40M Diabetes 10years WB PaJR

 

November 06, 2024

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

The PHR patient journey record PaJR transcripts below reflect the therapeutic uncertainities around the patient and their resolution through team based learning;

[22-10-2024 19.30] PPM 1: 40M with diabetes 10 years with recent concerns of AKI which appears to be NSAID induced.

[22-10-2024 19.35] PPM 1: Share the patient's investigations and seven point sugar profile when they become available @PPM3.

[22-10-2024 19.35] PPM 3: Ok sir.

[23-10-2024 09.18] PPM 3: GRBS of the patient

23-10-24 8am - 

10 am - 161mg/dl

3 pm - 221mg/dl

7 pm - 139mg/dl

10 pm - 303mg/dl

2 am - 190mg/dl

7 am - 126mg/dl.

[23-10-2024 09.20] PPM 1: Please insert the interventions and the time they were administered. Please prepare a 24hr chart leaving blank the slots where the data may not have been collected.

[23-10-2024 09.21] PPM 1: Serum creatinine 2.0. Please get a quick CUE to check for proteinuria and share the images of his ultrasound kub ASAP

[23-10-2024 09.22] PPM 1: HGM normal.

                                                                           USG report

[23-10-2024 11.52] PPM 1: Is he on glimiperide 2mg and metformin 500 mg!

No post two hours of after taking the drug was taken today! 😨😳

[10/23, 11:55 AM] PPM 1: Get his post lunch two hours without fail

[10/23, 11:59 AM] PPM 1: He has had an episode of hypoglycemia two weeks back AFTER he took a light meal and 7PM when he felt hungry and found his sugars were 75! Felt fatigued and had mild tremors

[10/23, 12:00 PM] PPM 3: Patient was not in ward at 10am to check his post breakfast sugars sir

[10/23, 12:00 PM] PPM 3: Ok sir

[10/23, 5:33 PM] PPM 3: GRBS

10am -119

1pm-170

4pm -190

[10/23, 7:32 PM] PPM 1: Can anyone convert this from voice to text @⁨PA

[10/23, 7:34 PM] PA: After eating a sweet apple his sugar level became high

[10/23, 7:48 PM] PPM 1: Which high value is he talking about? What time?

[10/23, 7:48 PM] PPM 1: @⁨Meta AI⁩ translate to Bengali

[23/10, 19:34] Patient advocate 23F Weight Gain: After eating a sweet apple his sugar level became high

[23/10, 19:48] PPM 1: Which high value is he talking about? What time?

[10/23, 7:48 PM] Meta AI: I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.

[10/23, 7:49 PM] PA: আপনার সুগার এর কোন value টা বেশি , কোনটার কথা বলছেন?

আর কখন এর কথা বলেছেন?সময়টা উল্লেখ করুন

[10/23, 7:53 PM] 24F PA: সুগারের কোন value ta

[10/23, 8:13 PM] PPM 1: This is one of the reasons it's difficult to adapt to voice as it takes up a lot of our time!

[10/23, 8:13 PM] PA: He said at 6.45 evening his sugar level became high to 30 -40

[10/23, 8:15 PM] PPM 1: 30-40?

[10/23, 9:31 PM] PA: 30 to 40 point he said

[10/23, 9:38 PM] PPM 3: Grbs @7pm -229

[10/23, 9:39 PM] PPM 1: 👆What does that mean @⁨~PDOC1⁩ ?

[10/23, 9:39 PM] PPM 3: I didn’t understand sir

[10/23, 9:41 PM] PPM 4: What is the diagnosis for his Diabetes? Type 1 or Type 2 or Type 3?

[10/23, 9:43 PM] PPM 1: 2

[10/23, 9:43 PM] PPM 1: Will need someone to talk to him. Remind me tomorrow at OPD

[10/23, 9:43 PM] PPM 4: How and why please?

[10/23, 9:44 PM] PPM 1: 👆@⁨PPM3

[10/23, 10:08 PM] PPM 3: He is having Diabetes since 10yrs and responding well to OHAs sir

[10/23, 10.08PM] PA: 229mg/dl

[10/23, 10:28 PM] PPM 1: Two hours post dinner?

