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For every stage of learning, we've broken down these sessions into each subspecialty with each category of initial history, taking examinations all the way through to a simulation at the end. Um So that is the basis of the program. But before we get into the details of all the teaching, I just thought I'd say a little bit about myself. So I'm a core surgical trainee working at Saint George's at the moment, I'm on plastics. Um I am a Birmingham grad so a bit different to George's. Um and I graduated in the year 2020 which some of you may be aware was the dreaded COVID year. So I feel I have quite unique experience because I actually started um as an interim F one. So I started very early in May 2020. So dealing with acutely ill patients is my bread and butter is what I started on. And it's what I do believe has formed me into the doctor. I am today. That was my F one F two which I did in E six and then I did an F three because I was new to do surgery. But I missed that in COVID. And so that was in or plastics in Imperial trust. So this is where I've come across both as an F one F two and as an F three but angular RN and Imperial students who have all had this session er ranging again, as I say from second years, all the way, fifth and very, very good feedback. Um I started it because I feel like most of the feedback I had when I had shadowing on the ward is that they don't get this formal teaching and a safe space to kind of say, what do I do when a patient deteriorates, I'm gonna be a doctor in so many months and I can see it on paper, but I can't see it in person. And so that's why I put this together. So as you can see, hopefully the slides have changed is this is the 10 sessions I've planned. As I say, this is an each general starting at the beginning. So we're looking at more general surgery, chest pain, cardiac, those kind of things moving on to the latest subspecialty. So that's why my last session is usually on plastics. But in that, I also integrate in a bit of a LSB LS teaching that you're all going to need to pass by the in a medical school. So getting through those principles, it does work as hybrid, but the only way it works is by really interacting as much as you can. Um so we'll try that as we go along. If we get to being in person, it's hands on sim, where I'll give you actual feedback cos I was an OY examiner and we'll move on from there. But whatever happens today, I show you really, really benefit, I'll break things down. So you can see my thinking as an actual junior doctor and so you can start applying that to your practice. So as I said, these are the key four components. So it takes about an hour of the session. Um So hopefully you don't get too tired, have your coffee. So it starts with a history where I'll present you a case based on the general topic. We'll then work that through. I'll say what kind of questions I'm looking for. We then moving on to a focused examination again, I want you to be good at your general skills, just do your at e examinations but really also focusing what stigmata am I looking for? How do I present to the examiner that I have spent time on the wards in these specialties? Then knowing that you all have your exams coming up, I have put a few MC Qs in from my bank from back in the day. Don't worry about them only I see the results and honestly, you know, medical school doesn't matter, don't worry, this is the best thing you can do is just be relaxed, no judgment and really, really practice and then finally, as I say, this patient, either from the case or another patient on the ward will deteriorate and there will be hands on practice. So this is the first case, the acute abdomen um as a course surgical training, obviously, this is the most important case. This is the one that I've seen as an F two an A&E all the time. So what do we do with that? So this is the case. So what we start with is Meghan who's a 27 year old patient presenting in A&E with severe abdominal pain. You're the F one clerking. I want you to now consider taking a full gastrointestinal history. So focusing on what are the signs you're looking for. So before we move on to the next slide, I want you all to take a moment. I want you to put some comments in the middle box about what kind of questions are you asking, asking in your history of presenting complaint? So I'll give you a couple of minutes to think of that. Mm OK. So I'm hoping a few of you have had some thought with that one. So this is how I start with all histories. First lesson on the biggest lesson I want you to take with your histories is that I want you to clearly signpost at each point. So to the examiner, you've got to think how many med students do they see a day? What is going to make them keep focused that they know you've been on the ward taking these and that is signposting. So you start off like if you're getting flustered, you don't know exactly what questions to ask about abdominal pain, you forgot to ask about some associated symptom. You