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Ok, fine. Um If anyone's able to use the chat function, then please do, uh let me know whether you can hear me and see my screen. Um Just so I can keep track of that. If you have any questions, please just pop a message. Um I've got the messages open in front of me as well on my phone so I can see them and I will be sharing some polls. So please do sort of get involved to make the most of the session. Um So I'm not sure if any of you have joined last year. Um But I did a, a series on us to see the patient. Um Our first session this year is going to be the patient with abdominal pain. So it's going to be nice and simple. Um I've aimed it at sort of new doctors. So F ones F twos um and usually on my on call and c parking shifts. Um So if you have any questions, let me know. My name is PA and I'm an FY three. So I've just finished my fy two year and I'm just low coming at the moment. I did my F one and F two in writing Wigan and Leigh NHS Foundation Trust and I'm continuing to work. There was a local. So let's get started. So the objectives of today's session is to develop a logical standardized approach to assessing acutely unwell patients. The theme with these, ask to see the patient sessions uh generally to improve our knowledge of and working through the A to e system of assessing unwell patients. So that's what we would primarily be doing um in different organ systems. And this session is to mainly understand the differentials for abdominal pain in the acute setting. Um to become familiar with important first line investigations and management in common scenarios that you'd be presented with as an F one and F two and to become more comfortable with the sbar and escalating patients appropriately. Ok. So, in terms of the general approach to abdo abdominal pain, I'm just going to go through the brief history that you'd, you'd need to take first. So, um in medical school, I learned the um acronym Socrates. So, site onset, um character duration, exacerbation and relieving factors for abdominal pain associated symptoms. Um obviously, with abdominal pain, there's quite a significant number of associated symptoms, um which would make you sort of come up with the differential diagnosis. So, and distension, vomiting, constipation, diarrhea, pr bleeding, hematemesis, jaundice, pruritus, dysphasia, weight loss, fever, anorexia, all amongst the associated symptoms. And, but they're not limited to just those um the past medical history is very important, um, especially things like IBD previous hepatitis or current hepatitis known gallstones, um, malignancy, um, reflux, any recent trauma, which should hopefully be quite obvious. Um, any recent surgery or past, um, surgeries, periods of immobility. Um, and then as any history, you'd want to know the allergies, um, social history in terms of alcohol intake, smoking history, occupation, baseline functioning diet to see baseline function is very important just in the fact that if they're a candidate for surgery or not is important, any recent travel to things like hepatitis and family history of any malignancies, gi disease. So, abdominal pain obviously can, can be so varied and the presenting complaint is essentially trying to establish exactly where the abdominal pain is. So, depending on that, you can narrow down your differentials quite a lot, especially in certain groups of people. Um such as the elderly where diverticulitis is very common in young people where appendicitis is probably more common. So it's very, it's it's much easier to gauge what your most likely differential diagnosis is by locating it to one region. So in obviously in the right hypochondrium, you've got most likely gallstones, cis, hepatitis, um liver abscesses, potential cardiac and lung causes as well. On the left, in the left hypochondrium, you've got your spleen. So most splenic causes and epigastrium, you've got mainly sort of esophagitis, peptic ulcers, um duodenal ulcers, gastric ulcers, perforated ulcers, pancreatitis. And then in the umbilical region, you've got appendicitis or like early appendicitis anyway, can present in that region. Um in Children mesenteric lymphadenitis is quite common. Um And then Meckel's diverticulitis, lymphoma is also and then in the right lumbar and left lumbar region, you've got your colleagues and pyelonephritis, right? Iliac fossa, uh your classical appendicitis that migrates from the umbilical region doesn't always happen, but it can do um any cecal obstruction, ovarian cysts can present in either right or left iliac fossa, which is quite common in, in, in young women, hernias can obviously present in either um right or left iliac fossa. And then the hypogastric region, you can have pain associated with testicular torsion, urinary retention, cystitis, placental abruption, particularly in elderly people, um palpating the suprapubic region. Um a lot of the time if someone's in retention, it's, it's, it's a, it's a good indication that that's the problem. And then obviously con constipation can present in any region as well. A lot of the