[10/23, 10:30 PM] PPM3: ThanksPPM5. Which OHAs?

[10/23, 10:40 PM] PPM 5:  Currently on metformin and glimiperide sir

[10/23, 10:41 PM] PPM 4: Thanks again. Since when has he been on Glimepiride?

Can you please share his fasting, post prandial and HbA1c numbers please?

[10/23, 11:11 PM] PPM 3: He was on glimiperide +voglibose and metformin for last 2-3 months sir and currently on glimiperide and metformin as advised by PPM1 SIR

Fasting blood sugars -124 

GRBS

7am-126 (pre-breakfast) 

10am -119 (post breakfast) 

1pm-170 (pre-lunch)

4pm -190 (post lunch) 

7pm - 229 (pre dinner)

[10/23, 11:16 PM] PPM 4: Appears like this is MODY. Any family history chart for diabetes?

[10/23, 11:17 PM] PPM 3: And thanks so much for taking the time and sharing this

[10/23, 11:17 PM] PPM 4: Classic IFT with easily well-controlled post prandial sugars

[10/24, 7:36 AM] PPM 1: @⁨PPM3⁩ @24FPA please try to get his family tree made mentioning who are diabetic and share it here

[10/24, 7:36 AM] PPM 3: Ok sir

[10/24, 7:41 AM] PPM 1: Although that alone may not be able to distinguish MODY from type 2

https://pmc.ncbi.nlm.nih.gov/articles/PMC1327713/

[10/24, 7:44 AM] PPM 1: The diagnostic criteria for Maturity-onset diabetes of the young (MODY) include: 

Age of onset: Diabetes that begins before age 25 

 Insulin production: Sustained insulin secretion and a serum C-peptide level of more than 200 pmol/L 

 Family history: Diabetes in at least two consecutive generations 

 Autoantibodies: Absence of pancreatic islet autoantibodies 

 Other features: Mild, stable fasting hyperglycemia, and no significant obesity 

Considering all data around this patient particularly his trunkal fat and sarcopenia I'm currently putting more money on Type 2 than MODY

[10/24, 11:09 AM] PPM 1: The patient identifier is visible and hence having to delete

[10/24, 11:12 AM] PPM 4: Before age of 25 is generic. However, because quite a few go unnoticed, diagnosis before 45 and no Type 2 phenotype should raise suspicion

[10/24, 11:14 AM] PPM 4: Also important to know how his phenotype was at the time of diagnosis.

Sulphonylureas are known to cause trunkal obesity as they are insulin secretagogues

[10/24, 11:19 AM] PPM 1: Bottom-line is all these quests don't change our management plan which is essentially to bring all diabetics to shape and address sarcopenia and trunkal fat regardless of their diabetic type (as all types technically can become type 2 too)!

Our cornerstone remains normal diet and normal exercise (again the standard deviations around the normal is albeit debatable) for diabetics as well normal people (who are also congenitally afflicted with a sexually transmitted disease called life)!

[10/24, 11:21 AM] PPM 1: @⁨PA⁩ Apnar diabetes jokhon prothom dhora pore 10 bochor aage tokhon apnar pet ebong muscle kemon chilo? Aekhon jemon ache temon chilo naki pet ta aro boro chilo?

[10/24, 11:21 AM] PPM 4: I agree to an extent. However you can reduce pill burden (Metformin and the voglibose previously), genetic link and if female the much higher risk of GDM.

[10/24, 11:23 AM] PPM 4: Fortunately/unfortunately I'm starting to see all diabetes with a "specialist" lens, heavily tinted currently by first World dynamics.

[10/24, 11:26 AM] PPM 1: Yes I have already thrown out the voglibose

Metformin is not given much leverage in general.

It's the secretagogue that rules

[10/24, 11:29 AM] PPM 4 Agreed.

I always believe making precise diagnoses can enable precise treatments and minimize adverse effects.

Noticing here that quite a few on Metformin eventually have B12 deficiency (not the serum levels thankfully but through macrocytosis, anemia and neuropathy) requiring b12 supplementation.

