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Okay, guys, Let's start then. I hope you can all hear me. Eso Today will be our last session off the assets X Got a Muslim medics. Oscar Siris. Um, it's should be a good one. And thanks a little coming. So as I know, a lot of you have attended the last ones. We've heard all of these, thanks to all of our team we will been working hard on. I know you guys have your risky soon very best of luck. And I hope this will be beneficial for you. So let's get straight into it. What we're gonna do, we're gonna work through a few cases together. One of the cases we're going to get a volunteer to do it as a mock station, essentially on the other cases will kind of work through together, I think think about things in, ah, you know, logical manner. So let's start Rebecca, 43 year old female presents to the emergency department with central diffuse abdominal pain on diabetes to be in distress. She has also found it very difficult to pass stool for the past three days and occasionally has watery stools. So, um, just by reading that you are some differentials that come to mind if you just use the chat function to write down some differentials, Esther and drives us. Okay. Yep. Good differentials. Someone's right. Small bowel obstruction, diverticulitis, ideas, obstruction. Yes, Reglan. See these old good differentials concerned the lower ball? Yes. Okay. There's some good differentials, everyone's butt. So in your risk, you'll essentially need to maybe give four or five good differentials as long as you could justify them. So if we go into this slide, we are. So what I've done here for you guys is small bowel obstruction and large bowel obstruction on inflammatory bowel disease. Now, what will make you and excellent student is if you can give for a small bowel obstruction on the large bowel obstruction some causes. So if you could just write in the chat what's, um, causes for a small bowel obstruction? Let's say the most common ones. Great city Jin's any? Uh okay. Yeah, let's green. So what we've got for small bowel obstruction is adhesions and Khenyeza that by far the most common course is adhesions for small bowel obstructions. And now I've saw some of you wrote volvulus and tumors. Well, that's actually coming on Two large bowel obstructions. So what are some causes for large bowel obstructions? Concert. You must. Great. Anything else? Bullous. Excellent Diverticular disease interception. Yes, that's good guys s. Oh, yeah. Colorectal cancer, Volvulus sigmoid or sickle volvulus Diverticular Strictures on again? Yes. Become Complexion is correct. And by far the most common cause of a large bowel. Obstruction is a cop. Colorectal cancer, and probably probably is about 60% off large bowel obstructions are due to Colorado or cancer. And then another differential and pumped about sees a lot of other differentials I saw mentioned are perfectly balanced. A swell. So just by seeing your defenses and organized way small bowel obstruction caused by this and that large bowel obstruction caused by this implant you about these you've already got many different styles. And it shows to the examiner that you're aware of the different causes as there are distinct causes to the different types of obstruction. Okay, doke. Swell done, guys. So how would you guys investigate this patient now? I'm sure all of you are aware of the order that we go in. So start off with bedside bloods offices imaging. So if you guys can just put down some investigations. Regulant easy test. Very good. Yes. Yes. Yeah, right till exam. Very good There. Okay, so here are some investigations that you go through a bedside. Full abdominal examination, including PR exam. PR exam is very important. You know, if you missed, say, doing up your exam, that would classify as a red flag. This is very important. Any acute abdomen, any abdominal issues and you're doing abdominal examination. Remember that PR exam? You must do it on bend vitals. So we're bloods. You'll be doing your full blood. Count your knees. Lft is lactate, amylase and light piece. As long as you can justify the reasons for them, then that's okay. Offices, PR and external handle offices examination. And I've got a red flag for either. I don't know. Can you guys see my mouth when I move it? Someone could just put in the charts. Any we can moment if you just take it to read pointer one second. Can you guys see that? If you could just put in the child? Yeah, we can see that. Okay, great on Ben. Coming on to x ray slash imaging. Um you've got your abdominal X ray on your erect chest X ray, you wouldn't go straight away to do an abdominal CT. However, this will give you more detailed imaging on. But if the patients were, you know, quite stable, you can find out what's happening in more detail on direct chest X rays. Very important investigation in this case on. Well, come on to that. In a moment on, Do you do a routine E c g. On? But I saw someone write down pregnancy test. Now, that's very good. This is a 43 year old female with abdominal pain. Any any pain, any female who comes in with abdominal pain. A pregnancy test is very important on not saying that could be considered a yellow or red flag. Okay, so here we have. We're Becca's abdominal radiograph. No. If I remember, whenever you first the abdominal radiograph, they'll be patient details. You need to confirm the patient details. Say what you're looking at, Have a comment on the adequacy off the film Onda. So, yeah, you would just say this is an abdominal radiograph, which I can see and then have Vesely comment on the abnormalities. You see on then and then you can work through it and comment on the normality. Ease. So can anyone tell me what they can see here in the child? Yeah. Yes, they just central by loops. Excellent. Anything else anyone could see? Okay, Anyone give any signs that in my, um they might know any names of signs? Obviously, on this not really convinces. Yes. Excellent. So, firstly, when you're you're saying that the bowel loops are dilated now, this there's a maximum normal diameter for the small bowel and large bowel, the maximum more. But damn toe for the love of the small bowel is 3.5 centimeters for the large vial, 6.5 centimeters. So on the actual radiograph system, you can measure the the distance using the system that they have in hospitals on that would show if there's ah dilation and mean there's some sort of obstruction causing the about to react in that way. What bodily convent sees is here. You can see these lines if you can see the my am pointer which run away the way through the bowel. Now that indicates that this is