Gharsat Amal - Bridging theory to practice

Assalamu alaikum. وعليكم السلام ورحمة الله وبركاته هاي هاي شو اسمك محمد محمد العجرمي أخ محمد أنه سنة أنت سلام عليكم وعليكم السلام ورحمة الله وبركاته هاي هاي شو اسمك ناو That was repeating.

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Yeah, there's an echo. I can hear it.

So I am also, I am also broadcasting on YouTube. No, that was repeating.

Oh my goodness.

Hold on, hold on, hold on. Something is not working.

Nah, check this out.

So I am also I am also broadcasting on YouTube. No, that was a repeat one. Oh my goodness, something is not working. There we go. Now it's better. Something is—

there we go.

Now it's better.

There we go.

أخ محمد عم تسمع؟ أيوة أيوة معاك ربنا تمام أوكي technical difficulties بس ما في مشكلة اللي إنه إيش سنة أنت؟ سنة ثالثة بجامعة الأزهر إن شاء الله سنة ثالثة إن شاء الله والسنة الثالثة اللي عملنا معكن هالأسبوع هو خليني أشوف سنة الثالثة عملت معاكن الهماتولوجي أنكولوجي وهيك آه صحيح خلصناه دخلنا في مصر وسكرتنا دخلت في المسكلسكلتر طيب ان شاء الله الاسبوع الجاي يكون المسكلسكلتر كيف كان عندك الهمتو انكولوجي والله الحمدلله عدة كنا متغول بننقل المكان لمكان فمركزتش كتير على الانكولوجي فبس يعني مريت على الهمتو انكولوجي الهماتولوجي أنكولوجي اللي عملته معكن إنه غيرت ستايل تبع ال how do I teach I wanted to make it something more interactive زي ما قالولي إخواتك بال بالواتساب ستايل فلتقال إنه لو ممكن نعمل أسئلة وأجوبة وخلال الأسئلة والأجوبة يكون يعني explanations and discussions فهذا اللي كان مقرر اليوم ماشي الحال ولا do you want to talk about something else؟ لا أتوقع الله هذه أول شغلة تاني شغلة عملت ثلاث lectures على الhematology oncology باليوتيوب I don't know if you heard them ولا ما كانش ما تيسر لكش إن تسمعهم.

لا والله ما شفتهم لسه.

طيب، okay. Let's start with. The questions that we have. فأولاً in in the WhatsApp group أنت متسجل بالWhatsApp group مو هيك؟ صحيح ها بالWhatsApp group. أنا اللي كنت فاقد requires permission طيب فهذه هدول الlectures باليوتيوب لشان يكون أحسن أسهل إنه تتتفرج عليهم recording يعني إيه recording قلبي آه recording كله من واللي بعمل إنه باخد material من الويب سايت اللي انتو عندكن فيه الماتيريال تبعكن ليكشرز وكل هالشغلات وبلخصه بس كمان بعمل ابحاث في السوشيال ميديا ابحاث في البوبماد وباخد منهن كونسبت اللي يكونوا difficult as well for other medical students وبدمجهم مع الكورس اللي بعملها عشان تكون accessible something useful عشان ما نحكي على complex items اللي ما تنفعك بالسنة الثالثة ففي ثلاث هيدي التالتة Module number three, how to read the blood smears and anticoagulations. Okay. وبعدين إجيت وعملت ال the questions. So we're gonna look at the questions now.

إن شاء الله بارك الله فيك. إن شاء الله راح أرجع لهم لازم أعمل revision بال المثارج لأن مريت علي مرور صراحة.

ماشي ما في مشكلة أنا بغير ال style لأنه في اللي بيستعمل الأسئلة فيه اللي بيستعمل lectures فيه اللي بيستعمل discussion live فبدي إنه أجعل الماتيريال يكون يعني مستعمل I'm not here to make complex stuff that nobody uses فهمت علي؟ okay okay أولاً رح نروح ل questions questions and personal قصة client قصص تيك توك ميتست أوكي creation content Here we go.

Here we go.

So أولاً الوحدة اللي شفناها كانت بالWhatsApp وفيها Blood Cell Diaries Number One. Okay.

Perfect.

So blood cells number one. فال blood cell diaries number one هذه بتشوف بتشوف ال ال السؤال no? Can you see it?

