Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. A very good afternoon. Good evening, good morning to one and all joining us from UK and the rest of the world. My name is I'm one of the Sh Os working in WWO NHS Trust here in. Uh I would like to firstly welcome everyone joining us here today on the platform. Uh we are part of a group called the Medics where a group of junior doctors trying to, you know, spread awareness about a few of the topics which, you know, new, new students like medical attendees, foundation, doctors struggle with, struggle with when they first enter into NHS. So it's gonna be a series of one hour sessions every week where we kind of touch upon these topics and try to ease people through on how to actually approach these situations and conditions when you, when you kind of see it. So it's gonna be every week. And I think if you guys have any doubts during each session, just drop, you know, uh questions in the, in the chat box and we'll just come to it. And uh essentially we hope that you enjoy these sessions and you kind of follow through and through because we have a lot of these teaching scheduled over the next few months. It's definitely gonna be very useful for you guys. And uh if you find it useful, do share the links that we share with you guys every week with everyone else so that they can join as well. Uh for the first session today, uh It is gonna be uh from my colleague, Aisha Krish. I'm gonna let her introduce herself and she's gonna be doing a teaching on all of the very common conditions or symptoms. I would say which you know, people come admitted with. So without further ado I start the session. Hello, everyone. I'm Ashura. I'm working as a junior clinical fellow at the NHS in the Department of Medicine. And uh before I start my session, thank you so much for attending this and ni thank you for introducing me. And yeah, so today I'm just going to give you an overview of a very common complaint we come across when we start working in the hospital. So most of them come with this particular complaint. So I'm just going to give an overview of how we would take history, investigate this particular complaint and how we would manage it. I hope my presentation is going to be of some use to you all. And any questions, please feel free to drop them in the chat Boxx. And also, whilst I'm sharing my presentation with you, I'll probably be looking down into the phone, but that's only because that's the only way I can access your questions. So please excuse me for that. Are you guys? Ok, for me to start my presentation, uh it's gonna be more about uh it's gonna be a combination of primary care and a gender thing. OK. So before I begin, can someone tell me when you see the term or when someone tells you they are having shortness of breath? What is your understanding of it? You can always type your answers in the chat Boxx and wait for like a minute. Am I audible to you guys? Ok. Yes. Very good. Mhm. Anything else does anybody else wanna answer? Hm. Ok. So basically it's just this frightening sensation of being unable to breathe normally or feeling suffocated, right? Or you can also come it as this unaired of your breathing. This is actually pretty normal if you've like just come back from a workout or if you just played something, it is like really vigorous. So it's common in terms of like when you've done like really extreme physical activity. But if not, that's when it becomes bothersome and the medical terminology for it would be dyspnea, right? So now I'm just gonna give you all a few definitions and I want to also tell me if you all know the medical terms for it, right? So we have like different kinds of dyspnea, probably come across in your med school or if you are still in med school, you will probably come across it sometime soon. So when you feel short of breath, when you're lying down, do you know what that means? Like, what's the medical term for it? Shortness of breath or lying down the medical term? Yes. Perfect. It's orthopnea. And what about when someone tells you that they were asleep and then they woke up in the middle of night, like after two hours and that's when they fell short of breath. Do you know what that is called? Ok. So that would be paroxysmal nocturnal dyspnea? Ok. Yes, exactly. B and D, uh, the next one is, do you know what it is when you feel short of breath, when you lie on one side, like either on your left side or the right side and just feeling extremely short of breath in these positions, do you know what that's called? Ok. So that's called tra apnea. So when you lie, when you feel extremely short of breath, when you lie down on a particular side, it's called trap apnea. And the last one is quite interesting. It's pretty rare. So this one is where you feel short of breath when you've stood up and you actually feel a lot better when you're lying down. Do you know what this is called? Ok. So this is called pla apnea. This is pretty rare, but that will be fun to know what this means. Ok. All right. So now moving on any questions so far? Ok, I'm gonna go ahead now. So the next thing is, so how would you grade this breathlessness? Right? So everyone tells us that they're feeling short of breath, they are feeling like they're feeling suffocated. But how would you grade, how would you know if this is severe or not? So, for this, we have different scales. So the first scale is the modified mrc dyspnea