Gharsat Amal: Session 2 - The art of summarizing a patient's case

And as usual, as soon as this is done, I will make it available on my YouTube video. And I send it to Christine so she makes it available on their website. It'll be open on my YouTube channel that I created. And I will have all the slides available for you. Today, what I heard from some of you was that you will be starting, inshallah, clinicals. And one of the first things you are called to do is to summarize someone. And it's one thing to do it on paper, and it's another to say it quickly on the go in rounds when you are with your attending, etc. So at least for me and my students, it is something that is not easy to learn quickly. It is easy to learn, but it's not easy to learn quickly. So what I'm going to do is I'm going to walk you through how do you try to summarize a story of a patient. One thing I want to say is I took a great deal to learn your— as much as I could, what is available, the environment in which you will be practicing. If this is not your reality, please let me know and I'll change it. What you may not know is, you know, I am in the leadership of one of the organizations called National Arab American Medical Association. Those are doctors in the United States from Arabic heritage. And we try every year to have an international lecture in a country elsewhere. Inshallah, it will be a reality as well one of these days that Allah makes it so, where you could join us even. And One of the themes last year was about case reports and studies coming out of Palestine. So what I did was I tried to get from that some of the cases, and it will be presented today in terms of how to practice. So let's get started. I'm going to share my screen. If you don't see it, let me know. Okay. I will be speaking like the last time in English and in Arabic as much as possible, but I'm going to try to keep 60% of it English. It's more how to think clearly for the patients. Last time, if you have listened to the session, and you do not have to listen to each session before the next one in order for you to understand this one. They are separate. But if you were, you would understand that medicine is working in what we call framework. And a framework means, Lema bin Fatkir, Plan. We start with one thing and then the next and then the next. In general, is very complex and can be sometimes overwhelming. So what is— let me increase this. So why does this matter? Why does this matter? It matters because the challenge is we can often collect information exceptionally well. We as Arabs are storytellers and we listen. We listen very well and we can repeat by the detail the other person, what they said to us. We are also very empathetic. We are compassionate towards the other person. So we listen. The problem is we struggle to summarize it. Sometimes what I put as a challenge, and this is at the end of today, it's not that you won't know to tell the story is I want you to the important in a few seconds. And that's what challenges us. So many of us, as we are learning this, we fall into the trap of presenting a report rather than a summary or a narrative. A patient presentation, I like to call it, it's a clinical argument. We are showing what matters, what does not, and what you think is happening. Okay. Fa bin lakhis al-muhim, wulimu sh-muhim, wintal koon shaif shu'ambi sali. I know it's important to say what's happening, but also What is not happening? If someone comes with cough, it's important to say they have cough, but it's also important to say they do not have a fever or they do not have diarrhea. We call those the pertinent positives, the pertinent negatives. And that's because we all have theory in our brain. We all have the reality of what's happening. The theory maybe is I learned what asthma is, but the reality is this patient did not learn the textbook like me. He came or she came with some things, but not other things. What I see in front of me is not always clean. I joke my first case was very difficult. Not because I did not learn medicine, but because I learned seizure, diabetes, pregnancy, each one clean chapters. And the person in front of me was a pregnant diabetic that was having a seizure, and I was having a seizure myself. I did not know how to put it all together. So in real life, especially in conflict settings, the patient's stories can be incomplete, can be disjointed. You may not have a medical record. Sometimes the person in front of you is quiet, traumatized, stressed. It is our job to extract that information and to put it in a framework that is easily understood. Fa bilwaka alhalat li bin shufa, especially, inshallah, in your— our job is to bring the order without erasing the reality. Of the patient's situation. If I'm going to present to you a case of a patient, how do I present it? I present it with one thing in mind. If I had only 10 or 20 seconds, what is the core message? What is the core message? And the core message has to answer 3 questions. Who is the patient? Why are they here now? What do I think is happening? What do I think is happening right now? Are we good so far? Okay. Yes. Yes. Excellent. Now, when you asked to have a bridging session, it was to bridge what you have in your mind and what is in reality. This is what I call the one-liner. What is the one-liner? The one-liner, meaning it's one line. If I was to summarize everything in one line, what would it be? That's how I start. Now, I may go above one line. This is what I have. The listener's brain. When you speak, you speak thinking about your listener, not about your own brain. How do I understand it? So for example, if I am a medical student or a doctor, somebody comes in and tells me, my patient has cough. Well, before you tell me anything else, I want to know if it's a man or a woman, if it's a child, If it's, uh, an adult, if it's an elderly, are they smoking? Are they not? So we usually start, the first thing out of your mouth is the age, the age, and then the gender. 