صحيح ظاهر ظاهر.

طيب. فالسؤال هو مشكل كأنه بتحكي مع blood cell وال blood cell بتقول لك I used to be perfectly round. بس اتقطعت ملابسي اتقطعت. Then something shredded me while I was traveling through tiny blood vessels. كنت مسافرة بين طينيه صماله بلاد فيسولز، and as I was traveling something shredded in me. Now I look like broken glass. Who did this to me? Is it J6PD deficiency, Haydell enzyme glucose-6-phosphorylase deficiency, or thrombotic thrombocytopenic purpura, or hereditary spherocytosis, or iron deficiency? What do you think?

I think it's TTP. Thrombotic thrombocytopenic purpura.

You think it's thrombotic thrombocytopenic purpura?

Yes.

أولاً what is this cell؟ السؤال إنه what is this cell؟ لما بنشوف ال ال cells على blood smear. في cells that are small, في cells that are big. Well, you know, I um, بوعدك إنه لو if you listen to the lectures, there is a lot of this simplified stuff that you hear it, you understand it, and you can remember it. Okay? ف let me share. The answer, and we'll answer at the end of this. I will share with you all of these answers. For blood cell diary, can you see the answer? Blood cell diary is number one. The answer is J six PD. ليش اللي عطيتيني أنت هو TTP، TTP بيحصل على platelets صفائح والصفائح هي أكبر بكتير من red blood cells فلما بتشوف هدول they are the same size as this cell which عندها قرص أبيض We call that central clearing. This is what a normal red blood cell looks like. The one that is here looks like it, but looks deformed. ولا ما بيكون J6PD بتكون deficient. We call these bite cells ولا blister cells. فحصل oxidative damage and the RBCs Could not keep up with the damage لأنه J6PD ما عندهم لتحميهم فبيكون shredded RBC. Okay? Clinical clue شو بتشوف عند العيان بيكون عنده episodic مرة مرة في مرة مو بيكون continuous hemolysis after an infection ولا بيأكلوا الفول فاضى beans ولا certain drugs هدول بيعطوه ال RBC oxidative stress and the RBC cannot deal with it واللي يعطيك الكلو إنه the size of this is about the size of a normal RBC so it must be an abnormal RBC لساتك معي معك معك الدكتور بس أنا ما درعتها شفت صور ما ما عمت في كيف الصور بس كانت الـ RBC لسه يعني لسه سيركولر نوعاً ما بس فيه البيت سلم بينه وفيه بس لسه سيركولر فأنا شفتها تشتغل الكتير بس تار لين تقريباً أول مرة أستخدمها وما تعرفتش عليها بتعرف تاخد وقت لازمك تشوفه مرات عديدة لتعرف عليه أول مرة J six PD هي the most common hemolysis, most common. والشغلة الثانية إن بتقول لك إنه the they they go through the spleen and when they go through the spleen there is inside the red blood cell فيما يسمى بالHeinz bodies. سمعت على الهاينز باديز؟ ما في مشكلة رح نحكي على الهاينز باديز هم كمان من الأسئلة اللي بنحكي عليها فالهاينز باديز are قطبان بيكونوا داخل ال ال blood cell ولما بيمروا على الطحال الطحال they spot them and they remove the Heinz bodies when they remove the Heinz bodies then the shape of the blood vessel starts to change and then we call them bite cells you're good for now نروح للسؤال الثاني عنا تسع الأسئلة اليوم إن شاء الله نروح للسؤال الثاني والسؤال الثاني هو This smear. Caption this smear comes from social media. لما بيقولك شوف هالصورة وعطيني عنوان لها الصورة. So caption has this smear. بتشوف هال smear أول ما تشوفه أنا بقله الميكي ماوس smear. So what do you think? What do you think you should call this Cell. What is this cell? فإحنا حكينا إنه السلز اللي عندهم قرص أبيض هذا اسمه the red blood cell. بس بس ال الcell اللي هون هذه اسمها إيش؟ إلي مرة تانية لأن ما سمعتك.

Is it hypersegmented neutrophils or not?

