer of the larynx and prostate. AB
has a history of stomach ulcers and has previously undergone endoscopy.
Following post-surgery recommendations, AB discontinued his use of aspirin
and other non-steroidal anti-inflammatory drugs (NSAIDS). AB also has a
history of cigarette smoking and alcohol use but reported no longer
participating in either of these former habits.


AB is currently retired. Prior to admission, he lived at home with his

wife who was recently diagnosed with terminal metastatic cancer.
Unfortunately, ABs wife was referred to hospice the night before ABs
admission, and he reported caring for her when his symptoms developed. AB
has two stepsons that are assisting with the care of both AB and his wife.
Upon admission, AB was found to have an ileus of the small intestine. A
computerized tomography (CT) scan was conducted along with an
exploratory laparotomy, which involves penetrating the abdomen through a
small incision to examine the abdominal organs. This procedure discovered a
mid-jejunal perforation with 100-200 milliliters of fluid and several diverticula
throughout the jejunum. A small bowel resection of approximately six inches
was performed with a primary anastomosis to reconnect the intestinal tract
on October 25th.
On October 26th, AB was ordered nil per os (NPO) except ice chips. A
nasogastric tube was placed to suction gastric secretions until the intestinal
tract healed and ABs diet resumed. The cardiology team also observed the
patient to review cardiac enzymes and electrocardiogram (EKG) results. The
cardiologist observed ABs troponin levels to be elevated. AB did not report
experiencing any chest pain, however, his history of CHF required further
monitoring of these levels to rule out acute heart failure.
On October 27th, cardiology reported no changes in EKGs or cardiac
enzymes and approved transfer from the ICU to the telemetry unit. Patient
progress notes reported no symptoms of nausea or vomiting and hypoactive


bowels. Bowel sounds were observed on October 28th, and the patient
reported passing gas. His diet was then advanced to clear liquids. On
October 29th, the patient was tolerating the clear liquid diet well. AB was able
to ambulate about his room and was transported by wheelchair to visit his
wife in another unit. ABs follow-up nutrition assessment determined that AB
was consuming about 75% of meals. At this time, AB reported an increased
appetite and tolerating the clear liquids well. AB was drowsy and seemed to
be in pain at this time, so this nutrition follow-up was brief (about ten
On October 31st, AB reported a bowel movement and was advanced to
a GI soft diet. A 24-hour recall and nutrient analysis from November 1 st is
listed below in table 2. Discharge orders were placed to a local skilled
nursing home awaiting tuberculosis test results and nursing home
acceptance. On November 3rd (post-operation day 9), ABs surgical staples
were removed and replaced with Steri-strips. Discharge to a skilled nursing
facility was planned with physician follow-up orders scheduled in two weeks.
ABs diet prior to admission was assessed by inquiring about his usual
intake. AB reported that he does the cooking and grocery shopping. AB does
not follow a diabetic diet but avoids concentrated sweets. His blood glucose
is well controlled by medications, with levels consistently between 80-190
mg/dL. A glycosylated hemoglobin test was not available at this time. AB
reported consuming grits or toast for breakfast. He often consumes a turkey
or ham sandwich for lunch and usually TV dinners or processed meals for


dinner. AB reported that he does not consume fried or greasy foods often and
eats out only a few times per month; however, AB reported consuming fast
food more often lately while caring for his wife. AB reported eating a fish
sandwich from McDonalds the evening before his hospital admission.
Prior to discharge, material was provided on the appropriate diet to
prevent dumping syndrome and complications of a small bowel resection.
Information regarding a low-fat, low concentrated sweets diet was provided.
ABs meat intake consists mostly of fish and chicken. Recommendations were
made to purchase skinless chicken or to remove the skin prior to cooking. AB
reported consuming ground beef occasionally, and recommendations were
made to purchase lean meats (90-95% lean) and to drain the fat or rinse the
meat after cooking. Avoiding fried or greasy was strongly recommended.
Increased consumption of vegetables and one serving of fruit per meal was
recommended. AB was told that some foods may be tolerated better than
others, and his initial diet will require some trial and error testing of which
foods he may need to avoid in the future.
On November 3rd, AB was discharged to a skilled nursing facility. AB is
scheduled to return to Memorial Hospitals rehabilitation unit on November
14th. AB will stay for two weeks in the rehab unit until he is fully recovered
from surgery and able to independently complete most activities of daily