scale. So grade zero is basically you get breathless with strenuous exercise and I think this would happen to any of us. So that's pretty normal and nothing to be worried about. Grade one is you get short of breath when hurrying on the level or walking up a slight hill. Grade two, you walk slower than people of the same age on the level because you're feeling short of breath or you have to stop for a breath when walking at your own pace on the level. And grade three, you stop for breath after walking about 100 m or after a few minutes on the level. And grade four, you're too breathless to leave the house or when you're dressing or undressing, you're feeling breathless and one such other scale that we use. And this is more in terms of as a background of heart failure and things is the nyh A classification. So here again, when you say the symptoms we're talking about here is fatigue, palpitations, chest pain dyspnea, and syncope. So no symptoms but normal physical activity, normal functional status. So maybe you have like just one symptom fatigue but everything else is fine. So that would be class one. Class two is mild symptoms again, one or two symptoms, but normal activities is comfortable at rest. Slight limitation of your functional status. Class three is moderate symptoms with less than normal physical activity, comfortable only at rest, marked limitation of your functional status And class four is severe symptoms with features of heart failure with minimal physical activity even at rest. So now we know that ok, that's breathlessness. So how we would divide the causes is like broadly, it would be respiratory causes cardiac causes and non cardiorespiratory causes like someone earlier said, cardiovascular and respiratory symptoms affected. When I asked, what exactly do you mean by shortness of breath? So that's how we categorize it into respiratory causes cardiac causes. And the other broad categorization would be non cardiorespiratory causes. Some of the common respiratory causes are asthma, bronchitis, COPD infection COVID. That's a new thing. Now, interstitial lung disease, pneumonia. V etb cardiac causes again, arrhythmia, cardiac failure and psychological causes like anxiety, panic attacks, spinal causes scoliosis, kyphosis, then you always have anemia, anaphylaxis, deconditioning diseases, obesity, smoking, sorry and thyrotoxicosis. These are just some common causes I listed below. And now the same causes, we'll have to divide it into acute se acute and chronic. So acute would be something that that last with over minutes or hours. So you have asthma, cardiac arrhythmias, dissecting aneurysm, pneumothorax, p like all this happens in like minutes. Subacute again, asthma could be subacute or acute again, valvular diseases bleed heart failure, plural effusion. So this is something that develops over hours or days and then something that develops over weeks or months could be anemia again, some certain cardiac diseases, malignancy, obesity, lab dysfunctions, et cetera. So now I'm just gonna give you a few details of a patient just looking at this. Can someone tell me how they would proceed with this case? So someone comes and tells you there's an 85 year old lady, her name is Mary. She says she's feeling difficult to breathe and these are her vitals. So looking at this, what are the first few thoughts that will come to your head? And how would you start managing? Can someone just tell me a few points like one or two on the chat box, please? Yes, of course. But wouldn't that come later? Mhm. Ok. Um ok. Mhm. Ok. So let me tell you one thing. So how I would proceed with this patient is so now somebody tells me maybe 85 difficulty in breathing and these are her vitals. So heart rate is high, right? I mean, obviously we don't know the background but just looking at this looks like the heart rate is high. Respiratory rate seems. Ok. Spo two seems a bit low but OK, she's 85 so it's probably still fine, but you don't ha have an idea regarding her background yet, BP is slightly on the lower side for her age, I would say. And temperature again seems like there is a rising temperature. So the first thing is obviously you go talk to the patient, but if you feel the patient is not stable enough to talk to you, you proceed with the A two E assessment, right? And maybe you can just give her some oxygen, some symptomatic things like to bring down the temperature, maybe start her on some fluids. And then if she's more settled, then proceed with the history or when I speak to her, if I feel like she's fine. Like by the time I go there, if all this has already been dealt with, then you can directly jump into the history if she is in a state to obviously give you history. So now when you take history, can someone tell me what is the first thing you would ask the first thing? So here we know that the most the chief complaint is difficulty in breathing, right? So how would you proceed with your history taking from here? Yes. Correct. When. Yes, good. Ok. So basically everybody seems to be aware of the fact that you need to elaborate on the chief complaint, correct. So that will be called as your history of the presenting illness, right? So for things like breathlessness. One of the acronyms we were taught back in med school was OD para. So, O stands for onset days, duration, eyes, the intensity p is the progression a aggravating factors are relieving factors. And the last A