the small bell that's being affected for the large bowel, you would see something called How Stroke. They don't go away across the bowel just like you can see here. So next investigations continued so less. Look at this spit by but, um, or the vitals the heart rate's 101 respirator, 19 on BP. 90/55 sats, 89% on they have a fever 38.5 And that's their appearance, and they're clammy and sweaty. So just by looking at, um, just by looking at the also guys, if anyone has any questions used a Q and A from the Q and A function toe, ask any questions and a team will help answer. Um, so just by looking at these vitals what? What are they telling you about this patient essentially going into shock? Yes, that's a shock. Yes, yes. Okay, so you know, they're clearly unstable. They're clammy, they're sweaty, their blood pressure's dropping, you know, their know off. They're very unwell. This is a patient where as soon as you when you first see them, you'll you know you'll be worried about this on from your history. You discover that four months ago she had a laparoscopic removal of an ovarian cyst with no complications. Okay. On examination. Diffusely tender abdomen with noted guarding and rigidity. Bile Sounds not present. Now, what does the gardening and rigidity on the on the examination findings tell you here tonight? Us? Yes. So this indicates parroting is, um that they have. This would be it would be a surgical acute abdomen. Essentially on. You've got a wreck test extremely on. You can see the pneumoperitoneum which suggest that there's about preparation. Um, that would mean on the bowel perforation with secondary lead to peritonitis. Um, as content would leak out into the parent any, um, that's how it works. Okay, So, knowing all of that, how would you manage this patient? Yeah, cool, citizens. Great. Well, okay, you guys got the just I can tell that you guys have impairing well, for your risk is coming up. Right? So split your management into Ah, logical manner. Start off with acutely. So acutely. Initially, we've got our ABCDE management for this type of station. You would want to go through the A, B, C, D and E and slightly more detail. Then you would in other stations, as this is an acute problem, you'd start your sepsis. Six. A swell. So if you guys could just write what the sepsis six is, I'm sure you guys know it to three and three out. 26. American therapy fluids Oxygen out Zeka to rise. Want to monitor your and outputs? Yes, blood culture and lactic. Excellent. So as well that there's kind of two things going on in the station. There's the Septus management on. Then there's the management of the bowel obstruction. So there's a drip and stuck drip and suck approach Um, which you you need to put the patients know by mouth and give IV fluids on. Insert a white ball nasogastric tube with free drainage. Not there's not the type where they use for feeding. Otherwise, essentially won't work. You need to let the bowel gas the air, building up within the bowels to to release itself. Six. Senior support. You won't be doing this on your own. Notify I to you as they might need to go there after any interventions or what? No on down general surgeons, you need to get a general surgeon involved. So on. Then you could say for conservative it support care with regular Motrin. Uh, vitals. Some cases can resolve on their own. Obviously, for this patient, conservative management won't be suitable. But there will be some bowel obstructions where you can just take the drip and suck approach on. Give support. Can they can resolve on their own. I just put that in there just to make you guys aware. Um, Andi in analgesia I saw someone say that that was good. Um, and the antibiotic cover, obviously on. Then a surgical management is dependent on the course. So from this case, what do you guys think the course is? What's causing the bowel obstruction? Yes. On what? From the history made you guys say that? Yeah. So they've had recent surgery because the scarring on from from about two weeks until even a few years later, they can present with with a small bowel obstruction due to the scarring interleukin with the bowels on call, causing an obstruction. Well, then, guys, um for if there's for a Correctol cancer and it's a little a large bowel obstruction, we would need to go for emergency resection of the chronic resection of the tumor on and repair that the surgeons would repair any perforations that they could see. So that's the first case, Guys, this is a very, you know, classical surgical case, bowel obstruction, something very common and important to know for your exams as I can easily come up. So this is just some key point to remember for this case. Um, bowel obstruction is split into small bowel and large about each having their own distinct causes. Um, always remember, erect chest X ray, Not just chest X ray. You don't want to miss and you were pertinent. Um, do not forget about colorectal cancer features that are cause of concern that you need to listen in. Your history includes blood in stool change in bowel habits. Weight Last knew I deficient in union appetite loss on in a this kind of history. Changing about how it is extremely important to ask about if you're suspecting something like that. Okay, so this is the case where we'd like to have a volunteer. It's the volunteer. Could just right in the the charts again. I know someone was asking a lawyer on save if you could just ask. Um, are you, uh, on safe? If you could just allow him to speak. George is going one second. Do you mind changing your name? Time on so that I can easily give you contrary to me a second. Great. Do you want to put your micro non? If you want to turn your camera on his Well, that's good. That we can see. Uh, you know, worries. You know, comma is not waking is fine. Don't worry about cancer. Okay, So what we have is a day 63 year old male on. He's presented to the E. D. With multiple vomiting episodes, and he's generally feeling unwell. What we're gonna do, we're gonna do a four minute focus history. Try and get as much as you can on Think about possible differentials and how you'd address them in your history on day. Just let me know. Yeah? Somebody with you. Okay. I'll just set a timer for movement. Okay, You can start now. It's so high. I mean, it was a mark on the fourth democracy and see family name. Did the birth, please. Oh, yes. I'm a day and I'm 63 years old. Okay, So what? We're going to see a study. Oh, I've just had a horrible vomiting. Um, so it's either entered. Um, what about cities? Yeah, well, it kind of started two days ago on, but I've just been vomiting a lot. And it's been