45-year-old male, 3-year-old, uh, girl, 20-year-old female. Always start with the age, gender. If you are in a place that has multiple ethnicities, I am aware that some of you may be doing a clinical outside of Palestine and they are in some other country temporarily for one month or whatever. You can see other ethnicities when you are, then you have to put there also an ethnicity. Hatab baladi bil maghrib. Sometimes we have to add if the person, for example, is of Black ethnicity, of Amazigh ethnicity. Why is that? Because sometimes in a diabetic, for example, Black people would have a response to certain medications that is different from somebody of white heritage. And this is actually science. This is not anything else. For example, asthmatics, they may display a certain response to inhalers or to a diagnosis in a different way than someone who is of Hispanic origin or someone who is of Asian origin, for example. We have a significant amount of studies coming out of China in lung cancer, but in non-smoking lung cancer. So as you go into medicine, you will find out that we are not all the same and we are all different in our responses in the way that we display a diagnosis. So start with the age, gender, ethnicity, if it's relevant, if there is a relevant context, someone who is from Gaza City is not someone who is from, is born and raised somewhere else. Someone who is, for example, from the north is not from the south. Someone who is, and so on. You understand what I mean? Yes. You mean like they have some genes in common. That's the point. That is the point. When we speak, I want to augment your point By saying there is the genes that are in common, but the genes display themselves differently. And we call that the phenotype. So there are two things. There's a genotype and the phenotype. I may have a gene, but I may have need to have two alleles of that gene for me to display it. Otherwise, I'm called a carrier. For example, there are genes that are carried by a certain ethnicity. And if you have, you know, the DNA has two strands. If you have an allele in one strand and a normal in the other, then you would be displaying normal. So your genotype is one allele, your phenotype is normal. If you have two alleles that are abnormal, then your phenotype displays the disease. So you have the genotype and the phenotype. They display them differently. The third thing is the chief problem or the chief complaint. What is the main reason that they came? Let me tell you why this is important. As your teacher today, I like to tell you also my story in certain things rather than tell you what to do, because then it actually gives things in a context and it doesn't look like I'm better than you. So I walked in and I saw in my intensive care unit one lady, and the nurse came and said, she came yesterday with low potassium. We replaced it. It's normal today. I think she could leave the intensive care unit. And I said, what brought her to the hospital? No one likes the hospital. The hospitals, you have to be really sick for someone to come to the hospital. Even if you have a condition, you wait until it gets really sick. That's just how we are in Arab culture. It's not right, but that's what it is. And she said, oh, I don't know. I looked at my student and he looked at me and says, oh, I don't know. I said, well, she didn't come in with a sign that says low potassium. She didn't know. What is the symptom? So I walked into the lady, she was 47 years old, and I said to her, what brought you to the hospital? And she said, I came in because I had malaise in my abdomen. I didn't feel right. I said, well, that must have been some kind of malaise because You don't just come to the hospital for malaise. It must have been really bad. And whenever you have a middle-aged woman that has vague abdominal symptoms, you must think of ovarian cancer. You have to rule it out. And so what— that's the first thing I wanted to do is I said, I asked her, is the CAT scan available? Let's send her for a CAT scan. Well, we did. And lo and behold, here's what we found. She was bleeding internally. And then I turn to my student and says, let that be a lesson to you. The chief problem, the chief complaint is always your North Star. You must always keep it in your narrative because you will be distracted if you do not keep it in there. Yes, she came to us in the ICU for low potassium. We replaced it. But now that we asked, do you really think now she needs to leave the unit with her internal bleeding? Of course not. So