time it is in the left iliac fossa. So we're going to be working through a scenario. Um It's, it would be really useful if you could use the poles. Um I still haven't seen any messages to suggest that people can hear me. Um So if you can, that would be great, just pop a message on the group chat and say what grade you are, whether you're a medical student or if you're a doctor, what level you are that would be great. Um I know previously there have been people who can't actually access the messages. So um we'll see how this goes. Um I'm, I am gonna start poling as well. So you'll have a question that pops up just to do with the scenario. So let me know and just fill in the poll when you can. Ok. So scenario one, you've got your surgical fy two day on call, you've been referred a patient from A&E to Clark. Um She's Margaret. She's 72 years old. She is a female. She's been referred you to abdominal pain, nausea and vomiting. She's got a past medical history of atrial fibrillation type one, diabetes, osteoarthritis of both knees. She's using a one currently, she's tachycardic with a heart rate of 100 and 10. Her blood show um VBG with a lactate of 3.4 but the other lab results are still awaited and her abdominal X ray has been requested by A&E however, hasn't been done yet and she's been started on some IV fluids as well by the A&E team. So pole one um is what are your top three differentials based off the given information? I know there's no, there's no right and wrong answer. So if you could just put in whatever, whatever you can, that would be great. Ok? Like I said, there's no right or wrong answer to this. So if you can just put in whatever you think, um Because obviously this is just the beginning scenario. Ok. Cool. So most people think it's bowel obstruction, um, which could be the right answer. We'll find out. Someone thinks it's ischemic colitis. So we'll, we'll find out no one thinks it's diverticulitis so far. All right. Fine. So what do you want to know? Um, obviously you want to take a good history. So she's had one day history of worsening. Abdominal pain started centrally, now, progressively worsening, not localized, started feeling nauseous, vomited three times this morning, opened bowels this morning, some diarrhea, no pr bleeding, reduced appetite, feeling a little short of breath, no fever, no weight loss, no lower urinary tract symptoms. So it kind of rules out quite a little bit as well. Narrows it down a little bit too. No, I had morning dose of bisoprolol. Ok. Cool. So what else do you want to know? Obviously, we continue taking a good history. So, past medical history of atrial fibrillation type one diabetes, osteoarthritis of both knees and she's got some hypertension as well, which we kind of mostly knew from the A&E document. She's got a past surgical history of AC section two T two C sections over 40 years ago. Um, she doesn't have any known drug allergies. She's on Warfarin for her af she's on Lantus for her diabetes. She's on novorapid for her diabetes and she's on some Bisoprolol for her af some amLODIPine for the hypertension and she's on some pr and Ibuprofen as well. Assuming for the osteoarthritis. So we continue taking the history in terms of social history. She lives with her husband. She is independent in her activities of daily living, which is a very important thing considering that she may be a potential surgical candidate. She's a nonsmoker and nondrinker. She immobilizes with a walking stick and she has a family history of bowel cancer and her dad died at the age of 68 with bowel cancer, which is very important to know as well. So in my sessions, I make it a point to really highlight how to generally approach assessing an unwell patient. And I will keep hammering it in that the at E is the most important part because it's the only way that you can prioritize what's important and it will make your life much, much easier. Ok. So in terms of the A two E assessment, uh a airways patent in terms of breathing, um her trachea is central, she does have an increased work of breathing. However, and she's using some accessory muscles of respiration. Her respiration rate is 22. Her saturations are 96% on room air. So she's still maintaining her sats, her chest is clear. She's got bilateral air entry. Her heart rate is, is 100 and 22. So she's quite tachycardic. Her pulse is irregular but we know that she's got af um so she's in fast af now her heart sounds are normal. The cap refill is less than two seconds. Her BP is 100/67. So a little bit on the lower side, um Her input and output has not been calculated as of yet. Her JVP is not visualized and she's not catheterized either. And in terms of disability, GCS is 15 out of 15 still, which means that she's not confused or anything, she's alert, her pupils are equal and reactive to light and her blood sugar is 4.6. So comes on to the most important part of the examination is she's got a high BM I um her abdomen looks distended. She's got a central midline C section scar from the history. We know that that's expected tender throughout in terms of hernial orifices. She's