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Uh Hello, Brian. Can you hear me? Can you write in the chart or maybe uh you, you can able to open your mic and say yes if you can. Ok, thank you. So I was just going to play a short video quickly and then we'll get back to it. Uh So uh with this, I'm sorry, just a quick question with the video. We couldn't hear anything. It was just there's no no, there was no order with it, no audio with it. Oh I'm I'm really sorry. Um I'm not sure what's happening but can you hear me? I can hear you. Ok. All right. II will just try one more time. Just give me a moment you can see. Right. Um Right. Just ok, we can't still hear it. Uh I'm sorry, I'm not sure what's happening but yeah um just gonna say good evening everyone and thank you for joining. We'll fix that my problem for the next time I think. So we have with us, our doctor Princess and she going to present our talk and yeah, I will just hand over to our doctor Princess. Um Yes. Hello everyone. My name is Princess from Shefali. Um just a brief introduction to my um of myself. So I'm II, graduated from Sophia Medical University and two years ago, I'm currently in my fy one rotation in oncology. I going to my next rotation coming December in Reno. Um So my topic for today is just a brief introduction. I think everyone has a, a rough idea of general surgery as a um specialty and orthopedia as a specialty. It's just, I'm just introduced some cases and I want everyone to be quite interactive with this. So ask some questions. So beloved. I know you guys can't unmute to yourself. So just t um type anything in the chat and then we can go from there. OK. I'm just gonna share my screen now just to add to it. I think everyone should able to open their mic because we changed the setting. So uh can you guys all see like a mic sign next to it? So you can just open your mic and then ask uh Doctor Princess about any questions you have or want to discuss anything? Can everyone see my screen? Yes. Yes. Yeah, we can. Ok. That's good. Just one second. Just gonna push in. So it's just gonna be a brief a to e scenarios. We're gonna talk about cases. It's not gonna be a brief um um seminars today you're gonna be. So I think everyone is quite a bit of time. I think everyone has had a probably a busy day today. So, just a brief introduction of cases that you probably see as a, um, junior doctors in your day to day, um, um, jobs. So the first case is about, um, you're an fy one working on a weekend shift in general surgery. You're register on S hr S club in theaters and you get a call from Ed. The patient information that I've spoken to you was like a 25 year old male who presented to EED with a two day history of right fossa pain. What is your um what for you are in terms of the nature of the pain? Anyone? Hello? Hello. Can you hear me? Doctor Princess? Yes, I can hear you. Yes. Oh, ok. So we will ask uh uh uh ii in a sequence uh about its side, it's uh it's onset, its character, it's uh radiation, uh aggravating factors, relieving factors uh duration. Uh This is all like uh you must ask uh uh about his pain beside this. Uh We can ask him about uh its associated symptoms uh If it is rightly FSA pain. So we much uh we must uh reach our DD X differential diagnosis. So, uh first of all, we will ask about any nausea, anorexia, fever. Uh And, and that, yes, at the moment is quite loud. But what are your status? Correct? We use the um based on the site onset radiation, correct to the symptoms, the time that Oh, you want to mute yourself for a bit because I think it's quite your background is quite loud. Hello? Can you hear? Can you hear us? Can you, can you hear me? Yes, I can hear you. Yes. Yes, I can hear you. OK? You said that your background was quite loud. So I don't know if you can text me hear or to hear me. OK? I will change my position. OK? So just to follow up of what you have just said, um what you just mentioned everything was correct. Um In terms of what? Ok, just to wait. Yes, doctor, I can hear you. I think what you just said, everything was clear with a slight onset of radiation timing, associated symptoms, um exacerbation factors, site of pain um and also the severity of the pain. So that's what you based on either if you get a cough with this sort of um uh right area for the pain and based on this well brief um history of this patient with the right area of fossa pain. What is your differential diagnosis as an fy one? We're thinking or right area of fossa pain in the abdomen? Where is the uh what structures at the in at the right area of fossil is there that will immediately, that should immediately just be to you in terms of what it's what is your differential diagnosis? So, can anyone just tell me what the differential diagnosis is? Yes, Erebus. Um, well, I've not a, the appendix is the right side, um, appendicitis by dawn. That's correct. Yeah. II, II, assume you mean appendicitis of the appendix. Um, so you differently diagnosed appendix, uh, appendicitis. Anything else from anyone else? Med Ureteric Stone. Pardon? Mid Ureteric Stone? Yes, cause that's the, yeah, the right ureter stone. Yes. Mass is correct. Appendicitis, hernia if it's a female. Yes. Um, atopic pregnancy or a cyst where if it's a male, does anyone have any? Um, of course, we know this is a, a male if it's female mass or your um, depression diagnosis, correct or, whereas if it's a um, male, what's a differential diagnosis? What would you expect at that site of, of pain? Amy Sis A Yes. Can you spell that? I don't, I don't know what you're talking about. Can you spell it? A AAA S am oe bi A si S abiosis? Oh, ok. Yes. Yes. Yes. But it's usually. Yes. Yeah. Yeah. Diverticulitis. Yes. Don't always forget your ibs your Crohn's because of the um, terminal um, areas on that side that could cause the right area cause the pain. Um, I'm just going to go to terminal terminal ileitis due to phite fever in fever. Yes. Yes. I'm just gonna go to the next page just um, so just to give you a proper um history, the background of this patient. If you have, if you have gone to examine this patient, you see that it's a sharp stabbing pain in the right. I first, which is worsening by movement and the pain, he's current, the pain out of 10, out of 10. And he said that two days ago, but it's worsened today. Um, with the gen symptoms, there's nausea, vomiting, loss of appetite, but there's no fever with the absence. Why is the absence of fever re relevant? Does anyone know? Is it because, you know, it's not an active infection