age, gender, ethnicity, relevant context, chief complaint, and then the timeframe. So let me teach you another lesson I learned. I usually, when I was getting to learn medicine, I would learn, ask your patient what's wrong, right? Why are you sick? How long have you been sick? Well, one of my teachers taught me to ask, ask the patient, when was the last time you were well? I've never heard that before. So I started to ask that. 42-year-old male, white, came in with cough for 3 days. I turned to him and say, hey, when was the last time you were well? And he says, what do you mean? It always takes people by surprise. And I said, really? When was the last time you were well? And he said to me, oh, well, well. I said, yes, well, well. He says, oh my goodness, it's been 7 months or so. I said, really? 7 months? A number. What happened 7 months ago? Well, I started to feel— actually, I started to cough then. I forgot about that. Suddenly, a cough of 3 days became a cough of 7 months, and that changes things completely. So here's the question to ask. When was the last time you were well? Many of them may not remember. You have to let them feel okay. It's okay if you don't remember. I just thought I would ask. So the one-liner. So this is how a one-liner starts. This starts the conversation. The golden rule is no surprises. What does that mean? Well, if you have The idea that this is a myocardial infarction, heart attack, sepsis, an infection that moved away from the source of origin and makes everything else sick, or spinal injury, the clues must already be in your story. You must be telling me, as I'm hearing you, remember I told you you have to put the listener in your mind. As the listener is listening to you, they have to formulate their own conclusion. And that conclusion, they have to, you have to be moving them in that direction. If I tell you 45-year-old white male presented with chest pain, and then I start saying, and cough and fever, you know I'm moving you towards an infection versus chest pain that is moving to the left arm. He was running at the time where this was happening. You know, I'm moving you to a heart attack. Or chest pain that is retrosternal, behind the sternum, and it happens mostly in the middle of the night after he's had late dinner. You know, I'm moving you towards heartburn and reflux. So the story has to move you towards that conclusion that I have that I'm preparing you for. Okay. I want to go into framework right now, and don't worry, then the second half of this is going to be cases so that you can actually have examples to practice with. But first, what are the framework? This is the most popular framework. I honestly, do not know what is the framework you use in Palestine, in your university, whichever that university is. I do not know which is it. So I gave you 2 or 3 because it isn't important which one do you use, which one you're attending is asking you. It's important that you have one. So we call this the SOAP framework. I find this almost everywhere I go. And if you Google something, you will find it easily. So what it is, is Subjective, objective, assessment, and plan. Subjective is what the patient says. Objective is what you see and what you confirm. Assessment is your summary and also your differential diagnosis, the list of possibilities. And plan is what you will do realistically. So, let's start. Subjective, huwa al-qissa bin rakkiz ala tassal sul izamani, What is the most at stake? What is the most dangerous that might happen to your patient? You do not need to repeat everything the patient says. You are summarizing. Objective. Objective. You are not reading. The chart and reading every lab. You are selecting the evidence that matters. Pertinent positives, pertinent negative. I listened to the chest and it is clear there is no sounds, but I touched the abdomen and it is painful. Yani, ma bidna nikra al-milaf, bidna niktadl adil al-muhimm. Assessment. Al-assessment houwa The most important part, it's your synthesis, it's your summary. And then it also summarize it in one sentence, but you also tell me, I'm thinking I need to rule out this, I need to rule out that. And then once we are doing this, it's probably that. And we need to make sure that we treat this until we have the results come out. So you have to admit when you are uncertain, you are not here to give me a diagnosis. Sometimes there is no diagnosis. Sometimes I have a diagnosis. So if I do, I give it to you. If I don't, I give you what I call the syndrome. I give you the collection of symptoms. It's sepsis. a syndrome. And then the plan, which is thinking, but you have to think in what I'm going to do. Here are the diagnostics in order to confirm or deny my differential. But here's the therapeutics. My students and my residents, the same thing. Whenever you are in front of the patient, Even I catch myself sometimes say, I'm going to do this and I'm going to do this and I'm going to do this. And then I realized, hold on, all of the actions that I took are diagnostics, but have I treated the patient? Have I at least alleviated their symptoms? Fa. The plan has to be in diagnostics and therapeutics, and it must fit reality. Sometimes the tests may be delayed. Sometimes they may not be available where you are. So