مية بالمية. Neutrophil, neutrophil, absolutely. فهذا neutrophil and the nucleus is hypersegmented بس وفي الlecture بنحكي عنها. ما بيكون أكثر من اثنين ثلاثة. If it goes to five six seven, that's not normal. Hypersegmented neutrophil. وشو في ال في ال في هاي segmentation؟ فيها DNA. لو فيها DNA معناته لو كان hypersegmented, that's not normal. It's leukemia ولا lymphoma. Okay? So a number of segmentations is important. And here we go. Neutrophil just photobombed my perfect smear. So that's your caption. لنروح على السؤال الثالث. السؤال الثالث. من الكتاب. Spot the liar. All four patients have microcytic anemia, but one sentence is a lie. اللي محمد تعرف كيف to classify anemias? Microcytic, normocytic, macrocytic.

أيوه المايكروسيتيك تحت ال يعني النورمال حيكون من ثمانين لمية ال الهايبر حيكون فوق المية المايكرو الماكرو حيكون فوق المية المايكرو حيكون تحت الثمانين.

Perfect. فا ال ال the question is حسب لك بدأ سواني لتخمم فيها فهي A or B or C or D بصراحة أنا بعرف B و C و D و شايفهم صح بس A ما بعرف المنزل index طيب لنحكي على المنزر إندكس عندك بتشوف ال ال الشات للزوم let's see if I can put in there the manzer index منزر إنديكس هو الـ MCV divided by the RBC counts. الم سي في هو مين كوربوسكلر فيوليم والار بي سي كاونت هو اللي بنحكي عنه. أوكي، so الجواب هو سؤال اللي بيسألونك هو is it iron deficiency anemia معناته المنزر index فوق 13 ولا المنزر index أقل من ثلاثة عشر. لو ك كان أقل من ثلاثة عشر، it's thalassemia. فوق من ثلاثة عشر، it's the iron deficiency anemia. والمنزند إندكس هو لما بتاخد المين كوربوسكولر volume divided by the RBC count بتقولك how much volume do you have in your blood؟ فلو الvolume كان كبير معناته إنه iron deficiency لو الvolume كان صغير معناته فيه thalassemia okay أديك examples هدول examples شو شو حكينا عنه ال iron deficiency anemia المندزر index أكثر من ثلاثة عشر. أهلا أحمد.

أنت سمعني؟ فيش مشكلة. بتشوف ال ال chat؟ يا يا يا.

أوكي، سعملت لك هناك المنظر إندكس. المنظر إندكس هو الـ MCV divided by RBC count. معناته إنه بنشوف خمس ملايين RBC وكل واحد فين فيهم عنده mean corpuscular volume. ف divided by that gives us the full mean corpuscular volume of the entire place. لو أكثر من ثلاثة عشر معناته الخزان كبير بس ما في شيء iron deficiency anemia. لو أقل من ثلاثة عشر معناته الخزان صغير and that means it's thalassemia. Okay.

So can you can you repeat that? Okay.

Menzer index typical pattern. How with a chat? Iron deficiency anemia more than thirteen. Thalassemia less than thirteen.

Yeah, I got it.

So now let's look which one is a lie.

Here the men's the men's are already shows like it's lower than thirteen, so it's it's supposed to be thalassemia. So I go with A.

Excellent, excellent, excellent, excellent. فلما بنشوف the Answer: infection, immune, pardon me, iron deficiency anemia. لأن المنزل إندكس لازم يكون أكثر من ثلاثة عشر. And quick facts: iron deficiency anemia معناتها low iron, increased TIBC. Are you familiar with TIBC? Okay, so TIBC is when you when we are doing in in anemia, بنشوف في عوامل بنشوفها. قلت لي قلت لي إنه في microcytic and Normocytic and microcytic. هيدا ال MCV.

Yes. Yeah, a little bit of both.

The next one is going to see. You see iron level. Now, if the iron level is low, ما بنعرف إنه لو ال iron level is low. لأنه العيان ما بيأكل آيرن، فهيز ديفيشنز إن آيرن، ولا الآيرن فيه بجسمه بس مخبي. So it's either it doesn't exist or it's hidden. So first we see the iron level. The iron level comes back low. We still don't know. The second one is we do ferritin.

ما تعرف الفيرتين، no? Yeah, the afterpay, the the store form.