Summary of Primary Disease


A diverticulum (plural: diverticula) refers to a pouch or pocket that

forms in the wall of the small intestine. These pouches often occur in an area
of weakness in the wall of the small intestine, such as where an artery meets
the muscle layer (Ferreira-Aparicio et al., 2012). Diverticula are most often
seen in the large intestine or colon; this presence of diverticula is referred to
as diverticulosis. Diverticulosis is very common, especially in the elderly
population. Diverticulosis is rarely seen before the age of 40 but is seen in
almost all individuals above age 80 (American Society for Gastrointestinal
Endoscopy, 2014). Diverticula do not typically present any symptoms,
however, in some cases these pouches may trap intestinal contents or stool
and become inflamed. This inflammation of the diverticula is termed
diverticulitis. Symptoms include fever and severe abdominal pain (FerreiraAparicio et al., 2012).
Diverticula of the small intestines are much less common than that of
the colon or large intestine. Jejunal diverticulitis is quite rare, with an
incidence rate of <1% of the population (Akbari, Atqiaee, Lotfollahzadeh,
Moghadam, & Sobhiyeh, 2013). Jejunal diverticulitis is seen more often in
men and typically occurs with acute onset of symptoms. These symptoms
may include diarrhea, severe abdominal pain, bloating, nausea, vomiting,
flatulence, or malabsorption.
Diverticula are typically formed from the general weakening in the
muscle layers of the small intestines; however, the exact pathogenesis is
unknown. Diverticula may occur from motor dysfunction or weakening of the


smooth muscle layer within the intestine (Lempinen, Salmela, &

Kemppainen, 2004). While this may be due to aging and general wear and
tear on the organs, low fiber diets have also been suggested to be a cause of
diverticulosis (American Society for Gastrointestinal Endoscopy, 2014). The
prevalence of diverticulosis is much lower in regions with generally high fiber
intake. It is also thought that low fiber diets lead to constipation, which
causes pressure and strain in the lower intestines during bowel movements.
This chronic strain on the walls of the intestine is thought to contribute to the
formation of diverticula (American Society for Gastrointestinal Endoscopy,
2014). Extensive research has been conducted, however, that has found no
decrease in the incidence of diverticulosis with a high fiber diet. Peery and
colleagues (2012) determined that a very high fiber diet and greater
frequency of bowel movements per week actually increased the incidence of
diverticulosis in adults age 30-80 years old. Non-steroidal anti-inflammatory
drugs (NSAIDS) have also been associated with increased damage to the
mucosal lining of the gastrointestinal tract. While damage typically occurs in
the stomach or the ileum, it is not necessarily limited to these regions and
may be the cause of perforations or damage to the jejunum (Akbari et al.,
2013). In the study conducted by Peery and colleagues (2012), individuals
with diverticulosis were more likely to take NSAIDS than those without
diverticula; while this does not establish causality between diverticula and
NSAID use, the association between the two is observed.


Common complications that can occur with diverticulosis are intestinal

obstruction or perforations. Obstructions may occur in the small intestines
due to large diverticula compressing a nearby intestinal loop, creating a
kinked-hose effect (Lempinen et al., 2004). Obstruction might also occur
secondary to the formation of small stones in the diverticula called
enteroliths. These stones are created when bile is trapped in the diverticula
forming choleic acid. This buildup of choleic often contributes to a blockage
or ileus in the intestines (Patel, 2008).
Perforation of diverticula in the small intestine is very rare, possibly
due to the low pressure of the small bowel; however, untreated perforations
of the intestine can lead to dangerous outcomes with one-year mortality
rates of approximately 19% (Peery et al., 2012). Perforations may cause
infection leading to peritonitis, or inflammation of the peritoneal lining of the
stomach. Peritonitis presents symptoms of infection such as fever, nausea,
vomiting, and abdominal pain. Without immediate treatment of the
perforation, the infection may progress and spread throughout the body
causing a systemic infection (Patel, 2008).
Jejunal diverticula are typically diagnosed by a computerized
tomography (CT) scan. An exploratory laparotomy may determine if
diverticula complications are present such as hemorrhages, perforations, or
inflammation. Initial therapy includes bowel rest, NPO with placement of a
nasogastric tube to suction, intravenous fluids, and antibiotics (FerreiraAparicio et al., 2012). Perforated diverticula that present intestinal


