Transcript Methods of examination of gynecologic patients

Methods of examination of
gynecologic patients
.
Diagnostics
and
treatment
of
gynecologic diseases is based on the
data of the anamnesis and objective
research which is made on certain
system,
Allowing to elicit the main facts and to consider all details
which will promote correct statement of the diagnosis.
For inspection of the women, suffering gynecologic diseases,
use
Gathering of the general and special gynecologic
The anamnesis,
General objective research,
Special methods of gynecologic research.
The anamnesis
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The general
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The special
The general anamnesis includes:
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Age of the patient;
Complaints of the patient, obvious symptoms;
The transferred diseases, including illnesses at children's
age, illness of other bodies, various operative interventions,
traumas;
Heredity (gathering of the information on the diseases
transferred by parents and other nearest members of a
family), and also a state of health of the husband / the
sexual partner;
Conditions of labour activity and life, feature of a way of
life.
Poll of the patient
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It is made under the following plan:
1. Passport data. Special attention thus turn on age of the patient.
2. Complaints of the patient.
3. The transferred diseases: illnesses of children's age, infectious, illnesses
of various bodies and systems, a heredity, operations, traumas, the
allergo-anamnesis, haemotransfusions, diseases of the husband.
4. Life and work conditions.
5. The special akushersko-gynecologic anamnesis:
- Character менструальной, sexual, genital, секреторной functions;
- The transferred gynecologic diseases and operations on genitals;
- Transferred урогенитальные and venereal diseases.
6. Presence of pains and their character.
7. Development of the present disease.
8. Summarising, an establishment of the preliminary diagnosis.
At survey define constitution type:
The female;
Man's (high growth, big shoulders,
Long trunk, narrow basin);
еvnuh (high growth, narrow shoulders,
Narrow basin, long feet, short trunk).
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. Оволосение and a condition of the skin
Covers: superfluous оволосение, a skin condition
(The raised greasiness, акне, фолликулиты, the raised porosity),
stretching strips, their colour, quantity and an arrangement.
Condition of mammary glands: the size,
gipoplaziy, a hypertrophy, symmetry, changes on a
skin. At sick in a standing position and lying spend
a consecutive palpation external and internal
kvadrants glands. It is necessary to mark absence
or presence separated of nipples, its colour, a
consistence and character. Knots in the mammary
glands, defined at a palpation, serve as the
indication to ultrasonic of mammary glands and
маммоgrafy.
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Definition of length and weight of a body is
necessary for calculation of an index of weight of a
body (IWB) — parities of weight of a body to a
square of length of a body:
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IWB = Weight bodies (kg) / Length of a body (м2)
In norm IWB of the woman of reproductive age
it is equal 20—26.
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IWB more than 40 (corresponds to adiposity of
IV degree) speaks about high probability of
metabolic infringements.
Stomach research
Stomach research spend in position
of the patient lying on a back. At a
palpation define the sizes of separate
bodies, exclude асцит, метеоризм,
volume formations.
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By a palpation the condition of a belly wall (a tone, muscular
protection, диастаз direct muscles of a stomach), painful sites,
presence in a belly cavity of tumours, инфильтратов is defined.
Stomach research can give very valuable information. So, if at
sick with volume formation of a small basin volume formation in
эпигастральной is revealed or umbilical area, it is necessary to
exclude a cancer яичников with metastasises in the big epiploon.
The gynecologic Research
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Gynecologic research spend on a gynecologic armchair. Feet of the
patient lie on supports, buttocks on the brink of an armchair. In such
position it is possible to examine a vulva and easily to enter a mirror
into a vagina. Survey of external genitals: a condition and size of small
and big sexual lips; a condition of mucous membranes (juiciness, colour,
a condition of cervical slime); size klitor; scalp development; a condition
perineum; presence of pathological processes (an inflammation,
tumours, ulcers, kondilomay, fistulas, hems). Gipoplazy small and
The big sexual lips, pallor and dryness of a mucous
membrane of a vagina specify on гипоэстрогению.
Juiciness and цианотичность a vulva mucous
membrane, plentiful transparent secretion are signs
gipoestogeny. Pay also attention on openid a sexual
crack; having offered the woman to strain, define,
whether there is no omission or losses of walls of a
vagina and a uterus.
Survey of a vagina and uterus neck in mirrors
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It is spent to the women
conducting sexual life.