Yeah. So the ferritin is an enzyme, and هل enzyme عنده behavior؟ هل بيهيفير إنه بتكون أكثر لو في التهاب؟ So ferritin is an inflammatory marker. لو عندك برونكيتس، لو عندك نيمونيا، لو عندك جاستروينتريتس، هبتيتس، الفيرتين بدغلة. Doesn't matter. Inflammation هي inflammation. لو عندك ميننجيتس، لو عندك Tooth abscess, ferritin goes up.

Okay.

فلما بشوف iron level down وال ferritin up معناته it's iron low because of inflammation. So we call it anemia of inflammatory disease. الفيرتين ملتقي بالايرن معناته إنه لو ما في التهاب وكان الايرن ناقص الفيرتين تكون ناقصة كمان. So when you do blood test on someone and you do the iron level, first you see anemia hemoglobin is low. تاني شغلة، iron level. لما ال iron level بيكون low, you ask yourself is it inflammation or is it deficiency? You do the ferritin. The ferritin, if it's high, inflammation. If it's low, iron deficiency anemia.

الساكتة بعني؟ هاي معاك معاك. Okay.

So TIBC. TIBC is sometimes confusing, but I will clarify it for you. إحنا بنشوف TIBC فيها الـ I وفيها الـ iron بيتهيأ لنا إنه حتكون تابعة. للأيرن، أوكي؟ بس مو صحيح. The total iron binding capacity it's the capacity. احتسبها إنه هي تاكسي، أوكي؟ لو التاكسي اللي هو الcapacity، لو الأيرن اللي هم الركاب كانوا نقصين، الcapacity تبع التاكسي حتكون كبيرة. ليس في space. There's only one or two of you. التاكسي بياخد ستة. بس when there is no iron deficiency معناته في الركاب الcapacity تبع التاكسي حتكون ناصرة. Does this make sense? So, إتاكسي هو اسمه إترانفيرين. So when we do measures of anemia, we do hemoglobin for the anemia. بعديها we do iron to see if it's deficiency. بعديها بندو الفيرتين to see if if it's Iron deficiency of inflammation versus iron deficiency, true iron deficiency. بعديها بنعمل TIBC اللي هي capacity. Binding capacity. لو عملنا بالbinding capacity, if iron is high, capacity is low. If iron is low, capacity is high. بس الcapacity of what? شو اسمه التاكسي؟ The capacity of what? The capacity of التاكسي هو اللي بيساعد على transferring iron from one place to the other. We call that transferring. Okay? Transferring هي البروتين اللي تاكسي بتاخد من هون لهون. Okay? So when there is no iron, high transferrin. When there is high iron, there's not much transferrin. لأنو transferrin كله مشتغل. Okay, so transferrin and the capacity both go opposite.

Okay. Yeah, that's clear.

So that's how we talk about all of this. We آخر شغلة إنه بنسميها transferring saturation. Let us الليش they make these complicated? I don't know. I just know that this is what we have, and I need you to understand them. فما بكذب عليك أي امتحان أي عيان بيكون بيكون أصادي every time I have these I have to walk this into my mind because otherwise هتلاخبط ف a transferring هي البروتين بس a transferring saturation a transferring let's say هي تاكسي لو التاكسي عامر ممتلئ بالناس saturation is high فهمت علي؟ لو التاكسي transferring is ما في ما في أي ركاب transferring is low iron deficiency transferring saturation is low iron of inflammatory Transferring saturation is high because the iron is there; it's just hiding. Do you see the difference? So, حنراجع مرة ثانية. Iron deficient. This النفسك. Is it low or hiding? Hiding where? In the reticulum. And you studied about the reticulum, right? What in the cell? في الخلايا في الخلايا فيهن.

And the plasma, what and it's not reticulated.

Hold on. Okay. So when you look at the cells, when you look at the cells, do you see the cell that I'm showing you? يا يا فهذه السل وهذه النوكليوس وبعد من نوكليوس في هالست्रकشر اللي هي كونفولوتد لايك ديس شفتوهم هادول بال بالسيليلر بيولوجي تتذكرون مو مو هيك؟ The seventh grade in school.

Yes.

And that's my job. I want you to feel that هالعلم كله مع بعضه makes sense as you go into medicine. في شغلات اللي كنا بن نتخيلها إنه this is too much. I don't know what I'm going to use this for. You will start understanding. Why is it important? ف when you have iron deficiency, you ask yourself: Is the iron not existent in the whole body? الخزائن يعني فارغة ولا ال iron متخبي وفيين بيتخبي ال iron بيتخبي في ال endoplasmic reticulum. Okay.

