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Hello. Hi. CVS. We can hear you. How could you please share your screen? Yeah, just just like in your, uh So everyone can hear me, right? Oh, yes, we can, I think. Hello, everyone. Uh, no. Vera, can you please confirm, uh, everyone able to hear me, or is there a problem? And also, if I think your audible multiple, uh, guys, if you are able to hear me, um, so that we can start this lecture, you can just, uh, yeah, send a text in in this chat box. Okay. We'll start in a second. Let's wait for two more minutes and we'll start at 6. 35. We'll wait for a couple of more people's. Yeah. Okay, so let's start. Hello, everyone. My name is a Hib. I am, uh, Jamal. I'm currently working as a junior clinical fellow in the Department of Journal Search yet, uh, WWL Energies Foundation Trust. So, first of all, thank you so much for joining. Um, I'll try that we all learn something from today's lecture. Basically, I learn something from you guys, and you guys can learn something from me. So the main aim of this lecture is to go through. How when nurses call us and they ask us to come and see a patient, especially in the Department of General Surgery, Or you can see subspecialties and we'll quickly go through some some of the post operative complications as well. So we'll start with the scenario. So let's say you are a foundation here, doctor. You guys can comment in this chat and I'll try to read everyone's comment, and then we'll go together through this. So let's say you are a foundation, your doctor and you're doing your night on call, uh, one of the nursing staff from a surgical ward. She bleeps you, and she asked you to review of 79 year old woman who had an emergency bowel resection and anastomosis done five days ago. She basically wants a review because she has just noticed that this lady is spiking a temperature of 38.4 centigrade. So how would you approach this patient? Um What? What will you do? Um, once the nurse has spoken to you on phone, how are you going to approach this kind of fashion? Anyone? Uh, so now what? I'm saying we'll start with a B. C. d. That's good. But anyone else? Okay? Okay. So, basically, um, before you go and see this patient, uh, there are a couple of things that I usually do. And most of my colleagues and most of my seniors, they also do this. And I think it's very beneficial. First of all, if someone tells you to see the patient and tells you to come and quickly review the patient, don't just rely on that bit of information. Always ask the specific person, the nurse or whoever is calling you. Like, how is the patient clinically at the moment apart from this patient, for example, is apart from having temperature. How is the patient clinically if the patient is clinically stable? Uh, that definitely gives you some time to do a couple of other things. By that I don't mean that you go and start doing something else. Uh, I mean, you can will go through that, um, five things that I specifically like to check. Um and always, always I try to, you know, kind of negotiate with the patient, uh, with the nurse. I bring that patient on screen and I ask couple of questions about the clinical condition of the patient. Five things that I personally like to check before I go and see the patient is I like to check. Why is the patient admitted under us? Um, that can include any specific kind of surgery. The patient had any specific kind of condition that we are treating the patient for. Uh, because if you know, um, the reason for the patient, uh, admission, then obviously, it gives you an idea. It helps you to, you know, know the patient in a better way. The next thing that I usually like to check his past medical history because, uh, past medical history gives you a clue and also helps you in during the management part. For example, let's say if a patient is known to have heart failure when I will go, and I will see the patient is hypertensive, I will try to, you know, restrict the flood limit. Uh, similarly, if a patient has a past medical history of any clots, uh, then, uh, this will also give me a clue to look into this kind of suspicion as well, Then I usually like to check observation of the patient in last 24 hours. How are they before and how are they now? At the moment, what is, uh, specific thing that has changed? Also, I like to check, uh, the recent blood test results that we have done and specifically their trend in general surgery. The kind of blood is very important because it gives you a massive, you know, information about the ongoing clinical condition of the patient. For example, a massive drop in hemoglobin will give you, um uh this clue that patient is bleeding from somewhere. A massive rise in CRP or White cell count will give you a clue that there is an ongoing infection that we need to treat. And the last thing before I go and see the question is any change in the medications? Uh, if any specific antibiotics the patient is having, uh, specifically in this patient because, uh, the nurse is calling me because patient is spiking temperature of 38.4. So