Which is why my obsession with diagnostic precision. You can then throw out the Metformin as well!

[10/24, 11:30 AM] PPM 4: Could you kindly let me know his HbA1c please?

[10/24, 11:35 AM] PPM 1: This would be a very interesting project

[10/24, 11:36 AM] PPM 1: Not done I guess?

[10/24, 11:37 AM] PPM 1: In our hospital one of our diabetes thesis PGs cracked the mystery of our Hba1c values never ever having risen more than 7.5-8 perhaps in years! Blame it on latex agg (ours) v HPLC (standard)

[10/24, 11:40 AM] PPM 4: And I was also told by a lab technician that they extrapolated it from fasting sugars!! 😵‍💫

[10/25, 4:10 PM] PPM 1: @PPM3⁩ please pm me his signed informed consent ASAP.

10/25, 16.10] PA: 77mg/dl

[10/25, 8:37 PM] PPM 1: @SE can you help us with his graphical chart of sugar values since admission that were shared here

[10/25, 8:39 PM] PPM 1: In the daily blood sugar monitoring chart, it would be nice to also mention the diabetes drugs and their time taken apart from what was well done in the other patient's chart

[10/25, 8:45 PM] PPM 1: @⁨~PA2🙂🙂⁩ ke bolun apnar voice message ta ekhane text kore janate

[10/25, 20.45] PA: 105mg/dl

[10/25, 8:53 PM] PPM 1: Please text.

We can't hear voice messages or take calls

[10/25, 8:59 PM] PPM 1: @PPM3 please share all the sugar values in this patient since admission and also mention what medication and what dose he's currently on

[10/25, 20.59] PA: 140mg/dl

[10/25, 9:48 PM] PPM 1: Aekhon apnar patient er glimiperide koto dose nicchile?

[10/28, 2:10 PM]PA: খাবার পরে pp 180 ঔষধ এক বার খেয়েছি 12.05pm 28 তারিখ দুই দিন গাড়িতে ঔষধ বন্ধ ছিল

[10/28, 2:19 PM] PPM 1: Oshudher naam ebong dose?

[10/29, 2:42 PM] PA: খাবার দুই ঘন্টা পর ২০০ আরো এক ঘন্টা পর 75 ভাত সব্জি খাবার পর 90 কোনও প্রবলেম নাই ঔষধ কি তিন বেলা চলবে না দুই বেলা

[10/29, 2:46 PM] PA: খাবারের তালিকায় ছিল ভাত শাক সব্জি মাছ

[10/29, 3:31 PM] PPM 1: 👆Oshudher naam ebong dose ebong kone kone time a gotokal niyechen

PA: 

[10/29, 3:40 PM]PA:  একটা খালি পেটে আর খাবার পর তিন বেলা তিন টা

[10/29, 4:54 PM] PPM 1: Blood sugar ta soptahe jekono aek din aeibhabe janaben👇

Fasting 

Breakfast er 2 ghonta baade

Lunch er du ghonta bade

Dinner er du ghonta bade

[11/4, 10:43 AM] PA: সুপার খালি পেটে 100 খাবার পরে170 কিন্তু ট্য়লেটের প্রবলেম হচ্ছে পেটে কপ কপ ডাকে আর গেস্ হয় কিলিয়ার হয় না আর আম আম টয়লেট হয় গস হলে পেসার বারে

[11/4, 10:45 AM] PPM 1: Toilet er problem ta IBS

Shothik khawa ebong haatha chola activities korle bhalo hoye jabe.