ويتخبى.

How do I know إنه في inflammation اللي عملت إنه ال iron بيتخبّى هون؟ I check the ferritin أولاً. The ferritin elevated معناتها there's inflammation. ولما تكون inflammation the body goes into storage mode رح خبي للأيام الجاية لأنه عنا inflammation وخايف انه البادي ما ياكل منيح فحخبي الiron لما يكون احتاجه in two three days فبيتخبأ لما مناخد الiron level فين بناخده؟ بالسيرم It's circulating. Serum that is circulating will be low because it's hiding. بنقول بنسميها anemia of inflammatory disease ولا anemia of chronic disease. How does iron transfer from point A to point B? Will اللي هو will rough in the plasma. How does it get here? It gets here.

ما بسمك؟ بيا ترانسفير.

بيا ترانسفيرين. ترانسفيرين هي اللي بتاخدوا بتبديل هون. لو نشوف على ترانسفيرين، what do we measure in the transferring? We measure transferring saturation. We measure transferring Binding capacity. Let's name. Is it saturated? What is its capacity? El capacity kubira. معناتها iron is low. ما في ركاب. ففي في فضاء في في space. There is room. So when transferring capacity is high. An iron deficiency is low. معناتها ال iron مو موجود، مش متخبي، مو موجود. بنشوف كمان transferring saturation. لو transferring saturation عالية معناتها it's saturated ferrocab. معناتها it's not iron deficiency. The iron is hiding. Does this make sense? When you talk about iron deficiency, we are going to do iron level. We are going to do ferritin. We are going to do TIBC, and we do transferring saturation. هدول المتريكس للعين ديفيشنسي. Okay? Iron level is low. Ferritin is high. Inflammation. We will find TIBC.

It—

iron exists, it's just sub-B. So TIBC capacity is going to be low, and no iron is being transported and transferring Saturation is high, and the saturated iron level is high. It is low. بنشوف الفيريتين low معناته there is no iron anywhere in the body. There's no ما في ركاب خلت الدنيا. ف TIBC which is capacity. A taxi. Does it have capacity or not? It does. So capacity has gone high. A transferring. Is it saturated or not? It's not because the ما في ركاب. So transferring saturation is low. Are we good?

All good. Okay.

راح نروح هلا على this. Now you have this smear. The intern is wrong. The intern saw this smear and said this is a target cell. Is this really target cell? If not, what is the most likely cause of that? What is the most likely cause? Think about it for a second, and let's go through it together. So, ال المشكلة إنه when you see that target cells do not like look like that. The target cells. This is how what those cells are is this. When you see them, you see that they are the same size as the RBC. Okay, but it does not have the central clearing. The most important thing for you to understand in the, in the hematology is to see the lineages and how they look like. وعملت بالlecture one section where I speak about the lineages, the WBC and neutrophils, monocytes, and then the platelets. فلما بتشوف الRBC، الRBC بيكون أولاً عندهم nucleus, and then eventually they lose the nucleus. That's why you have القرص الأبيض. فأبل ما يخرج النوكليوس بتشوفه هناك. بس which what you see also is that There is perfectly round and very dense RBC without any القرص الأبيض. ف بنسميها hereditary spherocytosis. ولما بيكون hereditary for spherocytosis معناته it's not flexible. So when it goes into the body, the body tries to destroy them. Hemolysis, jaundice, splenomegaly, لأن التحالبيا كلهم، and then family history. Then we have four pictures left. What happens here? Twenty-two-year-old woman with heavy period. Fatigue and pagophagia. Now, pagophagia هي تأكل الايس. She loves to eat ice. Labs شو بنشوف هون؟ Hemoglobin 7.2 low. MCV Low, so it's microcytic. El ferritin low. معناتها iron deficiency. Ferritin is not there's no inflammation. Well, iron is low. So معناتها إنه it's iron deficiency. So you start giving oral iron. لما بدأت ال oral iron زي ما بيكون You're standing in a kitchen and there's nothing to eat. And then somebody brings some vegetables and you say, yay, I can make soup, or I can make something. When you do that, what happens to the people in the house? They all come to the kitchen. So what happens to the reticulocyte count in about 7 to 10 days? You just gave iron. What would happen to the reticulocyte count? A reticulocyte count is the stage before the RBC. A reticulocyte is the baby RBC.