go, you don't fluster and keep circling back, you just move on and say past medical history and you can go back and sign post that you want to go on to a systems review. But I want you to really make clear in each stage of your history. OK? This is my presenting complaint. This is the history like, tell me more about it. And then when you're presenting it back again, using those sign posts. So this is how we started it. So this is, you know, a young girl who's had been coping with abdominal pain over the time. She's also just feeling a bit generally unwell. That's all she'll tell you. You'll have this girl turn to you say, yeah, I thought it was just period pains. I've kind of got used to it. It just, it's got to the point today where I'm just so I can't cope with the pain anymore. I'm tired all the time. It's a classic classic symptom, but she's mentioned the word pain it's been given in your case. So what I want you all to go through should be easy, easy, Socrates. So you really want to hammer home, getting all of that because on the tick box for osk, it genuinely has sight on the set of character. So, by making sure you're sticking to that easy acne, you'll make sure you're ticking these boxes. So you're thinking about someone, she's not got a point tenderness. So that's why you're thinking of, uh your differential start to come in. So you're not gonna think of, you know, is it going to be an appendix? She hasn't had any trauma. It's kind of a generalized tummy pain that's been going on for a long time. No other associated symptoms apart from she's got diarrhea and nothing's making it better with, um, gi histories. The associated symptoms you have to ask is your b symptoms. So your night sweats, weight loss, unintentional being very clear with that blood in the stool, whether it's constipated and diarrhea, you really have to Hummer that hammer that home and also about appetite. So, is there any gluten she's having? And that's triggering it off you then finally go into your nausea and vomiting and urine. These are the key kind of extra things you have to get through in your history presenting in plain that's separate to your systems of you. Cos they're the kind of things that you're thinking of what's in the tummy. Well, a lot of organs, what else could it be? So, making sure the key things are po weight and sickness. They're the ones in addition to your B symptoms. So, we're moving on kind of thinking now, what kind of past medical history is a 27 year old gonna have? It's not really the one I'm worrying about. I'm thinking of a young patient. The one I want to drill into is family history because then I'm thinking worst case scenario, we always think she's got weight loss. This is what we found out in the history of presenting complaint. What else could it be? Is it the sinister thing? So we're thinking of HNPCC or any other genetic cause of a colorectal cancer. So, doing that home, as I said, she's 27 I perhaps a case a while ago, but I just knew she's not gonna have anything significant into that drug history. You want to make sure you're going into your over the counters. So she's taking loperamide. Think about this is more to the family is what risk could this have loperamide? She could be having diarrhea that then ends up in an obstruction cos she's taking something to slow her down all very important. And again, mainly for the earlier years, you have to take off that you've done your pack history and being very clear what, how many pack years the patient has and in this day and age, especially when I'm on plastics at the moment with vaping. It's being very clear. Does it have nicotine in it? Because it's the nicotine that causes the vasospasms, bronchial history with vaping. It is going to damage the lungs. But it's being very clear how many cigarettes or how quickly they get through a Vape cos, then you can start to calculate the grams of nicotine they're going through in a week, um, final years as well in history. If you, we, when we start doing this in person, if you don't ask me allergies, you failed your exam cos you're gonna be a prescriber in a few months. So, really dr home, what drug allergies do you have? I don't care that she may be allergic to a cat. So it's all very interesting but drug allergies, if you don't ask it in your final year history, that's it. That's it. Fail because you're a prescriber, interesting points from this case is that she's a current smoker and that, yeah, family history. She didn't have anything to scar. Her brother had his appendix removed. We all know that's not genetic. So, but the main thing I'm taking away from this is that she is a smoker c, that's the history I have picked out for you. What differentials are already going through my head. But I do want you all to take a minute now to think what are the differentials and you should be having at least 3 to 5 differentials to present to your examiner based on this history. So, take a minute and we'll have a think. Just put the timer on. Right. So, I'm hoping you've all