very, oldest time kind of vomit. And yeah, and I may be formatted five times in the last two days. Okay? And what state content of the moment? Well, now that you say that it's has a weird is very dark appearance with I don't know how to describe it, really, But it just has a very dark appearance. No normal at all. And what color is it? I'd say he's a very dark brown look. Is this the first time something like this has happened? Yeah, the first time. Something like this and with the warmer thing. Is there any pain that you experience? I've just experienced some discomfort, but not necessarily pain. Okay. And Indy on before the the episodes of vomiting, have you have you seen fit in with otherwise, um, Well, yeah, I do have, um, problems with my liver that I see a doctor about. And you know what problem is? Um, they don't term. We haven't told me exactly. I'm not. I'm not very sure, but something like my liver's in very small and sculpt up something like that. Okay. And are you on any medication for it? Um, no. You know, I medication? No, I am on other medications, but no liver problem. And what medication are you on? Um, I'm on something called statin. Uh huh. Onda for my authorizes. I'm on Brufen. Okay. Anything else? Yeah, I'm, um I had a stroke four years ago. So, um, I'm on something to think my blood? No. You take any over the counter medication? Um, no, No. Allergic to anything. I know. And when he goes to your background, do you smoke at all? No, I don't smoke. It'll, um Have you smoked in the past? I know. I've never smoked. Yeah, I do. Drink on. Would you be able to tell so much drinking? I drink quite a lot if I'm honest. Maybe two liters of side a day day. And how many times a week do you do this? Almost every day. Okay, Onda, um axe. Um, we delivered, um I'm just living me and my partner. The kids have a left the house. Okay. On just few more questions. That's okay. Do you have any? Even the American dish in on the family? Uh, no, no. On back to the vomiting. So you said you had a two day history of vomiting. Bumped it five times a day, Five times so far. And it's dark brown on how much pain with have experienced anything else like that has You know what to expect. Okay, my water works are fine. What about your bowel motions? Well, now that you say that my bowels have just been really smelly okay on. But I think it's a consistency. Yeah, They're really, like, thick and sticky. Okay. And when was last time in your bowels? Um, I opened them about a couple of hours ago. Okay. And when do you notice the symptoms with your bowels? And when with the bowels? At the same time that the vomiting started. Okay. I mean, same pain, that's all. No, no, no. Really. Pardon? Sorry. I said, anytime. Your pain. I No, no, no, nothing. Again. If a few more questions I mean, it's any recent weight loss, and, uh, and the night sweats. Um, I'm just in the past two days, I just felt a bit more sweaty than usual. Not necessarily at nighttime. Okay. Yeah, that's your time up. Um, thank you very much. Well done. Um, so if you could just summarize the history, Okay, So are your case from a 63 or gentlemen presented with that two day history off vomiting from doing farm time five times a day, and then completely, it's Ah, uh, brown in color. There's also associate ID, especially Molina. Um, but they just his background years know sitting in the smoking history, However, he does, uh, have a significant drinking history front to be suicide that day. Um, here's this partner, and he has no second been possibly history. Uh, I'm, uh, family history. However, he's on seven medication. Quitting a statin of a bruising. And medication is, uh, uh, osteoarthritis is, um Okay, great. So while some differential that you're thinking off eso my because of his history of, like, hepatic problems on his Molina, I would suspect a, um much I bleed. Um, the French would be most of the viruses because of his, um, drinking history Order to, uh, consider a peptic ulcer. That's my differential. Let me bring this one. Onda um, that you talk to differentials. Great. Um, okay. So based on that, how would you want to investigate this patient? So initially, I would like to admit dissipation. I move him to resource. Um, I miss you Stabilized following this. Like t uh, that side investigations with with focused history on an upcoming examination. Um, checking. Doing PR exam is well with the separate president. Can check intending offices. Let me that I could do some basic observations to get a new score, make sure the patient's stable and do bloods. So I've got to do your blood count for your ent for anemia infection. Um, needs to check kidney function activities and clotting. That's what I was still being here. So, um, I was like to do an ABG kind of potential. Ah, Good and safe. And on and cross cross missing. Wouldn't say. I don't want to do an EKG on percent imaging. I ST question abdominal ultrasound scan. Come on. X ray in a wreck, a chest X, tra and ah, if possible requester. Uh, the city. And also endoscopy. Potentially a colonoscopy. Okay. Right. I'm I'm gonna show you some investigations. One moment. Do it without showing the other thyroids. Okay. Okay, so you've got some results in your exam. You would You would see the results. I've just put the abnormality seen. Um, now, imagine that you would have checked the patient's details when the bloods were taken, etcetera. If you could just make a comment on the vitals and his blood results make else after taking the patient credentials for the most, the most of the most I can see is he's like a cardiac and hypertensive, and he's decided straight. He's on Just you're just sensitive, man. I just get a increased company full time because it was a piece perfect. And call him. And if he is confused because his blood results, he's anemic. It's got high your ear. Um, a a t is high amp is around four times up limits and, ah, normal. I'll be on a low sodium. Yeah, so just so they give me it. But anyway, he's in shock, Um, on because that would be I mean and so so the vital. Surely at show that he's in shock. Um, and his much results indicate there's some soft bleed, because if the low hemoglobin and raise Syria. Uh, the raised a teenager play indicators pathology. There is room. Okay. And why do you think that the area is raised? Because the bleed. So it's because of upper jaw, Actually, this time for the blood to be adjusted on by just blood presents in it. Doesn't protein present in the area, but it doesn't. The blood from the vaginal bleed you're hungry, but it's okay. So how? Based on everything now, how would you manage this patient? Okay, Firstly, because