In the serum or the The question about the serum, yeah, and the blood.

I'm talking about the blood, yes.

Yeah, it will decrease, I think, because we will start producing RBCs.

You just gave it food so it can start making them.

Yeah, you will go up with the RBCs, so erythrocytes will, will go To the normal side, I think.

So I love that you are thinking the right way. And the way to think about it is what happens next, because you gave it iron therapy, it will increase eventually, but 7 to 10 days is too short. It takes about 3 weeks. Okay, so first it will stay the same, and then it will increase because you were going in the right place. I hope you're proud of yourself. I know it sounds confusing, but you are getting things placed. Because you keep hearing these things and they make no sense. Once you start using them, they start making sense. 45-year-old man with deep vein thrombosis, a blood clot in his legs. And the CBC shows low platelets, thrombocytopenia. No drug history, no infection, and the coagulation profile is normal. And then you see this. What is the diagnosis? And what is the one clue that made the diagnosis obvious? I'll give you about 5 seconds. So what you see, that big thing, is not what's important. What's important is to see that there are what we call schistocytes. وأنا خدت هالأمثلة محمد لأنه رغم إنه بتشوف هالأمثلة they may be a little bit tough to understand now but they are one of the most commonly asked examples. You will always have schistocytes in your questions. Always. Lee, Lee Annu, when we make questions for exam, they're not to trick you. They are to bring to your attention something you will not see every day. But if it's in front of you and you miss it, it's very dangerous for the patient. You cannot miss a heart attack. You cannot miss a stroke. You cannot miss a high Potassium. You cannot miss. فهمت علي؟ So when when we bring this stuff is when something is really wrong, and if you do not know this, your patients will die. So we bring it over and over and over and over and over again. Do you see this cell right here to the right of the big cells? The big cell we already know what it is. أنا بس ألا علي. That's helmet cell. That's an RBC that's been destroyed. And we will see more of those. I'll give you more of these as we go. لما بتشوف ال helmet cells معناته إنه there is microangiopathic hemolytic anemia from DIC. DIC عمرك سمعت على DIC؟ Yeah, I know it.

Okay. Disseminated intravascular coagulation. Yes.

Yes. بس اللي ما بنحكي عنه، بل اللي ما بنحكي عنه إنه لو عندنا a chapter.

Of—

these are all of the ways that people die. They die of a blocked coronary. They die of high potassium. They die of pulmonary embolism. They die of multi-organ failure secondary to septic shock. They die because of complete Metastatic cancer, and they die because of DIC. Does this make sense? DIC is a form of death. ولو ياسر عرفات مات بالDIC. في كمان politicians and others they they they die with DIC. One of the most common ways of DIC to happen. is when you have something die inside you. Let's say a woman has an ectopic pregnancy. Let's say that, you know, you just got bit by a scorpion. Poison causes DIC. Let's say that you got just hit by lightning, electricity. That causes DIC. The IC is a form of death, so you can understand how important it is that we study it. Why does the IC happen? The IC is the symptom, not the cause. The cause is microangiopathic hemolytic anemia. Microangiopathic معناتها الشعيرات the circulation. شعيرات الدموية. They get destroyed. ف the body blood vessel blood cells that go through them get destroyed too, and they come back to the circulation. Now, لما بتروح على cellular biology, and you study what is in a red blood cell. Oh my gosh! There is something called lactate dehydrogenase.

LDH.

Huh, I knew about it. I knew what's the normal value. I didn't know what it does. This is an enzyme that spills in the blood. They also have J6P. Huh, that too spills in the blood. They have small little vesicles that have enzymes in them. Huh, they spill in the blood. There are enzymes that break down DNA as it repairs itself. They spill in the blood. All of those are enzymes. Enzymes—you know what they do? They clip. They clip protein. What protein? Any protein. El albumin, el el el protein on the blood vessel wall, el protein of any protein. So you have these enzymes going around, that's like literally injecting bleach. And it starts to cause trouble. It starts to hurt the blood vessel wall. If the blood vessel wall is hurt, it engages the coagulation cascade. And all the coagulation factors come in, all the platelets come in, and they start to try to go into this area that just got hurt by The enzymes and got uncovered and triggered the coagulation. فكل هالشغلات اللي بنتعلمها في دروس isolated, they all now come together. Does this make sense?