Sheta ki bhabe korben ebong share korben sheta aei patient er group a click korle jante paben 👇

https://chat.whatsapp.com/JjNdlilfItm7FIxmVSh3Xs

[11/4, 10:48 AM] PA: ইউরিনে পেসার আছে কিন্ত ইসপ্রিট অল্প কম

[11/4, 10:51 AM] PPM 1: Otao urinary bladder er aek dhoroner IBS jeta overactive kimba underactive bladder bola hoi

[11/4, 10:52 AM] PPM 1: Etao join korte paren shudhu regular shothik khawa ta janar jonnye 👇

https://chat.whatsapp.com/BwTGZStKGN9I50hmyNKLPI

[11/4, 11:27 AM] PA: IBS টেবলেট বুঝতে পারতেছে না আগে পিছে নাম চাচ্ছে

[11/4, 12:27 PM] PPM 1: Na IBS er kono tablet nei

Oguno khawar dorkar nei

[11/4, 12:28 PM] PPM 1: IBS rog ta ekmatro shothik khawa dawa ebong shothik hourly daily activities er dwara thik habe

[11/5, 10:49 AM] PA: সকালে খালি পেটে 85

[11/5, 10:55 AM] PA: IBSখাবার পরে পেটে কোন প্রবলেম নাই টয়লেট কিলিয়ার ইউরিন ভালো হচ্ছে সরিলে এনার্জি আছে

[11/6, 8:23 PM] PA: সুগার 5pm টিফিন করার পরে 8pm 70 চকলেট খাবার পরে 85 ওষুধ কি বন্ধ রাখবো

[11/6, 9:00 PM] PPM 1: Hain bondho rakhun.

Oshudh er dose koto chilo gotokal ebong ajke? Oshudher chobi share korun jate dose ta dekha jai

PA:  

[11/6, 10:02 PM] PPM 1: Oshudher chobi share korun

Ekhane jeta lekha ebong apni ashole jeta khacchen duto alhada o hote pare

[11/7, 7:09 AM] PA: 7.am সুগার 100

[11/7, 8:56 AM] PPM 1: 👆

[03-08-2025 21:15] PPM 1: Unar creatinine beshi kabe theke jana geche?

Aer aage last kabe test korechilen ebong koto chilo?

Uric acid er jonye khawa dawa shothik korte habe ebong kichu ta creatinine barar jonyeo bereche!

Aekhon uni bortomane ki oshudh khacchen?

Aeto din ekhane kichu janan ni keno?

22.10.2024

[04-08-2025 16:56] PPM 1: Aer por serum creatinine blood test ta kora hoyechilo?

[04-08-2025 16:58] PPM 1: Apnar patient eta kotar shomoi khan?

Apnar patient er

Fasting blood sugar 

Breakfast er du ghonta por blood sugar

Lunch er du ghonta por

Ebong

Dinner er du ghonta por blood sugar ta glucometer diye jekono chutir din kore janaben

70F CAD, ACS, NSTEMI With Pulmonary Edema, Altered Sensorium Telangana PaJR

01-08-2025 

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

 [01-08-2025 PPM 1: Afternoon session:

Courtesy yesterday's data shared by @PPM3 

70F with acute cerebral stroke and acute posterior wall and inferior wall myocardial infarction. Discussion on ECG and echocardiography findings with images of handwritten history and progress notes for archival.

[01-08-2025 15.40] PPM 1: https://youtu.be/Q8qLXTe12ug?si=Cd5phLYsGUaQLXPW

[01-08-2025 15.41] PPM 1: 👆Also for @PPM4 's Web 3.0 system to process.

[01-08-2025 15.47] PPM 1: https://youtube.com/shorts/hIC-dz01vxQ?si=odzHwNJ16HybrHAK

[01-08-2025 21.31] PPM 1: 

[01/08, 15:50] Dhu Pm: Sir

Ecg image quality reduced by whatsapp

[01/08, 16:05]cm: True but on checkin it appears sufficient to make the diagnosis

[01/08, 16:06]cm: Focus on the changes evolving in V1V2 and 2,3, aVF

[01/08, 16:15] Dhu Pm: i have this notes sir

I'm still under confident in understanding Ecg sir.

Attaching notes, please guide me via that recent reports you shared. 

(wrote this notes myself by listening to Gmeet class 3 yrs ago)

[01/08, 16:37]cm: Keep practicing by seeing the real patient ECGs we posted in the group and keep asking us questions on it.

That's the only way to learn ECGs practically quickly and usefully.