thought out through some differentials there. So the main ones in this, I'm thinking a young patient start off with common is common. She's someone who's generally unwell tender all over. She's got diarrhea is a viral gastritis. I think gastroenteritis is a very easy common diagnosis. That would be probably on my list. Again. She's young, persistent long term pain, diarrhea. I'm hoping you've all thought of inflammatory bowel disease. So that's two separate diagnoses there. That's ulcerative colitis and also Crohn's disease. Moving on from that again, this is an acute abdomen. You wanna think surgical? Is she someone with peptic ulcer disease? That is now because the pain has got so much worse. Has she got an acute obstruction because of adhesions or has she got um a perforated ulcer and now is acutely septic. All of these things should be running through her. They're my main five. You could justify other things like cancer. You could justify an appendicitis. But again, these things, yeah, their comment is not the main things I think with her age group and a chronic history, you've got your two inflammatory bowel diseases. Again, you could throw the cancer in there. It would be probably the most ones you could justify. But then as I say, common is common, it could be anything. So we move on to our examination. So I'm sure you're all quite used to doing your examinations. Like this is something that has happened since probably first year medical issue. It's the first examination you do. I'm gonna give you some tips. But my main thing um is when I see you doing your A to E in the future is I'm gonna help you with your technique because I feel like as medical students, we're not taught to actually examine a tummy how a tummy should be felt because most of the patients we see their BMI is high. So you're going to have to be using a lot more pressure than they're actually teaching you. So see in this picture here, he's barely touching that abdomen. Yes, you can see it's caving in cos it's a simulation. It's an empty mannequin but really on superficial. I want you to use this technique and on deep, really push you down both fingers. And that demonstrates to the um examiner what like you know what you're doing, you've moved on, you're using your hand, you're using the soft but to diagnose is there a mass? Is there something wrong here? Can I pinpoint this pain? So where does any examination start? It starts from around the bed. Ignore that she's got a plaster cast on. But what kind of things are you looking for in this patient around the bed? What are the stigmata you're thinking of that you're really looking for in a patient who's general surgical again? Give you a minute just to think about it. If you wanna put your ideas in a box again. Great. Ok. So looking around the bed, what I can see there is a urine pot. Very simple things in a general surgical. I want you looking under the bed seeing are they catheterized? Can I see that urine there? Is it clear? Is there blood in it? What's going on again? Bedside? There should be a news chart. So make sure you're checking the observations, a stool chart, potentially a nutrition chart. Have you got an NG feed in or even simple things? What's above the bed? Is there a sign saying no by mouth? Why would they do no by mouth? Because they've got an acute abdomen. So they're the main things. But when you come in the room do an examination, show off to the examiner, bend down, look under the bed and that just shows in 20 seconds even that you don't have to say anything that, that you've looked for that peripheral stigmata before looking closer. So you've looked closely, you've taken off the um blanket on the patient, maintaining dignity. There are three signs here. What signs does this case study? Have anyone can comment in the box? Yeah. Yeah. Clubbing someone's got perfect. So clubbing, I can bet 100 lbs you're all gonna go and see a patient and you're gonna look for the window when clubbing try and actually see it on a patient. I will tell you it's really, really hard back in the COVID days when we had the CO PD patients. It was the, the time to see them because bless them, they were really chronically unwell. But what you're feeling for and you can google it for clubbing is the four signs where it looks like a drumstick at the end. And you can feel bulkiness of the nail bed. So I can go up to someone I can feel just by looking at the swelling and I can feel the nail fluctuating on the bed that is clubbing. And that is the kind of thing you can look for clinically during your exam. These examiners, they're probably some old school general surgeon who's never seen clubbing and doesn't care about it. They're gonna expect you to do finisher's window today. But as a doctor, when you're clinically looking for it, when you're in acute medical clerking, that is how you find it. Um then, so clubbing gastrointestinal, we know the two causes are chronic liver failure and IBD. So again, this is helping with our differentials narrowing down. We've also got