I would definitely like to know which antibiotics the patient is on, because clearly those antibiotics are may not be working, so we might need to escalate the antibiotics. So basically, uh, Navarra told us that a B C d approach. There was a comment by bringing that, we will start patient on sepsis. Um, I would definitely we can, um there is one way of doing it. But I would say that if we go in this a B C D approach manner, then it we might find something else other than starting, you know, because temperature can occur in other conditions as well. So we'll look at we'll look into it. We'll try to find out what it is actually the patient is having. And what should we do? Okay, so, um, a B C D approach involves airway breathing, circulation, disability and exploiter. Never look for the signs of airway obstruction. So basically, when you go and approach and see the patient, uh, just have a quick glance of what is happening with the patient. Is there any breathing noises that is coming? Is the patient chocking? Uh, is he turning blue or coughing, or is he even He's breathing or not. So, guys, um, we if if you have a feeling that the there is area obstruction, then treat is an emergency escalated at that similar point. Don't wait for anything else. Don't wait for your, You know, um uh, approach to complete. Just escalate. Ask one of the nurses or any member of the staff who is there to let your senior know that there is a patient who is and the most important person to make a various anesthetist. If you are suspecting any area obstruction because I have seen that these patient's they you know, uh, they deteriorate so quickly in like, a nanosecond. They will be like from 100 to they will be on, like, 10 or twenties, so we need to escalate it as early as possible. Then, if you don't know anything at all about like how to manage. If there is an area obstruction, then give ox is not high concentration. While you're waiting for help to come, this is the best thing that you can do as a junior doctor or as an f one. Our patient, basically in this idea, was answering questions so we can safely move on to breathing. Anyone knows, like, if anyone can tell me, what should we do in breathing anyone? Is my chat working or I'm missing something I don't know. Okay, so in breathing, we basically we need to find out. Um uh, first of all, how is the respiratory rate? Uh, in our patient, it's 22 breath permanent brain. That's good. Brain is saying, Well, check oxygen saturations and respiratory aid. That's good. Uh, so oxygen saturation in our patient is 96% on room air. Uh, so we can safely that our patient is stable from this point of view, but respiratory rate is still high, so we will proceed onto the examination of chest. Uh, in our patient, uh, patient's just is clear on examination on anti escalation, but since patient is quite sick, So we were unable to appreciate, uh, posteriorly. But there were no arid sounds interiorly anyone knows, like on inbreeding. Which investigations do we carry out normally? Quickly. Okay. So normally we do a chest X ray and a B. G s. So anyone who can tell me what are the findings? I have tried to, you know, kind of make it obvious for you guys, but considering the history anyone can tell me, what are the findings on the chest X ray. Okay. No answers. Is my chat even working or not? And I find out okay, Uh So, basically, um, if you look at this part of the x ray otherwise X rays like a good quality X ray. But this part if we see, see, then there's a partial collapse of the lung. So if we go back to the history and we'll see this lady is post of Day five, she had a an emergency bowel resection in a national Asus five days ago. So what happens is most of the surgical patient's that you will see there will have this partial collapse of the language. Um, you know, somewhere, um, and we basically in medical terms, it's atelectasis is What happens is after when we give anesthesia, general, it's easier to the patient. Then it changes the regular pattern of the breathing. So this leads to, you know, a partial collapse of the lung, and they start we breathe on their own. Uh, this is a very common, very, very common finding on chest textures of surgical patients, especially those God long surgery just like this one. So next we we we will move on to circulation. Will, uh, three things that we need to do on our examination. Um, we assess the color temperature of, uh, color of the hands temperature of hands and which are capitally. Refill time. Uh, capillary refill time usually should be less than two seconds. We escalate the hot, hot, uh, record an E c g at that point. And look, uh, usually, uh, I like to do this in circulation point of view because I work in, uh, surgery. So, uh, if you need to look at the sites of, you know operation, any wounds, is there any bleeding? Is there any infection? Are the trains working? How much is the quantity of trains? Uh, so we should look at this on the circulation part in surgical patient's, um, if we check vitals of the patient, our patient's specifically had a vital heart rate of 104 a minute under BP of 1. 