going on? Yes. Correct. It is an active infection that you're thinking? Oh, if you, for your differential diagnosis, is it a perforation? It's an a form you'll be thinking about that part, um, part a different diagnosis and then the past medical history. Um, what sort of past were you thinking if you asking this patient, the past medical history in terms of what you're trying to find out some certain certain diagnosis? I think we have spoken about it briefly. But what history might, you might increase the suspicion of a certain diagnosis, shall we ask if they've had an appendectomy in the past? So we can rule out if, even if it's not active inflammation, if they have some problem with the appendix. Yes. Um, so from the presentation, you can see that there's no significant past medical history, no surgical history, no allergies in the family and um, no allergies, uh, medical, um, allergies, family history wise, there's a family history of diabetes and hypertension. The father he does not smoke or drink or is a drug user. So that, that limits that line all our di differential diagnosis and you can do a systemic review and you find out the patient has no symptoms in the um card of symptoms, head neck or eye sympt, no headaches, no visual disturbance, no chest pain or shortness of breath. No gi mentioned diarrhea or vomiting, um symptoms, um symptoms. Um in general, you look at you, look at the patient from up to down as you, I would assu assume as an fy one. If you're going to see a patient, you always look. Um first of all, ge look at the, look at the room, look at the patient from top to bottom and then work your way up. Um but you noticed that there was no weight loss or fever, no night sweats, all um findings on your physical examination will heighten your suspicion of the impress of your impression. You're currently having elevated c physical examination or laboratory um investigation. Yes. Check for the abdomen, potentially. Yeah, tenderness. What sort of tenderness are you looking for? Rebound? Rebound tenderness? Yes. Correct. Beside this uh doctor beside this, uh it was mentioned in history that uh patient experiences pain when he moves. So uh it uh it denotes uh peritonism. Yes. So that is localized peritonism. Yeah. So I think Ariba has mentioned it rebound tenderness and pain. Um I'm looking for more signs in terms of what your impression there are certain signs, I'm sure we have gone through in medical school. What they tell you about if this patient is, if your, if your differential diagnosis is what you have listed here, there are certain signs that you do an examination to just prove that it's certain that it, that it is that um your impression. Does anyone know of anything else? Ok. So I'll just move on to the next um presenting um slide. So you on physical examination, the patient in general appearance, ill looking, uncomfortable, grasping abdomen, but the patient has no fever, the vital signs you've done on observation, this is all normal. Um on the tendon, there's a tendon in the right leg foster. We have spoken about it for positive signs. You see there's a r no tenderness, the mab burn signs is positive and the so sign is positive, negative um findings, there's no flank tenderness running signs is negative. What is the significance of the um Mack burns point? And the rebound tenderness. Does everyone? Does anyone know what that means? Does that point? Yes. Do you know how to Yeah. And what about the um so sinus anyone? Yes. Yes, yes. Yes, yes. So that basically, yeah, Mohammed is correct. Yes. So, well, based on your i impression, what, what would you investigate? What would you, what would be your investigation? What would you request in terms of investigation? I think someone mentioned it before we check for CPR levels. Yes. Well, you're on fy one. You need to request bloods. What bloods would you request for? Not just the, what, what bloods would you request for? C Yes, CBC S. That's American terminology, but yes, correct. Just use your knees, use your knees, lefties, andys. All correct. All correct. Um BG, you can do a quick BG ultrasonography, not necessary at this point. So, the for the, um, investigation, you have done a, a full blood count and it shows elevated white cell count by your biochemistry with your renal function test. Um LFT S and electrolytes are normal and you also do, you also need to do a urine analysis. What does an elevated white cell count suggest? And how would it guide all into a differential diagnosis? Yeah, you can do apr examination if you have time. So, yeah, let's see who's response inflammation. Yes. Yes, infection, inflammation. All correct. Um this in infection, correct. Correct. What is the most like a pro um provisional diagnosis based on the history and examination? I think everyone should come to um um um primary like an impression at this moment. Now, I, yes, that is correct. Yeah. Yeah. Yeah, everyone's er, you're all correct acu a appendicitis. A clear, this is very clear picture of, of someone coming to AKI appendicitis. Um So what's the next step in terms of investigation? What would you do as an fy one? I don't want you to go into too much depth. You know, this, I think everyone knows the terms of management they will do. But in terms of the uh junior doctors, you, you have been contacted by the ED, you have, you have done your examination, you have done your findings, you have done your investigation. What next step should you do as a junior doctor? Yeah, CT is usually the um, gold standard for appendicitis but you from the investigate from, I think mostly if you the cli clinical picture, clinical picture has a way of more limit in terms of um way more in terms of than CT scan, do a CT scan to rule it out. But because of the colette picture, we have, we already know it's appendicitis. So what would you expect for you as a junior doctor to do? Yeah, you can do ac Yeah, a CT scan. Yes. Pepti. Um as I said, yes, not necessarily abdominal x-ray, abdomen x-ray won't do anything for this patient. I kept um, appendicitis medicine. So with this initial, at this point, I would expect you to try and get in contact with your registrar. If you can't get in contact with your registrar, you need to um contact the consultant on call. But an fy one, you, what would you start? You stabilize the patient so far is correct, stabilize the patient, possible surgery. But that's not for as an fy one, you technically will not make that decision to make or patient will go for a surgery. Yes, a reverse current