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Hi, everyone. Welcome to Co Blue's final session for gastroenterology. Um So we'll just wait for some more people to join and then I'll hand you over to Hina and Elena who are going to the today's session. Um So we'll just give it a couple more minutes. Um And then I'll hand it over to them. Um And any questions feel free to put them in the chat as we go. Hello? Hi, Elena, there is able to get on the stage as well. Ok. This is my first time using this application. I'm, I'm not 100% sure how it works. So hopefully if you just click when you're ready, um the little sharing button, hopefully it should that you guys share your slides. Um I'll just be here monitoring the channel M off um and camera off as well. Um But obviously if you guys have any problems, let me know. Um I think we're nearly at the max. I think maybe a couple more minutes and then you guys can start if you want to. Does that sound? OK. Yeah, perfect. OK, perfect. So I'll just micro the camera off. Um I think we've hit a pretty solid number of people. Um If people still join, that's fine, they can come in. Um And yeah, guys, just as a thing as well, feedback forms will be automatically sent to the end. Um And slides will also be uploaded and sent out to everyone that fills in the feedback form. Um So, yeah, without further ado, I'll let you guys take it away. OK. Thank you, sir. Are we showing the presentation or? Yeah, are you pulling it up? Yeah, cause I, I'm on my phone cause I didn't manage how to download it on my computer. Yes. If you guys just share your screen, maybe if you share your screen, if possible, I think you're on mute. There we go. Perfect. OK. Thanks. You know, I didn't, I'm still a bit confused with this application but I think it'll be OK. So thank you everybody for joining. I'm not too sure how many people are in the session as I um can't really see anybody. Um Do you know how many people are in the session? Hina. I have no idea. I can't see it. There's 41. OK. So there's quite a lot of us. So lovely. Um So my name is Elena. Uh I'm currently in fy one. I was about to say fifth year medical student. But no, yeah, F I one, I'm in um North Midlands, so it's still on Trent Hospital. Um And yeah, I'm currently in geriatrics and then I'll be moving to general surgery. Yeah. And I'm here now. I'm another f, one. I'm down in Basingstoke in Wessex. Um, I'm just on general medicine at the moment. It's just a bit of like an acute internal medic medicine ward. Um, so it's a little bit of everything and, yeah, enjoying it sometimes. And gastroenterology is very important, especially if you have any general job. Am u, a lot of gastroenterology comes up. Even some geriatrics, obviously not as much. But, you know, it's one of the main topics of general medicine. So we'll just go through it. How we've created the session is we'll just talk through a bit about gastroenterology, but obviously because there's so many diseases, we thought it would be also helpful to maybe do a bit of Os practice. So if later on we could get some volunteers and we could practice that and then do something of that. So we can just see how it, we get on. Ok. There you go. Yeah. So these are the partners for, for Akie Blue G medics and stuff. Yeah. Um Yeah. So first thing is, what is there even in gastroenterology? There's a huge one list on the UK MLA website that's got goes through it all. And it's just a good thing to, I think, cast your eye on when you're going through your revision just to make sure you're not missing anything that, you know, you were taught in third year and it's been two years and you've already, you know, you've forgotten it or missed it out. Um, so it's just a useful list to find online. So a big long list of all sorts of things. Um, and Gastro is one of these really big ones, obviously cos you've got your upper lower and then you've got all of HPV as well. So it can get a bit. Yeah, a bit overwhelming sometimes. But I think if you just, it's stuff that we know, but it's just all kind of, it, it can be a little bit bitty sometimes. So it's just a useful list to have. I think the other thing about Gastro as well is that it's, the symptoms can sometimes be quite unspecific and you get all these other diseases that can masquerade as gastro symptoms, like, especially in women, um, or, or kind of a cardio sort of thing. So, I think it's one of these ones that's always worth bearing in the back of your mind. But just because someone comes in with what you think is a gastro symptom, it's not always gastro, it's just a very vague presentation a lot of the time. So, yeah, there's a list, but also it could be so many things. So I think keeping an open mind is always important, but this is just a useful list and in terms of, um, how well come up in your office, these cos, that's what we kind of wanna focus a bit more on today because you have five years of people telling you about, you know what, you know, refluxes and this and that. So it's just more useful to go through CCA stations. Obviously, you've got your history taking and your examination ones. But you've also got the A to E stations which I think are new in fifth year and then the same explanation and data interpretation stations. So we've got the four of the five of them. So obviously not the examination one today. Um for some of you guys to try out. Great. So some typical things when we think of gastroenterology, the usual symptoms as Hina was saying, it can be quite re uh quite broad and also a lot of things can masquerade it. So just it's always good just to have an open differential list whenever you're going into, let's say an A se a history taking. Even if you're thinking it's Gastro, there's always having an open differential list and thinking of any anything that it could be so usual things that we think of on gastro, obviously diarrhea, constipation, vomiting these things. It's just always important to us. How much of it, how often does it happen in the nighttime? Uh What color consistency and the content, especially if we're thinking of, let's say vomiting is there blood is it could be an upper G bleed, is it um diarrhea with mucus? And then we're thinking about