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Format & Guide to Oral Case Presentations


The quality of the oral presentation reflects your grasp of the patients condition and your capacity to reduce complex
data to a readily understandable form.
Giving an oral presentation on ward rounds or in clinic is an important skill for medical students to learn; they are
an essential skill for communicating with colleagues and the health care team (effective communication leads to
improved health care). It is medical reporting that is terse and rapidly moving. After collecting the data, you must
then be able both to document it in a written format and transmit it clearly to other health care providers. To
successfully communicate, you need to understand the patient's medical illnesses and the psychosocial
contributions to the HPI as well as the physical diagnosis findings. These need to be compressed into a concise,
organized recitation of the most essential facts. The listener needs to be given all of the relevant information
without the extraneous details and should be able to construct his or her own differential diagnosis as the story
unfolds.
Depending on the purpose of the presentation, different parts of the database are included. The same patient will be
presented very differently to the cardiology consultant who is asked to give advice on the optimal treatment for CHF;
the surgeon who is considering aortic valve replacement; the social worker that is helping obtain disability funding;
and the attending who needs to know who was admitted last night.
As you progress in your training, you will become expert at adapting and editing the story to serve its various
purposes. In taking your history, you have gathered more information than you will include in your write-up, and
likewise your write-up contains more information than you will include in an oral presentation.

Professional Standards
Each patient is an opportunity to sharpen your history and exam skills. Ask someone more senior to verify your
findings if youre uncertain. Practice will make you better! Here are some things to remember about professionalism:

Introduce yourself as a Geisel medical student working with your preceptor.


Address patients by their surname unless requested otherwise by the patients themselves.
Ensure patient privacy by appropriate draping during physical examinations.
Be careful discussing confidential patient information in public areas.
Attire is importantavoid tendency to dress in an overly casual or provocative manner.

Basic Principles
Presentation Tips
An oral case presentation is not a simple recitation of the case write-up; it is a concise, edited presentation of the
most essential information. A case presentation should be memorized as much as possible by third year
rotations. Notes may be utilized during the presentation, but should not be read out loud directly.

Length
Lengths of presentations vary depending on the service. A full medicine presentation in attending rounds should
be under 5 minutes. A presentation in the hallway on medicine walk rounds should take no more than 3
minutes; surgery is often less than 1 or 2 minutes.

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Coherent
Oral presentations should be coherent; they should strive for an organized format and follow a ritual scheme.
Coherent presentations help you to develop an organized clinical thought process and help the listener process the
data.

Concise
Present the pertinent and relevant information; leave out the non-essential information. You will learn this through
experience and feedback. Your write up should be complete and include full details of each of the components of
the medical history and physical exam; however, your case presentations should include only relevant details. You
will gradually learn what is relevant.
To keep the presentation concise, focus on: chronologic history (the patients story only, not your interpretation),
vital signs, general description of the patients clinical appearance, and pertinent physical exam findings. Dont
editorialize. In the first two years of On Doctoring, students find it hard to remember to keep patient history in the
history section and physical exam findings in the physical exam section of the presentation. Try consciously to do
this every time you present a case.

Complete
Your oral presentation should be complete; ask yourself, is any important information missing? Have you
described enough detail of the physical exam based on the chief complaint? For example, in a patient with a rash
did you describe the rash fully? In a patient with left shoulder paindid you examine the left shoulder?
It is really important to get into the habit of starting your physical exam with the vital signs and a general
description of the patient (i.e. does the patient look ill? In distress? Anxious?), the latter is a learned skill and will
come with time and clinical experience.

Compelling
The oral presentation should be compelling; at the end of year two, this means you must: know your patients
history by asking in-depth questions, have confidence in your assessment and plan, be specific with your plan, and
highlight your clinical reasoning process and the rationale for your plan! The assessment is your chance to interpret,
clinically reason and explain why you think the patient has a particular diagnosis, what were the other possibilities
you considered, and why you discarded them. The plan includes your suggestions for diagnostic tests and
treatment.

Structure & Organization


Similarities between written and oral presentations
Both are organized reconstructions of the patients narrative into a coherent HPI, not a random assortment of
facts. Subjective data derived from the patient, family, medical record, and objective data, which include your
physical exam and the lab/radiographic data from the day of presentation are organized in a standard presentation
format.