you have to think priorities. You have to think what are the dangers and you have to think always backup. What is my plan B? If this does not work, here's what I'm going to do. And know that patients may be seeing one patient, the doctor for the first time and maybe the only time. So if they are displaced, what do I want them to keep in their mind? So the next person that they see, they can actually tell them. This is important. I cannot tell you how important this is. You Cannot just give one something and then hope it will work. You have to say, if it doesn't work, what is this? This is where doctors are some of the best people because we always think, what is the next plan? What is the next plan? Okay. This is one framework. I'm going to tell you here, I give you specifically what these are. And then we go into the second framework. The second framework is when you have time to speak with others in order to debate. So this is for teaching rounds. We use SNAPPS. And SNAPPS is S for summarize the history and findings, N for narrow the differential diagnosis, A for analyze the option. You have to compare, you have to contrast. P for probe the preceptor. Ask me questions. P is for what is the plan? And then S is in the end, what is the issue that I learned from this case? Okay. I'm gonna repeat it again. Summarize the history and finding. That means Everything that the patients say, you have to select what is the most appropriate. Narrow the differential diagnosis. The differential diagnosis, sometimes when we start, it can be something that we can call— I don't know if you've ever heard the framework VINDICATES. There are multiple frameworks. But when I try to make a differential diagnosis, in order for me not to get too caught up with things and forget, what I do is I use VINDICATES. V for vascular, I for infectious, N for neoplastic, D for degenerative, I for iatrogenic intoxication, C for congenital, A for autoimmune, T for traumatic, and E for endocrine and metabolic. Let's go over them. When you have a differential, I'm gonna leave it here. When you have a differential, as you narrow for the N, I, when we have time, when we are just discussing, my students and I, what I ask them is, can you Use this to give me at least one diagnosis in each category. You have to, you have to train your brain to think not most likely diagnosis, but what else could it be? That's where doctors sometimes can miss or get taken into one direction because my colleague told me that, or the patient thinks that, and so they may make me go in that direction. I want to exit the most likely and create what else could it be? The list of possibilities. Vascular, meaning hemorrhage, vasculitis. Infectious, infectious. Neoplastic is, could it be cancer? That chest pain, it could still be cancer. It's 0.01%, but it could still be cancer. Degenerative means, is it perhaps that knee pain, is it arthritis? Osteoarthritis, meaning is the heart that way because the valve has gotten old or calcified. Iatrogenic, meaning I gave him that or somebody gave him or her a medication and that medication gave a side effect. And that side effect symptom is now mixing itself with the original diagnosis. Intoxication. Sometimes it is a blast and my patient has inhalational injury. Sometimes it is that someone was using fire to heat themselves up at night and so on. Congenital. Well, sometimes we see that someone could have a shortness of breath even though they're 20 years old because they have heart failure. Their X-ray showing huge heart and you say, how could that be? You're 20. Why would your heart be huge? Because there may be a congenital abnormality. Autoimmune, lupus arthritis, pardon me, rheumatoid arthritis and so on. Traumatic. Sometimes the person has headache. I'm going to say maybe the headache is due to a bleed in the head because they got up in the middle of the night and they can't remember and they fell and they hit their head and they went back to sleep and they don't remember falling. You never exclude something just because you don't think it happened. Always leave a possibility. And endocrine and metabolic. Sometimes, for example, My mother had multiple symptoms. She was always feeling low energy. She was always feeling that she didn't have an appetite. She was constipated. How do you put these together? Well, turns out that she has hypothyroidism. So endocrine is a possibility. So keep those in mind. So narrow the differential, analyze the option, compare and contrast between Why could it be a bronchitis and not asthma? Why could it be a kidney failure and not heart failure? And so on. You, if you are in a teaching environment, you ask your preceptor questions. In your experience, what other way could this be presented? In your experience, why did you move this way and I moved this way? When I was in your shoes, I always asked. If I am going to see a patient with an infection, I pick my own antibiotics and then I go to my attending and my attending tells me a different antibiotic. I don't get satisfied with just saying, thank you, I'll change my plan. Absolutely not. I will say, well, Dr. So-and-so, I chose this antibiotic. You chose this one. Could you teach me what makes you go to that one? Sometimes therein lies the learning. You