patients on statement for my senior, I'm called the incision uncle just like a central achy. And then I see foreign 80 approach. So make sure the areas Peyton, because he's hypothesis A let you give auction 50 nieces, uh, folks and staying on the big mosque on deck for bilateral symmetrical expansion of the lungs. Painful circulation because his hypertension. But you get to one will kinda and ask you for PSA by IV access and start with the justice resuscitation like to start with 500 miles minutes bolus. I says that dose. Let's check blood glucose on. The people are reactive to light. He's confused on, um like to expose the patient and make sure there's no other breast or trauma because he's in shock on this low hemoglobin potential bleed. Like to initiate the major humans protocol. Yeah, um, and then I'll actually moves before with the management. So because it is a potential bleed, um, there's not much. I bleed. Um, mostly give you 10 of person. Um, as a way to control the bleed potentially consider transfusion. It's been putting on the pages. Well, um, I would just I would on describe it methods a bit. First, I have to stop the offending agent. So insides on the on anticoagulants she's on. Uh, give us, uh, depressant on disk optically in this copied band. Ligation indicated in this case, everything would, um, before surgery, give problem CBT and perfect antibiotics. Um, I wonder if it to surgery. Yeah, if this is ra factor than considered a tips procedure. Uh, I don't think it matters when you were seeing for my senior for further in for. Great. Great. Okay, So, um well done. Um, our That was good. We're just kind of run through the case now. Altogether on dumb under that, you know of things as well. One. Okay, so the history. Um, so this is presented, please, not wanting. You went through your pre much. Got all of it. Um, I I I noticed that the end, you came back to the history percent of complaint because I was going to tell you not to forget how the bowels are, um, and a few other things. But you managed to do that anyhow, So this patient has a positive history of liver disease. Is that a stroke hyperlipidemia on osteoarthritis? These are some of the medications that he's on. Um, heavy drinker really important when someone says that they they do drink is to, um is to further ask how much they drink. Because the patient in your risk is is not going to give up the information just by asking, How much do you drink? Um, on different thing. You could have just I know it's a form of history is just touched on the ideas concerns an expectation. Just very briefly. Um, okay, so I could see a lot of you in the chat as well. We're giving many differentials that seemed appropriate. So virus, you'll bleed peptic. Also rupture, marry, raced. Uh, I'm not sure if you mentioned a malignancy. Legal Aziz can cause vomiting, vomiting in blood, especially esophageal gastric. And I'm usually small amounts of blood. And but yeah, just make sure you just remember malignancy on a zit shows a wider range of differentials and peptic ulcer up chur. So, um, this would present similarly, however, due to the past medical history of liver disease, this one would go below, um, variceal bleeds. As in liver disease, essentially, you get portal hypertension on that causes that hypertension within the portal system causes the esophageal. The essentially the esophageal arteries on veins to swell up on Deacon easily bleed on now how the virus is completely works. Um, And then, um, alleyways her? Yes. Another thing to consider. Um, it's usually self resolving. Um, Andi happened after many bouts of vomiting, a terror occurs essentially. All right, so we went through the investigations. You really happy that you got the group and save cross match coagulations green something that's usually forgotten? Um, on. But yeah, the PR exam is That would have been a red flag. Ah, got the chest X ray. Now. When you got your imaging, you seem to mention quite a lot of imaging tests. This is, you know, uh, apology. I bleed. For example, a CT is not really gonna be of much use here. So the main investigation that we're pushing here is arranging urgent and also be And that should be done within 24 hours of presenting. So that is essentially the main investigation here on it's gonna be able to identify entry at the same time. So don't you? Don't wanna be wasting your time on other investigations. The patient Continue your e it essentially. So you've got pretty much most of the management initial A, B, C D e, and no by mouth. Major hemorrhage protocol. Very important. 16. Your help. Um, transfuse o negative cross match. No us yet available on day fluid resource essentially start with fluid recess. If they're not responding, then you were transfused, and then you need to correct anything that can make the bleeding with. So this patient on ibuprofen or clopidogrel both will make the bleeding more substantial. That needs to be stopped. That's very important on That's something you need to remember from a history cause by the time you take the history or from a patient in your exam, the management will become relevant at some point on down this you will become relevant in management. Sorry on, then, if it's a virus, is IV truly pressing? We are suspecting Barris is on broad spectrum antibiotics. Now I put, um, and then the urgent endoscopy you could do banding for a salvage or viruses. He said that sclerotherapy for gastric are C's, and these other systems can be used as well. Especially the billing is uncontrolled. The blade want you or tips? Um, right. I know we're not suspecting peptic ulcer disease, but it's important to know how you manage that IV PPI after after endoscopy on DNA. Not before, because if you give it to them before, it can actually disguise the ulcer or the rupture within within the stomach on. But it will be more difficult to treat on how it's treated is it can essentially be with the draining injections, or it could be with sclerotherapy. So I one thing I can you remind me, Did you mention the, um, Glasko blast with broccoli? I don't think you did, but yeah, this is important to mention the glass go Blatchford, which is before and also could be on the rock all school. This will score you excellent points if you mention this, so that's good. Blatchford is before endoscopy on essentially what it tells you is. Can this patient be managed outpatient? It doesn't do any treatment up immediately, or and then, after you've done the endoscopy, do the rock or school this tells you were essentially the risk. Mortality risk and the risk of rebleed can erect management essentially if they need