How to approach patients for history taking + NotebookLM + Review GI

السلام عليكم مساء الخير إن شاء الله تكونوا بخير وإن شاء الله يكون بعضكم وصلني خبر إنه راح تبتدوا إن شاء الله الكلينيكلز هالأسبوع فرح نحكي على. كيف نتفعله مع المريض كيف ناخدوا الميديكال هيستري. This is today, but we've already had a session about this before. لو رحتوا على اليوتيوب ولا على لينك of the LinkedIn ممكن you can scroll back before and you will find a previous session about this. طيب taking focused medical history. Awellen, to make sure that we speak about how we are in clinicals. في مرات بنرتبك لأنه we don't we feel nervous. We do not feel ready to speak to the patients. We feel like we don't know enough. So how do we those of us that are experienced? How do we perform? How do we do it? It is not simple. It's simple, but it's not easy. معناته إنه when we speak about how to approach the patient, we usually want to speak about it in terms of framework. شو معناته framework that you come in, that you are a framework means إطار إطار تفكيري. So if you are organized in your mind, you will approach the patient in an organized manner, and you look like you know what you're talking about. So what kind of framework are we talking about? This is where these letters help us. So we're gonna talk about these 2 letters and how they would help us when we walk into The ward. A wellen, why does it feel sometimes hard when you see the patient and your attending asks you to go talk to the patient and come present? So Hadul, 2 phases. If in fact 3 phases. The first phase is how to talk to the patient. The second phase is how to think about what the patient told you. The third one is how to present What you heard from the patient. So why does history feel hard in real life? لأنه أولاً the patients when they come in they ما بيدوكم ال الخبر نظم فبيبتدي ب عندي صباح بعدين بيقولك إنه أكل شغلة ممنيحة بعدين بيقولك أنا عندي ثلاث أولاد بعدين بيقولك إنه بيشتغل ميكانيكي يعني ف When you put all of this together, it's confusing. Some of it is history of present illness. Some of it is chief complaint. Some of it is past history. Some of this is social history. But we are trained to think in an organized fashion. But the patients are not telling us this in an organized fashion. So it's very difficult if we just throw you in without preparing you. Then again, the symptoms that we learn in medical school, They are vertigo or syncope or high blood pressure. They are not. I feel weird or manifali, man tlachbat. We don't have these words in medical school, so it is our job to take what the patient tells us and translate it into something medical. And that feels sometimes very difficult when we start. Okay, شغلة ثالثة إنه. The emotion, then the patient sometimes can be very irritable, gets upset, angry, and no impatience. My head hurts, and you tell them, "Do you have chest pain?" Chest pain? I'm telling you my head hurts. Why are you talking about my chest? So يعني كيف يتفاعل الواحد مع العيان ولا العيانة and calm them down and try to organize them, try to. Establish trust without appearing incompetent. وآخر شغلة إنه all the symptoms come at once. I'm I'm dizzy. I'm vomiting. I have abdominal pain. At the same time, look at this skin lesion, and at the same time, my head hurts. My leg hurts, or you're confused. Multiple symptoms are presented at once. So what we're going to be talking about today is how do we organize this? تمام البيس؟ Are we? Do you? Can you understand me well? Is everything okay? You can either come off mute to talk with me مباشرة or كتبولي بالchat or give me reactions اللي بتحبوه. طيب. Is everything okay? تمام الدكتور كله مناسب. ممتاز. طيب ال it's not when when we're talking to to the patients we are not taking just a history this is not an information collection it's إحنا عرب والعرب عندهم يعني متمرنين على القصة. Storytelling. This is not a story. You take a story and you make it into a medical history. And so why? Because it isn't just because we want to talk about what the patient tell us. It's because we need to translate it into a decision. لو في أخبار بيقولك عليها العيان اللي ما فيها to to to to change your decision, then it's not helpful. I don't need to know if the patient has a car. I do need to know if the patient has a car that is going to bring them to their appointments, so they are مواضبين على follow up. Okay, so it has to mean something for you. It can't just be part of the history. Even if it is medical, meselen, my patient tells me they have chest pain and I'm thinking about heart. If they tell me they had a colonoscopy ten years ago, mumrim. So I will not include it in the history. يعني لزمن. If I'm just talking and presenting to my attending. Maybe I will leave the colonoscopy until the end, لأنه مهمة when it comes to