um like Crohn's disease also with that weight loss and appetite and intake changes. Um, so, and with weight loss, it's very important to think about. Was this wanted weight loss? Were they, let's say, eating healthier or for what? Or let's say geriatrics, maybe they're with dementia, maybe they're not eating as much or is this, they're just doing the exact same thing and for whatever reason they're losing weight. Uh And with that, obviously other gi symptoms that can join in with those two, then another important one is dysphasia because when we think of gastro, obviously it's from all the way up from the esophagus down to. Hello. Oh, sorry about that. I tried to mute my phone actually. Perfect mode. Sorry about that. Uh, anyway, so I was saying about dysplasia. Um, so that's very important. The esophagus all the way up to the colon and the anus so important with dysphasia would be the esophagus and the, the stomach. So thinking, is it dysphasia to solids, liquids or both? And which came first? Actually, something that I just recently learned was the, the reason why there's first, um, dysphasia to solids, you can have dysphasia to liquids, but not too solid. It's the fact that liquids just go down with gravity while sol solid you need like the actual peristalsis of the esophagus to actually bring it down. So that's like helpful to know what kind of dysphasia it is. I just found out recently, I actually didn't know when I was 1/5 year medical student. Uh, and then is the dysplasia constant? Is it intermittent? Is it getting worse? And also with that adephagia. So, is it painful when it's swallowing? Another important topic? Is reflux dyspas dyspepsia? Again, that could be mass as or thought of as chest pain or a heart attack or even pleuritic pain. Um, so yeah, just explore it as a pain and then think about red flags in terms of gastroenterology, anemia. So f for gastric cancer and then with anemia, obviously think about all the symptoms of anemia and the different uh symptoms that can happen with the different types of anemia. Like with iron deficiency anemia, you can have the nail changes, um being hungry for eyes, all these things, uh loss of weight. So as we said, the weight loss is an unwanted anorexia. So, um no hunger, uh recent onset of progressive symptoms, Melina. So uh the black stools, hematosis, swallowing difficulties. I saying with dysphasia, if they're over 55 years old, that's obviously a red flag and then over four weeks and then also persistent vomiting. So just thinking about all these things where we're thinking, ok, could this be uh just a normal gastroenterology presentation or could be there's be something more sinister going on and also with the g also change in bowel habit, as we were saying, obviously, with the diarrhea, constipation and rectal bleeding. So now that we've gone through all these gastroenterology symptoms, as we said that there's so many conditions that we have to think about it and whenever you guys revise, just, just go through the UK MLA website and there you can see all the different conditions for each of the specialties. So we just showed quickly what was there for gastroenterology, but just to make sure that you have all the different conditions that you need to know. And then, yeah, just thinking of gastro from sort of, yeah, from the mouth all the way down. Uh But just for the sake of time because we wouldn't really have time to cover all the different diseases. Uh We just thought we would do a bit of practice as I know, you know, obviously it's a bit early. So for the ACA but it's good to just get some practicing early, especially here. So we have a history taking a station, sbar station and a data interpretation. So everything should be uh stuff that you've already done except the A uh do you guys, are you aware well about what the A two E station entails or do you want me and hina to go over it before? Let's say one of you guys give it a go if you can just put it in the chart cause I can't really see many of you. Yeah, I think a couple of people are asking us to go through it cos I know there's something we really struggled with last year, not being taught until kind of, it was slightly later on in the year how to actually approach an E to E station. Um And yeah, it's kind of your bread and butter when you actually get onto the wards. So it's definitely something useful. Um Do you want to go through it here now or should I go through it? We could do one. I think the key is with an A ce station is just say every single thing that you're thinking. Um And that'll get you through, even if you think it's something like daft or you're not sure if it's right or not just saying it, it means that the examiners know that you're thinking and like using that critical thinking and thinking about red flags and all this stuff. Like in one of my ay, I got feedback saying I thought you didn't know what the diagnosis was because I was keeping it so close to my chest cos I just wasn't quite sure. So just say everything that you're thinking the whole like 100% of the way. So when you get in and the patient starts talking to you, the sp starts talking to you say I can assess the airway because the patient is speaking to me. And I know immediately that means that the airway is patent and then for a, that's a really easy way of just taking it off. It's, it's so easy, but it's so important as well. And if you just kind of um, talk through it and speak out loud, the dominant can't fail you. They, they, yeah, because I know, you know it when you've proved it. And I think also for me personally, it was just to make sure you have an open differential list. Let's say, even if we're thinking gastro, if it's a woman that let's say come in with, um let's say some suprapubic pain. And then we're thinking, oh, is this a uti or is this um I don't know, you check or like Crohn's disease and then it's like, oh then you're missing the gynecological diagnosis. So even if you're just think of it as a pieces to the puzzle, but they don't get so caught up into one diagnosis like one of the practice stations that I did. It was a woman that was being treated for cellulitis got a dose of antibiotics and was now scoring new score of