[01/08, 16:41] Dhu Pm: okay sir

I saw 2d echo

I saw 

some whitish appearance on the screen where you pointed to posterior wall and anterior wall 

Hypokinesia /dyskinesia (reduced movement or abnormal movement) 

I understood that part vi a 2decho

how does that interpret on ECG sir 

[01/08, 16:42]cm: Good

So now you just need to know where are the inferior and posterior walls represented on the ECG

Ask google and or chatGPT

[01/08, 16:46] Dhu Pm: got this info from google sir

Inferior wall ischemia in an ECG is primarily represented by changes in leads II, III, and aVF, while posterior wall ischemia is indicated by changes in leads V1-V4, specifically ST depression and tall R waves, or by ST elevation in leads V7-V9. These leads correspond to the areas of the heart supplied by the right coronary artery (RCA) and potentially the left circumflex artery (LCx) for the inferior wall, and the RCA or LCx for the posterior wall.

[01/08, 16:48]cm: Now check what serial changes are visible in the patient's ECGs and let me know

[01/08, 17:04] Dhu Pm: On 30th ecg 7am

Lead II, III ,aVF - T wave inversion 

on 30th 9.30 am 

I could see a t wave inversion on lead III 

and flat t wave in II and aVF 

on 31st 6 am

II - flat T wave 

III - depressed t wave 

aVF - looks flat (doubtful)

on1st 1pm

II, III, aVF - flat T waves

[01/08, 17:04] Dhu Pm: Correct me sir still not sure 😅

[01/08, 17:11]cm: What about 28-29?

[01/08, 17:12]cm: What about V1, V2?

[01/08, 17:21] Dhu Pm: 28th 12.15 pm

II - flat T wave

III- no Proper pqrs waves

aVF - inverted T wave

V1- ST elevation 

v2- slight ST elevation,R wave >5mm

v3 - Slight ST elevation R wave >5mm 

29th 1.08 pm

II- T wave flat

III- p wave depression and st elevation 

aVF T wave depression 

V1-St elevation, R wave >5mm

v2-St elevation, R wave >5mm

v3 -St elevation, R wave >5mm

29th 8.30 pm

II -T flat

III- T depression 

aVF- T depression 

V1- ST elevated, S appears Deep 

v2-ST elevated, S appears Deep 

v3 - ST elevated, S appears Deep

[01/08, 17:32] Dhu Pm: 30th 7am 

Lead II, III ,aVF - T wave inversion 

V1, v2, v3 - ST SEGMENT ELEVATION AND s waves appear deep (doubtful)

30th 9.30am 

I could see a t wave inversion on lead III 

and flat t wave in II and aVF 

v1,v2,v3 - ST elevation, R wave (>5mm) 

31st 6am

II - flat T wave 

III - depressed t wave 

aVF - looks flat (doubtful)

V1,v2,v3 - st elevation 

1st 1pm ecg

II, III, aVF - flat T waves

V3- Tall R wave (>5mm) 

 and T wave inversion

[01/08, 20:19]cm: In 2,3, avF the most important feature after the STEMI pattern on 29th is the appearance of Q waves suggestion an evolving inferior wall myocardial infarction 

In V1, V2 it's ST depression, not elevation but if one holds it against a mirror then it can appear as an elevation and this is a hallmark of posterior wall myocardial infarction.

https://pmc.ncbi.nlm.nih.gov/articles/PMC5293126/#:~:text=Acute%20posterior%20wall%20myocardial%20infarction,left%20scapula%20on%20the%20ECG.

[01/08, 20:33] Dhu Pm: I remember that reverse interpretation is because of the direction of current 

does that apply here sir.

[01/08, 20:34] Dhu Pm: and I vaguely remember we should cross check those v2 v3 leads from other v567 leads

[01/08, 20:38] Dhu Pm: Sir are these considered as Q waves?