inflammation and risk for infections require emergency surgery. This surgery
consists of a small bowel resection of the jejunum or anastomosis of the
jejunum to the ileum (Patel, 2008).
Removing a portion of the intestine puts a patient at risk for short
bowel syndrome (SBS). SBS refers to a decrease in nutrient absorption,
digestion, and often malnutrition due to the resulting decrease of absorptive
surface area following the removal of a portion of the intestine. Most patients
experience intestinal adaptation following a small bowel resection of less
than half of the small intestine (which typically measures between 300 to
600 cm in length). Patients with significant resections in which <100 cm of
the small intestine remains, however, often do not have the capabilities for
the surface area of the remaining intestine to meet absorption needs. These
patients often experience severe diarrhea, or dumping syndrome, in which
ingested contents pass through the intestines without adequate absorption
and are rapidly excreted by the bowels. (Wall, 2013).
Prevention of short bowel syndrome involves proper adaption by the
small intestines. Following removal of a portion of the small intestines,
remaining intestinal villi expand in length and depth to provide an increased
surface area for absorption. This process begins immediately following
resection and may continue for up to two years post-surgery. While the
adaptive mechanism is not entirely clear, certain factors are thought to
improve adaptive time and effectiveness. These factors include secretions
from the pancreas, bile secretions, and hormonal growth factors. Certain



nutrients, particularly complex macronutrients, are also thought to play a

role in intestinal adaptation; therefore, early diet initiation and nutritional
intake play an important role in intestinal rehabilitation following small bowel
resections (Peery et al., 2012).
Medical Nutrition Therapy
As previously stated, diverticulosis (or the asymptomatic presence of
diverticula) is extremely common in older adults. Prevention of diverticulosis
is widely debated. Initially it was hypothesized that a high fiber diet would
prevent the formation of diverticula by increasing fecal bulk and promoting
more frequent bowel movements; however, a large study involving over
2100 participants determined that participants who consumed larger
amounts of fiber per day (22 34 g/day) were 30% more likely to acquire
diverticulosis than participants who consumed the lowest amount of fiber per
day (6-11 g/day) (Peery et al., 2012). This study also determined a high
number of bowel movements per week (>15) also increased the risk of
diverticulosis in participants.
The Academy of Nutrition and Dietetics (2008) determined different
results in an evidence analysis of fiber intake and gastrointestinal health.
According to the evidence reviewed, a high fiber diet increased fecal weight
and decreased transit time in the GI tract; these findings have been
associated with a decreased risk of diverticular disease, however, the
research is not definitive. This review also determined that a high fiber diet
might decrease the risk of diverticular disease in participants above the age



of 60. Due to the conflicting findings, however, further research should be

conducted on nutritional therapy for the prevention of diverticular disease.
Recommendations for the treatment of diverticulitis are also
conflicting. During exacerbations of diverticulitis (resulting in abdominal pain,
inflammation, and GI bleeding), complete bowel rest is recommended until
symptoms subside (Nelms, 2011). The patient may then advance to a clear
liquid diet as tolerated with advancement to a low-residue diet as normal
bowel function resumes. Nelms (2011) recommends a final diet
advancement to a high fiber diet to prevent future diverticulitis flare-ups,
however as with prevention, a high fiber diet for the treatment of
diverticulitis is still unclear.
If surgery or bowel resection is required for diverticulitis, early diet
initiation is recommended and generally tolerated. Evidence indicates that
initiating a clear liquid diet within one day of surgical resection is safe and
well tolerated in most patients. Diets containing hard to digest or fibrous
foods should be avoided for up to six weeks or complete intestinal healing to
prevent an ileus or obstruction (Nelms, 2011).
Other evidence indicates that diets high in fiber and moderate in fat
are beneficial for patients following a small bowel resection (Wall, 2013).
Increasing intake of soluble fiber may help to delay gastric emptying,
increase time for nutrient absorption, and promote intestinal adaptation. This
diet including moderate fat intake (approximately 40% of total calories),