eight. And I was like, oh, this is sepsis initiating the sepsis six and turns out and I had looked at the drug chart that she wasn't allergic to the antibiotic and, and then I was starting the sepsis six. And then all of a sudden she's not breathing, the airway is compromised and it's like, ok, it's that anaphylaxis now. So it's OK, you're thinking the wrong thing. Just keep uh keep looking at what the patient uh is doing cause let's say it might be that the patient changes, it might be, you're starting an a and then all of a sudden the, the patient crashes or, and you have to, let's say, do CPR or whatever that may be. So, just making sure you're having just a broad list of differentials in your mind and then just um assessing the patient and making sure it's what's in front of you that's telling you what's going on, not what you're thinking. So, yeah, I, and if you're barking up the wrong tree, they'll just tell you they'll hover you on and say, oh, what else could it be? They'll help you out. They don't want to fail you. Some of them are obviously nicer than others. But if you're completely wrong, they're going to help you and bring you back a little bit and be like, what else? What else until you get it? So if you go in and you start saying, oh, they're airways patent because they're talking and they go, is it, you know what that means? So, yeah, always. So from Oh no, no. Yeah, go ahead. No, it's ok. No, I was just gonna explain how it works in the station. That is you, it's you with like a mannequin and then there's the examiner there. I mean, make sure you check whether it's changed for this year. Maybe they have better mannequins. I don't know. But for, from uh, when we did it, it was just a mannequin that was kind of just like a dummy. Basically didn't really even have breathing sounds or anything like that. I know other medical students do do that. Um But from our perspective, it's just a dummy and let's say you're just breathing, you're just like with a stethoscope listening to the airway and the, the examiner will tell you, oh, you can hear a wheeze, you can hear crackles, whatever cause you wouldn't actually be able to hear anything or like actually do anything. It's just a dummy. But then you just say, oh, I'm listening to your chest, I'm checking cap refill time and then they will tell you. So we just go through the A two week quickly cause we're blabbering on a is airway. And so it's just uh I'm guessing you guys have probably been told it before. Obviously, airway uh the at E is whatever is gonna kill the patient first. So airway oxygen inside then that's the most critical aspect that you have to think about. So if the patient is talking, then you know that the airway is patent. If they're not talking, then, ok, then now you're worried if they're not talking and then they're not breathing, then obviously, you have to go to the A SS pathway, but if they're not talking, but then they're breathing, you have to check why they're not breathing during the head tilt, chin lift maneuver. Having a look inside the mouth. Is there any um anything cloaked inside could be a child that could it be anything that you can aspirate out anything you can take out physically or if it's an anaphylaxis of uh obviously the airway is compromised and then they obviously we will have to speak to anesthesiology. But for what you can do there, if the patient still semi uh if they're having any snoring sounds, gurgling sounds which get better when you do the head tilt chin lift, then if they're still semiconscious, then you can put a nasopharyngeal airway in as people can tolerate that the best. Then if that's not working, then you can try the, the oropharyngeal, which is, you know, the, the gel, I think they're called, you know, the oropharyngeal, the different colors and then just measuring it out. And then if not, then the eye gel is the more secure airway and then obviously calling anesthetist. So that's a and then also if you think that the airway is not patent, then usually straight away you put 15 L of oxygen on. Do you wanna go through b you know? Yeah, so be, I mean, it's just, you're the same as how you start your rest of the time you're gonna, you know, be checking your cap refills. Oh, that's more serious. Those um but you know, checking your tracheal deviation, doing your breathing, your precautions, do the whole thing that you normally do in your respiratory exam. Except that is just your be, and you're talking through it, the, and the examiner will tell you what their oxygen that's are, um, as you go, but you'll, you'll ask them or I'll, I wanna know like what the oxygen sets are, um, and make sure you, you auscultate. So even if you, you can obviously ask the examiner what would be the breath sounds, you need to kind of go through the motions, make sure you're really kind of showing off what, you know what you're thinking, what you're wondering what you wanna know from them. Um Yeah, that's really for, yeah, and then for B is getting the re did you say sorry, respirate uh oxygen starts and then in terms of like the investigations that you're getting respirate oxygen starts, um uh let's say like airway sounds and then you usually do chest X ray. If there's anything that you find in the chest, always ask for chest X ray in terms of interventions. And then also if it's um yeah, and then an A ABG, then C is circulation. So just looking at the circulation D disability. So just that's BMS temperature pearl score and E is just having a look at everything else. Uh But yeah, I'm sure you, you'll get told that more as well in medical school, but we can just have a practice today and just see how we get on with that. And you know, then we can talk about that further as well. But just to get some learning in. So does an, would anybody like to volunteer to do our first station? It, it would be a history taking station? Anybody would like to do that. Yeah. Hopefully we've got someone, um, I can't see the chat on my end, so. Oh, lovely. I don't actually know how we get them to. Oh. Is still in the call? 00, you can go to people. Oh, yeah, I think should still be in the if you just invite them to be a speaker that should work. Let me know if it works. If