44 by 19 millimeters of mercury and on abdominal examination. His patient's abdominal was tense and distended. There was significant guarding. No, this is important to know. Like this examination. I'll ask you guys. Why is this a bit of abdominal examination so important? But there was no active bleeding going on. Uh, so we'll move on to, uh, circulation at this point. So, basically, now, according to a T L s guidelines, uh, if we are suspecting any kind of shock in any kind of patient and consider hypervolemia from the primary costs so immediately asked one of the nurses or whoever is there to help you to insert one or more, you know, large cannulas IV cannulas Um, immediately take bloods before you start IV fluids. And in surgical patient's, do not forget to take group and safe because you, uh, one of the part of your management might might be, you know, sending question back to theater. So it's very, extremely important that you don't forget to take drop and save, because if you do it later on, uh, you'll be, you know, highlighting patient. Um, you can't do it, obviously if you need to, but it's a good idea. If you are doing this in a surgical patient, just try to take Drew Princip then and there give a 500 ml of Hartman solution or 5000.9 persons would include right, uh, less than 15 minutes. If patient is having hypertension, then obviously you can repeat this until at least two liters. Then, uh, move on If we move on to the next part disability, then it's important to assess the patient's conscious, conscious level. So most of the people they try to do G. C s as well. But, um, one of the safest and easiest ways to do a VP. You, uh, so anyone knows what a p A VP you method is anyone? That's good. So Manisha, uh, is saying alert? Verbal pain unresponsive. That's good. Releasing alert. Reacting to pain or not acting. Uh, that's good. That's good. So, uh, a VP you is basically, uh, the conscious level of the patient is the patient alert? Um, when you go and see or is alert, is he responsive to your voice? Is he? If not, then is a patient responsive to your stimulation of pain? Or is the patient completely unresponsive? So this will give you a clue, you know, how bad is the condition of the patient at the moment? Examine the pupils. They should be, um um you know, equal, uh, via laterally reactive to write light. And don't forget to me your blood glucose, uh, to exclude a hypoglycemia. Obviously, in our patient, there is a temperature, but you should look into hypoglycemia in especially in surgical patient's, because I've seen it a couple of times, rather most of the times that they are mismanaged from their diabetes point of view before and after the surgery. Uh, so it's a good idea to look into, you know, blood glucose. Uh, there. So our patient was alert. Pupils were bilaterally reactive. Equal blood glucose was normal. Score. It's safe for us to move on to, you know, exposure part in exploiter, uh, full body expire. Um, try to, you know, maintain dignity of the patient as much as possible and try to minimize heat loss. So when we checked the temperature, it was actually 38.4. And examination of the legs was normal. There was no tenderness or swelling. Uh, so what do you think is the diagnosis from the initial, you know, management that we have done so far? What are you suspecting? So now they're seeing any intraabdominal source of infection. That's good. That's good. So anyone else Okay, so this is one of the most common scenarios that we usually seen. Surgical patient's post operatively, and this is all those you know, international medical graduates we're going to start, You know, their jobs in, uh, surgical department. This is one of the most you know, commonly asked interview questions as well. So they will give you a scenario like this. They might give you a bit of more detail, or they will just give you this much information. They will ask you to Do, you know, management. You will do your a B c d. And while you're doing that, they will give you all the information while you're going through it. Uh, but then at the end, they will. Definitely. Most of the surgical departments will give you the same scenario. So if we go back and we have a quick look on to what happened to the patient, so that will give us an indication. Uh, so this is a 79 year old women with an emergency bowel resection and an osmosis. So there are now two things. One emergency, all the things that are done in emergency. There is a likely chance that they I wouldn't say there is a great chance, but there is a likely chance that they won't be as better as anything done. Elective. So this lady had emergency bowel resection and then it was an asthma. So now, if we find out five days after, you know an Asmus is is mostly the leak is around 5 to 7 days, so it can be a bit early. It can be a bit late, but this is the usual time. 5 to 7 days, most of the patient's. If the league they will leak at 5 to 7 days and also research or and other studies. They also show that all those emergency resection and an asthma sis there