his chest pain. وشغلة ثالثة إنه لازم إنه يكون عنا وضوح في التقديم طبي. مو لازم يكون يعني لو عندي I have five minutes and I need to present my patient in five minutes. I need to be clear instead of being complete. Sometimes when I was a medical student, I just wanted to do a full job. Don't forget the patient told you that they had 3 kids. Don't forget the patient told you that their left toe hurts. Don't forget. And sometimes it's too much. So I'm going to have a goal to be clear rather than complete. That's when the framework comes in. How do I think about a framework? One is you have to ask yourself, could what could harm the patient today? Surely ممكن يكون بيدر my patient اليوم. You have to identify what is time sensitive. If somebody has chest pain, بس ثلاثة على عشرة وممكن if I press on their chest, it brings back the pain again versus something else they said, which is they felt dizzy and almost passed out yesterday. Dizziness أهم من chest pain. بس لو قال لي إنه chest pain is There, ثلاثة على عشرة بس إجا لما العيان ابتدى يعمل effort يعني that's important. ف what could harm the patient today? You have to identify what is time sensitive and life threatening. Number two, what information could help or could put aside everything that they said to me? If they said that they ate something, and we're talking about their chest pain, this information is not going to help. Rule in or rule out. What details ممكن يغيروا a list of possibilities, a differential diagnosis? وشغلة تالتة is why am I still confused? What am I still confused about after listening? هذه بتحصلنا كتير لما بيكون رفيقي بيقولي أسطورة ولا قصة على شغلي بيقله استنى استنى استنى مو قلتلي إنه صار لك ثلاثة أيام كنت مسافر فكيف كنت مسافر وبتقولي أربعة أيام كنت هون مع أمك حكي يعني وضح لي. So if you are confused about something, ask. This is not the time to be polite. ما فيني أخذش حياءه ولا يعني to make him upset. No, ask. I'm sorry. You said you stopped smoking, and now I can smell smoke on you. When did you restart smoking again? So if you are still smoking, confused about something about listening after listening, you have to ask. So is there a gap? ثلاثة أيام وأربعة أيام بين اليوم الرابع واليوم الثالث. شوف شو حصل. If something is not good in terms of character, wait. قلت لي إنه the pain was only three out of ten. بس لساتك قيل لي إنه ال pain woke you up from sleep فكتم من من نوم بسبب ال ال ألم ف is it high or is it not high okay so those are three things أولا what could harm this patient today two what information could rule that in or out and three after you're done what is still confusing When we talk about O P Q R S T, شو معناته؟ If someone tells us a symptom, we want to know all the characteristics about that symptom. Onset is O. Onset معناته ما انت تدت. When and how it started. Chest pain started in middle of the night or started when I was walking or started when I was watching TV. Q is quality. Describe the quality. الأسبوع اللي فات أبوي كان بيقلي عندي ألم بالمعده، فقلت له هل ألم كيفه؟ Is it burning? Is it stabbing? Is it tearing? Is it twisting? Is it pressure? فهل هل ألم كيفه يعني في واحد زي ما بضربك بال بال بالمعدة ولا زي ما something spilled on you like hot water or what kind of ألم is it pressure is it twisting so you have to understand what kind what is the quality of this pain severity how intense is it if somebody told me dizziness how intense is that dizziness can't I was about to pass out. That's one thing. Dizzy, but just because I stood up too quick. Those are 2 different types of dizziness. What brought it about? Provocation. Chest pain when you were eating is not the same chest pain as you were just starting to walk or run. Radiation. Chest pain that stays there is not same as chest pain that went to the left shoulder and to the left hand. And then timing. Does it come and go? Does it come and stay? Does it come at night but not during the day? فألم بالمعدة بعد الأكل مو the same as ألم بالمعدة قبل الأكل. I'll give you two examples. ألم بالمعدة قبل الأكل ب ب بن بنفكر بال بالقرحة المعادية. ألم بالمعد بالمعدة قبل بعد الأكل بنفكر بال بالحضم. So maybe it's the the gallbladder. So each time you have to look at onset, quality, severity, provocation, radiation, and timing. But مثلاً I've had this tightness. Okay. I've had this tightness since I've had this tightness since. سمحت لو سمحت تسمحولي. Here it is. I have had this tightness in my chest. And by tightness we mean يعني في ألم بس where is it? I've had this tightness since this morning. We're going to put this framework to it, okay? ف ف ب لما بيقول الواحد عندي ديق في صدري ولا شدة في صدري بنسأل العيان when did it start? What were you doing? Provocation. Does it change with walking or rest? Or how would you describe it without saying pain? And this is important because when you ask them to say, how would you describe it without saying pain, you're essentially asking them to use other فلما حنسأل العيان بيعبر عن هالشدة ولا عن هالألم بدون ما نقول ألم ضيق في الصدر ضغط في الصدر ولا تقل في الصدر so pressure or twisting or tightness انزعاج في الصدر شعور بالتعصر في الصدر إحساس مزعج فنسألهم كيف يقولونا بدون بدل من منقول ألم شو بتسميه؟ And that's how we get to say what is the quality? What is the radiation? What is the radiation? معناتها does it هل تمتد لمكان تاني ولا بتنتقل لمكان تاني و severity how bad is it from one to ten How bad is it? حنسأل العيان ولا العيانة. أديش شدة الألم من واحد لعشرة؟ And timing, has it been constant or does it come and go? And when we say has it been constant or does it come and go، بنسألهم على the T which is timing. هل بيستمر ولا بيجي ويروح؟ فهذول بيساعدونا. ناخدوا ال history من patients and as we are taking this we starting to make differential diagnosis in our head so that we can start to do actions for the patient. Okay. Now sometimes severity alone is misleading. Severity alone Meaning, if you're talking about severity alone, let's take 2 examples. When we take 3 out of 10 chest pain, it's 3 out of 10. It's not severe. But it happens with exertion, with effort. Okay. That's the first thing. Provocation. يعني بيحضر مع مجهود. Is it relieved by rest? Does it radiate to the jaw? And is it associated with shortness of breath? This chest pain is a lot more concerning, a lot more concerning than, for example, بيفير للقلق مقارنة مع ثمانية على عشرة. Severity, but it's sharp and localized. Okay, and sharp and localized means that يعني محدد بالمكان و بالموقع. And what reproducible on palpation? شو معناته reproducible on palpation mean ممكن تعيد هل ألم استحضار الألم بالجس ولا بال بال بال بال palpation okay and usually it doesn't radiate anywhere and it's constant it doesn't go away if you do that then that means it's probably what we call costochondritis فا it's التهاب بال بال بالدولور so that is not even if it's eight out of ten It's not as concerning. لا مو بيكتير للقلق مقارنة مع three out of ten pain بس with exertion. That's probably heart attack. Okay. حكينا على framework الأول، فبدي أسألكم في أسئلة هلأ؟ Is there anything that's still confusing? Tell me what you're thinking. Any questions so far? Okay. طيب ما في أسئلة راح نكلي نكمل الإطار الثاني the framework is called old cards and old card thank you أول أدهم. Old cards, man. It says something similar but different. Onset. Onset. Thank you, Mara. Duration. How long? And this one has something interesting, which is aggravating factors. You don't need to use both of them. You can choose one or the other. But I want you to know you can use these in order for you to Make your story better. So what makes it better? What makes it less? This is something that I use a lot, because when I start with the patient as a student, as a student, I was always taught: ask this, ask this, ask this, ask this. فالشعر الأول اللي مبتديت كان أنا اللي مرتبك، so ولما بروح على المريض ولا العيان، I wanted to be perfect. So I take my list and I have the list in front of me. و ببتدي بسأل السؤال الأول والتاني والتالت history past medical history past surgical history social history family history. But no, I then I need to stop and I need to do my physical exam. فكنت يعني رح نبدأ اليوم بالGI yes so what I heard إنه خبروني إنه هالأسبوع رح تبتدي الكلينيكلز so we are doing just a little introduction on how to approach patients and in about five ten minutes we will go back to GI again عملنا GI الأسبوع اللي فات ورح نعمل GI اليوم بس زي أسئلة To to put you in the mood for GI and how to think about GI. خلاص. Okay. ف aggravating factors and timing, location, character, relieving factors. فالعوامل اللي اللي بتزيد سوء الألم والعوامل اللي بت بت تخفف الألم. وبعدين severity as we said so you can see نفس المعلومات بس مركزة بطريقة مختلفة old cards ولا OPQRST فلما بروح على المريض وبسأله السؤال يكون عندي دير في بالكم لما بيكون عندكم ألم ولا بيكون الواحد مو على بعضه بيروح على الدكتور بيروح على الدكتور عندنا أمل إنه يخفف علينا Right? فلما بيجي الدكتور ولا الدكتورة بيسألونا نص ساعة للأسئلة الواحد بيضيء نفسه. Right? So I learned that I have to change the way I ask the patient. And usually if you start to ask them about this, the problem that they have first, they feel heard. They feel that you're not wasting their time. So this is why it's important when I start to ask the patient, I usually ask them about tell me what makes It burst. Tell me what makes it better. Tell me how long it's been. And by the way, have you had any stomach problems before? And then I start to move. Have you had any heart problems before? Do you have diabetes? And then after two or three questions, I go back to the الالم اللي خدت دواء للالم هل ألم حصل قبل ولا أول مرة؟ And وشو بتشتعل؟ So مر مرات بسأل على الأعراض وداخل الأعراض بسأل على الفاملي هيستري، سوشيال هيستري. ف I mix them. The patient does not feel like they are being interrogated. مفهوم؟ طيب. How do you close your framework? You make sure that you use those either OPQRST or old cards. You I use OPQRST when something is acute. لسات حصل أول مرة ولا المبارح ولا لو بيكون واحد عندي بالعيادة هدول بالchronic presentation so I use old cards for chronic presentation. في سؤال على كيف نسأل العيان ولا العيانة؟ أوكي طيب اليوم كلمنا على كيف نسأل العيان وللعيانة إن شاء الله الأسبوع الجاي بحكي معكم على كيف ننظم أفكارنا بعد ما نفهم من العيان وللعيانة their history how do we think how do we present فهذول three phases what we heard What we organize in our mind and what we present to our attending type. Hello, شو نعمل؟ I want to go back to teach you something else before we do GI. Those that are in In the fourth year, I learned one of the tools to study, and I want to teach you the same tool. Come on, Owen. Let me share. So here, what you see is something that we call Notebook LM dot Google. Dot com. سمعتوا عنه؟ تستعملوهون؟ No, yes. Okay, أبو بكر نمرح. You're using Notebook LM. So I'm going to teach for the others, and it's going to be quick. What's important about Notebook LM? إنه it helps you study everything that you need. How? Most of the time when your attending sends you a chapter, sometimes you're left by yourself. When you are in class, there are things you don't understand, and you don't feel like interrupting the class all the time to ask questions. بس لما تروح البيت you are by yourself, and if you have a question, you don't know how to ask it and how to solve it. Yes, you go to Google. Well, you choose to use something or the other. بس في براتمة it's not deep enough to explain to you. so notebook LM you click on create notebook and it opens this. شو في؟ في three panels. الpanel على اليسار هو اسمه اسمه sources. sources معناته إنه you have to upload. راح طلع على على notebook LM Your slideshow, ولا textbook عندك، ولا your notes from the class. So you can click on add sources. What do we see here? What do we see is you can put web. معناته you can put in here an address on the internet. فممكن يكون gi dot com. I don't know. Just to make examples. Okay. And you can upload files, and that means you can upload files from your computer. Okay, or you can put websites. هدول الويب سايت تبع ال somebody told you a website that you need to know, or you found something on the internet that you thought was useful, and you can upload something from your Google Drive. Okay. All the, the stuff that you have on your Google Drive from the website that you have. Okay. Okay, I'm going to choose, for example, to upload this. Okay, here it is. And lastly, Copy text. شو معناته؟ I put in here the text of my notes. You know, I go to my here and copy, and I paste it here. And this is from my notes that I took during my class. All of it is going to paste here. And when I'm done, now my sources. Are all here, and my sources will be what I use to study. Okay, when that happens, this is just an example. Okay, so you can go to the second panel right here, and you can start to ask questions. And to ask question. روح أرجع بك كمان دقيقة لو سمحتي. So I will when I have these things here, let's say I have a question. What does the GI bleed mean for the patient? Well, I don't understand. Why the gallbladder causes pain after eating? Well, why is bleeding becoming black in the stool? Whatever you have questions about. And this is like your teacher. It tells you anything you want. It You can ask it when you when it gives you an answer. I still don't understand. Tell me like I am a five-year-old, or anything of that nature. Okay. Will panel etalits? ممكن إنه you create a slide deck. You create quizzes, questions so you can test your knowledge. You create flashcards. You can create an info. Infographic, just one slide that has things visual. أنا ما ما بفهم when it's when لما بيكون text طويل وفي terms وبالغي وما ما ما بفهم عليه. So what I ask is give me a visual infographic. ولا you can create a video or even an audio. Okay. Here's how it looks like. We are going to Look, for example, this was something I did about asthma. Look at all the sources. I created a PDF. I added all of these video addresses on the internet. I added here a document from these guidelines. I added here and so on and so forth. These are our sources. It won't come out of these sources. That's all. So it will not have hallucinations. And then you have here This. So we're going to take a look at, for example, here is— I made a slide deck. Look at that. Uncovering the endotype, molecular damage. Wow. Okay, I created a slide deck, or I can start to take a look at a sound. This is—