got a right femoral hernia three by four centimeters athous and tender. So I guess that's the most important part of the examination that her calves are soft, non tender and she's got a temperature of 37.6. Ok. So again, we're polling again, it should be fairly straightforward this time given that you know, all of that information. What do you think they're given? What do you think it is? I guess there could be two right answers here. Ok. We got three people fine. Ok. So most people think it's a strong rated femoral hernia, which is probably the right answer, but it could also be bowel obstruction and could still be bowel ischemia as a result of that. So our top differentials that I've listed here are strangulated femoral hernia, bowel obstruction, bowel ischemia, perforated viscous. It could be any of the following. But given, uh, examination findings is probably a strangulated femoral hernia causing that obstruction in terms of investigations. I like to sort of break down investigations into bedside investigations first, then bloods, then imaging just to make the process more sort of logical. And that way you don't forget anything as well. When it comes to your abdominal pain, I think it's very important to get the observations. And E CG just not to miss some chest pain that presents as epigastric pain specifically. Um So I would always recommend getting an ECG for epigastric pain at least. And in people with the tachycardic in general, I think it is important just to make sure that you're um not missing any abnormal rhythms and then a urine dip um to not miss UTI S and it's also important to do a pregnancy test on um females of um so reproductive age groups. So surgical bloods, um most this, this probably covers everything. You don't need to always get all of them. But a full blood count, CRP S and E LFT S amylase pretty much for everyone. A VBG particularly for the lactate is important. Um The surgeons like that, um plus or minus a coagulation screen plus or minus group and save and cross match if you think that they're going to be surgical candidates and then comes to imaging usually, uh at, at an A&E level, it's important to get, uh a right chest X ray if someone has epigastric pain, just to make sure that you're ruling out any pneumoperitoneum secondary to sort of peptic ulcer, perforations and abdominal x-rays important for sort of suspected bowel obstructions. Um, so Pole three, we've got this ECG uh what does the ECG show again? None, none of the, um, none of the questions is super difficult in this. So just give it a go makes it more interesting for me. OK. So we've got f with fast ventricular response. S VT cool sinus arrhythmia. Ok. Yeah, I guess it's, it's difficult, it's difficult to appreciate um online when you're looking at an ECG. Um There are, there are really no definite P waves in this and the patient has no af um I would say that this is more sort of a for the fast ventricular response rather than a sinus arrhythmia where you'd expect to see some pee waves. Um And sinus arrhythmia is normal generally. Um, an SVT you'd expect um it to be more regular and obviously, it's a narrow complex tachycardia. It d it sometimes can be difficult to distinguish, but you'd usually treat the SVT and usually slow the patient down to see what the underlying rhythm is. But in this case, I've kept it quite simple. It's just, I have fast ventricular response. Ok. In terms of the urine dip, uh the urine dip is clear. Um Obviously, she is a postmenopausal woman. So the HCG has not been done in this case, but you should definitely do it, do not miss it for young patients. And then in terms of blood, we've got um a list of her bloods here. So, uh hemoglobin is slightly on the lower side. Uh She's got raised white cells, slightly raised platelets, uh low sodium, low potassium, slightly raised urea and creatinine egfr 62. It's raised CRP. Her amylase is normal. Her IDL is 3.1. So probably just bordering on the higher side for her af controlled with Warfarin. So the VBG shows ph of 7.52 P 24.8 hits you three of 29 lactated 3.8. So what does the VG show? Tell me what you think on the poll? Mhm. No. All right. Cool. Yeah. So, metabolic alkalosis, obviously, you got a PH of 7.52. So, alkalosis, there's a rise in bicarb. Um So it's predominantly a metabolic alkalosis. However, the lactate is 3.8. So there's no reason why that could be a metabolic acidosis going on. However, there's, there's a low potassium and sodium which could be driving the metabolic alkalosis. So, in terms of the impression, so we've got an AK going on. We've got hyponatremia and hypokalemia maybe secondary due to the vomiting called metabolic alkalosis, raised lactate, raised inflammatory markers and a borderline high inr but not too bad. So, in terms of the abdominal x-ray, this is what we have here. Um I'm not sure if you can appreciate the, um, the sort of the prominent valvulae Conte. Um, does anyone know how to identify the difference? It's probably difficult to, to get another reply from you. But, um, obviously you can see the green streaks of the prominent