Timely recognition of a cancer of
a neck of a uterus, erosion, polyps
and other diseases concerning
precancer conditions, is possible
only by means of mirrors.
Special attention turn on the
vagina arches as there volume
formations and peaked кондиломы
often settle down. At survey in
mirrors take dabs on flora, cytologic
research, it is possible biopsy
volume formations of a neck of a
uterus and a vagina.
Spend after extraction of mirrors.
Index and average fingers of one
hand dressed in a glove, enter into a
vagina. Other hand put on a
forward belly wall. The right hand
palpate vagina walls, its arches and
a uterus neck, mark any volume
formations and anatomic changes.
Then, carefully having entered
fingers into the back arch of a
vagina, displace a uterus forward
and upwards and palpate its second
hand through a forward belly wall.
Mark position, the sizes, the form,
mobility, a consistence and mobility
of a uterus, pay attention to volume
formations.
Spend necessarily in postmenopauzae,
and also in all cases when it is
necessary to specify a condition of
appendages of a uterus. Some
authors suggest to spend to its all
women is more senior 40 years for
an exception of accompanying
diseases of a rectum.
At rectaly research define a tone sfinctery back pass and a
condition of muscles pelvic a bottom, exclude volume
formations: internal gemorridaly knots, a tumour.
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Tests of functional diagnostics,
Used for definition of a functional condition of
reproductive system, till now have not lost the value.
These methods easily to carry out in any conditions also
include:
The test bazaly temperatures;
"Pupil" symptom;
"Fern" symptom;
Symptom of a tension of cervical slime;
KPI.
The bazal temperature (temperature in a rectum) depends on a phase
menstrual a cycle. At ovulatory a cycle with high-grade the first and the
second phases bazaly the temperature raises on 0,5°С directly after ovulation
and keeps at such level within 12—14 days. Temperature lifting is caused by
influence of a progesterone on the thermoregulation centre. At insufficiency
of the second phase of a cycle the hyperthermal phase proceeds less than 8-10
days, rises stepy or periodically falls more low 37 °С.
Bazal (rectaly)
temperature at normal
diphasic menstruali a
cycle.
At anovulation the temperature curve remains monophase
Bazal (rectaly)
temperature at singlephase (anovulatory)
menstrual a cycle.
"The pupil" symptom On an extent менструального a cycle under the influence of an
estrogen changes a muscular tone of a neck of a uterus and diameter of an external aperture
of the cervical channel. Expansion of an external aperture and occurrence in it slime begins
about 8-9 days менструального a cycle, to 14 days the aperture extends as much as possible
(to 3-6 mm in diameter). The slime drop that acts from it, at illumination against pink mucous
seems "pupil". The next days the quantity of slime starts to decrease and by 18-20 day of a
cycle this symptom disappears, the uterus neck becomes "dry". Absence of a symptom
testifies about weak эстрогенном influence, and is long the expressed symptom – about
increase of level of an estrogen above norm.
"Fern" symptom Cervical slime at
Drying on air possesses ability
To crystallise. Intensity of crystallisation
Depends on a phasemenstrual a cycle, that is from
estrogeny influences ovarica. Slime undertakes
Tweezers which are entered into the channel of a neck of a uterus on
Depth to 5 mm, then put on subject glass,
Dry up and investigate under a microscope.
The symptom of a tension of cervical slime the Maximum length of a thread will be
during the period ovulation, when viscosity of slime the greatest. The maximum
stretching of a mucous thread from cervcale the channel is necessary for a moment
ovulation and reaches 8—12 the symptom of a tension of a thread see In the second
phase of a cycle decreases and absolutely disappears before menzis.
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Kariopiknoticy index (КPI) – a parity the
superficial and intermediate cages at
microscopic research of dab from the back
arch of a vagina.
During ovulatory menstrualy cycle КPI
makes: in the first phase of 25-30 %, during
time ovulation — 60-80 %, in the middle of
the second phase — 25-30 %.
Definition of hormones and them меtabolity
In gynecologic practice in blood plasma define albuminous
(лютропин, фоллитропин, пролактин, etc.) and steroid
hormones (эстрадиол, a progesterone, testosterone, кортизол,
etc.). In urine define метаболиты андрогенов (17-ketosteroidy)
and прегнандиола - метаболита a hormone of a yellow body of
a progesterone.