chose You chose amoxicillin instead of penicillin. Why? This one is oral. This one is not. I, the guidelines say penicillin. Why did you choose this? And that's where the person said, because in my experience, this happened or that happened. So this is important for your learning. What is the plan and how do you select the, what did I learn today from this case? This is the third and last framework, which is the 5 Ps. The 5 Ps, usually when you are in the wards in rounds and you are just doing daily updates, just, we've seen this patient yesterday, we're rounding on them today. It should be short, focused, and the neck and looking forward. What is the problem? How has the problem progressed until today? This patient came to the hospital 3 days ago This is the chief complaint. We've done this, we've diagnosed this, we've started with the antibiotic, but he did not respond to the antibiotic. You see the progress. So far, what I have found out in what people teach about presentations is they only teach you one point in time. Nobody teaches us how do we change this as we move along. Day 3 is not like day 1. Guess what? Day 3, you can still go back to your patients and ask, you know, we found this in your labs and made us think of this differential diagnosis. Can I ask you new questions that I didn't ask day one because I didn't think about it? Do you have this? Do you have that? Is there somebody in your family who has this? So you start re-asking questions as day one with new data because of the progress. Pertinent data. How is the white blood cell count? How has the hemoglobin or hematocrit changed? What is the creatinine doing? There are some labs that you never give as a single piece of information. If my students came and told me the white blood cell count, I will tell them, do not say normal. Give me the number and give me the number from the day before and the day before, because we analyze trends. We do not analyze One number, especially if it is progress. What is the plan and what are pending issues? For example, we've done this, we've done this, we've done this, but we sent the sputum for culture. The microbiology is still pending. For example, we asked for an X-ray. It's still pending. For example, we asked for a colleague from gastroenterology to see the patient. It's still pending. So what are the pending issues? We are coming to the end of the presentation before we start 3 cases. What are some of the students' pitfalls? Some of the students' pitfalls, what that means is, um, what are some of the mistakes that we make? I said that in the previous, and I'm going to say it again, be a human. Remind yourself when you were a patient or when you brought someone of yours to a doctor, we are scared. We put on a brave face, but we're scared. So when a doctor comes and meets us with a series of questions and they use big words, it makes us even more scared. Sometimes we don't even want to tell them. So if I'm going to ask you, I gave you antibiotics, Did you take them? That sounds like judgment. So what I say is, I took antibiotics before and they made me sick to my stomach. I even thought of stopping them early. You normalize the behavior. You humanize yourself. The patient says, yeah, it happened to me and I stopped it on day 3 because I felt better. But if you approach them with that, so when did this start? What did you take? Did you take your antibiotic? It sounds like interrogation. And in our culture, we don't like to be interrogated. It makes us feel scared or intimidated. We don't like the other person. So don't sound like you're reading from a script. If you also present to me every fact as equally important, the cough, the chest pain, the headache, each one of them, We asked last time the arad, but also the intensity and the severity. And so if it's something severe versus it's not, don't present everything as equally important. And when you're speaking, you don't want to speak, you want to be human. And then you start to want to look too confident, so you hide uncertainty in order to appear smart. Mafi nafishakla. And no, shakwa, part of our job. And if I was with you and I told you, I don't know what's wrong, but we're going to do everything we can to find it, you're not going to lose respect for me. That's only in our mind. We judge ourselves. And then last thing, avoid overusing dense medical jargon for the patient. Okay? Don't speak about the creatinine and about— just say your kidneys may be unhappy today. We will do everything we can to hydrate you and to make them feel better. Okay? So the solution, be clear. Clarity beats complexity every single day. So what you don't know, own it. It is safer for the patient to know that you are uncertain and you're looking for it than trying to appear certain. I don't know if you've been around people that you know that try to make themselves feel Brave, but you know, you feel that they're scared. That's not something you hide easily. So try to be okay with the patient and tell them, I may not know now, but I am going to find out. That builds trust with your patient. Any questions before we move to the examples? How's it going so far? I want to stop and take the pulse. Perfect. Very good. Let me open the chat, see if somebody put anything in the chat