valvular conta and it's like pretty typical of small bowel obstruction. Um They also called the ple circularis, but they pass across the full length of the small bowel lumen. Um And is located more centrally as opposed to haustra, which, um, which you can see in large bowel obstruction and they're sort of not as central, they're sort of more peripheral on abdominal films. Um So that's essentially how you tell the difference, but that's quite a good x-ray to, to give us an example. So in terms of the right chest x-ray, um it looks pretty normal, there's no sort of evidence of any free end of the diaphragm. So I would say that's a normal chest X ray. Um I'm going to very quickly glance over abdominal x ray interpretation. Um Just because I think it can be useful sometimes. Um So the way I was taught it is at medical school is BBC. Um So B stands for bowel and other organs. So you've got your small bowel large bowel, liver gallbladder, stomach. So muscles, you can see your kidney spleen and bladder, not every abdominal x ray, you can see all these things on. Um, because a lot of the time there is some pathology in the, the small of the large bowel, sometimes you can see other things. So you were, I appreciate you're not going to be able to see everything, but sometimes you can just see the shadows and then you've got the 369 rule for bowel width. So three is for the small bowel six is for the large bowel and nine is for the cecum. Um So that's sort of how you would s say that more dilated and then b for bones. So you can see ribs, vertebrae, the sacrum, coccyx, pelvis, and sometimes proximal femoral fractures too. And then see for calcification another artifact. So a lot of the time you can see contrast, you can see renal stones quite easily. You can see like vas any sort of calcifications of vascular pancreatic gallbladder, costochondral origin, any stents, surgical clips, et cetera. It's very brief way of interpreting abdominal x-rays and then immediate management. In this case, there's three aspects. So as an F one F two, you're probably not gonna be managing any of this on your own or will need senior input quite quickly after you're close to reaching a diagnosis or knowing that the patient is this unwell or probably will deteriorate quite quickly. So it's important to escalate. Then the next thing is the need for further investigation such as it like CT scans or imaging. So in this case, act abdominal pelvis with contrast is urgent um to determine exact cause, define any anatomy and establish any vascular compromise. And it's really important to stabilize the patient and optimize her theater, which is probably very likely in this patient to unless there comes sort of a situation where you think that the patient is not fit for theater, which is different. So you keep them no by mouth, you'd say that ideally, you have two wide bore cannula for IV fluids and in this case, potassium replacement, um you'd insert a vials tube um to drip and suck, sort of decompress the stomach. So and prevent them from vomiting and aspirating as well. You saw them on some IV antibiotics according to your hospital guidelines. Um I think it, we it's usually iIn for any intraabdominal sepsis. Um You give them good analgesia antiemetics and optimized comorbidity is obviously varies differently for different patients. But um you, you may consider starting an insulin sliding scale and optimize the inr depending on the inr. Um The BNF does give a really good breakdown of what to give. Um for what inr when someone's on warfarin, sometimes it's just Vitamin K but if it's high enough, sometimes you have to give prothrombin complex concentrate to and you'd catheterize the patient. Mm Make sure you're sort of inputting the input output properly um to make sure, you know how much um sort of fluid requirements they have. Yeah. So strict monitoring is important. So in terms of escalation plans, people don't talk or teach about this very much at medical school, but it's really, really important as a junior doctor to think about it. Um and sort of nudge the seniors to think about things like this as well. Um Because if someone becomes unwell, there needs to be a plan of escalation. So involve a senior early, especially a surgical registrar. In this case, involve critical outreach team. There are good uh team in the hospital that sort of almost sort of mediate between you and ICU and a lot of time, a lot of times if they know there's a sick patient that may be for ICU level care, then it's good to get them involved. Um Is the patient for resuscitation or are they for, are they not, are they for full escalation? And every unwell patient always think about the setting of care. So are they ward level care? Are they for like sort of respiratory care unit, cardiac care unit or they for ICU? Um or they just for ward level care? A lot of elderly patients with multiple comorbidities, they won't be for ICU but they would be for sort of ward level care. Ok. It's very important to involve the family in this case, especially as the patient's likely for theater, you'd need patient's permission