escalate to your, to your registrar, your sa if you can't get in contact, always contact the consultant. Yes. Ok. Well, and yeah, we, we, we spoke about a differential diagnosis. So differential diagnosis would be diverticulitis right side iliac renal colic, which is alas to any sort of um, uti um, you have gastroenteritis, but that's usually uh the, um, not in terms of focal tenderness and you have IBD, then you have tension and testicular torsion. So as an fyi one, as a junior doctor, so you've seen this patient, what I will assume already strong would, would assume that you've already done it already. Um, taking, if you taking blood, I would expect you to have a point in IV Cannula. So as you're taking blood, you have, you, you put in the IV access, starting on fluids, try some antibodies, um, keeping you by mouth because you will potentially go for surgery. And of course, based on your, your trust, you go by the empiric um empirical antibodies and of course, pain medications. Does anyone have any questions in regards to this case? It's keeping them fasting specific for appendicitis. Well, if you're thinking of your knee surgery don't necessarily be near by mouth, but with the presentation just you have something to do. We have a, do, do we have a choice of, uh, any, uh, uh, uh, there, is there any chance of managing this patient conservatively. That can we go for that? Yes. Well, that, that will be a decision you make. You need to speak to your registrar. They have to come to conclusion because in terms of conservative management, surgical management appendicitis, if it, if you perforate, that's worse. So I think the risk and the benefits that we discussed and that's, that will also increase your investigation and also your imaging. But once the patients are having fever, I think automatically they have to make a decision on in terms of going for surgical management, it might change. If the patient has a background of let's say tumors or cancers, it might change because then you'll be like, oh, are we gonna affect the blood supplies in the around tumors? They're gonna make it worse. So I think a decision to be made, but that will not necessarily be done done by a junior doctor. It will be done by more of your sh or your registrar or your normal sho your registrar and a consultant. Make that decision. Not you any further questions. Ok. I'm going to go to the next case. So case two, you ca you have been called by a nurse. It's looking after a 35 year old female who's had a four days um POSTOP of laparoscopy and call lab call and she's now complained of mild pain and had a temperature spike. What is your a as an fy one? You get a call by a nursing team. What would you do with this case? Walk me through your at E scenario. Hello anyone? Ok. Let me see your vision. So initially, I would, I would assume as an fy one, you get a call by the nursing team. Um Yeah, for the observation for it. That's correct. First of all, you ask the nursing team, do a quick news, do observation. Let me see the new score. You go and review that patient work your way to your at E um at e um examination check airway. So correct. It's not necessary at the moment. We know she's in pain, but now we're trying to stabilize this patient because it's post stage four that can be done at while you're doing your um ATM investigation. Patient is quite stable. Yes, systemic exam. Yeah. Yeah. Oh Correct. So your internal investigation, we've spoken about it. We'll go you as a, a junior doctor F one fy two. We get a go and review this patient, what you look at the news, do your examination and then you come up to um in initial investigation. So we talk about fevers. You always, always, always, always blood cultures, you need to get a blood cultures because we need to see if there's any bacteria going to any bacteremia in the blood. So you take your FBC S your routine bloods. Um FBC S user needs LF TSC RPS and then you then take your blood culture, you can do a urine ana urine analysis just to see if you're having any uti infection and also do a quick V GTC, which is quite septic. So that will tell you that will give you a very fast lactic levels. Done waiting for a full um the antibody lactate levels coming on the routine bloods. So once that is done your differential diagnosis, we ask JJ says to find the cause of the fever. Does anyone know in terms of POSTOP, what would, what would does anyone know in terms of POSTOP um fever causes differential diagnosis. You're in output management? Yes, you can start that one. Yeah, possible sepsis. Correct my sepsis. Yeah. Yes. Yes, everyone is correct sepsis. So you have gone to see the patients. Everything is uh airway patent speaking in full sentence, breathing, no crackers or breathing could be could be here on both anterior and posterior chest e collar entry circulation. The capillary few time is less than two seconds. BP systolic is 11, 3/67 heart is 98 disability. She's um per um people that are reacting equally react reactive to light and she's alert exposure. The wound is slightly tender but no other notable notable findings. We're talking about what might be her cause of postop day four, which is we thought it was sepsis. So with POSTOP fever, there's different classification. You have the immediate fever, the acute fever and the subacute fever with fever that starts straight after the operating theater, not within hours, post surgery. Whereas the acute occurs in the first week after surgery, which is the most common one. And the subacute um happens between 1 to 4 weeks POSTOP. So based on her, her being POSTOP day four, what category do you think she, her fever falls under? And what would you suggest might be the potential cause for it? A shot? Yeah. Infection or breaking shot. Yes. Yes. Yes. Jasmine said SSI was an infection re correct. Yeah. So always, always when I came across um this, I, when I was writing a POSTOP come across a POSTOP, the five Ws what you know the five Ws wind water wound walking, wonder wonder drugs because I think it on the um powerpoint, you can see a clear um um description of it. I'm not gonna go into much depth of it, but always remember five Ws if a patient have POSTOP fever um fever, POSTOP always go through your five Ws and work your way through it to see if there's any, this could be the could be the cause of the um post fever. Has anyone before this um um presentation heard about um the five Ws Yes. Yes. Yes. OK. That's good. So it's not new to anyone else. OK. That's good. That's good. OK. So your different, you