there is a greater chance that they can leak as compared to something done elective. So will our diagnosis will be intraabdominal leak or, you know, sex is so, uh, from management point of you will start patient on sepsis. Six Anyone knows what is sepsis? Six. You guys must know. I know, But if anyone can tell me in chart, then we'll quickly move on to the next one. And it is also very important that if you see a patient whose abdominal examination will just quickly go there and if anyone's abdominal abdominus tense or distended and specifically if there is any kind of carding in this patient. There was significant guarding. Always. Always ask your registrar to come quickly and see the patient, because if there is guarding, then obviously there is something going on inside which needs to be treated. And especially if a patient is spiking drum pressure as well, then it's quite a bit concerned that we need to do deal with quickly. So start patient on Chapter six, which is give three and take three. Give oxygen, give antibiotics, give IV few words take. You know, blood's lactate levels are very important and check sure and output. Um, anyone can tell me like how much should be the an output for such patient's for any of the patient's anyone. So we should aim for, you know, sharing out 0.55 ml poor kg, you know, But, uh, asked for urgent senior if you, uh, try to escalate it with the radiologist, even if you're senior is not available, you can, obviously, but the city's can, uh, ask them to urgently proceed with it. If it's possible at all group and save the patient. Because if you're thinking that abdominus tree standard tense and very significant guarding, especially in a patient who's POSTOP day five foreign estamos is there is a league patient might be going back to theater depending upon the CT scan is also always try to, you know, uh, stay ahead of things try to do group and safe. Okay. Thank you so much. Uh, next one is, uh we'll go through another scenario before we move on to post operative complications. Quickly. Your n f I one and one of the nurses call you to review a 52 year old men whose you know, obese B m I of forties 40 kg, uh, a meter square. And, uh, he has suddenly become breathless. Uh, so the patient is basically admitted under us under surgical department because he had an emergency laparotomy done four days ago for a perforated sigma humor. So how would you approach this patient? Uh, so I want you guys to have a you know, uh, deep look into this scenario because this scenario can give you a couple of clues into the diagnosis. Even without going into any further information, you might have an idea what is going on with the patient. Anyone can tell me, uh, at this point what actually, What can be the differential in in this kind of patient? Okay, so? Well, we'll go through it and I'll let you guys know. So if we go through a B, c d approach areas intact and this patient breathing, uh, there is an increase in respiratory it, which is 28 breaths per minute. Oxygen situation is 88% on room ear. Uh, but it is increasing 96% on supplemental oxygen, which is two liters on examination. Uh, breath sounds. They are diminished. Chest X ray is normal. Sorry. Um, this is the just sector of the patient, which is fairly normal. There is no, you know, significant abnormality that I can see. Uh, ABGs are also bit normal. I removed into circulation part BP is 1 10 by 70 millimeters of my heart is 1 16. So a patient is tachycardia. Take. Um I wouldn't say hypertensive, but slightly on the lower side. Heart examination know marbles. Everything is stable there or in the disability part. Patient is alert. Pupils are bilaterally active. Blood glucose is normal on exploiter, temperature is normal and there is no leg swelling and pain. So, uh, anyone can tell me quickly. What are they suspecting? And then we will do the management. If we If you want to review the scenario again, you can perfect a brain knows more than I know. So he has already made a diagnosis from the scenario, which is very good. So basically, this, uh, I would suspect the in this kind of patient, because if we look into the history of the patient, first thing patient is obese. Okay, Uh, then obviously, he had an emergency laparotomy four days ago, a major surgery, a prolonged surgery and for perforated sigma humor. So there is a history of, you know, cancer patient had a major surgery patient is obese, which gives an indication that patient might not be able to, you know, mobilize well after the surgery. So he's now feeling breathless. This is a clear cut scenario of, you know, P E, which most of the you know consultants will ask in surgical interviews as well. And this is a must, you know, know thing for all the doctors working in surgical department as well. So start the patient on high flow oxygen, give appropriate energy. ZF The patient is complaining of any paretic chest pain. Order a CT p right away. Even the radiologists they won't cost. Um, it, uh, then if CTPE cannot be carried out immediately, then go through your trust guidelines or are likely called