[01/08, 20:38] Dhu Pm: I see a dip after p wave

[01/08, 20:39]cm: Yes

[01/08, 20:39]cm: Yes it's a qs pattern

[01/08, 20:41] Dhu Pm: Sir is this V tach

[01/08, 20:47]cm: Can't happen in a single lead alone

[01/08, 21:05] Dhu Pm: So what could it be sir

[01/08, 21:18]cm: Transient local lead 2 problem

[02-08-2025 11:31] PPM 4: For deidentification and archival purposes, here's the processed summary of the MRI brain report for the 70-year-old female patient, with all personal identifiers removed:

---

*🧠 MRI Brain (Plain) – Deidentified Summary*

*Patient Demographics:*

* Age: 70 years

* Sex: Female

* Clinical Department: General Medicine

*MRI Protocol Used:*

* Axial T1, T2, FLAIR, DWI & SWI

* Coronal T2

* Sagittal T1

---

### *Key Radiological Findings:*

1. *Chronic Lacunar Infarcts*

   * *Location*: Left thalamus

   * *Etiology*: Likely secondary to chronic small vessel disease

2. *Bilateral Confluent Periventricular Hyperintensities*

   * Suggestive of *chronic microangiopathic ischemic changes*

3. *No Acute Infarction*

   * *DWI sequences*: No restriction (no acute infarcts)

4. *No Hemorrhage, Calcifications, or Vascular Malformations*

   * *SWI sequences*: No microbleeds or vascular anomalies

---

### *Normal Structures Reported:*

* *Basal ganglia & right thalamus*

* *Brainstem and cerebellum*

* *Craniovertebral and cervicomedullary junctions*

* *Sella, pituitary, parasellar regions*

* *Hypothalamus, pituitary stalk, and posterior pituitary bright spot*

* *Orbital and globe contents*

* *Cortical gray/white matter differentiation preserved*

---

### *Final Impression:*

* ✅ *Chronic lacunar infarcts in left thalamus*

* ✅ *Chronic small vessel ischemic changes*

---

Let me know if you'd like this in a formatted PDF for upload to your case archive or integrated into the KIMS Hospital Syndrome CBBLE data set. I can also tag this for future reference under anonymized IDs.

[02-08-2025 11:34] PPM 4: Thank you,. Here's a deidentified and archivally formatted summary for the *MRI Brain Plain* report you shared for a 70-year-old female patient, suitable for inclusion in your KIMS Hospital syndrome CBBLE repository:

---

### *Case Summary: MRI Brain (Plain) — Elderly Female (70F)*

*Institution:* Kamineni Institute of Medical Sciences, Narketpally

*Date of MRI:* 28/07/2025

*Study Type:* MRI Brain Plain

*Sequences Used:* Axial T1, T2, FLAIR, DWI & SWI; Coronal T2; Sagittal T1

#### *Key Findings:*

* *Chronic lacunar infarcts in the left thalamus.*

* *Bilateral confluent periventricular hyperintensities*, consistent with chronic small vessel ischemic disease.

* *Normal findings* in:

  * Right thalamus and basal ganglia

  * Cerebral cortex (preserved gray/white differentiation)

  * Brainstem and cerebellum

  * Cranio-vertebral and cervico-medullary junctions

  * Sella, pituitary and parasellar region

  * Hypothalamus and posterior pituitary bright spot

  * Orbit and globe contents

* *No acute infarcts* on DWI.

* *No hemorrhages, calcifications, or vascular malformations* on SWI.

#### *Radiological Impression:*

* Chronic lacunar infarcts (left thalamus)

* Chronic small vessel ischemic changes

---

Would you like me to link this summary with the clinical video file or generate a table entry format for CBBLE archival?

Also, let me know if you want to flag this for any neurology or geriatrics inputs on cognitive risk correlation (e.g., vascular dementia scale integration).

[02-08-2025 17.03] PPM 1: Patient's chest X-ray and HRCT done yesterday.

[02-08-2025 17:28] PPM 1: https://youtube.com/shorts/OiKgeJZb_48?si=uKsyvJg_DsdQyP0j

[02-08-2025 17:29] PPM 1: https://youtube.com/shorts/typ6afQWGoU?si=J4G-3kAjBjg-VCqq

[02-08-2025 17:30] PPM 1: https://youtube.com/shorts/4ctcT2p-9ZE?si=vh7TXxJs8kwOKUIw

[02-08-2025 17:30] PPM 1: https://youtube.com/shorts/bRnOljIVHQg?si=StBj2bGAvoMsR_yJ