Yeah, yeah, all clear.

Good. My my job. Innu, I give you back the joy of studying medicine, putting it all together, understanding hikmet Allah and in making this body in this way, not just some numbers and things. Okay, we have, uh, 3 photos and we're gonna go through them quickly. Is this helpful?

تس إنه بيساعدك ولا لا؟ Yeah, very much actually. You're simplifying that perfectly.

الحمد لله. Because أصلي I'm I just want to give things that help you guys. It's not, and if if it doesn't, I I go to something else. So this is my first time teaching this way.

I feel like it's the like. You wrote the questions, the clinical cases, then the explanation, but more simplified.

That's— I spent a lot of time doing it this way. I know I was in your shoes, and I did not like it when I couldn't understand, and people just— it made me feel like I'm stupid. No, your explanation is stupid. So I needed to make it easy. So I need you to pick the wrong answer. So which of these answers is least likely, not most likely, to cause hemolytic anemia? The hemolytic anemia معناته إنه ال RBCs are destroyed. So في واحدة اسمها warm autoimmune hemolytic anemia. Paroxysmal, paroxysmal mania. It happens in different times. It's not sustained. Paroxysmal nocturnal hemoglobinuria, microangiopathic hemolytic anemia, sickle cell disease, vitamin B12 deficiency. Pick the one that Is not likely to cause hemolytic anemia.

Vitamin B12 deficiency, because it's the cause of megaloblastic anemia, the macrocytic type.

Let's think about it for a second. This is not about getting an answer right. This is about testing your knowledge and filling the gaps. فلو سمحت، do me a huge favor. I know I was in your shoes, and we are told by our professors, here's an exam, you must get it right. بس مو الحياة كلها امتحانات. الأسئلة والأجوبة they bring أنس at the الtrauma of the exam. Don't do that. فلما تشوف إنه the answer that you did not give is is the right one. That means you have a gap there. خليني أو أف and I try to fill the gap. Don't feel that you are deficient ولا ما فهمتش صح ولا you don't you're not like as smart as other people أبداً. Okay, for sickle cell disease, less likely to cause hemolytic anemia. ليش؟ لأنه yes, sickle cell disease causes hemolysis. بس المشكلة إنه الhemolysis اللي بتحصل مع السيكل سيل is after the occlusive. فالسيكل سيل هم سكل معناتها they clump together and they go into they keep going going going going going and the blood vessel diameter starts to get narrow narrow narrow narrow narrow and they come to a place and they get stuck there okay and when they get stuck there they cause a stroke circulation is not there So they can cause a stroke in the brain. They can cause a stroke in the kidney. You can have infarcts. They can cause a stroke in the spleen. You find infarcts in the spleen. They can cause heart attacks. Fa' occlusive disease هو أكثر sickle cell problem than the hemolysis itself. The hemolysis happens بس يعني It's almost if you had a big glass of water and you spilled it. The spillage is only a little bit. So the hemolysis is not the biggest risk from sickle cell. It's the veno-occlusive disease. هدول الآخرين yes we do have hemolysis vitamin B12 deficiency can cause hemolysis a sickle cell least likely to cause hemolysis. Most likely to cause veno-occlusive disease.

Two more.

I realize we're over time.

Two more.

Two more is Hadul. I will post them on the WhatsApp so you can go back and read them. Please, if you cannot figure something out, I don't care if I have repeats the explanation ten times. I will. That's the good news. I'm not your professor. I am not giving you grades. You don't have to impress me. Just use me as your knowledge.

Now, actually, we want you as a professor.

Absolutely, absolutely. So if you go to the lectures I did, wallahi, if you go to the lectures I did in Module 1 and 2 and 3, إن شاء الله حت حت تلقى فيهم things explained in this way.

Okay. والله I wish I I did before the exam.

إن شاء الله. ال هالأسبوع الجاي راح أشتغل على الماسكلو سكالتل. لا تاخد في ذلك. We're gonna continue. This is على الدوام إن شاء الله. Blood cell اللي بنشوفها هون. Hey Doc. I'm too big. That's too immature. How do I know it's immature? Because the the nucleus is huge. Too immature. لو immature لازم يكون في البون مارو شو بيساوي بال بال بال circulating blood، peripheral blood. So is that normal? I'm big. I'm immature. I'm in the peripheral blood. Is that normal? Normal. خلينا نشوف لو هاد normal ولا لا.