hematologist on call and get an advice regarding therapeutic anti coagulation, uh, try to, you know, escalate it to medics so that they are aware of him, just in case if anything happens, you have already escalated it. Um, they might offer, you know, in their in therapeutic anti coagulation. While you're waiting for the CT p r results to come back now in this in such kind of patient's I wouldn't waste my diamond doing D dimer is to be honest, but yes, you can do D dimer is. But if you know there is a high clinical suspicion of E if you're well, score is more than four, then you don't even you know, you can skip the timers and you can actually proceed to because there is a high suspicion of ct p. A. Okay. Uh, sorry. High suspicion of me. So any questions so far? Okay. I think everyone is okay so far. Okay, now we'll move on to a few, you know, post operative complications or post operative conditions that we see in our department. Um, guys, uh, the you know may name of a B C D approach is not to stabilize patient or, you know, to treat anything. The main aim of a B C. D. Approach is to, you know, by sometime stabilize the patient at that point so that you have enough time to manage to escalate to sort out this patient. Uh, so it's always a good idea to start everything with a B C D. Because it gives you a clue to what is happening with the patient. And it's a good idea always to treat whatever you find then And there, for example, efficient saturations are low. Then just give a high flow oxygen. Um, also, if BP is low, give, you know, bowlers of IV fluids, um, and give some time before you reassess anything. Otherwise, you know it it our body doesn't respond so quickly, so give a couple of minutes and then check if oxygen situation that is rising or not. Similarly, BP is rising or not. Okay, so we'll move on to some of the post operative complications. Um, so post operative complications They caused death and suffering, uh, longer hospital stairs and increased costs. So, uh, patient's who have complications, they are more likely. Even after five years, they are more likely to die. And, uh, in UK hospital every year, 20 to 25,000. That's they occur following surgery. So all of those who are very interested in surgery they should be aware of these post operative complications. Okay, so first of all is hemorrhage. Post operative hemorrhage is a common complication, which we see after any surgical procedure. Uh, hemorrhage is classified into three type of categories. Primary bleeding, reactionary and secondary. Anyone knows the difference between primary reactionary and secondary bleeding. Anyone can tell me in comment Box, chat box. Sorry. Uh, Manisha Good. Good. Abrahim. Okay. Okay, good. Anyone else? Okay, so, um, if we, uh sorry. Just a second. Yeah, so if we classify it, I talk bleeding, then. Primary bleeding is the one that occurs during the inter operative period. So this is a kind of bleeding. For example, if we were, you know, doing a lab Cooley. I mean, while we have, um you know damaged the cystic artery and there's a bleeding going on. Uh, or we, for example, if we we are doing any other surgery in which we at any vessel we cut any vessel damage on the vessel, there's a bleeding going on. So that kind of bleeding is primary bleeding. Uh, it basically occurs because of, uh, you know, mostly because of surgeons mistake or, you know, as a part of procedure, we need to, uh, cut some of the vessels. So, uh, that kind of bleeding is primal bleeding. But this kind of bleeding should be dealt with in the same inter operative, uh, you know, time. Actually, bleeding is bleeding. That occurs within 24 hours of operation. Most cases of directive hemorrhage. They occur because if, for example, if we had, like, gated a vessel and it, you know, slips or there was a vessel that was so small that we missed it, we didn't notice that there is an active bleeding going on, so we couldn't you know, uh, like, gate it, uh, so that can cause actually bleeding this small amount of bleeding that it's, you know, uh, becomes massive after a couple of hours So this kind of bleeding is reactional bleed bleeding. Secondary bleeding is the bleeding, which occurs within, you know, 7 to 87 to 10 days postoperatively This kind of hemorrhage, the most common cause of it is because of an infection. So what happens is, uh, if there is an infection, it, you know, spreads to the vessels nearby, it erodes them. And then the bleeding starts. Always. Always. If you see a patient who's post updates 7 to 10, you know, more than five days, I would say, And they are coming in with, you know, bleeding. Uh, there's a loss of hemoglobin. There is, uh, rise inflammatory markers. So always suspect that there is an ongoing infection that could be causing this secondary bleeding. So classification of hemorrhage is very important. You might not want to, you know, uh, remember everything, but just so that you guys are there, um what can anyone tell me? What is the most important thing to you know? Know if patient is having, uh, a shock? Yes, I a hemorrhagic shock. Which