would be other symptoms associated with shortness of breath. So this is a pneumonic we used to use to elaborate on shortness of breath. So now here we know it's sudden in onset and she tells us that she's feeling unwell for the past one week. It's worsened over the last two days, breathlessness and fatigue with minimal activity. So, and the associated symptoms are cough with expectoration, chest pain, predominantly on the left side. And she says aggravating factors, any kind of activity and relieving is rest and medications. So now just looking at this with the intensity and progression, I just want to ask you guys a question. So she says breathlessness and fatigue with minimal activity. So, what grade of breathlessness would you put this under? I could go back to the MRC grading slide if you want to if you want me to. So we start with minimal activity, right? So where would you put this? You could always ask her these questions as well? Ok. When, what exactly do you mean by minimal activity? So you can ask her each of these questions like it's not wrong so that you get a better idea of what exactly which grade does she fall under? And she tells you that, you know, even after you're walking for a bit of a distance, I'm really breathless this and, you know, it's grade three, but she tells you like, you know, I'm not able to do anything die what? As grateful. So you have to elaborate more on her minimal activity because at 85 someone's minimal activity would be very different to a 20 year old. Right? So you have to elaborate on that a bit. Now, the next thing in history taking we know is background. So background. The first thing she tells you is she's a hypertensive on medications. She's also a known af and she takes anticoagulants, uh, appetite. She says she's not been eating and drinking very well. But again, this is something which is very subjective. So we'll have to elaborate a bit more on it. Like, what exactly do they mean by not eating and drinking? Well, is, has this been ongoing for a long period or is it something new? So you get a better idea of what's happening with the patient and she says she's lost about two stones in six months. Now, would this be significant or not? Oh, would you want to ask more information regarding it before you think? Ok, this is significant. Ok. Have you guys heard about significant weight loss? Yes, exactly. Intentional or unintentional is very, very important. And also her baseline weight is again, very, very important, right? Is she a big lady or is she? And was it sudden, or was it planned like intentional, unintentional? Yes. Yes. Exactly. Yes. So, significant weight loss. Well, it's about 5 to 10% of your baseline body weight that's dropped in about, in six months of time. So that would be like significant weight loss and then it would probably be malignancy and other things. But maybe this is something to think about. Like, when she mentions that to you, you could ask her a few more questions regarding it. But the most important would be, was it intentional or unintentional? Then the next thing is, so she did say that she worked in a textile factory. So about that, like someone mentioned earlier, if there were any chemicals or aspirator exposure would also be a good question. She's an exsmoker and fa I'm sorry, family history, there's nothing significant in there. Now, the next thing would be the general physical examination. So she appears and fatigued. She seems a little dehydrated. Uh the breath sounds were diminished and cause crackles were heard on auscultation in the left lower lung, feels heart was fine, abdomen was fine. All the other symptoms were fine. Now, just looking at this, what do you think is happening with the patient like so far? You know, ok, like what are you suspecting? You remember the observations earlier? Right? Do you want me to go back to that? These were the observation she presented with? And you've taken a history now she told the associated symptoms were cough, chest pain. Of course, she does have other risks and could be anything at this moment. But what are certain differentials you're thinking of? Yes. P it could be p anything else. Ok. There's a ball there. If you could answer the question. Yes. Most of you have chosen pneumonia. Yes. And I, I agree that could be the top differential and it could be pe, you could also think of malignancy. But I think with all that is she, whatever it is she is spiking temperature, she is coughing with the cough again, you'll have to elaborate a bit more. She said cough with expectation. So ask, ok, like what was the color of the sputum? Was it foul smelling the quantity? Was it blood stain? No bloodstained? So all this is also something you'll have to elaborate upon. So now, ok, we've come to the conclusion that the most likely diagnosis is probably pneumonia. So now with pneumonia, what first thing is we get a chest x-ray, right? And what do you expect to see in this chest x-ray? It's right there. So you will confirm the presence of any consolidation and most likely you looking it in the left lower lobe because that's why you heard the crackers right now. Next ecg in this patient, I think the mo because she's a known af and things like that, one of the most common things you would probably see on the ECG is AF and maybe the rate would not be under control at this moment, but driven by the infection. So, treat the infection first before you increase