Basic Structure

Introduction/Opening Statement (includes the Identifying information/chief complaint)


History of present illness (HPI) including relevant ROS only
PMH/Other active medical problems
Medications/allergies
Brief social history, habits (tobacco/alcohol/substance use), and family history (current situation and major

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issues only)
The complete ROS should not be presented in oral presentations
Physical examination (pertinent findings only)
One-line summary statement
Assessment and plan

Organization
You want to flesh out the bare bones enough to make your presentation engage and give the listener a feel for the
patient as a person.

Identifying Information / Chief Complaint (ID/CC)


The opening statement is a broad overview of the patient, includes the reason for the visit and duration of the chief
complaint. This is also called setting the stage. The introductory sentence may include details of past medical
history if the patient's illness directly relates to an ongoing chronic disease.

Structure
Mr./Mrs./Ms. is a _____ year-old man/woman who (one of the following below):
presents with a chief complaint of _____.
was electively admitted for evaluation of ______ .
comes in to clinic for follow up of _____.
Mr. J is a 55 year old man with a history of heart disease, s/p coronary bypass 2 years ago now presenting with a
6 hour history of substernal chest pain.
Mrs. S is a 77 year old woman with history of diabetes, dementia, congestive heart failure in clinic today with a 2
day history of fever along with swelling and redness of the right lower leg.
Include the race or ethnicity of the patient only if it is relevant and will make your listener weigh diagnostic
possibilities differently. To orient your listener, the identifying information should include the patient's relevant
active medical problems, of which there are usually no more than four. You will list these problems here, by
diagnosis only, and will elaborate on them later in the HPI or other medical problems/PMH. Your small group
facilitator should help you identify which problems are relevant when it is not obvious. Include habits
(tobacco/alcohol/substance use) when relevant.

Good Examples
Mr. Smith is a 65-year-old smoker with a long history of diabetes mellitus, cirrhosis, and chronic obstructive
lung disease, who presents with a chief complaint of fever and productive cough
Jessica is a 9-year-old girl, otherwise healthy, who presents with left leg pain and inability to walk. She was in
her normal state of health until
Mr. Jones is a 58-year-old man whose active problems include coronary artery disease, diabetes mellitus, and
chronic obstructive lung disease
Avoid presentation of distracting information such as an overly detailed discussion of the patient's medical
problems in your introductory remarks, as the presenter does in the next example:

Bad Example
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Mr. Jones is a 58-year-old man whose problem list includes coronary artery disease - myocardial infarction x
2, the last in 1996, multiple negative rule-outs since, ejection fraction equaled 35% in 1994; diabetes mellitus x
10 years, insulin requiring for five years, complicated by retinopathy; chronic obstructive lung disease - with
a FEV 1 of 1.2 liters and steroid dependence
In the bad example, the listener will forget the chief complaint by the time the HPI is reached. The good example
is concise and does not interrupt the listener's train of thought between the chief complaint and the HPI.

HPI
Introduction
The HPI is a very important component that should be presented in a chronological story. Define the nature of the
complaint clearly, the duration of symptoms, progression of symptoms, significant treatments (OLDCARTS). Be
interested and get a complete story from the patient.
"Mr./Mrs./Ms. _____ was in his/her usual state of _____ (i.e. excellent health/poor health) until _____ (i.e.
three days prior to admission) when he/she developed the _____ (acute/gradual) onset of _____.
Don't mention that an event occurred "on Saturday"; refer to the time relative to the day of admission; i.e. 3
days prior to admission.

Review of Systems
Mention only significant positives and negatives. DO NOT report out each system review!
Review of systems is positive for occasional nosebleeds and frequent heartburn after meals. He has chronic
longstanding constipation.