on the left erythema nodosum. And then yes, we've also got it right in the group that is scleritis or iritis or sc scleral iritis, some Greek or Latin term, but basically showing we've got widespread inflammation. We have got irritation to the tissues, what is going on here to cause this localized reaction. So this is where this is how also in your clerking. I know obviously we're moving very much to typing with our notes but this is how I was in a paper hospital. This is how I draw my abdomen. I'd make sure I do the cross or I'm shading in where is that area of tenderness in this patient? It's tender all over. So you can abbreviate that in your notes. She's on soft, uh superficial and deep palpation. You're being very clear that she's tender all over with no focal point. Tenderness you can feel for the liver, feel for the spleen. It shouldn't be enlarged, really make sure they take a deep breath and you're cupping your hand under to catch that. And that is how you catch it. If you're just pushing down, you won't feel the liver edge, especially in someone with an inflammatory disorder with the nodules, you've gotta catch it under and you'll feel it hitting. So really scoop that tissue and again, with percussion practice at home is the only way you can practice getting that point on your fingers where you can tap to actually hear what you're doing. So whizzing through with infected, we palpated with percussed with auscultated. We've listed for bowel sounds which she has and there's no renal bru. So how do we complete an abdominal exam? So, as with you've done your history, you've done your exams here. I don't need you to say obviously, I'd take a full history from the patient. But what are these side investigations that you can round up to use to do your abdominal exam, I'm hoping I've animated. Right? Yes, here is an acronym to help you. Remember if you all comment in the box, what you think each letter stands for, for your bedside investigations to how to follow up um, an abdominal examination. Any ideas? Ok. We're going for, please. Here's the first one H is for hernial orifices. So after each abdominal examination, I want you to check in the groins. Most important thing that is missed, you could have someone she could have had a femoral hernia that she's ignored for weeks. And suddenly she's obstructed and that's why we've got this diarrhea and now she's got generalized. Um Yeah, someone has done, got one correct in the books. L You're correct. That is 10, we've skipped too early. This one. So this is a sign to do your scrotal examination, your external genitalia, same thing as hernial oris. But just thinking of those inguinal hernias when they're direct can go down indirect, even go down into the scrotum r for rectal examination. So yeah, we're doing ad re make sure we're feeling the prostate and we're checking for the stool where we're looking for any blood mucus. Again, thinking for inflammatory bowel disease, feeling any obvious masses if we're worried about an anal carcinoma. And the D is for a urine dipstick. If you say after your exam, after exam to complete this examination, I would like to make sure I have examined all of the hernial orifices, including the external genitalia. I would then want to make sure I've completed a dipstick of the urine and complete a di digital rectal examination that is so sophisticated, you're ready to clot. That's it. That is me as an examiner going. They know their stuff. They've turned up external genitalia. It is still relevant in the female patient because it, well with abdominal exams, we think you have liver pathology so they can have issues they can have um in the breast. You're looking for any estrogen changes, checking the axilla for any axillary hair loss. All of these things are still relevant. Everything is justifiable. You should always be examining the whole patient, not leaving anything out. But the main ones to think about mainly your male patient is to check the scrotum. Yeah, these if heard it just, it just is a nice way to summarize it. I know you thought of your systems review and you've thought everything through. But yeah, so we also moved on to do some bloods. So I haven't got reference ranges on here, but I'll start breaking them through to you. Cos I've been doing this a long time. So HB is 107. So if we think the usual reference range is around 100 and 20 this is a 27 year old girl. She could just be anemic. We haven't drilled into what her diet is. So we're not sure we'd want to make sure then another sophisticated way you presented this new exams is you want to check the size of your M CV to make sure if it's macrocytic microcytic. Again, helping with your differentials, white cell counts is significantly raised. So we know it should be less than 11. A neutrophil is less than seven. So we know we've got a neutrophilia. So this is a bacterial cause of this. Again, we're looking at the C RP less than five is normal. So 100 and 32. OK. But on a unique neutrophilic patient with raise inflammatory markers, indicative