Last years at inspection of women with displays гиперандрогении and carrying out of
hormonal tests instead of definition 17-KS in urine investigate the maintenance in blood
plasma дегидроэпиандростерона and its sulphate and 17-gidroksiprogesterona —
predecessors of testosterone and кортизола. Definition прегнандиола also has given
way to progesterone research in blood.
Functional tests. Unitary definition in blood and urine of hormones and them метаболитов
малоинформативно, these researches combine with carrying out of functional tests that
allows to specify a functional condition of various departments of reproductive system and to
find out reserve possibilities гипоталамуса, a hypophysis, adrenal glands, яичников and
эндометрия. Tests with гестагенами are most often applied; an estrogen and гестагенами;
with dexamethasone; кломифеном; люлиберином.
Additional methods of research
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Additional methods of research concern:
Laboratory,
Tool,
endoscopy,
rentgen.
Laboratory methods of research in gynecology
concern:
bacterioscopy,
Bacteriological,
The cytologic.
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Definition of microflora of a contained vagina and the possible activator in
dabs taken from an external aperture of an urethra, цервикального the
channel, заднебокового the vagina arch.
Depending on character of microflora distinguish 4 degrees of cleanliness of a
vagina:
I degree of cleanliness – under a microscope cages flat эпителия and
лактобактерии, leukocytes отсутсвуют, рН – sour (4,0-4,5) are visible only;
II degree of cleanliness – лактобактерий is less, эпителиальных than cages
much, there are individual leukocytes (to 10), рН – sour (5,0 – 5,5);
III degree of cleanliness – лактобактерий a little, dominates кокковая flora,
it is a lot of leukocytes (to 30), рН – alkalescent (6,0-6,5);
IV degree of cleanliness – влагалищные sticks are absent, the motley,
bacterial flora prevails, there are individual trichomonads, the weight of
leukocytes, эпителиальных is not enough cages, рН – alkalescent.
I and II degree of cleanliness are considered normal, III and IV degrees
correspond to pathological processes.
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To cytologic research subject the cages
received in dabs from a neck of a uterus,
пунктате (volume formations of a small
basin, a liquid from позадиматочного
spaces) or аспирате from a uterus cavity.
Pathological process diagnose on
morphological features of cages, a
quantitative parity of separate cellular
groups, an arrangement of cellular elements
in a preparation.
Cytologic researches are a screeningmethod at mass routine inspections of the
female population, first of all in groups of
the raised risk.
СКольпоскопия — detailed survey
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влагалищной parts of a neck of a uterus, walls
 Vaginas and vulvas through the optical
 System of lenses with increase at 6-28 time.
 At кольпоскопии define the form,
 Size of a neck and external pharynx, colour,
 Mucous membrane relief, border
 Flat эпителия, covering a neck,
 And cylindrical эпителия цервикального
 The channel.
At expanded кольпоскопии before survey the uterus neck is processed by 3 % a solution of acetic
acid which causes a short-term hypostasis эпителия, swelling of cages шиловидного a layer,
reduction подэпителиальных vessels and blood supply reduction. After detailed survey spend
Schiller's test — the neck is greased with 3 % with a solution of Ljugolja. Iodine paints cages healthy
flat эпителия necks in dark brown colour; истонченные (атрофичные) and pathologically changed
cages at дисплазии cervical эпителия are not painted over. Zones pathologically changed эпителия
thus come to light and sites for биопсии uterus necks are designated.
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Кольпомикроскопия – lifetime histologic research
влагалищной parts of a neck of a uterus. It is made
contrast luminescent кольпомикроскопом or
кольпомикроскопом Hamou (type гистероскопа).
СOLPOSCOPY С140
Colposcopy OCS-500
Colposcopy allows you to specify the nature of
pathological changes of the vagina and the
vaginal part of the cervix, which is very
important for the early diagnosis of malignant
tumors.
Thanks colposcopy has become possible to
control the treatment of various diseases of the
cervix
There are several varieties of colposcopy, but in the
volume of outpatient care is used most often:
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Simple CP - without the use of drugs
Enhanced KP - inspection of the mucous
membrane of the cervix with the use of various
special tests
Tasks colposcopy:
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to assess the state of the mucous of the cervix
and vagina
to identify the lesion
to differentiate benign changes from suspicious
of malignancy
make the targeted collection of smears and
biopsies, which significantly increases the
information content of the last
Colposcopy can be assessed:
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color fabrics
the state of the vascular pattern
the surface and the level of the mucous
the presence and form glands
the boundaries of the identified entities (crisp or
fuzzy)
Mixed education identified at colposcopy:
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Exophytic condyloma - result
human papillomavirus infection.