was spoken about differential diagnosis. And I think Jasmine already said SSI S which is more likely to due to the surgical site infection due to tendons of the wound. So you now know this though, your differential diagnosis or in terms of your primary um impression of what's actually going on? What would you do as an fy one? What is, what are you limited to do as an fy one? Oh, sorry, apologies. Yes. To me. That's funny. Yes. Was it episode three? Yes. Well, um does anyone know in terms of so do next as an fy one? I already it's already on the screen anyway, is do an E CG. Um urine dip stick gonna do an E CG but E CG should have complex pain and she's not having a, a mild chest pain during E CG men that B to check for the metabolic and the lactate blood including core. Because if she, if it's more than just an SSI she might need to go in for another operation for clean out with blood blood transfusion BT S sample. And of course, we're going about the septic screen. Does everyone remember the septic screens? Three in three out three in oxygen. Um IV fluid empirical antibodies, three out routine bodies lactate and blood infection and also urine analysis and also just take a wound swab from it. So what would be your initial management plan? Yes, you, you also escalate but at this point, she's quite stable. So you can start off and then you can escalate your registerr. Yes. Yes. Yes. Yes. And, and yeah. So get empirical antibodies, um, supportive care with oral analgesia to man, manage mild pain hydration. You want, you can tell the nurse to repeat it after giving her both um um um, a bit of IV fluids if she's quite because she was quite uh, so I think her BP was 116. It was quite stable, but you can give us a bit of IV fluids and hydration. Once a vital signs get a wound swab, just to make sure there's nothing going on it and just clean, clean, the wound can tell the N to clean and dress the wound and also just escalate your registrar to just inform them about the situation at hand and then see they, they might need to add anything to your management or review the patient for possibly going back to your face or wash out. Does anyone have any questions regarding the last case? Yeah. So with the sep sepsis, screening or sep sepsis six, as you mentioned, is it immediately when we suspect it, then you do you send her for those labs and give them the IV fluids O2 and antibiotics or do we wait for something to be confirmed? We know this, that she's always um her trao is quite stable. The only surprise she's having these temperatures. So you can just take the blood culture. It's not necessarily you have to start with oxygen IV fluids, but just the, the seps, I just put the sepsis six just for you guys to remember that if you're thinking sepsis, then it's three and three out. But at this case, I don't think you will need any apart from the routine blood and, and blood cultures can possibly speak to you about to start with im um antibodies. Um, sorry, antibiotics, probably IV antibiotics because it was supposed day four. Um But the main initial thing is take routine blood coag screen in case she might need to go back to the for wash out um and blood and blood transfusion with the blood culture because of the fever. So while we are waiting while we are speaking to your registrar as an F Yy, you can tell the nurse, oh, I'm gonna speak to my registrars and let them admit her. Can you give her paras signal to get the temperature a bit down? Oh, yeah. Yeah. Yeah. Sorry. Is that any, do you mind? Does that answer your question? It does. Thank you. I also have another question but it might sound a bit silly. Sorry. But what exactly is it that we're looking for on the coagulation screening? So calculations because she's post up um how fast have blood clots. So in sometimes based on your inr levels, if it was, let's say, what depends on each consultant. But from when I've worked in the general surgery. Some, some prefer to 1.1 0.2. If it's more than that, then you might need to get Vitamin K just to bring that down because you don't want it to bleed a lot in, in the future. And is that a routine thing after anybody has an issue after surgery? No, that's an issue if previous, if she's received previous Vitamin K So as in why, before she came in for the operation, she would have gotten the, that all bloods taken co screen everything taken. But if the vitamin she received Vitamin K before the theater, then to be wise enough to do um um repeat Vitamin A. Well, not um sorry, quack screen, not necessarily doing it for every patient initially. Yes, but not for every patient. Ok, thank you. Um, Tosha has a question. I work in out of hours. Could you have on or um, you, mm I will say no because this is a um because of this temperature, it's with this sort of temperature and the fact that she's uh, her, her back in terms which had surgery four days ago, some oral antibiotics um might not be the best. Um, in terms of guidance, I think II would say to give her or you can give her IV paracetamol, oral, paracetamol. Um just to get the temperature a bit down and then you speak to your for you start on IV II think IV will be your best way to, um, in, rather than oral antibiotics cause IV antibiotics, which you put to be, to be, start on IV antibiotics. And then we have to watch if there's any more spikes in, um, um, temperature, they will continue with IV antibiotics or if there is no more spike, then after 24 hours, 48 hours, then you can have a discussion of switching them to oral. You can, I was them, well, for, for the, the new, with the new temperature, I think a sign of IV mix will be a probably a good start off. Ok. Any more questions? Ok. I'm going to the next case. Um you received a call from a GP, not necessarily as an fy you as in general surgeries but fy two, you might. So you received a call from a GP regarding a 65 year old um woman that they visited at home, she's experiencing abdominal pain, vomiting and has no bowel movement for three days. The GP examined her. She has dry mucous membranes and abdominal distensions while your initial diagnosis. Yeah. Yeah. Yeah. Yeah. No obstruction, constipation. Yeah. Yeah. I Yeah. II yes. Could be. Yeah. Ok. I think everyone has a rough idea. They are thinking something was wrong with the bowel. So I think that's good. Um So with the next um um slide uh um brief um history, um she has today history of colic central abdominal pain. She's vomiting in the last 24 hours. Of course, her b, we already noted that her bowel hasn't opened in