complex carbohydrates, and increased fiber promotes energy absorption and

appropriate bowel movements (Wall, 2013).
Choi and colleagues (2014) found similar results regarding increased
intake of dietary fats. This mouse-model study found that a high-fat diet
(approximately 42% of total calories) promoted intestinal growth and
adaptation following a bowel resection. This diet also promoted weight gain
approaching pre-surgery weights in mice following the high-fat diet
compared to a liquid diet (Choi, Sun, Guo, Erwin, & Warner, 2014).
High fat diets are generally not recommended for patients with heart
disease, and controlling intake of the types of fats should be monitored in
diverticulitis patients with multiple co-morbidities or heart conditions. After
the analysis of multiple research articles, the Academy of Nutrition and
Dietetics (2007) concluded that low-fat diets and Mediterranean diets (with
dietary fat intake composed of mostly unsaturated fatty acids) promote heart
health and decrease the risk of cardiovascular events in diabetic adults. This
evidence analysis should be considered when making recommendations for
patients with secondary disease states.
The majority of vitamins and minerals are absorbed within the small
intestines; therefore vitamin supplementation is recommended for almost all
patients following bowel resections. Because nutrient absorption varies
throughout the intestinal tract, it is generally recommended that patients
take a daily multivitamin following surgery (Wall, 2013). A chewable vitamin
may be initially recommended to prevent GI pain or obstructions. Individuals



with major bowel resections may initially require total parenteral nutrition
(TPN), or dietary intake via intravenous formulas. General multivitamin
supplementation may also be provided through IV administration, however, a
review of the literature determined that additional supplementation of
human growth hormone and glutamine may provide additional benefits to
patients recovering from surgical resections (Wales,Nasr,deSilva,&Yamada,
2010). These additions may promote intestinal absorption and weight gain, as
well as assist patients in transitioning from TPN to an oral diet.
Fat-soluble vitamins, including vitamins A, D, E, and K, tend to be
poorly absorbed following intestinal resections due to decreased absorptive
area, decrease lipase secretion, and steatorrhea (or fat malabsorption)
(Hadjittofi et al., 2013). Hadjittofi and colleagues (2013) found that
supplementation of 50,000 IU of Vitamin D every other day may promote
intestinal cell turnover and adaptation in a rat model of short bowel
syndrome. Vitamin D supplementation was also found to increase postsurgery weight following a 75% bowel resection.
Nutrition Care Plan
ABs estimated energy expenditure was calculated using the Mifflin St.
Jour equation and predicted to average 2,321 kilocalories per day (including
a stress factor of 1.3). Estimated energy needs ranged from 2265 to 2640
kilocalories per day based on a 30 to 35 kcal/kg target body weight formula.



Based on a 1.2 to 1.5 gram per kilogram target body weight formula, ABs
estimated protein needs ranged from 91 to 113 g/day.
Anthropometrics. Upon admission, AB weighed 109.5 kg. ABs weight
was taken only once upon admission, therefore weight changes cannot be
noted. Upon assessment, however, AB reported that his usual weight
fluctuates around 240 lbs. His reported height was approximately 510 and
was used for nutrition calculations because the patients length was not
measured during his inpatient stay. According to his weight and height, ABs
body mass index (BMI) equals 34.6 kg/m2, which is considered class I obesity
(BMI 30.0-34.9 kg/m2). ABs ideal body weight is 166 pounds, so he is
currently 144% of his ideal body weight.
Lab Values. ABs pertinent laboratory results during his hospitalization
are displayed in table 1 with abnormal findings defined below.
Table 1. Laboratory values.