Inflammation may be diffuse and local.
Atrophy - as a rule, is the result of a
deficiency of estrogen. Frequently seen in
postmenopausal women.
Ulcer (true erosion) is a defect in the
epithelium, local his absence. Occurs on a
background of inflammation, hormonal
imbalance, injury, etc.
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Endometriosis, colposcopy foci of
endometriosis may look like cysts bluish
color or bleeding of line and point areas.
channel or beyond the external OS. Can be
epilepy cervix outgrowths, vypyachivalis into
the lumen innymi or multiple. The goal of
colposcopy is not only to identify but also to
assess the state of the surface by the usual
criteria.
Thus, the expanded colposcopy is one of the
highly informative methods for diagnosing
pathology of the cervix and vagina.
Hysteroscopy is the inspection using
optical systems of internal
surface of the uterus. Hysteroscopy is
diagnostic and operating.
Diagnostic hysteroscopy
now is the method
of choice for the diagnosis of all types
intrauterine pathology. Indications
to hysteroscopy are
cyclic and acyclic nature of uterine bleeding in
women of any age, the clinical picture and the history data allow to suspect
intrauterine pathology: uterine fibroids with submucous the host location,
polyps, adenomyosis and endometrial cancer, as well as foreign body in the
uterus (scraps CMC - intrauterine device). After visually determining the
nature of intrauterine pathology diagnostic hysteroscopy can go online
either immediately or deferred, if necessary, prior preparation.
Hysteroscopy is the inspection of the
uterine cavity using ultrathin optical
instrument - hysteroscope, which is
inserted through the vagina, the
cervix. Currently, there is no doubt
that this method is the most
informative instrumental method for
diagnosing the state of the
endometrium and the uterine cavity.
There are two kinds of survey:
diagnostic
that helps
diagnosis
surgical, i.e. medical
Indications for hysteroscopy :
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indications for diagnostic
treatments are:
Suspected internal endometriosis, submucosal node
fibroids, synechia (growths) in the uterine cavity, the
remains of the ovum, cancer of the cervix and
endometrium, endometrial pathology, perforation of
the walls of the uterus during the abortion or
diagnostic curettage
Suspected malformations of the uterus
The menstrual cycle in women of childbearing age
Abnormalities of the uterus
Bleeding in postmenopausal women
Infertility
Control study of the uterine cavity after surgery on the
uterus, miscarriage, after hormonal treatment
Indications for surgical procedures are:
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Submucosal fibroids
Intrauterine septum
Intrauterine synechia
The endometrial polyp
Hyperplasia of the endometrium
Removal of the intrauterine device
Contraindications to hysteroscopy :
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Recently transferred or available to the time of the
study the inflammatory process of the genital organs
Progressive pregnancy
Profuse uterine bleeding
Stenosis of the cervix
Common cervical cancer
Common infectious diseases in the acute stage
(influenza, pneumonia, pyelonephritis,
thrombophlebitis)
Heavy status of the patient with disease of the
cardiovascular system, liver, kidneys
Description of method:
Minimally invasive procedure that is performed
through a natural orifice of the cervical canal of the
uterus through the vagina. The procedure is
performed
under
short-term
intravenous
anesthesia. In the beginning of the procedure is
pain in the area of the cervix to facilitate dilation of
the cervix and with the aim of postoperative pain
management. Then through the cervical canal is
fed a small amount of sterile glucose solution, and
then into the uterus in the same way you enter the
optical system, the camera and the illuminator,
which displays the image enlarged 20 times, on the
monitor screen.
The cavity uterus
Hysteroscope
After inspection of the uterine cavity and the
exact localization of pathology, through the
channel in the optical system enter the optical
drive and using an electric current produce
destruction of the nidus. At the end of the
procedure there is no need for suturing. The
procedure ends with the removal of the uterine
cavity optical system and the liquid.