among these 45 credit years would you look at? And you would say, like, this is the most specific one anyone? Would you say heart rate is important. BP is more important. A respiratory. It is more important. All during output. We should look at first. Anyone. Okay, so it's a common, you know, misconception that we try to link BP with hemorrhage. Uh, but unfortunately, BP is one of the criterias. This is ADLs classification of hemorrhagic shock. So if BP does not drop, you know, even if a patient has lost 1.5 liters of blood, even then you would find you can find I wouldn't say, uh you would, but you can find a normal profession. So two of the most important criterias that, uh, most that are mostly recommended to look at our heart rate, which is usually, you know, rises. If there is a loss of blood, more than 70 50 mils and heart rate will go above 100. But because of the body's response, BP might still be normal. And the second thing is to look at respiratory rate. Um, in in All the patient's were having an allergic shock. You would you will see a respiratory it of greater than 20. Um so it's a very good thing that you guys know that BP should not be relied on, uh, in in small amounts of bleeding. Small amounts of magic shock. BP might still be normal, so urine output is an important criteria to look at it. Um, in class 123, I wouldn't go through all the classes because I don't want to bore you guys, but you can just have a quick glass. But just remember that BP might still be normal when patient is bleeding, so just a process patient's with a B C with special answers on circulation. Don't forget to take group and say, while you have faster curricular, I'll take that. But do take group and save, uh, start on fluid resuscitation in all the surgical patient's According to uh, Royal College of Surgeons guidelines, Hartman's is the best solution. Uh, if you are insured to start Hartman's, uh, solution, give us that 5500 and a million 15 minutes and then re evaluate if needed, give more. But if you have given to three bodies is still BP is not going up. Escalated to your seniors at that point. Don't fit for it to, you know, further drop down. Read the operation notes. Clarify what kind of surgery? Patient. Hard. Check all the location of the wounds. Check trains Our what are the contents of the brain? Is there any, uh, zero sanguinous fluid, or is there any frank blood that is coming? So it's very important. Uh, then if, uh, as as even as nonmedical, you should know that if there is any bleeding going on, just apply direct pressure. Um, but if there is any foreign object, don't try to remove it. Don't try to mess with it. Just if you can just apply pressure on the side of the bleeding. Asked for urgent surgical, see near review and escalated with the blood bank and try to arrange blood transfer and as quickly as possible because you don't know like how much hemoglobin he has already lost, how much blood he has already. Also, you should escalate for urgent blood. Trans year. Any questions so far? Good frame is very active. Good. Very good. So next one is post of credit fever. Uh, I'll just quickly go through the most common causes of pyrexia. The most common causes infection without any doubt. But there is a very good you know, five w is that we use, um, in in surgery, Uh, in posture. Pretty fashions. Uh, this is a picture that shows so first one or two days, it's wind. It could be, you know, uh, most likely. And a lower respiratory tract infection or a respiratory source of patient's, you know, uh, fever. Uh, sometimes, even if a patient is spike in temperature on day one or two, it can be a normal inflammatory response of the body because there is an inflammation going on at the side of surgery. So it can also cause, uh, fever. Um, then, uh, they 3 to 5, mostly patient as a unique catheter. Then there's a chance that they could be having infection there. Similarly, because patient mostly patient's, they kind of, you know, less mobilized after the surgery. They're a bit of bed bound, so that can also lead to, you know, Stasis of urine, and that can lead to your infection as well. Therefore, to sex in surgical patient's most think of DVT or you can say P that can also cause low grade fewer. Uh, day 5 to 7 are most important for the moon, so always check. Uh, like, if there is any in, uh, infection of the wound are the wounds healing are the wounds Hell, the how the edges Now, is there any leakage? Is there any flirt coming out of the wounds? So they wanted to consider s very resource. Day three or five. Consider respiratory source or is unit track source day 5 to 7. Surgical sites are very important to be reviewed. Any think of any obsess any collection that could have formed any day. Postoperatively always, always. If you're seeing a patient post operatively, we just try to see how the IV lines or if there is any central line it can, because it can be a source of infection, mostly in many of the patient's. So this is a scenario that will quickly go through. If anyone can tell me, what do they think can be this condition? I'll