Welcome to the deep dive. You know, health topics, especially something like asthma, can feel, well, pretty complex sometimes, right? There's always new research coming out. So today we're diving deep into how our understanding of asthma is really changing.

Oh, hey, our listener wants to join in.

What's up?

Um, I do not know what asthma is. I don't know what asthma is. Can you tell me what asthma is? My connection is not the best. Try again. Let's try again.

Welcome to the Deep Dive. You know, health topics, especially something like asthma.

Oh, hey, I think our listener's got something to say. I do. I don't know what asthma is. Can you explain it to me?

That is a great question, and we absolutely want to explain it. You are asking about something called IL-5.

It stands for interleukin-5.

It's—

and then last thing I want to teach you is this. You can create a video for yourself, like a presentation.

Hey everyone, and welcome to The Explainer. Today we're diving into asthma, and I have to tell you, if you think you know what asthma is, you might want to buckle up because our Our entire understanding of this condition has been completely turned on its head. So let's get right into the science that's changing everything. First, let's just talk about the scale of this.

So what I wanted you to know is when you are creating this, you're— I want to teach you one more thing before we start the last 15, 20 minutes talking about GI. And to explain, this is notebooklm.com. Pardon me, I apologize, notebooklm.google.com. When you are creating, let's see if we can create this together. When you are creating, for example, this video overview, here's what it's going to ask you to do. It's going to ask you, do you want cinematic? It actually creates a cinema, a movie, or you want just an explainer, and you can choose the visual style. You can choose it to be this style or this style, or doesn't matter. Let's say we— but you can choose to do it in other languages. And if I'm not mistaken, it's in Arabic or Egyptian Arabic. So the only thing is it takes a few minutes to generate, and then you can actually say, I want to focus on the liver, or I want to focus on GI bleed. Okay, and you can click on Generate, and once you generate it, it's going to give you in Arabic. Same thing for flashcards. I usually say in flashcards, instead of choosing Arabic, I choose English, but in those instructions I say I want you to explain, to give it to me both in Arabic and in English. Okay, so this hopefully is going to help you Okay, so hopefully you can play with it a little bit, and it's going to help you as if you are a professor with you. If you don't want to ask these questions at school because, well, there's no time or whatever. I want to go back to one question about what we did. So بدي أسأل سؤال السلايد هون على ال old cards أفضل للأعراض اللي بتتطور تدريجياً في حالة استوارئ أو نوبات حادة جداً بنطبق نفس الاختصار بحدافره ولا بننتقل لفوكست history؟ ما في إطار بيتطبق بحدافره؟ كل عيان ممكن في عيان ببتدي معه على OPQRST. And let me go back and we can review this real quick. Where is my slides? Here they are. So let's Share. What happened to the slides? I think I closed them. صبركم معي لو سمحتم. Yep, I closed them. Let me reopen it again. Taken focused history. Here it is. And now we can go back to share. And so what we discussed is that What we discussed is use the OPQRST when you have acute presentation, when the pain, when the moment-specific symptom, when the clear starts, something that started as a clear time. OLD CARTS is more something that's evolving over time. So when can I switch, for example? أولاً بيجي عندي الواحد بيقلي عندي كحة صار لي ثلاثة أيام وأنا start بسأل العيان ثلاثة أيام بس فاليوم يوم الاثنين يوم الجمعة ما كان عندك شيء لا ما كان عندي شيء طيب أوكي بتتذكر رمضان؟ إيه رمضان فين كنت؟ والله كنت مع أهلي في هالمكان كنت معهم الشهر كله أي الشهر كله بتتذكر بالمغرب لما كنت بتفرق الصوم absolutely yeah yeah ما في حدا قالك على الكحة تبعك لا والله تعرف كيف هلأ بتذكر I think somebody told me why is it that I was coughing on the plate that I was taking to the table. Oh my God! هون انتقلنا من كحى بثلاثة أيام acute to كحى of شهرين شهرين ولا ثلاثة. And then you can move from one framework to another. فهمت عليك؟ So I think that what I want to say is it's not always Staying with the same framework, it's how the patient tells you something and you move with it. Did that answer your question? Okay, ممكن تحكي directly ولا you can type on the chat ولا أعطيني reactions. في كمان سؤال. Of course تفضل هذه ال sessions لكم so make it anything you want لو عندك أسئلة this is the time to ask مرحبا دكتور بالنسبة لheart disease severity في حالة الألم مقياس من واحد لعشرة لكن في العرض الثاني زي الإرهاق هل في مقياس طبي معتمد تقييم الfunctional impact ولا بنعتمد فقط على الوصف المريض لتعطل نشاطه اليومي أنه هو يحكينا يعني أكمل نسبة إرهاق فلو لا اللي فهمته من سؤالك إنه عنا واحدة العشرة للألم بس في كمان نفس الإشي بالإرهاق ولا بالدوخة ولا ب other symptoms and the answer is no you can ممكن ما ما في أي مشكلة إنك تستعمليها