two days and she hasn't passed fluctuant past medical history by reception for Crohn's 20 years ago, type two diabetes and she's on insulin. What for that question would you ask the GP, what you ask you what to do? Yes. Yes, definitely. That's correct. Yeah. Yeah. What other medication she's on? Yeah, that's a good question to ask actually. Yeah. What other medication she's currently on? So, um physical examination. Um So she's then she told you told her GP to come into the ho to bring her to the hospital. So you go review an ed on examination to have she has dry mucus membranes B virus. Vomit is ongoing. Still, her heart rate is 100 and 100 BP is 100 and 30/70 her temperature is 39.9. She has distent abdomen, tingling, bowel sounds mild midline lap laparotomy scar with no incision, hernia and her um on her pr examination was empty rectum. So what is then your next investigation? What would you do in terms of investigation for her? Correct? For? Yup. Yup. Erect abdomen. Yeah. Yes. Yes. Yes. But guys, you forget any initial investigation, you request abdominal x-ray. But what would you do in the meantime, while you're waiting for the X ray department to take her down, she's coming with vomiting. No one has decided to take. Yes. Yes. FBC S yes or rehydration. Yes. So uh yeah. And you Oh yes. Yeah. Yes. Yes. Yes, yes. So what I expect you from you guys to quickly do an im of course, uh always remember this, you know, doctors you see a patient you examine, OK? You, you automatically think this patient would need to stay in. So you put an IV access into it IV access, take your blood, your blood every six LFT S therapy just to chase everything um Replacement that. Yeah. Yeah. Um And then based on the fact that she hasn't opened her bowels and with the tingling bowels, I think everyone knows in terms of what the diagnosis is going to be. Investigation your other bloods F FBC S using these amylase im abdominal X ray or erect and chest X ray to just to why would you, why would you do a erect chest X ray? Does anyone know what abdominal X ray and chest X ray, abdominal X ray, uh uh erect x-ray for uh uh air fluid levels and a chest X ray for any air under the diaphragm? Yes. So I've done x-ray. That's actually just check for small b obstruction. Why the ECT and chest xray checks for any like perforation wise? Is it um fluid level? Um Yeah. Um and then then uh x-ray um I've done it. So don't ask the question. Actually, I'm sorry, how can you differentiate this with opiate induced constipation? Um You can't, well, we know she's, her rectum is empty because we've done apr examination. You can examine the abdomen, but then she's already have distended abdomen. I think with abdo, with uh constipation, I think one of the signs would be left either cause her pain cause the mass and should be complain of tightness. So, and I think unnecessary. I don't think her abdomen would be distended that much and she'd be vomiting because she's having s vomit. So I think that's probably would. Honey, ma I don't know if that answer your question. Yeah. So my own went to be too quick. What's your management guys? I think we've already spoken about the. Yes. Yeah. Yeah. Yeah. What would be your management? I think everyone me met him. I don't know if I'm saying it right correctly. But apologies. I'm saying it wrong. You have you, you said about oral hydration. But um, with this patient? No. So IV hydration would be better than oral because she would, we have possible have to decompress, decompress her abdomen before we give her any oral. So she needs to be actually new by mouth and IV hydration. Yes. IV fluids. And she might not. Pa yes, yes, she might not. She might pass up. Well, there's no room bar obstruction, there's two parts, partial and complete partial means you can pass the bit of gas. Complete means you, it's up to, you can't pass anything. So she's, she might y yes, she might pass gas. Yes. So with management um oh, I wanna be back. So hy rehydration ation you have to, well, you can't technically estimate the fluid loss, um daily needs. Um ongoing losses, monitor u um urine output using ease, monitor, um monitor urine output. You might to be catheterized and decompression. You put Anderson's analgesia D um DVT prophylaxis because you might be in the hospital for long term. Um Quick question. How would you estimate the fluid requirement for a pay for this patient? Pain relief? Yes, you can. Yes, but we think it start with either stop cut or I think stop would be your best bet. And based on that age, you can actually put on a driver. The driver means what a driver means a continuous um um stop injection underneath the skin, just continuous. So, so every 24 hours you change it um with the medication you can put on morphine. So course, so she can get that pain relief rather than giving her IV morphine. Yeah. How would you estimate the fluid requirement for this patient? Um No, it's no, it's not. Based on the amount of fluid she's lost. We can make an estimation but this has been ongoing for a while. We can make an estimation of what she's lost at that moment, but we need to replace her. I mean she to take her very quickly. So what would you guys give? What sort of fluids would you give her. Yeah. Yeah. Yeah. Oh. mm. Yes. Um I won't necessarily jump or it depends on trust based, trust based trust. My trust usually start off with plasmalyte. So we give her um 500 plasmalyte fluids. Um and yes, everybody but that would be based on the blood. Once you get your blood test back then you could then replace the electrolytes. Um So with her you give us that IV fluids. Yeah, it was 250 well, two fluid base. If she has any cardiac issues, she mentioned she had type type um, two diabetes which, which was insulin and she had a um, um surgery. But so, but she has no heart condition. So you can actually give her faster fluids. So 500 that sometimes based on how quickest we now know she's having, she's, this is only good for a while. You can actually give her 1000 or the faster rate. So give her 500 twice and then give her 1000 on a faster rate. And the fast the weight, the rate is, um, uh, measured is based on her. The cause adults need to need 2 L of, of fluid per day. And then it be based on your how weight based on those two. Then that makes the rate. So the rate here 40 45 50 55 50 60 7585 and then 100 I wouldn't do that because there was no issues. With her, uh, with her type two diabetes, she's, she's, she's controlled with insulin. And the only time you give Dextros dextrose is if, um, she's