10/28 10/29 11/01


6 20 mg/dL

22 (H)




0.5 1.2 mg/dL

135 145
3.5 5.1 mmol/L
8.8 10.5 mg/dL







3.4 5 g/dL

Blood Urea

Normal Range
70 110 mg/dL




Glucose. Glucose levels may be elevated due to insulin resistance

(type II diabetes) or medications such as statins that cause levels of glucose
in the blood to rise (Mayo Clinic, 2012)
BUN. Urea nitrogen levels may to be elevated in individuals with
congestive heart failure. Fluid overload or edema experienced by the patient
could elevate urea nitrogen levels in the blood due to the increased workload
on the kidneys and inability to filter out these waste products (Pujol, Tucker,
& Barnes, 2011). Levels might also rise due to increased protein catabolism
following an intestinal obstruction and the inability to absorb the necessary
nutrients from the diet. Urea nitrogen levels are also often elevated following
a GI bleed or intestinal obstruction (Eckstein & Adams, 2013).
Sodium. Sodium levels may be depressed in individuals with heart or
fluid overload. Because sodium is not synthesized in the body, sodium levels
can only be increased by dietary intake. Patients who are NPO or not
receiving sufficient sodium from IV fluids may develop low sodium levels
(Eckstein & Adams, 2013).
Calcium. Low calcium levels may be observed in patients taking loop
diuretics for congestive heart failure. This is due to the fact that calcium is
reabsorbed in the nephrons. Because diuretics function to decrease
reabsorption on water in the kidneys, calcium reabsorption is also decreased
and serum levels may decline (Pujol, Tucker, & Barnes, 2011).
Clinical Signs and Symptoms. Upon admission, AB complained of
increasing abdominal pain and constipation. He reported feeling the urge to



have a bowel movement with no relief. Two days post-surgery, AB was

drowsy but reported feeling better. At this time, AB reported that his appetite
was fair, however, he was still under NPO orders. AB recovered quite steadily
with reported pain decreasing over time. ABs bowel sounds returned within
three days of surgery. His first bowel movement occurred six days postsurgery.
Dietary History/recall. Upon admission, AB was placed under NPO
orders due to his ileus and surgical procedure. Following the procedures, a
diet order was not placed until bowel sounds resumed. On October 28th (postoperation day 3), bowel sounds were observed and the patient reported
passing gas. The physician then approved orders to begin a clear liquid diet.
AB appeared to tolerate the clear liquids well with improvement in
intake and no reported symptoms of diarrhea, abdominal pain, or bloating.
On October 31st (post-operation day 6), AB experienced a bowel movement
and a GI soft diet was ordered. A 24-hour recall was conducted based on ABs
reported intake and nurses notes. Results are listed below in table 2.

Table 2. November 1st 24-hour recall

Scrambled eggs
Cheese grits
Pork loin and gravy

Percentage eaten







Green beans
Cream of chicken soup
Saltine crackers
Roast beef sandwich
Grape juice





Protein: 59 g

kcal = 1,283
Carbohydrates: 151 g

Fat: 50 g
Medications. ABs medications delivered during his hospital stay are
listed below in table 3.
Table 3. Medications

Purpose/nutritional significance
Opiod narcotic used for pain relief. Opiod
narcotics may slow peristalsis and gastric


Synthetic injection that acts as an incretin
memetic. Exenatide, the main component of
Byetta, is a synthetic form of the hormone
found in Gila monster salvia. This hormone
acts as a glucagon-like peptide 1 agonist to
increase insulin and decrease glucagon


secretion (Mayo Clinic, 2014).

Diuretic used for congestive heart failure.
Indirectly lowers blood pressure by


decreasing water reabsorption by the


Potassium-sparing diruretic used for heart
failure patients with hypertension and/or


Xanthase oxase inhibitor used to decrease
uric acid production. May be used to
decrease gastric ulcer relapses (U. S.


National Library of Medicine, 2012).