of sepsis have a very low threshold and six that point because it now and that as soon as you recognize that no one will cross you as an ones. Yeah. And in your exam just say like with the nutrition is right going where I've targeted this case and it's all they're normal. So kids culture um to be sending off both a urine for an mc Ns and stool for an MC Ns. Oh, struggling to hear you. Check your wifi. How are we doing? Are we back? We're back. OK. Sorry about the connection issues. I'll just briefly go through that again. We've got an anemic patient who is neutrophilic with high white cell count and a high CRP. So, sepsis being thrown in, we're starting the sepsis. Six. We're thinking of our antibiotics, our fluids, our urine profile, our renal profile is normal. So we're safe to administer a bolus 1 L, 500 mils, whatever you're more comfortable with stat depending on their BP, albumin is low. So we're also thinking of malnourishment. But the main thing of sepsis. Yes, as a lactate is very helpful and we titrate our fluids to lactate levels is to get cultures. So I want a stool sample sent, a urine culture sent and a blood culture sent they are essential to mar up this patient cos they could have had C diff all along. So you never know. So we obviously follow up with anything with some imaging abnormal x-rays are a bit useless. Um I've never really seen one done except for one plastic patient who kept putting things in her tummy. The main thing we're wanting here is a colonoscopy. I don't know if any of you have seen these before, but I want you to start thinking in the back of your mind. What is this pathology suggesting? What sign can you see on the right? Give you a couple of seconds to think about it. OK. So this is cobble cobblestoning. So we definitely know where we're at now. We can think of our criteria for inflammatory bowel disease that this is Crohn's. I did do an Abdo X ray. As I say, it's not showing much, you could say there's a bit of thumbprinting there, but it's just proven my point that the main thing is we can't really see much on there. It's unnecessary, minimal radiation but unnecessary. So to help this, you may wanna take a picture of this next slide. This is the difference is between UC and Crohn's. This is what you're looking for of your overall sign and what you're seeing on your colonoscopy. It's a classic M CQ. It came up, I think in both my fourth and final year exams. So take a picture, learn this by RO and you'll be fine and you'll easily be able to differentiate between the two. Mm. Ok. 543. Hopefully you've all got a picture of that because now I've done enough talking. It's time for you guys to get some most out of the SIMS. This program M CQ practice. So I'm hoping this will work. This is a QR code. If you scan it on your phones, you should be able to get through to six MC QS. Um, which hopefully will work and we'll be able to work through the answer soon enough. So if you scan that, I'll start seeing if people are joining. No. Yeah, I have the watch. Good news. Ok. Give it 10 seconds if anyone else is ready to join. 01 more final question. All right. Give you another 10 seconds. No. Oh, no. Five. Ok. Could, every time I get to the final count I want to keep it in an answer. Right. I'm gonna stop now at work. Oh, I've lost it now. Right. Can you all see the right answer. I hope so. Ok, we'll move on to the next question. Hopefully that's all up on your screens not looking like him. That be gas. Ok. 54 three two one. Next question. Ok. 54 three two one. Next one. Ok. 54 three two one. Don't worry I know these ones are getting hard. Ok. Ok. 54 three two one. Ok this is the final one. Ok. 54 three. OK. One. There we go. So that's the end. You can all breathe now. It wasn't too bad. So we're gonna start going through the answers now. So you can always see how you did. I'm sure it alert you as we went along, what these signs are. So number one, what is not associated with appendicitis? So the answer was D Murphy sign, which is actually to do with the gallbladder. So the rest are all to do with irritation of the appendix obturator. So not really, II, don't examine people with this. It's just a classic M CQ question. The most important is rough things. You will definitely get that paradox of when you're palpating on the side, it will get pain there all about that irritation of the peritoneum free fluid in the right iliac fossa. Again, this is localized information that you can do in younger patients, an ultrasound and that is why that is associated with that because you've got that low c irritation again, at the bottom, leading to fluid. So D was the answer in this one. This one. So the key things that you should be underlining in this is they've got right upper quadrant pain, jaundice and a palpable gallbladder. This is what's known as the overall triad of signs, which means it cannot be cholest and this is the signs you've got. It's charcots triad. So it's cholangitis. So when you've got the fever, the pain, this is where you're saying this is