لا وصلا.

So what it is? It's a microcytic RBC, as you see them there. Do you see the not the targets, but you see that small little dot that we saw earlier? Okay. And then you see a lot of RBCs. Most likely diagnosis: it's thalassemia. So this was a trick. Everybody went to the big cell, but the big cell is normal. What's not normal is all the small cells around it. Do you see them here? Yeah. This is muy con el curso. Abiad, muy esmalte. So this is a target cell. This is thalassemia.

Nice, you got me.

So آخر واحدة إن شاء الله، and then I'll let you go, and I will post all of this. So آخر واحدة هي. Have you seen a patient with this? Sixty-year-old, fatigued. Dark urine, and his hands. Look at the hands; they are jaundiced. شو بيتسمو جاندس بالعربية الفلسطينية شو بيتسمو جاندس واحد أصفر.

I think it's صفرة يا.

اللي صفرة. فعنده dark urine fatigue, and labs is eight point one. It's a little bit low. The MCV is high. الـ LDH is high، bilirubin is high، reticulocyte count هو الـ baby RBC high ليش بنستعمل reticulocyte count؟ بتقولنا لو البون مارو بتشتغل ولا لا؟ لو عندك hemorrhage ولا عندك hemolysis you are destroying the RBCs You should see the baby RBCs high. معناتها الشركة اشتغلت أكثر من لازم لأنه it's trying to get more blood red blood cells. مو هيك؟ لو قلت لك إنه عملنا reticulocyte count، إن reticulocyte count is low. Doesn't make sense. معناته في مشكلتين المشكلة تبع الهموليسس والمشكلة إنه الخزان ولا الشركة اللي حتعوض ال RBCs مو مشتغل فهمت علي؟ So reticulocyte count always has to be high in hemorrhage and hemolysis. If it's not, there's a problem with central. Production. For reticulocytes, so bone marrow is normal. So that means this is peripheral hemolysis.

Okay.

علش ليش لأن ال LDH is high. The RBCs when they destroy, they spill. They spill bilirubin. They spill LDH. And we see that the MCV is high. So macrocytosis. What's going on? What's the important next step? What is the important next step? And the important next step is it's hemolytic anemia. You have to look at the cause and start the treatment. You have to check the hemoglobin. You have to check if the bilirubin is indirect or direct. Indirect means it's coming out of the red blood cells. Direct. معناته دخلت لل لل الكبدة and it got already transformed and now it's the liver that's not normal. So it's indirect bilirubin, reticulocyte count, or Coombs test. The Coombs test حيقول لك لو في antibodies ولا مفيش antibodies. The haptoglobin. When you do all of this and they don't know the answer, you do electrophoresis of the hemoglobin to see if you have Thalassemia, if you have. Okay, so it is hemolytic anemia. We know that, and the way to treat it is to further the workout. Is it making sense?

Yeah, so.

So, آخر شغلة هو you are aware of the LinkedIn page where I post. All of this, correct?

Yeah, I'll see. I'll see.

Inshallah. Inshallah. طيب. سلام عليكم لو احتجت أي شغلة please just put it there in the chat. I will take care of it. وال والله معكن. So عندكم المسكلو سكلة هل هل أسبوع يا؟ Yeah, inshallah. و وشو اللي شفت فيه إنه فيه صعوبات؟ وبدك إنه تتكلم عنه أكثر عطيني لحد الآن أنا بس درست أناتومي للأبرليم فما ما دخلت الباثولوجيز طيب والأبرليم بالأناتومي يا أغلبوا أناتومي هو كل المديول على بعض طيب أوكي الأسئلة لأنه ما عندي مقرر تبعكن so I just go to the website اللي اللي يعطولي وبشوف ال lectures وبستنتج شو فيه so it's hard to understand كيف بنفعكم so the more you tell me the more I make it yours طيب إن شاء الله ننطلع الأسبوع الجاي إن شاء الله شرفنا الله هذا الدور الشرف إلي الله معكم السلام عليكم وعليكم السلام