more close monitoring, especially if the rebuild risk is high abstinence services. If the patient agrees, optimize treatment for liver disease and the medication review, it was quite important you need to permanently stopped the ibuprofen. There are high risk of bleeding. Um and then ah, yeah, Okay. So keep eyes to remember in any patient vomiting the color, the appearance is there is a fresh blood in it. Or is the dark blood the dark appearance of the vomit? So really asking doc appearance to the home? I didn't say coffee ground vomit because patients might not always say coffee. Ground bomb. It's quite a medical thing. Um, so you asked. Doesn't appear like coffee grounds on that would tell you all this Upper gi I bleed could be happening. Never forget how the bowel motions are. Um, past medical history complaint in Upper Jabali. It will help you to find out what the most likely cause of the upper GI bleed. Any major bleed. The major hemorrhage protocol that will keep you safe. It's really important to say on then up a job lead urgent. Endoscopy is, um, essentially the main investigation that needs to be done. Oh, it was the investigation on treatment. Okay, so case three Jasmine, Jasmine 54. You are well done. Um, are for doing that sense of volunteering always. Um, so, case three. We've got Jasmine, just men of 54 year old female presents to her GP complaining of increasing right upper quadrant abdominal pain. So just right off the bat, guys, put into you at the chart. Some when you're out there in your station reading this. What kind of differentials? Which would be thinking off. Thank you. Go. This is like a gallstone disease. Yes. Anything other than acute cholecystitis. Yeah, yeah. Pancreatitis. Yes. Or good answers. Malignancy? Yes, Was an important thing to consider. Okay, Well done. Goes so Let's have a look. So acute. Colecystitis. Yes. There's probably one of the most is quiet, very common cause you got to consider malignancy Be that off the liver or the pancreas. A sending cholangitis on biliary colic. I saw some other differentials there. Those are also 50 Ballad And just make sure you come back them up in your investigations. Um, okay, so, yes, work through it. So just after seeing that, how would you investigate a patient like this? Just considering your differentials we've come up with? Yes. Hey, be seen Abdo pr exam. IUs of them. Well, blood count lft is uh huh. Families like crazy. Yes. Any potential seeing is we said in all differentials, um, malignancy, Any Marcus tumor markers you You'd want to think off. Yeah. F p c a 199. Yep. Okay. On what you guys think the most important? Well, the first in imaging. You would go for what? Imaging. Modality. Do you think you guys go for first Ultrasound? Yes, Mother. Okay. So as it a lot of you said, full update exam, including PR exam. Never forget he or exam of on our basic vitals. So lactate. Um Elise, like, pays for your pancreatitis. F p for about cell carcinoma. See, a 199 is for pancreatic cancer. Um, ultrasound abdomen. So with the ultrasound abdomen, what would we be looking for? You guys could just put in the child what we're looking for. Yeah, Yeah. Essentially, we're just looking for gold stones. Is there a dilated mild? That's great. Um, and the c g. And if there is a special test, um, a heater scan, which can be done if the ultrasound is You're still suspecting gall stones, but it's not very clear this is a test that can be done on then, As you guys have recognized essentially any female coming in with abdominal pain. Um, a pregnancy test is key, so we've got some investigations back on. What they're showing is by vital. So essentially, the vitals are heart rate. 97 respirator. BP 118 temperature, 30.2 90% oxygen. SATs. So the eso the, um the vitals aren't too bad. We just got a bit of pyrexia. Appears to be quite stable. Okay, that's the most important thing when you're looking at vitals. What, you're trying to find out is is, um there are they stable or not? Um, I can see some questions. If you have any questions, just put them into the Q. And a section on our team will get them answered. Okay, So, um, on examination, generally tender with noted pain on palpation of the right upper quadrant on some gardening, um, arrest of inspiration were pressing over the right upper quadrant with the hand. A question notes. Normal bowel sounds present. So from the, um, examination, what is that showing to you guys? I've been seeing someone for. And Murphy's sign? Yes. Okay, great. You've identified that. It's messy signs on Benwick. Looking at the ultrasound. We've got thick and gallbladder wall on. Do with some stones. Visualized. Okay, so there are some stones visualized in investigations now, um, their blood results. So if you guys just have a look, what are the things that are that are, um, that you can see here? I can see a nurse. Could. John has roots and descending colon joints because of temp? Not quite, but we're going to come on to the in the seconds. Just bear with me. Leukocytosis on read. Um, Elise Yes. Okay. Great answers there. So the amylase is high. At first, you can just say Okay. I'm Liz. Hi, pancreatitis. Well, no, that's know exactly how it works. The amylase needs to be about three times the upper limit of the normal. Amylase can just be raised you to the inflammation occurring within the within the liver area on the gold bladder is no a sense. It's not essentially 100% specific to pancreatitis. That's something they could put there to try and catch you out. So remember, amylase is not always equal pancreatitis on. Someone has said the white cell count is high. Yes, indicating that there's potentially some sort of infection occurring. So based on that guy's, I can see if you have already written it. What is your final conclusion? That what? The top differential is acute. Colecystitis? Yes. So how would we manage? This patient just dropped. Dropped down in the chart. How you would manage them. Okay, So would you do sepsis? Six. Based on these vitals, I can see if you people have written except they're six. No. Yeah. So the patient is quite stable. They're not in shock. Their temperature is likely to do with acute cholecystitis. You wouldn't. Essentially, you go for sepsis. Six in this case. Okay, so you guys have put lots of things. That's good. ABCDE management has always seek seem to help. General surgeon referrals. Um, supportive care on regular mountain of vitals. Know my mouth and intertubing vomiting analgesia patients in pain, Antibiotic cover. So for you. So this acute colecystitis the defense of management is an early laparoscopic cholecystectomy a Zyrtec