the rate, controlling medications of your jaw atrial fibrillation medications and then check the heart rate again and see if the A F is controlled or not. Next, we'll do blood tests, we'll do the full blood count can do the ESR, you can do the CRPS WBCs, neutrophils all this. So it gives you an idea of the infection like how severe it is or not. She said she's bringing out sputum. So sending that for culture would be a good thing and because her A T were 92 she probably needs some oxygen right then start on empirical antibiotics. We were suspecting an infection. You can wait for the bloods. If the inflammation markers are raised, you can start on empirical antibiotics. She looked a little dehydrated. So we'll give her some fluids. And then, so this is how preliminarily you would treat her in the hospital. And once the infection is completely settled down, you can always do a repeat chest x-ray to see if the consolidation has improved. And if you're suspecting a malignancy in this case, just I'm just giving uh what a look if you are suspecting it for various reasons, you can always follow that up after you treat the infection, but the priority would be to treat the infection. Ok? And the other thing they do here in the NHS is that after you treat a patient for pneumonia, you do an outpatient chest x-ray and follow up with the pneumonia clinic in six weeks. So you do the chest x-ray to check if there is, the consolidation has come down, has improved. Ok. So now when do we know if we this like these patients can present you anywhere they can present to you maybe in clinic or in hospital. So if they come to you in clinic, right? Like when do you know if the patient needs can be sent home with antibiotics that they need to be admitted in the hospital or if they need ICU admission. So for this, we have something known as the curb scoring cob 65 scoring. So that involves confusion, blood urine nitrogen of more than 19 respiratory rate of more than equal to 30 systolic BP, less than 90 or diastolic, less than equal to 60 age more than equal to 65. Even if you don't remember the uria levels, we can definitely remember four things here and each of it gives us 11 point, right? So this is what it says. So if it's score zero or one, the mortality rate risk is low. So it just outpatient care. If it's two, there's an increase in the mortality rate. So admit them for a few days, observe and then maybe you can send them home and if it's more than equal to three, again, depending on how they're presenting, you can admit and observe or if you feel like if the score is like five or four and you feel like, OK, this patient is to draw really acutely unwell, then you can also send them to IC U. Uh I hope you guys are finding this interesting so far. This is the next case study that I have for you all. So John 18 years male, he's a student. He says he's having shortness of breath for the past six months and these are his vitals heart rate, 72 BP 1 20 temperature, 36 respiratory rate, 18 sas 94 on room air. So again, elaborate the chief complaints. So do the odi para so recurrent episodes for the past six months worsened in the last three days, it occurs approximately twice a month. He notices that symptoms worsen when he plays football, relieves on rest. The associated symptoms are tightness, sometimes experiences coughing particularly at night a little more on the history. He has a background of eczema, no allergies. He is aware of nonsmoker and no family history. He avoids these triggers because it aggravates his symptoms and also nighttime coughing, shortness of breath, no change in appetite on examination, vitals are stable, no signs of distress, mild wheezing on auscultation, especially on the expiratory face. Rest of the symptoms are fine. So with this, what is your top differentiate? Like what do you think is happening with this? Ok. Yes. Anybody else wants to. Yes or do most of you agree with? Ok. So 100% of you have said, oh, great. So all of you have had asthma. Yes. Correct. So then here we will get basic investigation. So chest x-ray ecg blood spirometry because that is the, that is something that will actually be confirmative then allergy testing because he told us that he had a background eczema. So what exactly is he allergic to is something we could find out? Then you the peak peak flow monitoring, then you educate them regarding asthma. If you're starting them on inhalers, like how to use it. This so symptomatic control medications, long term medications, but all that would be a lot later only after you've investigated the patient and you know that 100% of this is asthma, right. Then environmental factors like keep away from them. So it's going to be more of education first and then the treatment depending on the severity of it, follow up visit. And you can always refer them to the respiratory consultants who would probably investigate this matter a bit more and then come to a conclusion of the diagnosis and then start the patient on treatment. So nice guidelines for this treatment is. So step one is you start them on a short acting oh Bronchodilator basically. So it would be your draw salbutamol right? Then if that doesn't work if the symptoms don't subside on that, you add to that inhaled corticosteroid but low dose. So this would be uh like fluticasone budesonide those things, then if it still doesn't subside with that, you add a Lama antagonist, which would be