be very happy. Uh, this might be a bit relevant to the ongoing postoperative thing, but I just wanted to include this scenario because it includes very good learning point. So anyone can tell me I'll give you I mean to to our look, then you guys can let me know in Jack Box, if that's okay, you bring him. What do you think it can be? Manisha? Uh, Gabriel. What? What do you guys think? It's okay. You know what is? You know it is. Well, we'll go through it. Anyone? Just a few words. Seconds. And then, uh, we'll go through this scenario together. Okay? That's very good that there is a gallbladder issue, but do you know what issue is Colecystitis? Good. Mhm. Anyone else? Okay, we'll go through it. Uh, together. So this is a 72 year old lady who is normally fit and, well, she's She's admitted with the five days history of Chandra's and abdominal pain. So we know that there is something going on from, you know, from jaundice with there's a cultural issue or liver issue. She's having abdominal pain Now, this is a short history. Five days. The street, this is the morning to remember. Then she was feeling nauseated, had a dark urine. That's another indication on initial assessment. She was deeply trick and our temperature was 38.2. So that means patient is spiking temperature. She is kind of septic at this point, we know that. But she has a respiratory, it of 25 the oxygen saturation of 25% or Lumia. So, uh, respiratory. It is high heart rate of 92 which is, um, slightly, you know, kind of normal. BP is 96 by 60 millimeters. Now, BP is really low, so it's not very low, but it's, you know, uh, less than 100 millimeters systolic BP is quite, you know, a concern in surgical patient's so systemic examination did not re reveal any other abnormality. Specifically, there was no Strittmatter of chronic liver disease. So we now know that this jaundice is not from the liver issue know organs are left notes for palpable and that domino's soft and nontender so per patient's abdominal is soft and nontender on examination. Uh, so biochemical blood test a show or leukocytosis um, neutrophilia hemoglobin of 11.9, uh, will say 119, white cell count of 13.9. So white cell count is raised neutrophils. They are slightly raised. An acute phase response was evident with a CRP of 1. 31. CRP is also massively various LFTs were a LP of 3 40 which is high. Lt's high GTs slightly. You know, the high and bilirubin is very high. Hepatic synthetic functions was preserved with albumin. Albumin is normal pro from the diamonds. Normal. So from all the blood testing from examination, we know that there is, uh, you know, less concerned about the liver. Uh, it's now kind of more related to go Alberta. Now, there is a very, you know, important tried that we use, which is, um, Greene holds, uh, sorry. Shark codes tried. And Reynolds Panter that we use for, uh, these gal breaded patient's. Anyone knows anyone knows what is, uh, Charcot Strength. Yeah, the brain. Thank you so much for bringing up. So I bring, uh, he has told us fever, John. Decent abdominal pain. So basically, the patient is having a gallbladder stones, which you know what causing the obstruction, which is evident by a patient being jaundice electric, uh, and raised pylera been a LP. So that indicates there is any obstruction in the CBD. And now the vision is spiking temperature. So this gives an indication that now this Stasis has caused an infection that is going on in the body. So basically, this was a scenario of buildings absence. This is also one of the scenarios that you guys should know. Uh, some of the patient because we cannot. It's kind of, you know, difficult to manage patient's with a nice recommendations of doing any R c p within 72 hours for CBD stones. So some of the patient's I've seen 23 patient's going to I see you, uh, because of, you know, having build receptors. So I I I just wanted to include this scenario so that you guys are aware this is also one of the it's I wouldn't say one of the common, but it is one of the complications that I have seen in surgical additions. So sepsis, um uh, Q sofa score, which is a short form of, uh, sequential organ failure assessment score that is really using. I see you to, uh, you know, um characterized sepsis. Uh, so this is a kind of, you know, a short form of that sofa score. It indicates that if someone is having greater than or equal to two points, then they should be managed for saps is as early as possible. This one of the criterias rest period of greater than equal to 32 minutes. It will give us one point. Efficient is having, you know, ordered mental state. It will give another one point, and a systolic BP of less than 100 will also give us one point. Our patient was having two of these points, so he should be. And we are suspecting, suspecting that there is a source of infection because of the temperature, so he should be treated as substance from a B C D approach. Uh, if you're suspecting sepsis, then especially in surgical patient's whose spiking temperature then don't forget to do septic screen, which will indicate taking bloods. Try