Good Examples
Mr. Smith is a 63-year-old former 30 pack/year smoker who has a long history of chronic obstructive lung
disease characterized by two block dyspnea on exertion, FEVI of 1.0 liter, and home oxygen therapy. He was in
this usual state of health until three days prior to admission when he developed the gradual worsening of his
shortness of breath, associated with a cough productive of yellow sputum and a fever of 102.
Tommy is a 5-year-old boy who has a history of congenital heart disease due to tetralogy of fallot s/p reparative
surgery in 2007. He was in his usual state of health, until the weekend prior to admission he began having
dizziness, and the night of admission, he developed syncope while getting ready for bed.

PMH
Give a brief summary of the current ongoing issues (diabetes, HTN, etc.), major past illnesses, surgeries, current
medications, and allergies. Specifically characterize the major presenting symptoms, including patient attributions
(what the patient thinks is causing the symptoms), any prior episodes, and complications and the relevant ROS
questions. Relevant ROS include those related to the major and adjacent organ systems, constitutional complaints such
as fever and weight loss and epidemiological risk factors or exposures. If there were any evaluation of the chief
complaint prior to hospital admission, such evaluation should be included though it should be presented in a
summarized fashion (e.g. One week ago, John was seen by his primary provider for his cough and was diagnosed
with pneumonia and prescribed amoxicillin).
Use the OLDCARTS mnemonic to make sure all those bases are covered.
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Bad Example (poorly characterized and too brief of an HPI)
Mr. Brown is an 83-year-old man admitted for evaluation of chest pain. He was well until three weeks prior to
admission when he began to feel chest heaviness whenever he exerted himself. He saw his local doctor who
prescribed antacids with little benefit. The pain woke him last night so he came into the emergency room for
evaluation. His other problems include

Good Examples
The past medical history is significant for hyptertension and diabetes. He is s/p appendectomy and inguinal
herniorraphy. Medications include metformin, lisinopril, and glyburide. He has no allergies.
Mr. Brown is a 33-year-old current intranasal cocaine user, admitted for evaluation of chest pain. He was in
his usual state of excellent health until 1 day prior to admission when he developed a second episode of
sudden onset of chest pain, characterized as a sharp, radiating to his left shoulder, lasting several hours.
The pain was aggravated by exertion and relieved by rest. Associated with the pain were shortness of breath
and nausea. One week prior to admission he was seen in the emergency from for a similar episode of pain and
without other testing was diagnosed w ith gastritis and prescribed antacids without benefit. There was no
history of cough, heartburn, weight loss, fever, chills, or sweats. (Relevant ROS) The patient has no known
risk factors for coronary artery disease. He has no history of high blood pressure, hyperlipidemia, or
diabetes, and has never smoked cigarettes. He has no known FH of early coronary heart disease. (Pertinent risk
factors for coronary artery disease and pertinent FH/PMH). He has been using intranasal cocaine for the past 3
years, several times a week. Last use was an hour prior to the onset of his chest pain. He does not use any other
drugs, nor does he inject cocaine (pertinent habits).

Other Medical Problems


Include here details of those problems that are active and you feel are relevant to the present illness. These are
usually the same problems you mentioned in "identifying information." For example, diabetes mellitus is relevant
to a patient being seen for hypertension. Consider each condition separately, briefly recounting the details in a
chronological fashion. In general, discuss the most important problem first, and then present the others from next
most important to least important.
Key words and phrases summarize an ongoing chronic illness and are discussed in this section (or may be
included with the HPI if they are related to the current problem as discussed above). The key words vary with the
nature of the problem. You will learn them as you gain clinical experience and by listening to others summarize
and present cases. In general, key words emphasize date of diagnosis, its treatment, current symptoms,
complications, and any recent objective tests.
his other medical problems include insulin-requiring diabetes for 12 years, complicated by retinopathy,
polyneuropathy, and nephropathy. His recent creatinine was 1.7
long history of chronic obstructive lung disease with steroid dependence and the requirement for home
oxygen therapy, a 1994 FEV1 of 0.8L, and three hospital admissions for exacerbations in the last year. He
has never been intubated
2 year history of congestive heart failure, felt to be secondary to alcoholic cardiomyopathy,
characterized by chronic two block dyspnea on exertion, three pillow orthopnea, and ankle edema. In
addition to his long-term therapy with furosemide and enalapril, digoxin was added 6 months ago. An
echocardiogram 4 months prior to admission showed four chamber enlargement and global hypokinesis
During a case presentation, avoid presentation of irrelevant diagnoses. What is irrelevant is not always obvious
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to you at your level of training and also improves with your clinical experience. Consultation with your
facilitator and preceptor will help you make this determination; i.e. "gonorrhea in 1945, malaria in 1940,
cataract extraction in 1972, and tinea pedis" are probably not relevant during presentation of a patient with
diabetes for his/her new onset chest pain.
Know all of the patient's problems and include them in your write-up, but presentation of problems that are not
relevant to the currently active problems only distracts your listener.