Montelukast, Za Lukas, et cetera. Now, despite all this, there's still no improvement. Step four would be, you add the short acting, the corticosteroid, then you add a long acting, the long acting would be your salmeterol for me. And with this, you can either keep the Lama Dogen antagonist or you can admit it depending on if you feel it added anything to the treatment, like if it had any effect on the patient's symptoms or not. So you can either keep it or you can take it off. It's up to you. Now, despite all this still, there's no improvement. You do something known as the mach therapy, right? So here what you do is s low dose, inhaled corticosteroid with a long acting. And again, you can either keep the LTR A or you can excluded with low dose. It doesn't work. Next, you try a moderate dose of corticosteroid and then you do the laba and either keep or eliminate the LTR. Still, things don't work. You can do add a short acting plus corticosteroid of moderate dose plus a long acting plus or minus if all these steps don't work, then refer to a specialist and then see what else can be done. Now moving on a 33. Ok. So Robert Anderson, age 77 retired again. His complaint to shortness of breath, heart rate is 83 BP 104 by 68 temperature, 37 sats 92 1 room air Audi para first thing. So he reports experiencing shortness of breath and feeling of tightness of the lower limbs for the past two months. His symptoms have gradually worsened over this period. He notices more pronounced symptoms when lying flat or exerting himself resting in an elevated position, alleviates his symptoms. So what do you think is happening? Just looking at that one particular statement, what do you think is happening? Resting in an elevated position, elevates his symptoms. What what he's trying to say is he feels better when he's propped up when he's in an elevated position. So what is this particular symptom called? What is he having? Ok. Look at the next one. He frequently wakes up at night due to shortness of breath. What do you think is happening? What are the two symptoms? Do you think he is complaining of? See, patients are not gonna give us the medical terms? Right. So what do you think are the medical terms here or what could be? Yes, exactly it orthopnea or tnd like we discussed the definitions at the beginning. Oh, little bit of background. So he's hypertensive diabetic, he's got elevated cholesterol. So he's on medications for that as well. Has had an M I previously and has had a stent put in place. So he's on multiple medications. So just looking at this, what, what does the background actually tell us? Like, why do we ask background in every patient? Can someone tell me, is it relevant or not? Can you skip the background? And if you say yes, it is relevant, what is the relevance of the background? Like why do we ask? Mm Yes. Yes. Here it's heart failure. But in general, I'm just asking like, why do we ask for the background? It's to check the risk factors, right? Like the risks involved, like why is the patient per presenting in this particular manner? This could be the diagnosis or what is leading to that. So it's basically to check the risks. So here he has a lot of risk factors. If you look at his hypertensive, he's having high cholesterol. He is a diabetic. He's had mi I previously, he had a stent put in place and his age of course is also a risk factor. So and next he tells you that he is he has quit smoking like 15 years ago, he was an exsmoker, which is again a risk factor. And so you know that he's not like a very active mobile person because he's had limitations because of the previous M I uh white is BP is a bit elevated. Heart rate is regular. Respiratory rate is ok. Uh He like he's like really, he looks really anxious and a bit tired but serious examination. You see that there pulsations and his neck veins as bilateral pitting edema. On respiratory, you hear inspiratory crackles, abdomen is ok, peripheral as bilateral p edema extending up to the knees. So, I mean, this can come either in the peripheral examination, but it's always better to add it in cardiovascular, especially if you're thinking in terms of heart failure, it's always better to add pitting edema in the legs under the cardiovascular examination. Uh So now investigation, so chest x-ray. So when you know that it's heart failure, the most common thing that you would do is like an you get a chest x-ray. But what do you expect to see in a chest x-ray? Right? So we expect to see one is the batwing appearance that will be the alveolar shadow. Then we see the curly B lines, a big heart, then the upper lobe vessels will be like really divulge, divulged and like dilated and then pleural effusion. So there'd be blunting of the claus angles. The next test we do is the NT BNP because this is something that's produced by the myocardium. So anything that's troubling the heart, the first thing that is produced will be this particular marker. So if you know that that's raised, you know, there's something wrong with the heart, then the ECG ECG could be normal or it may show some changes. But in this particular patient I think like a very common thing you probably see is the presence of prominent Q waves because he's had a previous M I. So there will be changes, those changes you would definitely see, then we have to get an echo done. So an echo is mainly done to see how well the heart is functioning because you're suspecting