hyp hypernatremic, well, she needs fluids so you could possibly give her dextrose, but I won't give her dextrose because her type two diabetes controlled insulin. Yeah. Um, uh, of course, the differential diagnosis, adhesion, surgical histories, ch strictures m malignancy classification of small bowel obstruction can be divided into intraneal such as something's blocking it. Gallstones might necessarily be, but tumors can be Crohn's can be adhesions from previous surgeries, which is one of our um uh in our history. Um What signs would you indicate this patient might esca might you need to escalate to surgical intervention? Oh, no. So, um in terms of you've done, uh once you have done the abdominal x-ray, inform your registrar because before you do any other, any imaging, you have to inform your registrar. So I'm sorry about that. So, before you go down the line of um putting an Anderson, an NG tube, you can tell the IV once you're taking blood to give her the IV fluid, which she's quite stable. Speak to your reg order your abdominal X ray and there'll be a discussion about if you still have a continuous ng and vomit. She, she Anderson tube into the compressed A do. Yes. Yes. Yes. Yeah. Frida, I hope that answered your question. Apologies. II went to be too quick. Well, Yeah. Yeah. Ok. Medicine, yes. Perforate, yes. Rigid abdomen. She's not having fever. The pain has gotten worse. The, the pain is changing nature. But that usually once that has happened, well, I would just stay as an fy and get, get you all registrar immediately because with this it's very, it can happen rapid. So you need to get your registry and involved once it, once it's a change in nature of the pain and of them is not r so you just need to get in contact with your registrar. Oh, sorry. Yeah. Uh, does anyone have any questions with this case? Ok. So in general surgery as a junior doctor, they necessarily don't expect you to know a lot more what they expect you to know how to handle it. Stabilizing the patient, stabilizing the patient means onto the gus there. Make sure the patient is alive or? Yeah, that's what it mean. You stabilizing the patient. You can also, if you feel like the, the, if you feel like the patient is getting, is deteriorating while you examining her, always, always our advice. Pull the, just pull the bell, then everyone just comes around straight and just waiting for someone to just come and see you or with your favor to try to get there. If you feel like the patient is getting worse, she's deteriorating. Hold the bell. Yeah. Normally, yes. You know, like I, yeah, that's basically what you need to do and if you're struggling, always, just put the recess and everyone just comes around. So the with that, with the the um facility of that just, just, just, just let everyone knows that this patient, this is oh the appointment with CRM chest X ray is just to if you require an abdominal x-ray, they always say, OK, you, I could they ask you if you request an abdominal X ray, they ask you, OK, you want to do a chest x- just to rule out any preparation. So with abdomen x-ray, you read out um bowel obstruction but because of this is ongoing for a while, just to, to check, just do a chest X ray. Not necessarily for heart case at the moment because we already know there abdo abdominal um x-ray that show um obstruction. Yeah, it varies from patient. And I think the discuss, I told you once you have started the fluids, speak to your registrar and then she can then put your registrar, he or she can then guide you in terms of what is the right imaging to request or you can just initiate and tell her, oh, I'm gonna request the Abdo an X ray because I I'm gonna check a bowel expression in all things. Hindsight. I'm also request a chest X ray just to rule out preparation. And she might say, oh no, I can do a CT scan. That's way way better. So just before any imaging, always speak to your registrar. Yes. Ok. So the, um, it's quite a, um, t the, the scenarios is it varies cause now my next case is gonna be in pediatrics. Um, so I think, I don't know if anyone has any, um, experience in pediatrics. That was my second rotation fy one. So I'm just gonna briefly touch on it. There's a, quite a lot of cases. Um, some of them are quite lengthy, so I didn't add a lot of cases on to it. Just a bit two cases, but I've just presented to you guys. So you're an fy one and P UPU stands for pediatric assessment units. You come across a three months, three months old boy who presented with symptoms of runny nose, worsening cough, reduced fee feeding, decreased wet nappies. Um, the social histories to um, older adults with cold experts, to parental smoking. Outside. Only birth history was born in, um, at 2034 weeks, uh, but had no neonatal complication. What is your likely diagnosis? Come on guys. What's pediatrics? Yay. What is your likely diagnosis with this case? Yes, that's the only thing. Yeah. At this point, I think everyone and if, if you study in Bulgaria or anywhere, uh, well, Bulgaria or Sophia, mostly I think when we talked about it, this was one of the points they always bring into our ears. Always, always remember this. Yes. Bron Bronchol R SV. Yes. So you have, you have seen this patient? The three months or he's miserable but alert vital signs. He's now had a temp. He has a temperature respirator 56 which is low. Um res respiratory examination, the cleft fluid copi nasal secretions, dry, wheeze cough signs of respiratory distress which is toggled um trachea to again into sub recession, oscal noc. Um you have fine crackles, an expiratory reason and other symptoms system is unremarkable. What, what would, what sort of investigation would you do? And do you escalate or what would you do next as an fy one CC? Could be one. But do we have more of a barking cough, isn't it? What further investigation would you do? So you've come across this patient just basic, just that guys don't go into too much depth. Go no pediatrics. Everyone tends to turn around, just treat them, they're not younger adults but just treat them as what would assume if an adult comes in with this? Anyone does anyone there? Mm. See. And with this sort of in pediatrics, we tend not to do a lot of imaging on you otherwise. So with chest X ray, we probably have to speak to you at your registrar. But in the meantime, what we expect you as an YF VC is even with blood. Surprisingly, my rotation in pediatrics, we, we didn't take blood from babies until the registrar, they consult on blood. So the fy one you're not allowed to