Complications of hysteroscopy:
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exacerbation of chronic
the inflammatory process
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bleeding
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perforation of the uterus
Laparoscopy - examination of the abdominal cavity using an
endoscope introduced through the anterior abdominal wall.
Laparoscopy in gynecology is used as a diagnostic purposes,
and for surgical intervention.
Indications for routine laparoscopy are:
- definition of the fallopian tubes and the detection of the
level of occlusion;
- polycystic ovaries;
- abnormalities of the uterus;
- pelvic pain syndrome;
- infertility (if proven ovulatory cycles and fallopian tubes).
Indications for emergency laparoscopy:
• ectopic pregnancy;
• apoplexy of the ovary;
• acute inflammatory diseases of uterine appendages;
• suspected torsion of the leg or gap-like formation or tumor
of the ovary, as well as torsion subserous fibroids;
• differential diagnosis of acute surgical and gynecological
pathology.
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Laparoscopy is by far one of the most common modern
diagnostic (and in some cases therapeutic) procedures for
examination of abdominal cavity organs. Laparoscopy is a
surgical method of research. In the abdominal cavity is a
few (often two) tiny incision, then pumped the air.
Through a single incision is entered, the instrument is a
laparoscope (a thin tube with a lens at one end and an
eyepiece at the other; or one end of the laparoscope can
be connected with a video camera, an image which is in
the process of manipulation is transmitted to the screen),
through another incision is entered the device arm. It is
used to help the doctor to thoroughly examine the
internal organs, shifting them.
Indications for laparoscopy:
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clarification of the causes of infertility,
check the fallopian tubes, if possible restoration of patency,
identifying the cause of pelvic pain and, if possible,
eliminating,
clarification of the diagnosis of polycystic ovaries and, at the
same time, their treatment is wedge resection of the ovaries or
coagulation,
tubal ligation for the purpose of contraception (sterilization),
the exact nature of the anomalies of the uterus,
division of adhesions in the pelvic cavity in chronic
inflammatory processes in the uterus,
removal of ovarian cysts, small myomatous nodes,
diagnosis and treatment of endometriosis,
removal of the uterus with its small size,
the ambiguity of the diagnosis: the differential diagnosis
between inflammatory diseases of the uterus, apoplexy
(rupture) of the ovary, appendicitis, ectopic pregnancy.
Contraindications to laparoscopie:
Absolute contraindications to
laparoscopy are the so-called terminal
States of the patient (the agony,
perigonia, clinical death, coma), severe
abnormalities in cardiopulmonary
activity, sepsis or septic peritonitis.
Relative contraindications (i.e. those at
which operation is possible in
principle, but there is a certain amount
of risk):
extreme obesity
the blood clotting problems
the later stages of pregnancy
General infectious diseases
recently migrated open abdominal
surgery
Laparoscopy
Culdoscopy - examination of the pelvic organs using an optical
instrument, introduced into the abdominal cavity through the
posterior vaginal fornix.
This method is used rarely, it was completely superseded by
laparoscopy.
Use it if necessary inspection of the ovaries in women with morbid
obesity. The study is made in the knee-elbow position of women.
The area available for the inspection by this method is significantly
less than with laparoscopy - you can see the rear surface of the
uterus, ovaries, fallopian tubes.
Ultrasound examination
Non-invasive instrumental method used in gynecology for diagnosis of
diseases and tumors of the uterus, appendages, detection of
abnormalities of the uterus. The latest models of ultrasound
machines allow us to observe the growth of the follicle, ovulation,
record the thickness of the endometrium and show him hyperplasia
and polyps. Using ultrasound installed the normal size of the uterus
and ovaries in women, girls and girls.
In gynecology ultrasound spend
abdominal and vaginal sensors. The
use of vaginal sensors allows to
obtain more informative data about
the state of the endometrium,
myometrium, the structure of the
ovaries.
X-ray methods
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X-ray methods to date are widely used in gynecology.
Hysterosalpingography is used to establish the patency
of the fallopian tubes, detection of anatomical changes
in the uterus, adhesions in the uterus in the pelvic area.
Use water-soluble contrast medium (veratect, protract,
urografin etc). The study of appropriate conduct on the
5-7th day of the menstrual cycle, which reduces the
frequency of false-negative results.