amended. Bye. Nice. Essentially. And before they used to, they used to be over from You'd wait until about 6 to 8 weeks later until the vision of stabilized. But no you to go in with early cholecystectomy. Um, just a quick bonus question if if after the cholecystectomy the patient is still unwell on having pain, Um, and no improving after the cholecystectomy. What do you guys think? What could be going on? Yeah. So that could mean that this stone left within the common bile duct, Andrea, maybe try, You know, sippy stones in the bile duct. Just something to be aware of is sometimes seen. Um, I think it's maybe the statistic is like 15%. I'm not sure, though. we'll have to double check. So keep wants to remember so biliary colic. So, in any right contemplating, these are some things you need to be thinking. All, um biliary colic, postprandial eat after food, right upper quadrant. Pain only comes and then it goes, Um, especially with fatty foods. So remember to say that in your history, Ask about what? If any foods are triggering it on what know? And then you've got the acute colecystitis. So this one has developed the store. It's one step up from the biliary colic. You've got the right upper quadrant pain and you've got the fever slash raised white cell count. No, A Z we can see in our patient. That's essentially what they had, which made us. Point was this is the top differential. Someone said, Is this no east end in cholangitis? Well, the Asendin cholangitis has the tried a rifle contract pain. The fever raised white cell count. However, they also be jaundiced. If this patient was jaundiced, then you talk to friends would have been extended cholangitis. How would we confirm that the patient is jaundiced in the blood test? What would you see? Braised bilirubin? Yes. Okay, great. Um, Andi was the No, you don't on again. It's always important to screen in your histories for weight loss, appetite, loss in the history to exclude and help help point towards different differential. And you want to always consider malignancies a swell on day. Sending cholangitis is essentially means that the infection is leaving that the the cystic duct, which connects to the goal bladder on It's it's, um, exiting and climbing itself up towards up higher in the biliary tree, essentially, whereas the keep criticizes kind of contained within the gallbladder. If you've ever wondered what that is, what the difference in pathophysiology is. So our next case we've got Monty, a 55 year old male, presents to the E. D with severe central abdominal pain of feeling generally unwell. He's known to have hypertension and is a heavy smoker. So you're reading this outside your, um, history outside your AM station about to go in a while? Some differentials. You want to think about that? You want to ask about your history? Someone said pregnancy. Remember, this is a male. Okay? Got some someone I could see Triple a dozen turkeys. Keep me appendicitis. Great okay? Yeah. Could be balanced. Ruction someone's I can usually the case again. So there's fibro mail diesel. Be a central pain even generated. Well, okay, so you guys have pretty much gold. Most of them. A lot of the ones you guys have said. Also valid. So abdominal aortic aneurysm. This is should be at the movement. You're thinking, Oh, this is your top differential on this one that you don't want to miss out. And on day, if you're missing this out once you after you've taken your history, I found out in more detail and you're missing this out. Could be considered a red flag because it is extremely life threatening you. Then you've got some using targets. Kenya. Another serious condition. Um, from from your history for abdominal aortic aneurysms. What kind of things would you be wanting to know asking for? Yeah. What kind of beach is would you expect? This is the pain going through you more detailed smoking history? Yes. So is the pain radiating to the back central abdominal pain radiating towards the back. This is essentially that. That would immediately make you think abdominal aortic aneurysm potentially connected disorders? Yes, because other than smoking and things like that on hypertension. Marfan's on the low stand loss are connective tissue disorders that increase your risk. Family history s one. Okay, so, um, is enteric ischemia? So what's something's in history that would help your point towards me? Isn't Erica's Kenya history of a off? Yes. Yeah, they, uh all of you've got a palpitations. Yes. Onda, how would they be appearing as a patient? Say you had some What? This patient with the Triple A and the patient with them using Tereshinski Mia How? How? What? What? We see them. You know how which one would look appear ways to you, would you say Ah, yeah. Yeah. So yeah, well done. And the scheme is out of proportion with the pain. So she's in Turkey. May they have a lot of pain. Um however, when you go to see them there, the physical findings there are little or even know physical findings doesn't mean it's not serious condition as it is very serious and like threatening if not treated and it's chemical itis on. But we went through a bowel obstruction is given colitis is not so. See a serious asthma military it's Kenya, and it can appear. Is some blood in the stools A swell? Right. So how would you investigate? Um, this patient someone is saying which one is more serious? So they're both They're both very serious conditions. But what I'm trying to get from your history, if there's a central dogma pain reading to the back you trip trouble A would be at the top of your list. So how would you investigate this patient? Yeah, Okay. I can see it runs, Gloria. Urgent ultrasound. Okay. Well done, guys. So, um, we've got, uh, abdomen examination, NPR exam vitals. So we need a full blood count. Um, these lft is I have underscored lactate. So what would lactate in point you more towards if it was significantly raised. He's interactive. Scheming a great Now will help you, Um, now or down your differentials, More cross match group and save coagulation screen. These are very important in any patient. Where you if you're suspecting a bleed, just like an upper gi I case is something you need to do. Um, so bedside ultrasound, abdomen. So the reason I said bad side is if it's available, um, the patient way suspecting a triple A's very will be very unstiff there unstable. You can't be wasting time doing different examination. Different. Sorry. Imagings on. Essentially, they will be taken to theater for emergency surgery. So CD considered if the patient is stable, You definitely wouldn't be doing a CT scan on someone with the Triple A and they're