بس اللي درسناه واللي validated بالستوديز هو الألم مو ببأother symptoms like like tiredness or dizziness or headaches or things like that pain الألم لوحده كان درس بال بالscale of zero to ten بس في كمان cough الكحة عنده what we call visual scale zero to ten Visually, and the patient chooses which one. Hadul visual بنسميه V A S visual analog scale. Elvas مدرس مدروس على الكحال pain from one to ten مدروس for pain. So each one of them just because you can doesn't mean that it is anchored in science. It just means that you can use it if you want, just for your own. بس ما عنده validation. Yes. Great. Okay. آخر شغلة بدي أدرسكن إياها. Let me open it. And what we're going to do is go to. See if we can do some questions, and while we're doing them, we'll hopefully study some of these. G I and okay. One quick second, please. This is for what happened to the GI, the GYN. We had صبركم علي لو سمحتم. And we have here. Okay, let's go back and do it another way. And to make sure that everybody knows, في اللي سألني على على LinkedIn اللي فيه فيه اللي سألني على LinkedIn اللي فيه all of your announcements. This is the LinkedIn that has all of your announcements. So view as member and this is it. So غرست أمل. Okay, and what I'm going to do is also put it in your chat. Here it is. Fahon, I put both for everybody. So this is what we did last week. Every single Saturday, you will have, as soon as we're done within the hour, you will have the slides, and you also will have the video. That we discussed. So this is the slides that we discussed last week, and I'm going to go directly into, and you can actually download them from here. As you can see here, this right here, it's download, and it's going to bring them on your computer, and they're made into PDF, so it's easy to share with other people. So we talked about varices, we talked about liver failure, we talked about the biliary syndromes. And upper GI bleed, what to do in the upper GI bleed, which means we need to make sure that our patients is stable and that they have IV lines that are too small peripheral IV lines. What bloods to send and how do we resuscitate them? Again, you can go back to the video of last week and you will see what we discussed. We had the first case, which was the upper GI bleed. Is it variceal or not? And we also discussed acute pancreatitis. We discussed what cholangitis means. معناته the common bile duct عنده stone that stops it. And how did it connect to the? So we had a few slides that we can finish. So we let's talk back again about what is portal hypertension. Portal hypertension, let's take a look. We're gonna start with mnemonic. We we be zekarna acronym escape E esophageal varices S is stomach varices. شو معناته؟ As you can if you remember. We have in our anatomy, we have all of these small veins that are around the stomach and the esophagus. لما بيكون عنا تشمع الكبد liver cirrhosis معناته إنه now the circulation through the liver is going to be with traffic يعني congestion ما في circulation is not easy مو سهل معناته إنه the pressure inside the liver is high. And if the pressure inside the liver is high, the circulation is going to go around the obstacle, and that is going to go through those veins that are in the stomach, and they become big. بس مو معمولين لهال level of pressure. So when they are become big, they're easy to burst, and that's when you have GI bleed. So either منسميهم varices معناته Dilatation of the vein, and it's either in the esophagus or in the stomach. Hadul varices, part of portal hypertension, the portal vein. And because it's not just the veins around the stomach, it's the veins around the abdominal wall. When you look at the abdomen of the patient, one could see small little veins underneath the skin. هدول بنسميهم عندهم اسم لاتين اسمه كابيت مدوسا. and I will show you a picture in just a second. let's take a look at the picture of what كابيت مدوسا means. so let's share. كابيت مدوسا is This is how it looks like in the abdomen. We start to see that the umbilical vein that we had since we were babies, it starts to become big as well, much like the varices. And this is extreme. Okay, this is extreme. You won't see this all the time, and maybe you will. I don't know. But I haven't seen this in a long, long while. Caput medusa means it's the portal vein hypertension, and now the blood is looking for other ways to go. So you see this in your examination of the patients. Okay. Going back to our slides, going back to the slides. Here it is. Here we go. Let me share. Why are you giving me a hard time? Nope, it's not. Showing me what I want to. Here it is. Okay, let's go back, share, and here it is. So esophageal varices, stomach varices, caput medusa. And as you can see now, it's congested everywhere. The blood that doesn't go through the liver. Let me ask you a question. How much of 5 liters of blood go through the liver? 5%, 10%, 80%? 2% every minute, every beat, every beat. How much of the 5 liters of blood goes through the liver? Anybody gives me a guess? Give me a guess. What do you think?