Medications/Allergies
Provide a list of all prescribed medications and a list of any relevant non-prescription medications. Report any
relevant drug allergies and the type of reaction.

Example
"The patient developed a skin rash approximately 20 years ago after receiving penicillin and carries
the diagnosis of penicillin allergy."

Social History (SH) & Habits


Social History
Keep social history brief but bear in mind that it is often the social history that explains why the patient is
presenting now, as opposed to some other time. Include marital status, occupation, habits (tobacco, alcohol, illicit
drugs), and sexual history when appropriate. A well-described social history also allows the listener to see the person
behind the illness and provides context, which often helps to come up with a treatment plan. Patients may have
chaotic lives, limited financial resources, and little social support so they may not be able to afford their medications
and may not have the help they need to follow therapeutic recommendations on discharge from the clinic or hospital.
Knowing this will help you to devise an appropriate plan. Similarly, depression and feelings of hopelessness about
their conditions are very relevant to understand in caring for patients and should be included in the social history.
These factors, if not addressed, will tend to lead to the patient seeking repeated medical care.
If appropriate, include information about the patient's personal wishes for health such as advance directives (living
will and durable power of attorney), including discussion concerning these issues.

Habits
Habits (tobacco/alcohol/substance use) when not mentioned in the HPI (for example in a patient who presents with a
urinary tract infection) should always be presented here as these issues are always important to address in the
assessment and plan. Any opportunity to counsel for cessation of these habits must be taken when a patient presents for
a medical encounter.

Good Example
The patient is a retired welder. He is married and has 2 grown children. He has never used tobacco. He enjoys
1-2 beers on weekends only.

Family History (FH)


Those aspects of the family history that are particularly relevant to the present illness should be presented if not
mentioned in the HPI.

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Physical Exam
General description: describe the clinical appearance of the patient; be descriptive, allowing the listener to visualize
the patient. "The patient was short of breath" is inferior to "the patient was sitting on the edge of the bed, leaning
forward with his hands on his knees, breathing with difficulty."
Vital signs should always be mentioned, including postural changes if relevant. Mention only the relevant positive
findings and relevant negative findings going from head to toe direction ending with the neurological exam. An
example of the latter includes in, for example, the dyspneic patient: "the exam is remarkable for clear lungs
bilaterally." Use concise but complete descriptions of positive findings.

Lab Results and Special Tests


You may not have these available to you in the first two years of On Doctoring; only report lab results and special tests
if available. Give a brief presentation of the lab data and emphasize the abnormal results. Dont bore your audience
with reciting all of the normal lab values.

Summary Statement
The Summary Statement is an important component of both your oral presentation and your write up. It is a short, crisp
paragraph that summarizes the key findings in the history and physical exam using descriptors reviewed during the
clinical reasoning session in spring of Year 1. These descriptors are important because with practice they help you and
the listeners come up with a distinctly different set or different likelihoods of differential diagnoses.

Example
33 year old current intranasal cocaine user with recurrent sharp chest pain aggravated by exertion, relieved by
rest, and associated with shortness of breath (SOB) and nausea. He has no prior h/o hypertension (HTN),
hyperlipidemia, diabetes, smoking or FH of early coronary artery disease (CAD). His exam was notable for
elevated blood pressure, tachycardia, diaphoresis and a perforated bleeding intranasal septum.
In this case, the fact that he used intranasal cocaine and that his pain was sharp and recurrent, that he had no FH of
early coronary disease or usual risk factors for coronary artery disease, and that he had a perforated bleeding nasal
septum, would make one think of cocaine induced coronary vasoconstriction rather than primary atherosclerotic
disease as the leading diagnoses. This does not mean you do not have to think of coronary artery disease in your
differential, only that you would not think of it as the most likely diagnosis.