unstable. Um, okay, so let's see, we've got our investigations. Um, so from the vitals, were you guys concluding from that? No. So they're shocked. A lot of our patients are quite unstable today. Um, yes, there. Hypertensive, hypoxic, attacking Codec. Sweaty pill. Clammy there. They're very shocked. So the very unwell patient. First thing to take two a note. The examination of the abdomen. You've got severe pain guarding an expansive pulse. A little mass is felt centrally on some bowel sounds present. So you get to your bedside ultrasound. The fast scan on down, off the off the abdomen on what you find is ah, dilated aneurysm measuring at 7.4 centimeters. Para-aortic fluid collections than free intraperitoneal fluid. So, essentially, from this, you can tell that as you guys have said is that there's a rupture that's a good What is what? What am size would be considered a significant risk for rupture. What size off? Um, aneurysm. More than 5.5 centimeters. Yeah, exactly. So at at the point of 5.5 centimeters, Um, that's when the risk is considerably. Goes up on over one city to growth pill year. Yeah, well done. So how would you manage this patient you guys could write down? Okay, maybe see the e great make major hemorrhage protocol. A lot of our patients have needed that today for surgeons. Tell senior General Vascular surgeons Yeah. Senior review. Okay. Analgesia. Yes. Patients in pain. Always remember knowledge easier. And stop anticoagulants. Yes. All right. Well, the guys So initial a B C D management. Major hemorrhage protocol should be one of the first things you are staying to your examiner in any patient with the bleed. Um, if not responding, normal flu is you transfused, um, correct floating abnormality. Stop. Any thing that will make it worse, Like crackling anti platelets, immediate vascular review, and notify any statistic much. I believe. I saw someone say that, um, and prophylactic antibiotics in accordance with local guidelines. So one really important thing here is Do no waste your time with skin scans. If that patient's hemoglobin be unstable and you're suspecting a rupture, the patient goes straight to the attorney for major statistical repairs. One of those case one of the unique circumstances where something like that would happen. Um, as as if your waist, as if you were facing time, do scans. The patient is, ah, high risk of mortality on if the patient isn't treated immediately, um, on there untreated or it's missed. For example, does anyone know what the mortality rate is for Rupture? Triple A idea? Well, if they're actually not treated and it's something that's missed on the mortality is actually close to 100%. So this is why it's something that never be NIST So long term. If the patient survives acute episode, they'll need long term management and patient education, lifestyle for modifiable risk factors, smoking cessation advice, hypertensive control, diabetic control and hyperlipidemia control. These are many of the risk factors that go in that can cause Tripoli. Um, right, I'm I'm not sure why it's not mentioned here, but the medication review to stop any anticoagulant so anti platelets and want no So keep points to remember. For this case, Triple A is not something to be missed. If you wanna the main take away, Um, the consequences off are basically fatal close to 100% in the event of rupture. So if it's something and exam that you miss, this could be considered a red flag. If you miss this in your station, Um, don't ever forget the major damage protocol. Don't for this for Triple A, don't waste time ordering tests lactic and help exclude amusing Terex Kenya. So, like I was saying, he's until it gets Give me a thing called this. If there are a cute up, if there's a cute abdominal pain with little stash, no abdominal signs, um, out of keeping with physical signs. Okay, so this is ah, final case of the day, guys. Um, Terry Joe, a 63 year old gentleman, presents to them. I can see a question. Reach you. If you just ask your question in the queue and a section on, we'll get that answer for you. Uh, Terry Joe, a 16 year old gentleman presents to the e d. Complaining off epigastric abdominal pain. So we've got some epigastric abdominal pain. What differentials would you guys be thinking off? Yeah, pancreatitis. That's my I agree. Gord. Yes. Graphic concert. Great. All valid differentials, guys. Well done. So some of the differentials acute pancreatitis, us some good pancreatic cancer. Peptic ulcer disease. Am I so in acute pancreatitis. What kind of things would you be seeing in the history? Uh huh. Yep. Pain right into the back. Yes. And gastric pain radiating into the back. Hypoglycemic symptoms? Yes. Homeless. So essentially, what everyone is kind of get, which will get onto is using the causes of pancreatitis to help Thio and point which, But you basically use the causes too, and get you to ask different questions in the history. Essentially, everyone's doing well done. Um, so, God, what would you be expecting in that gastroesophageal reflux? The all right Muslim line? Yes. Up in sensation. Yes. Okay. Great. Were slot with certain foods. Yes. Yeah. So gorgeous. Ensure Lee. You get it after attention, eating something with, um with a gastric. Also, it's immediately worse after eating. Um, with the duodenal is, um, worse after it's worse. A few, maybe a few hours after eating. So, um, Packards pancreatic cancer. What would you be expecting? This? Which would be slightly different. Acute pancreatitis. Vague symptoms? Yes. Weight? Most Yes. Don't this? Yep. Pain less jaundice? Yes. You guys have hit the nail on the head and peptic ulcer disease on do ah, very important. Sent differential here on by. Think I saw one person say it is myocardial infarction. So this, especially in the epigastric region, this is something you need to rule out on its what we call a medical cause for acute abdomen. It's not a necessary, like a surgical acute abdomen. There's many different causes for medical acute abdomen. But this is an important one which we need to rule out. It kind of, um, present like this, slightly atypically to your typical central crushing chest pain. So I remember epigastric pain it mentioned Am I mean your differentials and we'll show to the example that you're really on the ball. Okay, So, based on all of that, how would you guys investigate this patient? You guys can just put in the comments, Okay? Yes. Uh huh. Okay, So we've taken from the history on we're thinking off this potentially acute pancreatitis. Um, we've got a full abdominal exam. As usual, the families on the light pays serum calcium. Um, ABG on a lipid profile. I'm not