20%.

Anybody else?

25%.

Anybody else? Well, it's just about a quarter, 25%. You were correct. So 25% goes through the liver every beat. So of course, when you cannot go through the liver, do you know how much One or one and a half liters of blood has to go through all of these small little roads everywhere instead of the big road, and that means it's not just in the stomach. Every small little vein in the abdomen, the blood is going to be congested in it. معناته إنه حتى ال ال rectum or hemorrhoids. So people with portal hypertension will have hemorrhoids. It doesn't mean people with hemorrhoids have portal hypertension. لنفرق معناته إنه if you have portal hypertension, your veins everywhere is going to be increased, and the umbilicus we just show shown the umbilicus. Okay, so escape. So portal hypertension—that's number one. Number two, cholangitis. Cholangitis معناته what are The symptoms that make you think either gallbladder ولا biliary system in general. If it's the gallbladder, you can have if it's cholangitis, معناته you have a blockage of the biliary common bile duct CBD common bile duct. You have five symptoms: you have fever. Right upper quadrant pain تحت الدلع على اليمين and jaundice and low blood pressure and confusion. هدول emergency. You have to call because they're becoming septic. Charlotte Delta topic number three is upper GI bleeds. When you have somebody who's vomiting blood, أو ويلن airway, you have to intubate them. Put them on ventilator so at least blood does not go into their lung. Breathing, you have to give them oxygen and breathe for them. Circulation, you have to support their blood pressure. And then you decide whether if they're stable, you call your stomach doctor to come in and do endoscopy with a camera so they can see. But you have to give them transfusions, you have to stabilize them. You can't just go in with the On the endoscopy, you have to stabilize your patient so you have time to do all of that. Number four, we discussed pancreatitis. معناته ال pancreas عنده شالتين two functions. A function الأولى endocrine. Endocrine means that it gives spills something into the blood. Exocrine means it spills something in the GI system. What does it spill in the blood? Insulin to help regulate our blood sugar. What does it spill into the GI system? Digestion. الهاضم enzymes تبع الهاضم. So when the pancreas itself is inflamed, ملتهب, that means what all of this is spilled inside your belly. And what do enzymes do? They chew, they destroy. So they start chewing your insides. So pancreatitis is very, very, very painful. And what are the enzymes to to digest? Lipase, amylase. فهذول بيكونوا طالعين كتير. ولو في إمكان نعمل الكاتسكان بنشوف ال pancreas edema, edematous. Okay. But this is what we talked about last week. This is just a reminder. What do we take home with us? Again, if you see me repeating something, that means it's very important. You will see it again and again, and you cannot miss it. GI bleed. First airway, breathing, and circulation. Then you pay attention to where's the bleed. Portal hypertension because of high pressure. You have varices, and the varices are everywhere. What does it mean? The varices—it's dilated vein, which means it's easy to burst. And when number three, when you have abdominal pain, especially if around the area, the umbilicus or تحت الدلر. What are the things you have to think about? Pancreatitis, cholangitis, التهاب المعرارة, biliary colic ولا peptic ulcer قرحة المعدة. Okay. So I'm gonna go over the two questions we had in our WhatsApp this week, and those two questions are. The two questions are. That's how نحن نحتم إن شاء الله. So I want to make sure that I go over them. So the two questions are. Let's go here and see. First question is. 45-year-old with decompensated liver cirrhosis presents with massive hematemesis, melena, hypotension, and splenomegaly. Okay, what? Which