abnormal cholecystitis is the Murphy sign. It's just irritation of the gallbladder. Cholangitis is where there is a gallbladder blocking it, irritating the whole tract. And that is why you get those signs. So, Shao's child, it's a common common. One. Fil colic is just pain, passing a stone. You're not gonna get a fever in this. You can get obstruction signs, which is your jaundice, dark urine, pale stool. You wouldn't get that pancreatitis. You can get a fever. But in your M CQ, it's not gonna be right, upper quadrant pain, it'll be pain radiating to your back. Ameri syndrome again, that's just pass it stone. Very unlikely you've got Charcot's trial there. So, pinpoint that out this one. So this was uh everyone did really well on this question. So this is a weightlifter who's got a painful lump that is showing necrotic bowel. So, yes, technically, it could be irreducible, it could be obstructed. But the necrosis means that it's strangulated and that is where this one an indirect as it explained to a groin hernia of an inguinal hernia. And a spigelian is a paramedian one in the abdominal midline, but very rare hernia. But usually they put these terms in just to throw you. But necrotic bowel always strangulated emergency. Next question. So this is one about pain on defecation and it's discontinued due to severe pain whenever you've got someone who's got enormous, enormous amount of pain during ad re this is a fissure, an anal fissure. So it's a tear all along hemorrhoids. Yes, you would get pain on defecation in blood, but it's severe, they're usually not severe, severe pain. A lot of these patients are reducing them themselves. They come in to the GP, they're not coming into A&E due to severe pain. Fistula is an abnormal communication. Usually you get mucus coming out of that. You don't really get blood. A hematoma is just bruised. You're not gonna get blood on the toilet paper, you could get pain, but you're not gonna get the blood on the toilet paper and proctalgia. Fugax is just abnormal cramping pain in the annual area. Wouldn't be getting blood once again. Number five. So this patient, we've got acute colicy pain in the suprapubic area, hasn't opened its bowels for two days, nausea and bloating. So this one is small bowel obstruction, which I'm sure you all got as well. I don't think you have this one actually. Now I'm saying through it no, you didn't. I got this one away in this one small bowel obstruction. We'll ignore that. The question you had was, let me check about which, um, surgery you should have for the malignant lesion proximal to the splenic flexure. And that is what you've got to think. Where is the location? So, it's along the transverse colon. So it's an extended, right? Hemicolectomy. If you're doing a right, you're not quite catching it cos it's five centimeters proximal an ap resection, abdominal perineal. So that's too low down. That's more for anal carcinomas to colectomy. You want to preserve what bowel, you can and remember the initial bowel is much more important to keep. And so that's why you want to do a to to colectomy if you didn't need to, that is reserved more for the inflammatory bowel disease when they've got pancolitis. That's where you end up doing a totect toy. Uh anterior resect again, is more for the sigmoid lower down cancer. So you wouldn't be using that just while this is on the slide again, this is a very common question. Tinkling bowel sounds small bowel, common is common. But then you did have this question. So this is someone with a grade three splenic injury. This is not one where they're acutely acutely bleeding. So it's one you'd watch and wait. So that is where the answer is b an urgent laparotomy. It's only for your high grade where the hilum has gone or they're acutely unstable that you'll move into an urgent laparotomy to complete a splenectomy. We want to resuscitate the patient permissive hypotension is to encourage clotting. So that means we don't push the BP too high to dislodge a clot. Ct is again monitoring with any bleed. And if you're going to watch it, watch and wait, you want to have repeat imaging prophylactic vaccination. If there's any loss to the spleen itself. Also, you can say it could be an open injury, justifiable for any prophylactic vaccination at this point. And aspirin is part of, if there is an injury, it's part of the guideline. Nice, don't follow it and not everyone gives it. But the main one here is that the initial management panel, a long term management plan shouldn't be a laparotomy ever really in a grade three. So that was a really hard one, but that's it. So this is the final part of the session. Usually, if it's in person, this is where we'd get a dummy or we'd get one of you to play the patient. And as a group, you'd go through and talk through the at e obviously, because we're all online today. What I'm gonna do is I'm gonna talk through how I would do it. So you can help put this in mind what you'd be going through and how you would best examine the patients. So classic sign the nurse comes