not, I'll do it if you let me know who you will invite to stage. Yeah, that's all right. Perfect gift. I'm going to invite you on. Thank you and apologies. I we're newbies to this uh this up. No worries guys, how that worked. So, I don't know. Oh yeah, there's an extra speaker. Is it gift gift it? Yes, there we go. There we go. Thank you for volunteering. It could have got very, very awkward that pause. Um So the first one we're doing is just an o sorry, a history taking station, sorry. Um that we've got, if I get the side up, we've got a bit of a brief there for you. So you can just take a minute to read that. So if we just ask everyone else in the in the chat, you know, think about feedback and we'll ask the BNP guys to just pop it in the chat or speak up about, you know, what went well, E BI S and all that kind of stuff. Um, and I'll be the SP and Elena can do the examining. Um, Elana. How long are we gonna do for the station? Just five minutes? Six minutes. Yeah. Well, let's do six minutes and see how we get on. Obviously we don't get through everything. That's ok. It's just, yeah, for, for a bit of learning, isn't it? Yeah. Um, yeah, perfect. Ok. Give, just let us know when you're ready to start and, and, um, you can, and we're in a, we're in a, a GP surgery. Ok. That's fine. Yeah, I'm ready now. Yeah, perfect. So you can take it away when you're ready. Ok. Hello? I am good and I'm one of the g on the world. Um, is doctor, um, ask you some questions? Yeah, of course. Ok. Can I just confirm your full name and how old you are, please? Yeah, I'm Mary Smith. Uh, you can just call me Mary and I'm 77. Ok, nice to meet you, Mary. So, Mary, why have you come in today? Um, I've just been really constipated. I see. How long has that been going on for? Um, maybe about a month or so. Ok. One month. Ok. Is it ok? If you could tell me more about the constipation you've been feeling? Um, yeah, I mean, I, uh, I just haven't been going as frequently as I normally do. I see. Um, so how, how often do you normally go to the toilet a day or a week before? Uh, normally just once a day, normally. Um, just, yeah, normally in the morning, but I'm usually quite regular before this. Uh, so now how often do you go to the toilet? Now, um, it's been like, maybe three or four days and, and yeah, so it's just not, it's been a lot less frequent. Oh, sure. And this question, is this something that started suddenly or more for blood work? Um, I can't really remember. I see. Ok. And, um, is it, does it always, uh, no, sorry. Um, sorry, II was just thinking of a question. Um, apart from the constipation, do you experience any other symptoms at all? Like what, uh, any pain? No, not really. No, the stool, the appearance of the stool has that, um, it's maybe like more hard and dry than, than it usually is. I assume. I see. Ok. And have you noticed any blood in there or anything like that? No, no, no, nothing like that. No. Ok. That's fine. Thank you. And have you noticed any, uh, unintentional weight loss? Oh, no, I wish. No, no, it's fine, thank you. Ok. And how are you like feeling in general? Um, yeah. Ok. Ok. Do you feel, uh, more tired? Um, no, no, he say so. No. Ok. Um Have you experienced feeling more cold? Um compared to people saying they don't feel that way, you know, are you feeling more cold than usual? No, no. Ok. That fine thank you. Um So going back to the constipation you've mentioned, so you mentioned that it started like about a month ago, you know, you used to go to toilet like about three times again a day. Now you feel like you don't go to toilet even for three or four days, you know. Um, and you don't feel any pain and the stool sort of look dry and hard as well. Mhm. Ok. And, uh, the constipation, how has it been since it started? Like, has it gotten worse or is it the same? Um, no, it's been about the same, the same? Ok. Yes, thank you. So, I'm still going to ask you a more set of questions to help me rule in or rule out seriously. Have you at any point experienced any nausea or vomiting? Uh, no, no. Ok. Any change in your urine, you know, your water work. No, no, no, any change in your appetite. No. No. How would you describe your diet? Oh, it's maybe not the best. Um, I just eat, yeah, I like the, I like sweet things. I see. Do you try to take in, um, enough veggies and fruits in your diet? I've never been very good with that. No. No. What about, uh, water? Do you try to take enough fluid. Mm. I'm ok. Maybe I could drink more, I suppose. Ok, thank you. Have you noticed experienced any fever or recent illness? Uh, no, no. Ok. That is fine. Thank you. So, the next question I'm going to ask is a bit more about your background. Um, do you have any idea what might be causing your constipation, you know, causing to put down? No. No, I'm not sure. Mm. I see. Is there anything that particularly worry you? Um, well, I, I'm, I'm just a, a little bit embarrassed by it because it's just, you know, affecting my life and just feel a little bit embarrassed more than anything I should. Ok. I will, I will ask you a bit more questions that, ok, so II could find the best way to, ok, less, less than a minute left. Sorry. Say that again. Sorry. So that there's less than a minute left. We're just doing a quicker one. Sorry. Um, um, what, sorry, you got one minute left at the stage? Ok. That's fine. Thank you. Ok. Um, do you have any medical condition? Um, I've got some rheumatoid arthritis and, and some high BP. Oh, I see. I see. Thank you. Any allergies. Uh, no, no, none that I know of. Ok. Do you, uh, drink or smoke, uh, um, uh, or smoke? No, no, I don't. Ok. Um, as you mentioned that you got rheumatoid arthritis and high BP. Do you take medication for those? Oh, yes, yes. Um I take some methotrexate and I take uh Lisinopril, Lisinopril, right? Sorry. Time stop here. So now he now will just ask you a few questions, ask him the questions so I can ask him, I'll, I'll ask you a few questions as the as the examiner. Uh So give, what further clinical exam slash assessments would you like to perform? And people in the chart also feel free if you wanna a answer that as well. But so what further clinical exam slash assessments would you like to perform? Um um uh abdominal um