take blood, you have to escalate it to your registrar. So with what all you can do with this case is escalate your straw. In the meantime, get a v um viral throat swab, bacterial throat, swab COVID swab. That's all you, all you can do is an fy one and then just escalate it because with um bronchitis, it can really deteriorate, the babies can really deteriorate very rapidly. So this uh this sort of presentation needs to be, you need to speak to your, your already straw oxygen wise, even oxygen, anything out of the norms, blood test, it depends what oxygen chest X ray. No, you can't start off without speaking to just draw even blood cultures because you're thinking, oh, the patient is um yes, you can give them a nasal disc congestion. Yeah, you can, you can. But then also it's just I think you can just have to speak to your registrar about it because allergic congestion, we know it's viral. So they might need to um oxygen require um oxygen support going forward. Mhm. So investigation. Oh, sorry. So your investigation would be I I've mentioned via throat swab, bacterial, throat swab um blood test if it's more than 39. But if that's if the the bacterial infections are suspected, but that will also come from your registrar because they're very strong thinking. Ok, we at, at the time we are, let's say we are at the month is November. This is the heightened period of R SV in most pediatric hospitals. So you see a lot of babies who is presenting symptoms, taking bloods might cause them more harm than, than benefit. So, diagnosis, your body spoke about is acute bronchitis. Um We're talking about it being a autumn to spring type of viral illness and it's predominantly in the infant and young adults. Um and the main cause is um respiratory cell virus which is responsible for 80% of the cases. Um management, supportive care for all this. We usually go through the registrar because sometimes with C A, they also need to go into the high dependent unit. So for supportive care, oxygen therapy hydration, because of the decreased feeding, they might have it to have an energy feed, um inserted IV fluids only in severe cases. But then that will be probably faster IV fluids, respiratory support. They might need a nasal oral su um suctioning and CPAP though, but that usually go by the consultant itself, not necessarily reg they can start it off, but because CPAP need to be um in high dependency unit um with acu bronchialis, there's no benefits from Broncho bronchodilators, oral, inhaled um steroid imod. So there's no benefit if you give them, they will actually get worse than anything else. Does anyone have any questions for that? Yes, you can aspirate. Yeah. Yes. Yes. Pediatrics, Mohammed and pediatrics always escalates even pre paracetamol itself. You can prescribe it, but you always always escalate because that is a very consultant led specialty. So you always escalate and with this sort of presenting, with the previous case one, presenting, presenting picture, you always escalate. I don't think we, well, if it's a 16 year old who probably won't come into the hospital with R SV, it's usually common in infants and kids and babies and Children. Not next. You're a 16 year old. Yes. Um Farida. Yes, depends on age, but a acute bronchitis actually caused by R SV usually is more than baby and infant than 16 year old. So it's limited to babies or an infant and 16 year old. Ok. Any questions is everyone happy for me to go to the next case? Yeah. Ok. Ok. Five years. So case two, a two year old boy also presented P UPM pediatrics assessment units with a 10 history of fever, blood, eye shot eyes, sore throat, rash, cough, additional symptoms with poor appetite. He is miserable hazard, travel or infection contact history. Previous treatment was six day course of Amoxil, which was done by his GP past medical history, had an inguinal hernia at two weeks of age. Otherwise healthy, healthy. What is your differential diagnosis? Come on guys. I think everyone should remember this. Yeah, we can, we can say that but it's 10 day history. So if this drug um reaction should have been cleared up by now or you're getting worse, not necessarily um plateau. I think everyone if, if you study Sophia and your probably your pediatric rotation. That's spoken about this. It's very, very, very not, it's rare but this, it's in pediatrics. This is one of the sort of fever, um depression diagnosis spoken about. Come on guys and there anyone how any depression diagnosis? No. Ok. So on clinical examination, you find the temperature had your baby, um the tear had a temperature or temperature of 39.8 findings, bilateral conjure um red EMA erythematosus and cracked lips. Erymas uhh Nonspecific, my rash on the trunk, cervical lymph adenopathy. The chest sounds clear but no other abnormalities. What would be your investigation? Uh What is it your differential diagnosis when I yes, could be a differential diagnose. Yes. But 10 day history of fever guys. Ok. So your blood blood tests and these are the values. So you have um white cell count is raised, neutrophils, it raised platelets is raised. Um And then CRP is ree se es R is raised. What is the diagnosis leaning towards? Now? Now we have had blood test results back. Yes. Yes, I'll wait for someone to say it. Yes. Um It, it is bacterial infection is 10 days and he had already had amoxicillin c um caused by amoxicillin. Not necessarily if it's bacterial infection. It should have been, I'm not sure I've cleared it, but it, I'm, it hasn't cleared it. So it was the diagnosis of the d at this point within the blood results. But anyway, before this either you see this of patient. Oh, I would tell you just escalate your draw because this is either means pimps which is pediatrics, immuno immuno. I can't remember what it stands for. Um and Kawasaki Kawasaki, this is further investigation and the consultant, actually infection disease consultant needs to be involved with this. So with this sort of case, if you see it just escalates your reg. However, with this sort of case, you might not even get in contact with. It might be a ward case where the patient be seen by the consult and a reg and you're more handed day to day um care of this patient. So it's Kawasaki um Kawasaki disease. Yeah. So of differential diagnosis, infection could be tuberculosis HIV disease like lymphoma, autoimmune disease, like juvenile idiopathic arthritis. Um miscellaneous can be drugs. I think everybody mentioned this or IBD. Does anyone remember the management of Kawasaki disease? Oh Medical school