to you doctor. I'm really worried about this patient and you're going right. What do I need to prioritize? Do I need to get there now? Well, how do I assess that? I want to know their news score. So they say to me their news 12, I'm automatically going. This is an acutely unwell patient. I want to make sure I'm completing my A two E with that, grabbing any notes on the way so I can understand what's patients. If I've got any imaging bloods available, I wanna see them now while I'm initially assessing this patient. So starting off airway, so you go up to the patient, introduce himself. I would say er sir madam, would you mind speaking back to me? So we'll say it's Megan in this case. So Megan, can you speak back to me? And then I would say your airway is patent. I would want to get SATS at this point, oxygen saturations and I'd be applying high flow oxygen. So this is 15 L by a non rebreather mask. I know obviously they teach you to titrate that oxygen that can happen later. Hypoxia will kill this patient earlier. So applying that bag mask, high flow 15 L ASAP, I'd be rechecking my sat at this point at each point of intervening, I will be then assessing that patient, I would then would say to the examiner, I'm then going to move on to breathing. So I've already got the saturations. I'd want the nurse present with me who would be helping me with this case to make sure we get a respiratory rate. And if there was any hypoxia on the ABG uh on the oxygen sats, I'd want an arterial blood class urgently. I would then want to inspect palpate percuss and auscultate in six lung fields across both anterior and posterior if possible for the lung fields and getting a chest X ray portable as this patient is AM 12 as of urgent breathing is then completed. So I'm now moving on to circulation. The best way is the first thing I do is I grab the patient's hand. Now you're making, why am I doing that? Is I'm already assessing their clammy and it reminds me to work my way up the arm to make sure I'm not missing anything. So I'm feeling their hand, feeling their clammy. Are they cold? Are they peripherally shut down and then feeling their pulse? I would ask them for a formal heart rate to be taken by the nurse so I can feed that back in my head knowing, oh, what could it be? Are they tachycardic? And then also working my way up the arm. I've already mentioned the ABG and then saying, what access do I have. So I want two large bore cannula in both and cubital fossa. And while obtaining this access, I'd want to make sure I'm taking off bloods. This is an acute unwell patient. We know earlier she's septic, but I would want to repeat full blood count, er, renal profile, liver functions, test, bro, bone profile, venous blood gas for another lactate. If I haven't got it and a group can save and cross match with thinking surgical abdomens. Here, we want to make sure we've got blood. We've also already taken our cultures. But if not, we're mentioning this now and then also ask the nurse, what is this patient's BP as soon as they're hypotensive, which they will be at a use 12 of this case, I'm giving a fluid challenge. So I want to give a 500 mil stat bolus of normal saline. A lot of people go on about Hartman's stick with simple, let's just give stat of Saline. And as soon as I I'd say to the nurse and in my simulation, um as soon as we've got through that fluid, would you mind recycling that BP and heart rate? So I can keep an eye on these observations to see if they're fluid responsive, moving up the arm again, I make sure I'm getting to the neck. Now, I'm asking the patient to turn to their side. You can look at the ju the fe as pressure and then at the chest, what goes on the chest, your E CG leads, always, always, always ask for a chest X ray and an E CG. It's simple, easy marks to do in your A to E. So it's the E CG So you presented this, you're gonna be given this hand to hand. What am I looking at here? So because in women, sometimes cardiac pain can present as abdominal pain. So we're looking across this, we can see P waves. It's regular. We've only got two large spaces. So 300 divided by two. You know, the heart rate is 100 and 50. We know it's regular. This is a sinus tachycardia, what causes sinus tachycardia? Anyone who's dehydrated or septic. So we've already got that in the back of my mind. Completing also circulation. I want to make sure then I could look at the abdomen as part of my circulation, very justifiable. Listening for the heart sounds and looking for any sources of bleeding. So that's the chest, abdomen, pelvis bones and on the floor. Just looking for that if they're catheterized, really important to do a fluid, um check their fluid levels at this point, get the charts up. So we've got through circulation. Now, we're reassessing. We're thinking of that in the back of our head. If we're worried, we've got sinus tachycardia, we're giving fluids, we're checking that BP. I'd want to make sure at this point before I even move on to disability, I would check with the nurse, have those