HMG-CoA reductase inhibitor that works to
reduce low-density lipoproteins and
triglycerides and increase levels of highdensity lipoproteins. Pravastatin decreases
the risk of complications from heart disease
(U. S. National Library of Medicine, 2014). A
pertinent side effect of statin use is
increased blood sugars. Individuals with
hyperglycemia or diabetes should be
particularly strict with diet and glucose
monitoring when taking statins. (Mayo Clinic,

Ipratropium nasal

Decreases nasal secretions (runny nose).

Inadequate energy intake related to altered GI function and surgical
procedure as evidenced by NPO status three days post-surgery, poor



appetite, intake of GI soft diet not meeting estimated energy and protein
needs (1300 kcal and 60 g protein intake compared to approximately 2,400
kcal and 100 g protein needed).
Nutrition Interventions (Actual and Proposed)
Actual interventions included recommending advancement of diet from
NPO to clear liquids as tolerated with a goal of <7 days NPO post surgery.
The clear liquid diet order should be advanced to a GI soft diet as bowel
function improves. Final diet advancement to a cardiac/diabetic diet was
recommended if the GI diet was well tolerated. Supplementation with
Glucerna twice per day was recommended to assist patient in meeting
energy and protein needs to promote wound healing. Education was
provided to the patient on following an anti-dumping syndrome diet.
Recommendations were made to avoid fried or fatty foods, increase fiber
intake in the diet, limit simple sugars and concentrated sweets, and take a
daily multivitamin.
A similar intervention would be recommended according to the
literature previously reviewed regarding medical nutrition therapy of
diverticulitis and small bowel resection. Early initiation of a clear liquid diet
one to two days following surgery should be recommended as tolerated.
Nutrition education should promote a higher fat diet upon discharge
composed of mostly unsaturated fats. Incorporating healthy oils, nuts, seeds,
avocados, and fish into ABs home diet may be recommended to promote
intestinal and cardiovascular health. Research regarding fiber intake and



diverticulitis is unclear; therefore; a moderate fiber intake appropriate for

ABs age and gender (25 g/day) should be recommended.
Nutrition Monitoring and Evaluation
Monitor patient intake and tolerance to diet advancement by patient
reported GI symptoms such as nausea, abdominal cramping, diarrhea, or
abdominal distention. Evaluate adequate intake as greater than 75%
consumption of meals and oral supplements. Evaluate improvement in
nutritional status by weight maintenance and normal ranges of nutritionrelated lab values (glucose, albumin, BUN). Evaluate patient understanding
of nutrition education by patient responses and goal setting. A follow-up
session should be scheduled to further evaluate the success of dietary
changes, appropriate wound healing, and management of diseases.
Summary, Prognosis, Discharge Plan
In summary, AB is a pleasant, 84 year old gentleman who was
admitted to Memorial Hospital for a bowel obstruction. Following a CT scan
and exploratory laparotomy, AB was diagnosed with a perforated jejunal
diverticulum and underwent a small bowel resection removing 6 inches of his
small intestine. AB is obese with a history of type II diabetes, coronary heart
failure, gastric ulcers, and larynx and prostate cancer.
ABs procedure required NPO until the intestine adequately healed and
bowel sounds resumed. AB was then advanced to a clear liquid and later a GI
soft diet. AB was recommended to follow this diet upon discharge to a skilled
nursing facility. AB will return to Memorial for a two-week stay in the



rehabilitation unit to regain strength and practice activities of daily living so

he may return to his home upon discharge.
As mentioned previously, perforated diverticulitis is associated with
one-year mortality rates near twenty percent (Peery et al., 2012). ABs
jejunal diverticulitis should resolve following his small bowel resection but
removal of a portion of his small intestine puts AB at risk for short bowel
syndrome. Because only a small portion of his bowels were removed
(approximately 15 cm) his intestine is expected to adapt appropriately
without significant incidence of malabsorption or dumping syndrome. ABs
comorbidities appear well controlled, and the patient reported understanding
of a healthy diet low in saturated fat, sodium, and concentrated sweets. It is
expected that AB make a full recovery from his diverticulitis and surgical
procedure and return home with a satisfactory quality of life.



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