examination um as well as a general examination and uh and the other set of observation? Ok. Thank you. So, what are your differentials and most likely diagnosis? Um I'm really struggling to be honest, my differential here. Um I'm going to go with IBS um Maly because, you know, she's a female young um and she does not like have any particularly red flags like um you know, uh Melena or any of those. Um However, the camera is not long enough to actually diagnose her, but just sometimes I will take into mind. Uh second. Ok. Anything different. So maybe um divert uh di diverticulosis uh because of the person lack of um fiber in their diet and a and uh not enough um uh fluid. Um Yeah. Mhm. Um Yeah, I guess so. Um Anything else you can think of or anybody else? In the chart. Mm. Yeah, we also want to rule out colorectal cancer. They're very unlikely but just something to rule out. Oh, yeah. Yeah. Yeah. Bowel cancer with something to rule out other. It's kind of benign, the red flag, like white, stuff like that. But, you know, n, yeah. Yes. And what would you think in terms of management for, for right now, uh, management? Is it for bowel cancer or just in general? I mean, if this person comes to the GP clinic with these symptoms, what, what are you thinking? You, you, so I guess I mentioned the other full uh set of herbs. Um Maybe it was either like a best side test. Um I'm not quite sure what the side test. Um, no other blood. So mainly like full blood count for like anemia. Um What cell count on the um in uh inflammatory marker for infection, the screen for infection? Um um uh uh another um you want a as well as um I, I'll have to process for baseline for medication. Um uh and obviously for imaging will be like endoscopy. Um I think she the uh two week, two week week criteria, uh referral, you know, the cancer part with referral because she's over 60 present with, you know, uh change your bowel habits. So I would definitely refer her, you know, within two weeks urgently uh for endoscopy to rule out uh bowel cancer. Ok. Thank you. Thank you. That was great. Thank you for for volunteering. So the only thing that we, we were missing in terms of the history was um always if you're thinking about it, just keep asking the questions. In this case, she also had some overflow incontinence. So especially if we're thinking about constipation. Are they having um, some, you know, obviously some, they just find maybe some stool in their underwear or their, yeah, obviously some incontinence in, in their bowels. Um But yeah, I think there's a good full history. Thank you for volunteering again. Um And I'm not sure I didn't really quite catch if you did eyes but just make for right now in the practice is ok, but just make sure and in the OSC definitely make sure you do ice. That should be at one of the first things that you guys do cause if you don't do ice in fifth year, they'll um, yeah, they'll get quite angry. So it's ok now. But yeah, just make sure you, you think about that mainly and then just in terms of clinical exams, if this person comes in and just don't forget Dre, especially if they're having constipation. Uh It can be very helpful if there's any hemorrhages. Is there actual, I have, I mean, in geriatrics we have lots of patients with constipation. So to be honest, I do dr es quite a lot to see whether is it is like a fecal impaction because if they're so constipated that you would need an enema, you would have to do a dre first to see, is it um fecal impaction that needs an enema or what kind of constipation is it? And again, can tell you if there's any, also any palpable fecal masses. And if it's a male or you can also uh have a look at the rectum or if there's any signs of hemorrhoids that could be causing, let's say any bleeding, if there was in the stool or the hemorrhoids could be causing the constipation. Let's say it's painful to pass, um pass a stool. That could mean that over time, let's say people could become constipated, which could then cause the overflow incontinence. Um with, if it's an older woman, especially with constipation, it's important to think about a probably, I mean, Erry. So I think about obviously older people, but just thinking about also as part of the pinch me criteria. So a person comes in with delirium, uh obviously like a geriatrics patient comes in with delirium. It could just be quite as simple as they're constipated. Usually a lot of times uh uh medications wise. So that's why it's important to see what the medication things like codeine. Um all the opioids cause constipation. So just make sure you, you look at the drug history and then sometimes when, if you're ever prescribing opioids, make sure you also think about prescribing some blood sensitives alongside it to make sure the bowels um regularly, sorry to interrupt. I was going to say it was a very good history. We could tell that you were thinking about all the differentials like we were talking about in the beginning. Things that can masquerade ask me about, do you feel cold? The hyperthyroidism side of things? It showed that you were thinking about a wider picture on a patient as a whole, which I thought was really good. Um And you were very nice. You were very polite and I think, yeah, you did do ice, but it was later on and my thing was that I would just always do it as soon as you ask the first couple of questions, just kind of for your own peace of mind. It's not necessarily what you have to do, but just in case you end up getting caught somewhere else and missing it out and then it's just off your mind. But it was a very good history and yeah, it was good clinical reasoning and such and everyone in the chat did lots of good. Yeah, talking about pain killers and dairy and everything. So you did very well and you were in front of everyone as well. So, thank you. Thank you so much for volunteering. Thank you. I um I want that so much. It forgot how old did the that will happen? No, no, that's fine. And again, that's something in the real a it will be like they'll have something that looks like that. So you don't have to worry about, you know, 20 year old doing a 70 year old. But no, that was very good. Thank you so much. Um And then should we crack on