Assessment & Plan


Assessment
The assessment and plan reflects your ability to put it all together. The assessment should include a differential
diagnosis and comments about what supports your diagnosis (i.e. your clinical reasoning). Depending on the case, the
assessment and plan may need a discussion of one or several problems. Each major problem may require a separate
assessment. Most outpatient acute visits have one major problem, however a complicated inpatient may have several
major problems that cannot all be rolled into one. For example, in a patient with diabetes presenting with diabetic
ketoacidosis who has a hematocrit of 25 and bright red blood per rectum, you would need a separate assessment for 1.
DKA with a blood sugar of 500, and 2. BRBPR with a hematocrit of 25.

Plan
The plan should include both diagnostics (tests you want to order) and therapeutics (your treatment suggestions).

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Examples
"The patient's major presenting problem is chest pain (avoid statements like rule-out myocardial
infarction). The differential diagnosis includes cocaine induced vasospasm, pericarditis, or early onset
coronary artery disease (CAD). The diagnosis of cocaine induced vasosconstriction appears to be the most
likely of these because _____.
"The patient's main problem of acute chest pain, could be due to a myocardial infarction, a dissecting
aortic aneurysm, pericarditis, and a variety of other diagnoses such as pneumonia, pulmonary embolus, or
esophageal disease. MI seems most likely because his description of chest pain is classic for angina and
because his ECG reveals a new injury current in the inferior leads.

Common Mistakes
Things to Avoid

Dont read your write up


Dont jump aroundorder is key
Don't recite the non-relevant data
Dont forget the opening line of your presentation (set the stage)
Dont forget to comment on the general appearance of the patient (does this patient look sick?)

Slow Labored Rhythm


A wandering, disorganized, and desultory presentation is the most common problem encountered by early
students. The ability to convert a written history and physical examination into a compressed presentation
requires careful thought and practice. Ask your attending or facilitator how long a presentation he or she would
like. You should maintain eye contact with your listener during the presentation, which means that you should
refer to notes and not read your write- up. To keep it under five minutes, you will need to practice it two or
three times in advance. It is helpful to practice with a classmate who can give you feedback and then let you try
again. It is also worth taping yourself and listening to the tape; you often give yourself feedback.

History of Present Illness Too Brief


Ninety percent of correct diagnoses come from the history alone; do not hinder your listener's understanding of
the case by omitting important information. The HPI portion of the oral presentation, as a general rule, should
take a third to a half of the presentation time. Common pitfalls include incomplete characterization of the major
symptoms, omitting pertinent negatives or positive ROS questions, and omitting specific information about past
history that relates to the present problem.

Failure to Use Parallel Reference Points


In both write-ups and oral presentation, relate time in "hours/days/weeks prior to admission." Avoid "at 2:00 in
the morning of last Wednesday" or "on May 25th"; instead, write or say "3 hours prior to admission" or "at 2:00
am, 3 days prior to admission."

Editorializing in the Middle of the Presentation


Avoid comments such as, "Do you even want to hear this?" or "Cardiac examination revealed a systolic
murmurwell, I thought heard it, but the resident didn't, so maybe it isn't there. I don't really know"

Use of Negative Statements Instead of Positive Statements


Positive statements add color and accuracy to your presentation. "Chest X-ray shows normal heart size" is
better than "chest X-ray shows no cardiomegaly." And "In summary, this patient's problem is acute dyspnea" is
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better than "the patient's problem is rule-out pneumonia."

Repetition
Vary your sentence structure. An overly repetitious presentation is monotonous for the listener. "On pulmonary
exam, the lungs were normal. On cardiac exam, the heart sounds were ____. On lymph node exam, there were
no cervical nodesetc." is difficult to listen to and unnecessary; your listener knows that S1 and S2 are part of
the cardiac exam! Use brief descriptive sentences: "an S3 gallop was heard at the left lower sternal border."