is likely the source of his upper GI bleed? And all of you got it correct: esophageal varices. ليش لأن المالري ويستير. It's mostly lot of vomiting. Bleeding duodenal ulcer, you would actually have had the ulcer symptoms before. And at the same time, it's not— it won't be coming with liver cirrhosis. It won't be coming with splenomegaly. Erosive gastritis, you won't have that much bleed. Okay, number 2. Number 2 is which of the following most strongly suggests a variceal cause of GI bleed more than peptic ulcer? حكينا إن ال ulcer is associated with history of inflammation. Okay, so it's not that known cirrhosis ascites and jaundice, and you guys got it correctly. Can you, with a variceal bleed, have epigastric pain? Very little. So this is not completely wrong, but it's not— it's rare. It's not always. So you guys got the questions correctly. So what I'm going to do today, inshallah, I will be putting Abu al-Adham, could you explain your question? شو بخصوص bridging? Is that what it is? Bridging? Bridging of what? سمح لي ما فهمت عليك. Bridging of what? And while you're جراحة أو باطن، okay. يعني there there is أي شغلة بنعملها للعيان. There is one principle that guides us, which is first do no harm. أولاً first do no harm. معناته إنه We need to make sure that our patients are not hurt by what we're doing. Okay, and if you do jaraha, and you're probably talking about tips, is that correct? If you have somebody with liver cirrhosis, one of the things that we can offer. Is let me put here you go. We're finding surgery quite difficult, and we're not sure where to start. If possible. Could you begin with bridging and help guide us through it? I'm talking about الجراحة كmodule, not just for GI bleed, right? Surgery in general. الاختصاص للجراحة ولا بتحكي على الجراحة لل liver cirrhosis للتشمع الكبد. صراحة إحنا رابعة مشتال. طيب. Okay. I will be including. I will be including surgery into the next conversations. Everything that we'll be having, I will be asking about surgical topics. هل تحكي لي على الجراحة لأنه بتديته الجراحة؟ أنا وصلني الخبر اللي وصلني إنه راح إنه بتديته الجي آي. Is that true or not? So ممكن نعمل GI and surgery related to GI. إحنا تالتة بالGI. طيب، ففي رابعة وفي تالتة. Okay. طيب. Understand. Okay. Understand. Okay. Let me see how I can organize this. أولاً I will be adding. سيرجري، great. This is important. تانيًا كان عندي سنة تلتة رايحين للسنة الرابعة وكان عندي سنة الرابعة رايحين للسنة الخامسة. هلأ عندي كمان سنة تلتة وقالولي إنه سنة تلتة they are currently doing GI. So I will be adding surgery and GI together. وأقول أدهم Talk to me separately. Send me a message. لو سمحت ونحكي على your needs, and I will start to incorporate them. ماشي؟ تمام إن شاء الله. طيب. ف when it's important since you brought it up, I'm gonna finish it today إن شاء الله. When we are talking about liver cirrhosis, one of the many treatments that we have. Is what we call transjugular intrahepatic portal systemic shunt, TIPS. And TIPS, manatu inu, you make a bridge. This is why I thought you were talking about bridging in liver cirrhosis between the portal system and the inferior cava system, so you can bypass and you can lessen the portal hypertension. This is one of many treatments that you can see in liver cirrhosis. Insha'Allah, I will be putting some questions about GI and I will add some questions that are surgery in GI as well. So everybody feels like they are benefiting from this. Okay. والله يعينكن. Keep the questions coming. Ask me more questions. I'm happy to make the content ينفع للكل. بس I want to make sure that everybody gets what they need. Okay? And أبو الأدهم رح نبدأ bridging جراحة والبعد شيء باطنية طيب والبعد Minors. سنة رابعة وسنة ثالثة. تمام. طيب. Next time, إن شاء الله، we're going to add some surgery as well. So you feel also that it helps you. تمام. يلا. الله يعينكم. And I will put the recording shortly on the LinkedIn as well.