with the next one then? So the next session is a bit of a two in one. So if we can get one volunteer to do the at session again, if people, obviously, as we're going through it, we have a main volunteer. But if you wanna go through and just do it, sort of if you have a piece of paper on your phone or whatever and also go through the station for your own learning, I think that would be quite, you know, quite useful for you guys. Uh So we're thinking about doing an at E station with an SBAR so one person could be doing the at E SE and at the same time, one or if a few people obviously wanna do it just doing the SB a method of the at E set and then can present it back to, to hina or myself, I'll be the one doing the at station. So then the sbar, if you would present it to hi. So if we can get one volunteer please to do the at E station again, the rest of you, if you wanna just do it as well on writing it down or anything, and then if we can get at least one other person to be doing the sbar as we do the A to E section. Yeah, if anybody volunteer I can't see on my screen. No, no one yet. Um, I mean, we could just do it as I think in the chart so everyone can just have a go and we'll just work through it a bit quicker as well. We can do it then with him and I sort of, we can do it with between us, let's say and then yeah, we'll just ask something and if everybody can just write it down in the chart um and then just the sbar as well maybe on the chat as well afterwards after the 18. Ok. So should we just guys? Sorry, you do have a volunteer work has. Oh, so I apologies. I can't see it from my screen. Oh, thank you James for volunteering. Oh, shall I let me do this thing? Um Yeah, sorry. You're gonna have to lead with this. I'm sorry, James, I'm just adding you on now. Ok. No. Is that the same one? Yeah. Oh, there we go. Ok. Lovely. Hello. Ok. Yeah, just one second. Ok. No worries. Ok, so yeah, so this is the station. Oh, sorry. So this is just the station for, for you James and for everybody to see. So you've been called on to the ward to review this 56 year old male unwell patient complaining of abdominal pain and vomiting. So if you just see the outside the station, you can obviously take a few seconds, just think. Ok, what could be going on and then whenever you're ready, we can, we can. Ok. And this is a section. Yes. Ok. So we'll do it like there's a fake patient there and I'm like the examiner. So you just ask me stuff and I'll, I'll be telling you all the findings and everything, how, how they would do it in the Os. Ok. Sure. Um So II walk in the room make sure there's no obvious danger. Um Just because I don't know what the environment is. Um And then I'll go up to the patient and say hello, my name is James. Um I'm one of the doctors here. Can you hear me? All right. So, but II don't know whether I'm looking at an, ok. I don't know if I'm looking at an unconscious person or whatever, but yeah. Um, well, you can even ask that you can ask that to myself. Ok. Um Could you just confirm your name and date of birth, please? Yeah. So, so his name is James. Hi. Oh, sorry, not James. He's uh Bart and he's 56. Ok, thanks. Um I hear that you've been a bit but I'm not thinking of history. Am I? So should I just go straight into the fact that airway is fine? Yeah, you can even ask, sorry, just not to cut you off just before it uh you could even ask, let's say uh is there anything that we know about the patient to the examiner? Because so the patient is there, but you can just be asking questions, like, do we know anything like any past medical history? What does the patient look like? So, you know, be free to ask me all those questions. Ok. Sure. Uh So yeah, um what do we know about the patient so far? Yeah. So we know as part of his past medical history, he has alcoholic liver disease and hypertension. Ok. Um Shall I go, I'll go to examine him now. Um So he's told me his name was date of birth which shows that his outweighs patent. So then I'd start checking b so I'd want to assess his respirate, get his po two down um check for things like half pill. OK. So, so how you would do it? So you just ask by one by one, sorry to cut you off again, just ask one by one and I'll, you know, you, you physically look at the chest and then I would say like, OK, the respirate is this? And then OK, what is the oxygen saturation? And then you would pretend you're listening to the lungs? What, what can I hear and stuff like that? Yeah. Um So if you want to try like sure. OK. So um looking at the chest, I'm just gonna come for the respirate. So the rest rate is 19 breaths per minute and, and then I'm just gonna apply this uh sax monitor to see what the SP two is. So 89% on room air. Ok. Um, the oxygen is a little bit low. So I want to um give you some nasal specs for now. Um give him some oxygen and how many liters of oxygen? Um It's a bit weird. I can't see the patient to see if they're acutely deteriorating. All. They're just a little bit on the low side. But like I could either do 15 L normally breathe or just some nasal specs for now, but I'll go 15 L normally breathe. Um check for um chest expansion so that that's normal. Ok? Um and then have a listen to the chest. So let's have a look of on front at the top first and then yeah, nothing, nothing remarkable on the chest. But you can see on the mouth that there's some vomiting, dripping of the mouth. Ok. Uh Just to check. So he's been vomiting but is the airway clear cos he was speaking to me? Yes, the airways paper. Um Oh I go to see um check for cap refill. Yeah, so the patient sign, no, top refill time is six seconds. Ok. Is that peripherally or central, peripherally sinus? Ok. And the oh cap refill times peripherally as well. Do we have a central cap refill as well be? Mm. No, but the main thing he just has, you know, he's look, feels very uh cold in the periphery, that's fine. Um, and check his pulse. Yeah. So the heart rate is 100 and 53. Ok. Regular. Ok. Um If I check his carotids, can I check for like uh character and volume? Yeah. Well, the volume of the radial is bounding and the carotid is just normal. Um And then can I listen to the chest, listen to the heart ones? Yeah. Heart sounds one and two. Ok. Um, I