the heart is not doing well. So you really want to know how bad it is. So you have to get an echo done. Then depending on the severity, we'll have to advise the patient with the management. But the first thing always before you start treatment and medications has to be dietary fluid restrictions, lifestyle medications because he has so many risk factors. He said he's an exsmoker, but you'll have to ask him if he has actually completely stopped smoking or is he still smoking and ask him about his diet in general? If he's been compliant with his medications that he takes for all the various risk factors, et cetera, then consultation with the cardiologist. And if community heart failure nurses, referral is something that we also do for these patients. So this is what I was talking about like when it's a chest x-ray, the things that you would look for, it's the ABC de, so that's the alveolar edema, the backings appearance. Then we have the curly be lines, then we have cardiomegaly dilated, prominent upper lobe vessels and pleural euge. Ok. So the last case for today, I'm not going to bore you all anymore. So, David, 60 years old male healthcare worker, again, increased shortness of breath and fatigue. Uh heart rate, 72 BP 1 10 seventies, he's 92 temperature, 37. Right. So Audie Para again. So he reports a gradual onset of increasing shortness of breath and fatigue over the past few months, he experiences shortness of breath even with minimal exertion such as climbing a single flight of stairs. He also feels easily fatigued. So he's like, I'm always exhausted. I'm always tired. Sometimes he has palpitations but he has no of his chest pain, cough or wheezing background. He just has hypertension. Nothing else medication again. He's just on medications to control his b but nothing, nothing else. Smoking is a nonsmoker. He uses alcohol occasionally diet. He eats well. He tells you he's a vegan. His appetite is great exercise, limited physical activity because he feels like he's constantly exhausted and tired. No vitals, BP, vitals are all stable. Ok. But when you look at him, he just looks really pale and he looks really tired. Heart is ok. Lungs were pretty fine. Uh, abdomen again, seemed ok. But he just looked epy. So you feel like there's some kind of low. So what do you think is happening with him? Like, what would you suspect like? And it could be anything? I agree. But yes, so the first thing that you would probably think of is anemia. So what would you do for anemia? So, the first thing we would want to do is check the blood, right? Like anemia. When you say the first thing like, oh hemoglobin levels and the other thing when someone's anemic, it's always good to check if they are having any bleeding from any of that. So ask those questions because even if they don't mention it, probably tell you like, oh yeah, I had blood in stools a few year, a few days ago, but I didn't mention it because it's not happening right now. So do ask if there's any bleeding from anywhere, the minute you're suspecting anemia and if that is ruled out, then then can think of the other causes. So do the blood test, complete blood count. So common causes could be iron deficiency b 12 folate. So get all these tests done check for any active bleeding size or occult bleeding. So the other test to look to diagnose a cul beating would be the fit test. So it's a stool test that you do, which will tell you that if there has been any bleed that's happening, which is not like it's been ongoing for quite some time then. So to further into this, we can do a blood smear to identify any morphologic abnormalities, hemoglobin, electro flus, but all that would be a little later. But first thing would be the top test that the ones that's mentioned in 0.1 do them. And then like if you've gotten your cause already, you can treat accordingly. So take the underlying cause, repeat the bloods and check if the hemoglobin level is really low. He's symptomatic, right. So you're expecting hemoglobin levels to be low. But if it's like very, very low and the symptoms are very severe, we can always give some blood transfusions and yes, then follow up to see if he's his symptoms have improved with this treatment. So your diagnosis was right. He was having this because sometimes a lot of conditions can coexist. So you can treat one thing, but maybe there's something else that's causing the symptoms as well. So it's always good to follow up and check if the patient is feeling better if the symptoms have improved significantly or not. All right, that's it guys. Uh Do you guys have any questions for me or is there anything you would like me to explain? I mean, if not now, maybe in the next session as well, I can get back to you all. It's completely up to you, but ok. All right. Thank you so much guys. Uh Thank you for attending and I'm gonna hand it over to my colleague now. A it is used for hi guys. Thank you so much for attending today's first session of a series of talks and teaching that will be conducted by either one of us and our group of other doctors will be joining us shortly. So next week's topic is gonna be A K I uh so just a heads up regarding the topic and I'll be presenting it next week. If you guys can just provide feedback, it will be very useful for us. And I hope this session was very useful for you guys. And thank you for the wonderful presentation. I'll see you guys next week. Take care. Bye bye.