sure if I'm not sure someone said a calcium and a liver profile or ABG. I'm not reversible that this is really important to remember. Um, so we've got our ultrasound abdomen looking for the cause. Could this could potentially be caused by Goldstone's? Um, consider ct you for more detailed imaging. But one thing to note is that, wouldn't you? Yes. That should be in the investigations. Troponin, Um, on also your e c g would help rule that out as well. So? Well, then, Vick, um, so acute pancreatitis can actually be diagnosed without imaging. It could be diagnosed clinically based on clinically and on the blood results of the amylase slash. Like peas, the re the importance, the reason for imaging and the coupon it ices to find out the cause. Um, on D e C G. Okay. So what are some causes for acute pancreatitis? I'm sure all of you know the new Monica. Anyone? I got smashed. Yes. So what do you looking for in your investigations? So we've got I get smashed idiopathic Goldstone's ethanol trauma, steroids, mumps or two immune scorpion sting the one ever remembers. Very, quite rare. Um, depending on what you are quite right in the in the UK um, hyperlipidemia ercp this I a Tradjenta cause onda different medications. So from your history, you can elicit what? What could be the cause that's occurring. Have they had a heavy about of drinking in the history? Have they been in any trauma to the other on steroids? Um, have they had any recent treatments and for any medical conditions pointing towards potentially Maybe they've had a ercp different drugs. That one. All of these will help you to find out what's going on. So we've got ah, vitals. Okay, Slightly talking. Cardec pressure appears to be stable. Low grade fever. So, for your history, Terri Joe tells you he has been drinking heavily in the past few days. Okay, well, this means that this could be the cause for his pancreatitis. Um, on examination, there's tenderness on palpation epigastric region. A listing pain with this relates to the back on air. A periumbilical discoloration is seen. So what do you guys think? This area of Perry And what was the sign. Yeah, that's occurring. Colin, Sign Yes. On essentially what that is is, um, an area off him, originally from the pancreas goes into the retroperitoneal space in the retroperitoneal retroperitoneal fluid on that tracks down towards the umbilicus on it forms this appearance. So this is quite rare, and it's not often seen. Um, anyone know what the other Sinus called? Yep. Great tennis. And that's on the flanks And Arab hemorrhage on the flax. Another rare sign. Don't expect to see it in everyone with pancreatitis. Um, okay. So any comments on the Bloods? Yes, Jimmy. Well done. So you're saying that indicates to be a pancreatitis? What is the, um So what is the system? But you're using? Yes, The glass ghost, the glass. Basically them. There's many different criteria for which will cover similar invest. Similar basically, points. But there's the modified Glasko school on. If you have three. If you had three or more, then that would be considered. That would then be considered as, um, severe pancreatitis. So moving on. Okay. Okay. So here's the modified glass. Go to school. Remember the new Monica pancreas? This is why ABG is extremely important. part of the investigations. Do not forget a BeeGees um way. This is a form part of the criteria age. Um, neutrophils neutrophilia calcium hypocalcemia. So hypocalcemic eyes. Ah, a prognostic. Um Ah. Poor prognostic factor, but hyper calcium, you, uh, is a cause off Pancreatitis in itself. Enzymes are be maintained on Google. Okay, um, one thing. What? The amylase here is very high. Um, but would be the prognostic implications of a very high. Um, Elise. Guys, excellent trick question. Amalie is not a prognostic indicator, and it's like, piece that actually matters in this. A swell. Okay, Well, don't guys, you're on the ball. Okay. Now, how would you manage this patient? Mm. Yeah, No. Okay. Treat caused. Yes. Okay, so initial A B C D e senior support. So the severity is important because it kind of guides your management. This patient is severe severity of hepatitis You need to consider for I t. U admissions and with a needle stick, your senior, um, support of management is usually the main stay with aggressive fluid resource. They're not routinely made nearby miles, unless they're vomiting a lot. Which usually they are vomiting, pancreatitis, patients on treat underlying course has stopped any causing medications. Um, right, so conservative patient education on Do you need to continue monitoring the patient for complications which occur a week later, like necrosis on pancreatic pseudocysts? So that's important and then optimized control for any potential causes. High book lipidemia hypercalcemic a Medication Review Now I have the antibiotics are only given if signs of infection and in accordance with the local guidelines on then surge and then dependent on the cause is we'll have, um, will have Goldstone's a cholecystectomy biliary obstruction ercp, um, abscess or necrosis would need surgical drainage. Yeah, and, er Matics. We're definitely are required. A Z Well, the patient's vomiting on is there? Oh, it doesn't. There's no mentioned here. Analgesia as well. Um Right, So what are some key points to remember here? So if you're suspecting Packard titers think about the cause is help guide your history of management. Um, assessing the severity is very important. Something that was given in my exam. I believe they were hypocalcemic and on, but I just have to spot that meant that was the main thing to spot for the for the bloods in my station. Um Andi. The management is generally supportive on of exaggerate. Here is I mean, fluids, IV fluids IV fluids on. Remember that? An important cause of a medical. Your abdomen is an M. I should always be on the radar. Some other causes of a medical qi abdomen is I be escapes. Trent, right? Started from Shin DKA. Not necessarily towards, um a no. Said these aren't surgical causes, right? So that comes towards the end of our session on be the end of our third series on last teaching for the act rest of the academic year. I believe. Thank you so much for attending guys. And I really hope these things were very useful. Um, Onda, you know, share with your friends on. We've reached over 4000 Facebook. Fall was where is when we first began? We had started the year we were about 1008 100. So it's really been great. Um, yeah. Thank you so much. And make sure you fill out the feedback form. Here is the, um QR code on. We hope that you guys soon. 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