feel like I'm missing something. Uh, BP. Yeah. So the BP is 90/69. Um, just to get back to when you said vomiting, uh, what's in the vomit? Is it, is it bloodstained at all? Yeah, there's a vomit bowl at the side of the bed containing fresh blood as well, right? And, um, so do I need to tell you the actions that I would be doing for each of these things as I'm finding them? Yeah. Yeah. Tell me as you go on. Yeah, but, um, you could tell me at the end, but if it's easier for you as you go on this. Ok. So there's fresh blood on the, in the vomit. His BP is low. His heart rate's really high. I'd want to, uh, do cross, I'd want to put two large V can a day and I'd want to do bloods, um, to start with full blood count using these L FTC RP, um, calculation, um, at, um, want to do a cross matching group and say get blood on the way as soon as possible for now I'd start some fluids. Um, 500 mL Saline under 15 minutes start. Um, just to be getting on with, um, I mean, to be honest, I'd want to contact the surgical team because II think we're looking at a variceal bleed. Um, I don't know whether to finish my Italy. Uh maybe I'll do that afterwards. Ok. Um Yeah. Um move on to D for now. Uh Blood sugars. Mm. Mhm. I'm sorry, it cut out there. I can't hear anything. Uh, blood sugars are 6.8. Ok. Grand. Um And can I do pupil reflexes? One reacted eight. Ok. She's coming back through now. Um I don't really know if I need to do much wine do like I found like I found enough to be going on with the um. Mhm. I'll move on to e just so obviously we've seen the vomiting, the vomit, all we've seen that he's vomiting. Um I could do an for examination at this point looking for any obvious sign of like liver damage. So you to check your, your kind of ask you your hepato splenomegaly, any um signs of distended, umbilical veins, um, ascites. Um. Mhm. If there's any, you oops, sorry. Yeah, go ahead, go ahead. Um Yeah, if his abdomen is distended in pain, if they even he's looking quite obviously anemic as well. Family. Yeah. So when you look at him, you can see that he's got ascites. He's got lots of Spider Nevi, he's got lots of bruising everywhere. Um So I think, you know, we're honing in, in, in on something there with that. No. Um nice. So if everybody thank you for, for volunteering for that James, so now we're just gonna go through the questions. So if everybody also wants to go to put it just in the chart, uh what, what would be the differential diagnosis? Upper gastrointestinal bleed secondary to Pharisees from um, alcoholic liver disease? Yeah, perfect. Uh Anything else, any other differentials? Um I feel like you have to add some but um, potentially peptic ulcer disease um with the ulcerated bleed and with that volume of blood, potentially uh like the gastro duty or artery or something like that to give that volume, um potentially an esophageal sort of um, cancer. If it's then ruptured again, another arterial bleed is the, um, what was the one where the esophagus ruptures it? I've never said that out loud actually. Um I'm trying not to look at the chaps. No. Yeah. No, there was a really, really good. No. Yeah, that was plenty, that was really, really thorough and good in terms of differentials and your whole A to e as well. Um That was really good and there's some good, yeah, thoughts going on in the chat as well. I think everyone was kind of in agreement about the liver cirrhosis and leading towards an esophageal varices. And that's what you were thinking quite early on. You mentioned that which is always a good thing to just drop in. So the examiner knows that you're on the right lines or even just on any lines that are sensible. So that was really, really good. Um In terms of um another question, this is something I used to always forget in medical school. So when you're looking on blood tests for an upper gi bleed, what changes would you see? Um, with you, I believe you get like the protein meal. So when you digest and all of that, um you get the raised um urea levels, isn't it? Yeah. Yeah. And then when you see a HB drop as well, but the urea is the one that I always forget in medical school. And then someone just explained it to me and said it's just, you're literally just digesting your own blood and it's just a waste product of that and then it just goes up which made it stick a lot more and yeah, lots of people put it in the chat as well. Um It's just a useful one. I think it's that thing where again, if you get very focused on gastro, you forget that, oh, you've got, you know, other systems that can get a wee bit involved as well. It can show in other ways um, like you think is so specific to renal when it can be to do with gastro periods as well. But yeah, that was really good. Sorry. We probably didn't explain, been quite as well that we want you to do things as you went it wrong. But all your large cannulas, that's something that they love for you to say you specified your bloods which ones you wanted to take, which is really good. Um And I think the only thing you were a bit unsure about is whether when to kind of get anyone else involved. And you can literally just say that at any point be on a ward, you'll have nurses and other people around you that you can be like, I'd ask a nurse to escalate to the surgical team or whatever. I think the only thing you maybe needed to specify just to seniors you mentioned not the surgical team but just saying, oh, escalate to a senior or reg or and start the major hemorrhage protocol, which essentially just means you pick up the phone and someone does double two, double two and instead of zinc cardiac arrest, they just say major hemorrhage. Um It sounds a lot more fancy than it is, but you said about the group and save and the bloods and everything. It was very, very thorough, it was really good. Um Yeah, so I'm very impressed and everyone in the chat was doing the the right things as Well, so along the right lines. So it was really good and I think that's kind of like your worst case scenario when it comes to gastro, um, kind of a, yeah, heats and someone being very unstable but you managed it all. Well, um, we were gonna do an sbar on this situation. Um, but I don't know how we are running. We've got one