to rule out all the areas where infection can be. Uh, you're in depth. Take to rule out any kind of your infection blood cultures, you know, urine cultures. If there is any wound and there's a leak wound swabs as well, try to, you know, rule out any chest pathology that because ing uh, if you are insured, then go for a CT scan. This is a quick management of, uh, different conditions. Um, if someone is having lower respiratory tract infection, then Cormack sick leave. If there is a visionary tract infection, then um, Cormack. Secure. Efficient is inpatient or nitrofurantoin. Change of catheter for surgical site infection. Flu clocks slain uh, Similarly, if there is a central line infection, then replace. I've always always don't forget to check trust guidelines. UH, because different trust, they might have different policies. But if you are insured, never ever hesitate to ask microbiologists, even if it's three AM in the morning, just give them a call and ask for their advice. They will review Definitely an advice. Uh, the last scenario is about It's not a scenario study. It's, uh, one of the most common conditions postop, nausea and vomiting. So I just wanted to ask if what do you guys like? Think if if a patient is drowsy and patient is having vomiting, what do you think, uh, is a patient at the risk of and what should we do immediately? Okay, if if the patient is drowsy and having moment ing, just don't think about anything, try to convince patient to, you know, pass and G tube, because we need to decompress the stomach. Otherwise, there is a risk of aspiration, which can lead to, you know, multitude of other problems. So always check what are the contents color quantity of the vomiting? Is there any oppression that was done? Um uh, some operations, like lab collie patient's, are more prone to having postoperative nausea, vomiting if you have excess, just trying to find out which anesthetic was used. Any post trouble with the drugs, especially opioids? If the patient is having for the pain control, that can also increase the risk of having postoperative nausea, vomiting any of the factors is patient, hydrated or not? Because studies they do suggest efficient as well hydrated, it decreases the risk of having nausea, vomiting and if a patient is already on any kind of anti emetic therapy in If not, then which one would suit the patient best? So try to use a multi model therapy because if patient is having you know pain and he's having nausea because of the pain, you don't treat the pain and you treat nausea that will still not, you know, sort out the problem. So I try to use a multi model therapy. Try to, uh, you know, uh, give efficient, different kind of drugs so that all the problems he's having then, uh, try to give adequate n algesia Try to give, you know, um uh, fluid addition. Uh, one of the most common questions that mostly people ask me is what kind of, uh, anti Matics. My junior mostly asked me what kind of anti emetics that we should give impostor operative Vision's. So in my trust, we usually try to give on dance citron because it's quite safe. And most of the population in the UK there are old age population. They may have other heart conditions and also, you know, other medical conditions. So on dansetron is one of the safest that we can give. I try to avoid giving cycle is in, but if needed, I can give cyclizine. If you know there is any spaces or gastric. There's a problem with Castro camping, then prokinetic such as metoclopramide. They can also help. So, under the drawn, I usually try to prescribe it and it works for me. If not, then I had cycle is, um um but try to make sure that patient is having adequate energy Zia adequate IV hydration, because that also decreases the risk of force objective nausea and vomiting. Thank you so much. I'm really sorry. I tried. I did want that. This session should not be, you know, just long. But unfortunately, uh, it's in our long session. So thank you so much. Everyone for joining, Uh, and you guys can go to the chat box, you can fill this feedback form, and then you might you you will get a certificate for attendance. And thank you so much. Uh, just try to keep, you know, joining, uh, you might get one or two things in every lecture that will help you lifetime. So it's always a good idea to give, you know, cloth, You know, 50 60 minutes for this. Um, thank you so much. Any questions that you want me to answer before we leave? Uh, you can just send in the textbook a chat box nowadays. Thank you so much for joining. Um, and don't forget to give your feedback so that you can have your certificate. Uh, I'll just drop down my trust email. So if you guys have any questions at all at all, uh, if you guys need any information about, uh, surgical departments, just let me know, Um, this is my email for you know, if you guys need any kind of help, just, um, send me an email, and I'll try to reply as soon as possible. Um, okay. I think we have you guys have had enough of me. So, uh, thank you so much for joining, and I have a good day. Um, bye. See you in the next session. Goodbye.