or family permission. Um Obviously, the the operating surgeon will need to gain formal consent, things to also consider, need to know someone's functional baseline. So that clinical frailty score and surgical candidates um who need potential laparotomies, we calculate what we call a NILA risk CALC uh score. So it essentially calculates the morbidity versus mortality for someone preoperatively to decide how important it is the surgery is and what their likely morbidity mortality would be. Um So it's important to sort of think ahead as well. Uh And then inform the onco anesthetist as they'd like, they'd need to do preoperative assessments. Um If it's obviously an emergency list and it's probably something to think about sooner. Inform the coordinators to sort of prep equipment and things like that. They'll ask you for the patient's allergies, what um procedure is going to happen. So it's good to clarify those things beforehand and liaise with ICU in case they're likely to need any ICU input or monitoring postoperatively and then they need to be consented by the operating surgeon. Um So coming back to this case, the CT Abd Pelvis report, it shows a small, right femoral hernia containing a small bowel loop, the proximal ilium, there is a moderately dilated stomach and jejunum with a large amount of fluid and air fluid levels within the dilators, small bowel loops and a transition zone within the right femoral hernia. So those two of the images that I've got and you can see the under there and you've got the fluid levels as well. OK. So in terms of definitive management for this particular patient, surgical management is obviously the definitive management. But obviously you've put in a vial tube, you stabilized the patient given IV fluids, IV, antibiotics, you've done all the basic things before that. So in terms of surgical management, she needs a femoral hernia repair plus or minus a bowel resection, plus or minus dober formation, depending on, depending on the sort of state of the bowel. Ok. So before we move on to the next scenario, um does anyone have any questions? You're more than welcome to just put them in the group chat? There will be a few more poles um when we discuss the next case, but if you, if you have any messages or questions, just please pop them in the group chat. Um I will be sending out a feedback form just at the end for you guys to fill out. Ok. Fine. Um Let's move on. So scenario two, we've got um you are an fy one in A&E and been asked to see the following patient. So, Andrew is a 19 year old male. He describes a two day history of pain in his abdomen. He's been experiencing some malaise and had a cough, but otherwise volunteers no further history. Ok. What do you want to know? We're gonna go through the history again. So history, two day history of pain around the umbilicus and right side of the abdomen progressively worsening. He's got an ache like pain. It's nonradiating, associated with nausea and vomiting times two since this morning, paracetamol and t seems to improve the pain, but he's not tried anything else and he scores it as seven out of 10. He's had the cough for around a week. It's nonproductive and dry. He's got increasing urinary frequency but no dysuria, no urethral discharge, he's had no change in bowel habit. So, what else do you want to know? He's got a past medical history of nothing. He is normally fit and well, um, he's on no regular medications. He's got no known allergies in terms of social history. He lives at university. He binge drinks socially. He has some recreational marijuana use. He is sexually active. Um, can I just say it's really important in sort of teenagers or like young adults in general to ask, um, a good sexual health history as well? Because a lot of the time they can have sexually transmitted infections. Um, and it's just important to rule out family history. He's got nothing. So, what differentials are you considering here? And I'm just gonna start the poll. Yeah. Ok. Ok. Cool. So, we've got a good mix of things going on. Um, some people think it's appendicitis. Some people, one person thinks it's uti one person thinks it's IBD. All right. Cool. Fine. Well, we'll find out soon. Yeah. So, yeah. Um, in terms of differentials you're considering at this point, it could be any of the following. It could be uti, it could be abdominal migraine appendicitis could be pneumonia. It could be levo capsule pain, could be nonspecific abdominal pain, but usually a diagnosis of exclusion more than anything. And then what are things that you don't want to miss things like appendicitis? A first presentation of diabetes, cholecystitis, pancreatitis. They can all be really dangerous and things you need to act on quite quickly. Ok. Sure. How do you want to assess the patient? Eight e just like the last case. So the a a assessment, the airway is patent, the trachea is central. He's got increased respiratory effort. However, he's got a respiratory rate of 24. His chest is clear. He's got good air entry bilaterally. There's no wheeze or palpitations. His heart rate is 100 and 10. So he is a