minute left. Um, I don't know if Karen, you'd rather we just wrapped up now. Um It's up to you guys to be honest, completely up to you. Um It depends if we have a volunteer, if someone wants to kind of act as if they've just done that A to E and then hand over, I don't know where it's gone. Um But hand over to me as the med uncle or whatever or we can kind of just leave it there and you guys can think. Um I think someone's just asked a question about you, explain the Cannula. Um I don't really, um it's just really that when you get to see cos you're explaining your interventions as you go along. So for a, you put on the oxygen B you'd take ABG S or BBg S um C, you just always say I'm gonna put in two large B Cannulas and take blood. I don't know, it's just something that we all say in reality, just try and get one Cannula in cos that's really plenty. But in eighties we typically just say two large bi think one more for fluids want to get bloods and such up. It's just something we tend to say. I don't know if Kane, you have any ideas about why we always say two large bore cannulas. Um, but that's it really. Um, so if anyone does wanna do the sbar, we can do it or we can wrap up now and you guys can enjoy your Monday evening. It really doesn't. We're happy either way. There we go. We've got Pujo who says that she, uh, she doesn't mind doing the sbar. So if you don't mind, um, I'll, we'll, we'll quickly do that and then I'll let you guys crack on with the evenings. Um, so I'll just invite you on to the main screen. Hi. Hi. Yeah. Thank you for volunteering. Um, we'll just do for the same situation. Um, you don't have the exact obs, obs right now. Um, but you can just kind of, yeah, I'll, I'll let you know if you don't remember off the top of your head because I don't have them up with me right now. But just act as if you've just seen this patient, you start them on the fluids and such, um, to make them kind of at least have initiated a little bit of treatment. Um, but now you want to escalate to your senior. Um, so in case start your sr when you're ready. Yeah. Um, ok. Uh, hi. My name is Puja. I'm a junior doctor on the ward. Um, I have a patient, um, who I was a bit concerned about. Is it ok if I pass on some information to you? Yeah, of course. Um, can I just confirm who I'm speaking to please? Yeah, I'm, I'm, I'm one of, I'm the med reg. Ok, perfect. Um is ok. So if I pass on the information. Yeah, of course. Ok. Um, so this patient um has basically come in with um uh some uh vomiting. Um So there's fresh blood in the vomit. Um And uh I was a bit um concerned as well because in the A two E assessment, um the oxygen levels were quite low. So at 89% cap refill was um eight seconds and the patient has cyanosis as well. Um And blood pre pressure was quite low as well. Um And uh since I'm suspecting um a uh varices um uh hemorrhage, then I think that it would be appropriate to um start the major hemorrhage protocol, which is why I was um concerned um in terms of the background, the patient has a history of uh alcohol, liver disease and hypertension. Um And uh in my observations, I saw that there was uh Ascites and Spider Navy and as well as bruising. Um So I've already uh given the patient some oxygen um and uh put a two large bore cannula and given fluids as well. Um So would it be ok if you could um, come and review the patient and uh for us to start the, the major hemorrhage protocol as well. Yeah, of course, I'll be down in a minute in the meantime. Can you do a PVG and call 222 and, and initiate the major hemorrhage protocol and put out a crash? Oh, ok. Call the emergency. Is that ok? Yeah, thank you. Good. That was very good. Um It was very thorough. You kind of very um like, you know, address what the main issue was. You're very clear from the beginning. I think it's one of these things where we sometimes are afraid to say what we think is going on. But I think just straight away saying it, you know, like how these same primary school when you do a newspaper thing or something just make the headlines so catchy and you were like, yeah, I'm worried, I'm worried it's so far I bleed and you kept saying you were concerned about the patient, which I think is really good. Um And you explained what you had done and what you were worried about what you thought it was and what you wanted from the person you were speaking to and you did all your instructions at the beginning as well. Um Yeah, it was really good and obviously in a real situation you'd have the patient number or whatever when you do that. But obviously we didn't give that to you that and you need to do that. Um But yeah, it was, that was, that was very good. Um Yeah, I think the only thing I just remember not about this was that before when we were doing the aci think we didn't mention about the V VG but just in that situation where you one when you've got a patient um hemorrhaging in front of you VBG is always a good thing cos it's a quick way of checking the HB. Um But obviously you wouldn't wait for that to start helping them if they were hemodynamically unstable. Just a side note quickly. I know the hate for while you wait for blood to come back and such. Um But yeah, that was really good. Thank you to everyone who volunteered and everyone who was writing in the chart, it was really, really um yeah, made our jobs a lot easier cos you guys were being interactive. Um So I hope that was useful. We did have one more. There was a data interpretation, but I think we were very, very optimistic about how much we could do and how little we wouldn't kind of talk at you. Um But yeah, thank you to everyone who took part and back a bit. So thanks guys. That was a really good presentation. Um I'm sure everyone will agree. Um So a feedback form for Hannah and Elena will be emailed out to you guys and everyone that fills it in will have access to these lovely slides. Um So yeah. Um I think if we'll say thanks to Hanna and Elena, um Any questions feel free to pop them in the chat. Um And just a reminder we'll be doing a final teaching series every Monday at seven. So join us for the next session. Um And yeah, thanks guys for coming. Perfect. So if there's no other questions, I'll end the session now.