that I didn't see. Okay. Alhamdulillah. Okay. If you have any questions, please send them my way. You also have the WhatsApp chat if this is not something you see in real time. I was pleased to see the video was seen dozens and dozens of times, so that means people see the videos outside of here. So it's great. And for the next 15 minutes, if you can write in the chat or even in the WhatsApp chat, is this a good time of the day for you? And is it a good day of the week for you? So we're going to continue, but I wanted to put this question out there. If you're watching this video outside of today in a different time, feel free to send it in the chat on WhatsApp. So the first case, here's the one-liner. A 12-year-old girl from northern Gaza presenting with headache and vomiting after a building collapsed 3 days ago. The question is, what must you not miss? What must you not miss is a delayed presentation because of access barriers. What that means is, um, for longer than for 3 days. And just because she didn't come to the doctor does not mean she wasn't suffering. Inu tiji al mustashfa, I need to make her feel that she did not do anything wrong. And I need to keep in mind the vindicates. Maybe there is more to the story. Maybe that this is nothing to do with the building collapse. The building collapse just exacerbated it. And maybe it's coincidence, maybe it's not coincidence. So you have to ask questions with all of this in mind. There is also, there is also a psychological trauma that affects the symptom expression. And she's 12. She doesn't have the words to express this yet. Another one-liner scenario is a 6-year-old presenting with wheezing after staying in a shelter that was overcrowded and she was exposed to smoke. The family ran out of inhalers 2 weeks ago. This is something that they may not tell you. I actually have to ask. It must be very difficult. Our job as doctors is to mirror and validate. If someone tells me, for example, I have been coughing, sometimes all you have to say is, you have been coughing. And that is an invitation for them to tell me more. So the environment is also history. There is a person who came in and we were treating their antibiotic with antibiotic and they were not working. And then it turns out that they were living in a place where there was a lot of birds. Now I'm starting to think, well, maybe this is not a normal pneumonia. Maybe this is a pneumonia that is coming from bird droppings. And so the environment is history. The context in this patient is smoke, overcrowding, and lack of meds. These belong in the one-liner. They should not be buried in the story later. And that explains why the exacerbation happened. Okay, keep in mind that how you make that one-liner is important, what belongs in it. Third case. Sorry for interrupting, but the screen is not visible to us. Oh, I'm so sorry. No, it's okay. Yes, thank you. I'm so sorry. Here we go. So quickly, a 6-year-old presenting with weezing after staying in an overcrowded shelter. The smoke exposure, the environment is history, but also the overcrowding, the shelter, the lack of meds. All of these belong in the one-liner and should not be buried later because it explains why bifesru in Nuba, Nuba al-asma, bin Samiha bil-Maghrib al-Dhikr. So it depends on what belongs in that one-liner. And then the last one is the public health context. I just shared with you the birds, but in this patient, sometimes in Morocco, we have tuberculosis that is endemic in Morocco. So even though the person does not say that they have TB, we have to keep TB in mind. So when we have prolonged cough, when we have weight loss, living in crowded living condition, So these belong in the one-liner. Crowded living condition, presentation in, as a public health context. So we considering an isolation of that patient immediately, wearing a mask and so on in our plan. So what is the take-home message? The take-home message is you're not performing. You are thinking. You are the brain of the patient. You are the patient's extra school. So you are thinking out loud for the patient. You and the patient are a team. So you have to be respectful, but you also have to be structured. You have to be honest and you have to be clinically intentional. So when you're done with this, I want you to practice, practice out loud. Whenever you hear someone presenting with symptoms, start to create this framework. Pick one and use it. Don't use all of them at once. Pick one, maybe this, the SOAP one. Okay? That's the most common. Take it and start to practice it every day. Maybe practice it with your friends back and forth. And then you have to accept imperfection. I actually like to say to my colleagues, residents, students, divorce yourself from perfection. Perfection comes when you judge yourself. Just think, slow down, and when you don't get it right the first time, own it and say, you know what, I could have done that better. Next time I'll do it better. And keep in mind that clinical reasoning begins with how you tell the story. I will tell you something important. When I am with my students and we round, sometimes I like to round without them because I want to make sure that maybe they did not take me in a direction that I wouldn't have gone if I listened to