bit tachycardic. He's got a regular pulse. His heart sounds are normal. He's got a cap refill of less than two seconds. His BP is 100 and 10/72. So relatively normal still, he's got reduced skin t suggests that he could be a little bit dehydrated, dry mucous membranes. Also suggesting you could be dehydrated. He's not catheterized in terms of disability. He's got, still got gcs of 15. He's alert. His pupils are equal and reactive. His blood sugar is 15. So it is quite a bit higher than you'd think for a normal person. E his abdomen is soft. He's got generalized tenderness. It's more tendon, the umbilical paraumbilical region. He's got no guarding or peritonism, no organomegaly. His calves are soft and tender and he's got a temperature of 37.2 in terms of investigations. So again, we're gonna start with the bedside investigations. So, observations, ecg urine dip bloods the same as last time. Um In this case, we don't know if it's a surgical course or you could potentially just hold off the coag and group and s group and save and cost much. But you'd want everything else imaging. Again, we don't know if completely necessary in this situation until we have a bit more information of what's going on. You could consider an right chest x-ray, although he's not described any epigastric pain, um abdominal X ray, it's difficult to exactly know, but it might be something you consider. So in terms of this ecg, um I'm not going to ask any questions here. Um You can see p waves, the heart rate is faster, it's regular, it just looks like a sinus tachycardia. OK. In terms of urine dip, there are three plus ketones. He got trace of leukocytes as well. And in terms of blood tests, we've got raised white cells, sodium of 100 and 32. So a bit low potassium of 3.2. So a bit low platelets, normal rare creatinine on the higher side suggesting that there's a little bit of arrangement in renal function. EGFR is seven. So borderline low CRP is 11 so a little bit high. His amylase is a little bit high but not very high. And he's got an IR of one on the VBG shows a PH of 7.32 PC, two of 3.3 HC three of 13, a base excess of minus 10 glucose of 18 lactate of 3.1. Um I would like to know what you think the VG shows. So if you could answer my pole, that would be great. Ok. Yeah. So most people think it's metabolic acidosis. So it's not a respiratory alkalosis because the P the PH is 7.32. So it's on the acidotic side, the, the bicarbonate is quite low. The base axis is, is quite negative. So you'd, in this case, you'd say it's a metabolic acidosis and yeah. Ok. Fine sir, there is some metabolic acidosis with partial respiratory compensation cause you can see that the P the PC two is a little bit low. You've got mild rise in inflammatory markers. You've got mild increase in amylase with the amylase. From my experience, you can also get a little bit of a deranged amylase with just like things like gastritis. So they'll be a little bit high but not very high, but it's not very specific. Um lipase is much more specific marker for pancreatitis. Um but it's not fully sort of um first line in all hospitals at the moment because sometimes it can take a long time for the lipase to come back. Um But I know in primary care they typically use the lipase more. Um but we use the amylase a lot in hospital, um be expected to be much, much higher in pancreatitis. Um Obviously, there is a mild arrangement in renal function as well. So in terms of the diagnosis, we think it's DKA because we've got a metabolic acidosis with a high um level of acidosis. So because we've got a low ph but my question to you is which of the following criteria is correct in the diagnosis of DKA. So if you could um fill in the final pole of the session, that would be great. OK. So we've got a bit of a mix going on at the moment. I'll see if anyone else responds to the other poll. Ok. Ok. So we got increasing number of responses to the last option and that is correct. So it's a, it's a bit of a tricky one because um it's very, it can be very difficult to remember the um the criteria for DKA. Um And obviously the other two options can be correct, but the very specific and correct option is um the bottom one. So we'll go through what um what the criteria for DK is. So a raised capillary glucose of more than 11 or someone who's a known diabetic. So this person is newly diagnosed, most likely or like his first presentation of diabetes is DKA. So a capillary ketone of more than three millimoles per liter or urinary ketones of um equal to or more than two plus of the urine and then a venous ph of less than 7.3 or a venous bicarb of less than 15. So, a lot of the time, don't worry if you can't remember it. Um because most hospitals will have their own um DK A protocol and usually it's right at the beginning of the protocol. So, um don't worry if you can't remember the exact specifics of it. So in terms of immediate management for DK A, um like I said earlier, it's obviously you'd start treating, but the, the most important thing is to escalate to seniors early because DK can be quite lifethreatening, um especially in