is what is the uh this is the only um this, well, this is a illness that we tend to use this medication. Otherwise we don't use the medication for kids because of the um syndrome. Does anyone know? Yes. Yes, yes. Aspirin. This is the only time you get to use aspirin um because of the right sy syndrome if it was right from pediatrics. So the first line man of Kawasaki is this is all to go through the consultant. I'm just letting you guys you know just to be a be aware you might come across but they're having a discussion about a patient going to need um IV and immunoglobins, um they probably have alot or each other pia jobs coming up. So IV, immunoglobins, intravenous immunoglobins, aspirin, high dose of antiinflammatory effects and low dose of antitropic effects, uh monitoring the cardiology of things to be involved. Cardiologists, pediatrics for echo echo just to because one of the complication is coronary a um artery aneurysm. But that is more in depth of if you, if you're interested in pediatrics can read, we can read on it more. But in medical school, I think you also have a point. And so I think if you're in Sophia Medical school, there's a point in pediatrics and also is in rheumatology in in um in internal medicine when I speak about Kawasaki disease. So what I use the um and the acronym I used to remember the symptoms because a lot of symptoms um you see in terms of diseases is crash burn. So you have contis crash, you have rash, um adenopathy s um then you have squamous Squam is where the skin, the skin starts to peel. And then in burn means there's more the fever is more than five days. Just remember crash burn. That's one of the um outcome the pneumonics you can use for. Just remember in Kawasaki, I think just to this is gonna be the last um slide. Just a complication of Kawasaki disease. Um Coronary artery disease is gonna lead to MRI sudden death. Um and then prolonged complication. We call prolonged fever if it's the fever prolongs with that. Even though they start IV immunoglobins and aspirin, um they may thinking more of pimps. What is II can't remember what pimp stands for. Is it pimps or ps? Uh um I think it's pediatrics, immuno um pediatrics. I'm trying to find the name. Am I saying it? Right? Symptoms. Yeah, pediatrics, multi inflammatory syndrome. That's basically this the the pediatric IOT system Inflammatory syndrome actually started after COVID when they realized there's a lot of p of patient ps patients coming in with known um the prolonged fever and it wasn't Kawasaki. So they had to stay in the hospital for quite a while. So with the start of with the heighten um um of COVID, then there was this diagnosis made, it's called PIMS PMIS pimps. Um But just for what for for but any does anyone? Yes. Yes. Yes. I Yeah. Yeah. P is most consistent immune inflammatory syndrome but that's it for me. Um Just a quick um I was gonna add a bit of more cases like febrile seizures, but febrile seizures is quite lent in, lent in, in details and I feel like everyone will get bored of it. So I didn't want to add that. But does anyone have any questions or in terms of helping? I think most people hear it from Sophia does anyone have any questions that could potentially help. And also, oh, he does want to say something what you about to say? Um I was gonna ask a question about um sorry, my mic wasn't working earlier. Um When you mentioned something about the p pediatrics, like you, you tend to not do as much imaging, you tend to not even like take bloods. I was gonna ask what does that relate directly to like babies only? Or if a 16 year old was to come into the ed? Would you do imaging? Would you take bloods? So you treat them differently? Yeah, you treat them differently because I think with the co the age an adult is from 16. So you treat them as an adult but beyond 16, you treat them well, you also take blood but then that would be on the guidance of your registrar. OK. Thank you. Yeah, I can share the slides with you. I also have a slide in febrile seizures. If everyone needs it, it breaks it down in terms of the pathophysiology and the drug mechanisms. I can share that with you guys. Just do a feedback for me for many things guys. And also we have an event coming up on the 14th and 15th of December. Um It's a workshop. So it's if, if anyone's in the country is in London, in Stanmore, you can just come in and then it's more we have clerking at examination scenarios, phlebotomy. Taking bloods. A lot of um a lot of workshops. So if you guys are excited about that, I probably will see you on the 14 or 15 of December. Do we escalate straight after? Yes. Yes. So after clerking, they probably would ask you what the impression so you can come up with a differential diagnosis, but usually it's straight after clerking. Yeah. Thank you very much, Doctor Princess. Uh So can anyone tell me in the message? Can you see the feedback form? Some reason? My message is like frozen for the last 30 minute. So, but thank you, Doctor Princess was like adding the bar code in the presentation so you guys can fill this out, please. Thank you guys. If anyone has any question in terms of getting um I don't know if what year you you know currently, but if anyone is helping to get at and just you can email me. I think Sh Shafi has my email or I'll possibly see you guys in December for the workshop. Sorry, what's your email? Sorry for somebody that would not be able to make it to the. So um my email is Princess. So just but just actually my email is Princess A anyway at ymail.com so you can just email me. So at Ymail ymail. Yeah, yeah. Um in the UK. Yeah. Oh, I could send you an invite. Um Sorry I could text you on linkedin. I don't know if you Yeah, I Yeah, I'm on linkedin. Ok, thank you. I can be helpful at some point. Yes. It uh, in the UK, I can just help you in terms of getting the steps if you need. I, ok, in terms I can give you some contact, but I don't know where, where in the UK you live? I, I'm from London, so that might be a good journey if you have to make. Uh, yeah, I live in London as well. Oh, ok. Yeah, you email, email me and I'll send you a a mess uh email back. Ok, thank you. Is that Manchester mrc? I'm sorry. Yeah, and thank you everyone uh for joining. So our next talk will be on 10th of November JMC registration. So we can, it's up in our Instagram. You can sign in for that one if you're interested and thanks again everyone for joining. No worries. Thank you, Shaila. Thank you everyone. Hope you have a lovely day and lovely week. Bye. Yes, bye. Thank you.