it directly from the patient without anybody to influence me. Okay, this is today's session. I hope that it helps. I hope that you have learned some way of how to start thinking about presenting the patient: age, gender, ethnicity, chief complaint. If it is after the first time, progress. Keep in mind the differential diagnosis, not the most likely diagnosis. How you tell the story must include Important stuff that may not always be related to the patient. For example, the context, the environment, maybe something they told you about their family. And then in the end, you have to ask yourself, what should I not miss? I should not miss bleed. I should not miss a heart attack. I should not miss a child traumatized. I should not miss something that is big. I'm going to open it for any questions, comments, reactions, chat. Oh, you are saying— I'm so sorry. You were saying that share your screen, it did help. Thank you for your efforts, Bissan. I appreciate you. Any questions that you have, Don't hesitate to bring them. Before I leave today, I do wish to share with you, and I shared it in the chat, but I am going to just bring it back up again, the, the plan, what we have. So we— how to take a focused medical history. Today we talked about how to present and summarize a case. Next time we're going to see how to create a differential diagnosis. Next, after that, we're going to talk about how to document in writing a patient's story. After that, how do you communicate with the patient with empathy? I have a framework in mind, which is how do you discuss with the silent patient, with the angry patient, with the patient that talks too much and you need to interrupt them. So the different ways of asking a patient How to deliver serious news, bad news. How to present a patient in rounds, a structured approach. Raneem, of course. I will send you examples to practice in the chat. Is it possible that you could interact with me in the chat section? You want to interact with me, I can make the learning ongoing, not once a week. I can put there some games to play with. But I do need to have something from you to tell me if that's what you want, not what you want, what did you do with it, so that we can continue that. If you interact with me in the chat, I'm happy to make this a continuous learning, and I'll be posting there continuously. I'll give you examples to practice. I do not know also your reality. So if you have the ability to access videos, one of my— not just videos, but artificial intelligence. I do not know your internet. So I can share with you some tools, but I don't know if they work or not. One of the things that I want to give my people is I am board certified and I practice daily with a variety of artificial intelligence. It gave us tools that before that it was just when you go some country that have means. Now we have these. It can make us extraordinary for our patients. So if you have that ability, give me feedback if you can or cannot use it. I will be posting these. One of the sessions is how you utilize artificial intelligence in medical research. I gave that to some students in one of the universities in Palestine. I will post it as well. If it's helpful, good. If it's not helpful, tell me so I can actually modulate this. I wanted something to be meaningful to you, not always borrowing somebody else's material. And give it to you. I want this for you. And then after that, we will go into the heart, the lungs, the abdomen, the physical examination. Some of you asked, how do you auscultate? How do you do electrocardiogram? How do you assess for various points? McBurney points, Murphy points. How do you approach somebody with various encounters? Chest pain, shortness of breath. I was told by you in the chat that those are labs some of you missed or didn't attend because of displacement. This is not a replacement for your medical education. These are just things to reinforce what you have. Is that good? I'm happy to go with you. However many months that is necessary for you to feel empowered. And there will be videos and they will be on my YouTube channel. They will have slides for you to take home. Anything you need, do not hesitate. This is for you. This curriculum is created for you. It is not created, borrowed from another university. It is not borrowed from another place. It is for you. You. So the more you give me questions, the more requests you give me, the happier I am because I can make them yours. Oh, my pleasure, Muhammad. We are almost at the hour. You will know that I try to respect your time because I need you to know when you are somewhere. I've taught classes of you guys before, and I understand sometimes you have pressures, you need to be somewhere, or your phone may die, or whatever. I need to help you plan. So you will always be here. I am so sorry about yesterday. Inshallah, I will do my best for it not to repeat itself. I wasn't feeling well yesterday, and I will communicate with you always if there's a change, if you can be there. If not, you will find it on my YouTube channel within 24 hours. He's not doing well. If you pray for him, that's all I'm asking. Thank you, Raneem. I am, as you can hear, I am feeling better, alhamdulillah. Take care of yourself, take care of each other.