someone that's young and may need ICU support. It's very important to escalate it early, especially because the fluid deficit can be quite significant. So, on that note, you'd need two white B Cannulas um usually in the um antecubital fossa and you start your local guidelines for DK within one hour. Um And we will go through the, the local guidelines for DK as well. It usually differs very little um from trust to trust, but largely it's the same and the patient is likely suitable for resource due to constant monitoring requirements. So if they're not in resource, it's a good um time to escalate to the sort of people in charge to, to make a B available if they're just in N A&E cubicle. Um it's important to monitor the potassium level and call the diabetes specialist team as well. So in terms of DK management, um there are different parts to it. However, insulin um is obviously a big part of the management and it's a fixed rate insulin of naught 0.1 units per kilogram per hour IV fluids. So before you start the insulin, however, you start IV fluids, there's no harm in giving a start bonus of 500 mils if you unsure what if it's a diagnosis of DKA. But if you, if you're fairly certain, it's important to start the IV fluid resuscitation immediately because this patient is likely in a deficit of liters of fluid. So the rapid resuscitation of IV fluids is very important. Most protocols will tell you to give 1 L over the first hour and 1 L over two hours and then another 1 L over two hours and 1 L over four hours. And because you're also giving insulin, insulin drives potassium into the cells, sir, you'll have a low serum potassium as a result of that. So it's important to replace potassium as well after the first bag. So most protocols will tell you to sort of replace potassium according to the, the levels I've mentioned. So if it's less than 3.5 it advises an urgent senior review. Um If it's 3.5 to 5.5 then you need 40 millimoles of, of potassium. Or if, even if it's less than 3.5 that's what you're more likely to need. Um just um a separate point, you shouldn't really be giving more than 10 millimoles of, of potassium generally in an hour. Um But obviously, Indica can be a little bit difficult because they're, they're likely to lose potassium quickly. Um And then if the potassium remains above 5.5 then you don't need to give any potassium with it. But it's important to keep monitoring. And then you also need to do hourly monitoring in terms of EB GS to see if they're still acidotic and what the bicarbonate is doing and what the blood glucose is doing. So, in terms of the treatment targets for DKA, this is what you'd expect once you've commenced treatment. So you'd expect the glucose to fall more than three millimoles per liter per hour until the glucose is less than 14 millimoles. Uh You'd expect the capillary ketones to fall less than to fall no 0.5 millimeter millimoles per liter per hour until it's less than naught 0.6 millimoles. And you'd expect the venous bicarb to rise more than three millimoles per liter per hour until it's more than 15. So, essentially, that's what defines you to be out of DK A and that's what you'd expect. So once the parameters have recovered, you switch the patient to subcu insulin and able to eat and drink whilst on the IV insulin. Um Something, something I also want to mention is that if someone is a known diabetic, you have to keep them on that long acting insulin throughout this. Um so never stop the longacting insulin. And in terms of the rest of the recovery parameters. So once the venous ph is more than 7.3 of the blood ketones are less than a 0.6. If the patient isn't eating or drinking, then switch them to a variable rate insulin from the fixed rate insulin. Once that they are reliably eating and drinking, then you can switch them to subcut insulin. Ok? A lot of the time the diabetes specialist nurses will give you advice on when you can do what, but it's good to know that when someone's reliably eating and drinking at that point, you can then switch them to subcu insulin. And then a lot of the time the diabetes specialist team will review prior to discharge to then sort of organize community follow up, um, if needed and they'll play around with any um, diabetic medications needed, especially if they're type two diabetic. Um, but generally not in DKA, but if they need to adjust any sort of insulin doses, then they will. So like I mentioned previously, it's really important to um assess someone's escalation status. So in this case, you'd involve a senior early, which would be the medical registrar involve the critical care outreach team and the diabetes specialist nurses. Um make sure that there is a resource bed available if the hemodynamically unstable and need monitoring. Um In this case, the patient would be for full escalation because they have no past medical history and completely independent and quite young, fit and healthy person. So they would most likely be for ICU level care if they were to deteriorate quite quickly. And it's important to involve the family, especially in a young adult like