fluids gone through yet. Would you mind recycling that BP, please? Just so I'm thinking I'm not going any further till I've done the things that could kill them first. So then they come and see this is the ABC that you were given. So we know they're not hypoxic, but they have got a very raised lactate and that acidotic. So I'm already thinking fluids were the perfect thing to get on board. This is the thing that are worrying me. I'm already addressing them, but I was worried for septic earlier. So I'd want to make sure that I've started my antibiotics. If not, then be speaking to micro. If I need anything better, you can see on the right the other bloods we've been given the white cells have gone up. So we're clearly not addressing, we wanna make sure we get more antibiotics in speaking with micro ASAP. Finally, you can see on that the HB is 70 it was 100 and seven earlier. She is someone who is losing blood somewhere. We haven't given her that much first to dehydrate her, er, to dilute her. And so we're thinking right, we've already got our cross match. What can we do have we looked for the sources of bleeding? Shall we get an urgent ultrasound? Where could she be losing this blood and giving blood as soon as possible? Always replace blood for blood if you can because the more fluids you just pump into them. Yes, their BP will pump up but it's not gonna cure the issue if they're acutely bleeding. This is the chest X ray. I asked you earlier. I think, um, I'll give you a little time to have a look, but what I can see quite clearly is a pneumoperitoneum. And so what we're worried about here is that she's perforated her bowel, which was something I was worried about all the way at the beginning of this session. So it shows that having those important differentials at the back of the mind are really, really important to have. So obviously, at this point, usually you'll be stopped because it takes you quite a while to get all the way to see. But making sure you go through, I'd say disability, never ever forget glucose. You'd want ABM, you'd want to check their pupils are equal and reactive to light and get an AU score. And then finally, with sepsis is always good to get a temperature and it forms the final part of your uh news and sepsis criteria considering giving paracetamol if they are febrile always helps to help bring down that fever and will help with the sinus tachycardia before we then move on to. Finally, we'd examine the patient again where you say you would fully expose the patient while maintaining dignity because it's important you assess them. But also you don't want to make them too cold if they're peeking a fever or they've got trauma and you, but you want to make sure you're assessing everything, checking the abdomen again, looking to see if she's got any bleeding perfectly. Look at her abdomen, but we've already seen the Neer peritoneum. We kinda know what this is. So that completes my at examination. The main takeaway points of this are getting your chest X ray, your E CG, your bloods all rolling off the tongue, high flow oxygen. Always from the off. It doesn't matter if they've got CO PD and make sure you're reassessing as you go along, doing minimal interventions, do what you can do as an F one. And as soon as you've done your at E, you finish off by saying I would like to escalate to my senior with this case. You're saying the medical reg or the, and the general surgical reg because the diagnosis is Crohn's. So a gastro case with a bowel perforation. So we want to let the gastroenterologist know you're going to have this person POSTOP, the person to call. First and foremost is the general surgical reg cos they need to be nil by mouth and get him ready for surgery. And that was the case. Obviously, the main things we're looking at this is a Crohn's flare. We give you steroids, you're going to give you VT regular observations. We want metroNIDAZOLE because they're septic as they may have, think of the gut flora. And then after she's had her surgery, it'll be about maintaining her remission. So giving all these relevant medications. So that is actually the end of the session. I hope that wasn't too long and I hope you all enjoy it if you wouldn't mind. This is a QR code for my feedback form. Um It doesn't have to be too long. It shouldn't take, it should take one minute tops. Um, and I'd really, really appreciate some feedback. Um And if you could put it in the comment box on the bottom, if like how many of you are keen to do this in person just so I can start, um gauging numbers. But thank you to everyone for your attendance today and I hope you all enjoyed it. Thank you so, so much, Char Charlotte. I think we all learned a lot. Um Just to remind everyone, we have another session coming up on Thursday. Uh for the in-person attendees, it'll be in lecture theater. A and for anyone online, it's the same links that you followed to attend today. Oh, sorry. I've just seen a question in the group about SVIA Law, which is, yes, someone has mentioned where I said earlier.