Disorganization
This problem is a result of lack of rehearsal. Stopping at the end of the HPI to say, "Oh, I can't believe I forgot to
tell you this" will kill a presentation. Or "in summary, this patient, wait, I forgot to tell you the most
important thing" You need to be aware that disorganization can happen even with careful preparation. The
best advice when you forget something crucial to your presentation is to work it in as soon as possible and don't
make it a big deal.

Physical Findings Presented without Proper Terminology


For example, "lymph node exam shows some small cervical nodes" is not as descriptive as "there were three soft
tender mobile nodes in the left anterior cervical chain that measure 1x1x2 cm each" Commitment to accuracy
will improve your physical examination skills.

Diagnoses Used Instead of Descriptions in the Physical Examination


Diagnoses belong in the assessment, descriptions in the physical examination. For example, avoid "exam
showed the murmur of mitral regurgitation." Instead, say, "a 2/6 holosystolic murmur was heard at the apex
when radiated to the axilla." Avoid "skin exam showed psoriatic lesions on the elbows" Say instead, "there
were several 2 cm diameter round plaques with silver scale distributed on the extensor surface of the elbows"

Source: Adapted in part from University of Washington School of Medicine thanks to Dr. Steve McGee and parts modified from
Dr. Richard Simons Oral Case Presentations PowerPoint.

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Sample Oral Presentation


CC: SOB (shortness of breath)
HPI:
Ms. Jones is a 37 y.o. female smoker with a h/o asthma who presents with worsening SOB. She was in her usual
state of excellent health until 5 days ago when she developed an upper respiratory infection with runny nose,
muscle aches, non-productive cough and felt exhausted. She has also noted more SOB and occasional wheezing
when she walked uphill or up > one flight of stairs in the past 2 days. She denied fever, chills, sweats, chest pain
or pressure. She was able to do her usual activities as a bookkeeper and mother although has been unable to take
her daily 2-mile walk b/o her DOE (dyspnea on exertion). She had not been using her Flovent for the past 4
months b/o not needing it but resumed this 2 days ago. She also increased her albuterol from once a day to
4x/day 2 days ago and this has helped. She has had no other flares in the past year and has never been to the ED
or been hospitalized for this problem. No other pulmonary disease. This is the worst SOB she has ever had. No
new exposures, no recent allergic symptoms, or hobbies.
Positive FH of asthma in her mother and brother.
Smoking: 1 ppd for 23 years; quit for 8 months when pregnant with her 12 yo; wants to try and quit
Medications Flovent 2 puffs bid, Albuterol MDI prn
Allergies NKA
Relevant SH - patient lives with her husband and daughter; husband smokes too; no new life stressors
O: Ms. Jones is coughing, leaning forward, barely speaking in full sentences, using accessory muscles of
respiration
Afebrile, RR 24, BP 126/78 P 100
HEENT: slight pharyngeal erythema without exudate, shotty anterior cervical nodes, freely mobile, nontender
Pulm: no f o c a l dullness to percussion, scattered wheezing throughout all lung fields,
prolonged expiratory phase, moving air well
Cardiac: Heart sounds distant, nl S1 and S2, no murmurs audible
SS: 37 y.o. smoker with a h/o asthma, off Flovent for 4 months who presents with acute worsening of SOB in the
setting of recent onset of URI symptoms. On exam she is afebrile, tachypneic, tachycardic and has diffuse wheezing.
Assessment: Patient is presenting with an acute asthma flare, likely triggered by her recent URI. Differential
includes a community-acquired pneumonia, but the absence of fever and focal findings on lung exam make
pneumonia less likely. She has not been adherent with her MDIs although she has restarted these at the onset of her
recent symptoms. She continues to smoke and is interested in trying to quit before her daughter becomes a
teenager.
Plan:
1. Renew Flovent and Albuterol
2. Reinforce importance of staying on her inhaled steroid (Flovent) chronically
3. Prednisone taper, beginning at 40 mg, reduce by 10 mg q 4 days.
4. Patient instructed to call office if her SOB/wheezing dont improve within 2-3 days
5. Reinforce importance of quitting smoking; ask patient to set a quit date, offer options (nicotine gum, patches,
medications) to assist in quitting
6. Follow up in 3 months to check on progress

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