this. So I know that's quite a lot of information. Um And I'm sorry if there's anything that I haven't addressed in these scenarios. Um I'm more than happy to take questions, but the the the take home points for this would be abdominal pain is not always an acute surgical abdomen. There are many times as a surgical acedia that I've come across many non-surgical abdomens and it's very important to be able to differentiate between the two. Um Sometimes it's very difficult to do so. Um and the most you can do is make sure you have all the relevant investigations in front of you and doing a thorough a two E assessment to try and sort of come narrow down the differentials before you start ordering imaging and stuff. But sometimes any imaging can really tell you what exactly the diagnosis is, sometimes it can't tell you that either. So you've got to try and do as much work as possible before that. When in doubt, go back to the A two E assessment DNA to E, don't ever forget the glucose. It's, it's massively overlooked. Um, but it's a very, very simple test and it can tell you a lot. So, don't ever forget the glucose. Um, always consider patients baseline function comorbidities, especially when they are potential surgical candidates. That's very important because if someone's potentially for surgery, however, they have a very, very poor baseline function, then it might be that they would need conservative treatment and surgery would actually would not be in their best interest at all. So for that reason, it's important to sort of gauge the baseline function early. So you can report that back to seniors escalate and ask help if you're ever unsure. Um Sometimes is it can be very difficult to examine a surgical abdomen. It's difficult to examine hernias. My advice with hernias is to examine patients, um stood up, especially men. Um uh you should be examining hernia orifices in everyone if, if they're a surgical patient and never forget all these sort of additional investigations like las lactate urine dips, pregnancy tests and ECG S when investigating abdominal pain because you never know what else it could be. Um There are many times that I've come across many gynecological problems. So, um make sure you get a good sort of past medical history from the patient with regards to sort of gyne history as well is my advice. So that comes to the end of the presentation. Um If anyone has any questions, feel free, please feel free to sort of just pop a message in the group chat. I am going to send a feedback form in the group chat as well. So please, um, fill that in. I'd be very, very grateful. Um Yes, of course, one second. And so that was the ECG, I don't know, I can't see any messages. But did you have any questions about that or is that? Ok. So it's very, I don't, I don't know if you can see the ECG properly, but the reason I'm saying is atrial fibrillation is you can't see definite P waves and it's an irregular rhythm, an S VT, you'd expect it to be more regular and usually faster. Ok, sir. With atrial fibrillation, obviously, you're looking the, the first part of the ECG is that you're looking for P waves. It's very difficult to, to find any P waves in this particular E CG, those more look like T waves rather than P waves, especially in the rhythm strip. You can't see anything. Usually you can see P waves quite well in V one very difficult to appreciate any and the same with any of the leads as well. You can see more sort of T waves rather than the T waves themselves. It's an irregular rhythm as well, which you wouldn't, which you wouldn't see in other cases. Is that ok? Ok, great. Um, it might be worth um, us doing a session on ECG S as well. If, um, you guys are interested then that's something we can definitely do. Does anyone have any more questions? Um, ok, fine. I don't think there are any more questions, but thank you so much for attending and please please please fill in the feedback if possible, be very much appreciated. That's the only way we can kind of like gauge um how many people found it useful and what I can do to improve the next session as well. So, thanks very much for attending. Um And my email is in the group chat. I'm just gonna pop into the group chat in case anyone wants um to send any further sort of suggestions on teaching you'd like. Um I generally do the ask to see the patient sessions. Um So if there's anything in particular you think you're struggling with, then please let me know. Um And if you have any questions about anything um life in the UK working in the UK, um I'm more than happy to help with that as well. So that is my email and thank you very much, everyone. Have a good night. That's fine. We can definitely do more E CG sessions. Um If you want the slides, then you can email me and I can send them to you via email. But I think you can also, um, I think you can also rewatch the presentation on Metal if I'm right. But if you want the slide specifically, then you can email me. That's great. And we can definitely do more cases about EC GS. I'm sure someone will be able to do that for us. All right. Goodnight everyone.