Computer tomography
Option x-ray studies, allowing to obtain a longitudinal image of the
study area, the slices in the sagittal and frontal or in any given
plane. CT gives a complete spatial representation about the test
body, the pathological focus, quantitative information about the
density of a particular layer, allowing, thus, to judge the nature of
the lesion. The resulting image structures do not overlap each
other, and CT enables you to differentiate the image of tissues and
organs by the density ratio. The minimum size of the nidus, which
is defined by CT, is
0.5 to 1 see
Instrumental methods
The sounding of the uterus
Invasive method
diagnosis, which
aims
fixing positions
and direction of the cavity
uterine its length.
Contraindicated in
suspected pregnancy is wanted. Is the sounding
of the uterus in low operating.
Puncture of the abdominal cavity through the
posterior vaginal vault
is in the hospital in
when it is necessary
to determine the presence or
no free
fluids (blood, serous
exudate, pus) in the cavity
the small pelvis.
Tissue biopsy
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Lifetime taking a small amount of
tissue for microscopic examination
for the purpose of diagnosis.
In gynecology use sexciting (excision
a piece of fabric), sight (under visual
control using a colposcope or
hysteroscope) and needle biopsy.
The biopsy is most often performed
with suspicion of a malignant tumor
cervix, vulva,
vagina etc.
Aspiration biopsy
Aspiration biopsy is performed to obtain tissue
for microscopic examination. Its essence lies in
the fact that the uterus is extracted content using
the tip, placed in a syringe, or a special tool
PayPal".
Ultrasound is the most affordable and
harmless method of investigation. It can be
used not only to diagnose a variety of
gynecological diseases and for monitoring
the treatment of disease, but also to
monitor the progress of your pregnancy.
With 4-5 weeks of pregnancy through
ultrasound appears the only opportunity to
see what develops in the womb baby (xrays and a CT scan at this time it is
impossible to do).
With ultrasound you can see and evaluate the body
condition of the uterus, cervix, ovaries, fallopian
tubes (if pathology) and surrounding organs.
During the ultrasound measured the dimensions
of all of the available research agencies, assesses
their structure and compliance with the phase of
the menstrual cycle. For the first time to
conduct ultrasound at any day of the menstrual
cycle, excluding days of menstruation. If the
diagnosis is unclear or need clarification, you will
need to re-conduct research on a particular day.
X-ray methods:
Hysterosalpingography x-ray contrast
the study of the uterus and
the fallopian tubes.
Holding hysterosalpingography
During research into the uterus and the tube
through the cervical canal using a special catheter,
a contrast agent (contrast for x-rays), and then
perform some x-rays.
Hysterosalpingography allows you to
identify:
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the endometrial polyps
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submucosal myoma
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malformations of the uterus
Evaluate the results based on the images. If the contrast
agent passes through the pipe into the cavity of the
pelvis, it is considered that the tubes are permeable. If
the contrast agent does not pass through the fallopian
tubes, therefore, they are impassable. If after passing
through pipes contrast does not run freely in the
abdominal cavity, it indicates the presence of adhesions.
• Hysterosalpingography is performed without anesthesia (possibly
local anesthesia with high sensitivity). The study can be conducted
from 8th to 25th day of the menstrual cycle. An indispensable
attribute of the training to the testing procedure of the fallopian
tubes is the elimination of active or dormant infections in the
genital organs and appendages.
Before performing hysterosalpingography need to examine vaginal
and cervical canal on the degree of purity. Hysterosalpingography is
performed on empty stomach (fasting), and the bowels should be
cleansed by using enemas.
Mammography x-ray method examination of the mammary glands.
Helps to identify various tumors in the mammary
glands and is therefore one of the main methods for the
examination of women on the subject of cancer. The
harmful effects of ionizing radiation on the organism
during the study is minimal.
Because mammography effectively detects cancer at an
early stage, so it should be done at least once a year for
women over 35 years. Many doctors are unanimous in
recognizing that mammography is the most effective
after the onset of menopause. During this period, the
Breasts are less dense structure and is not affected by
the hormonal fluctuations that occur during the
menstrual cycle (they affect the mammary gland and
may lead to spurious results). In addition, women over
50, on the one hand, have a higher risk of developing
cancer, and exposure to them is less dangerous than for
women of childbearing age.
Most oncologists recommend regular mammograms at
the age of 50-69 years. Studies show that it reduces
mortality in this age group at least 30%. Experts believe
that the age limit for a mammogram should not exist.
Thank you for
attention!