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If we're really interact, get the most of it. It's very relaxed, judgment free zone, got so many eggs. So the more you hackle the better you'll get a lot from it. So session today is on endocrinology. This is your case. So this is how we're gonna start the session. So you've got Duncan a 16 year old boy, he's coming to a, his mum's worried about him and told him not to wait for a GP appointment. You're the F one taking the history. What do you wanna ask? What's your easy one? What's going on? What's been going on? I just don't feel great. I just feel really tired all the time and I felt a bit sick the start. So it stopped a few days ago. Was there anything that proceeded? As I say, I've just been feeling unwell, I'd say for a few weeks, let's say, and I just started to get worse and then I started to feel sick a few days ago and now I've been sick today. This happened before. No, any blood say no. Was it just once, no, eight times in the space of how long this is in about 24 to 36 hours. Other, any other symptoms that can, yeah, I've just got pain all in my tummy everywhere in the tummy. Yeah, all over before this. You began the day more. No, anything, a bit less. What's the pain like? Does it come and go, or is it there all the time? It's kind of there all the time. It feels quite bruised all in my tummy and you can make it worse, throwing up. What about make it better? No, no, no, it's just getting worse and worse now. Um Quite small, less frequent. Yeah. So this is the basic, this is your history presenting complaint. Front row. You, you can start sharing. So what did we pick up here? So I mentioned pain. What is the buzzword that's gonna get you your marks and is a at for an Osk examiner, Socrates, So So Socrates. So whenever anyone mentions that buzzword of pain, tick off every box, we've got most of them getting the 110 out of 10, any exacerbating factors you've got kind of covered it all. Whenever you're thinking, gi we've got the right thing. We were thinking bowels, we got nausea and vomiting also really drilled into the urine cos people always forget that and then it's also like fluid resuscitation status. So the fact he's saying he's been sick eight times, he's now got dark less volume urine. What is in the back of your mind? I'm gonna have to prescribe him some clothes. He's a 16 year old kid. If he starts to deteriorate, he's not. Well, so these are the things that should be ticking over in the back of your mind. As he said, he's been generally unwell. He's losing his appetite. Always remember your b symptoms. So, looking at the fevers, if he's had that, that also helps you think of your viral symptoms. And if you're worried about anything sinister because this is a sick kid. So that's your main thing, your history presenting complaint. The other things you're gonna think about are what is your next signpost? Easy marks past medical history. So none, next one family history. Um, he doesn't know his dad very well, but you know, his dad has a condition where he injects himself where he injects himself regularly. Is he on any medications at all? No, no. Regular by the GP social history. He's 16. Are you still gonna ask about cigarettes? Yeah. Yeah, because he's smoking cannabis actually socially. So you've got to think of these things in your histories, especially as you get further along in your career. It's just flexing that, you know, your steps in your head, you're gonna get flustered, especially when you've got more information in your head. Go back to the signposting, get back to what do I need to, to ask in drug history. Allergies always drill down to it. Anything illicit family history becomes less important in your real career, but it's definitely something they're always gonna pick up on and then finally do a system review, take off their symptoms. It's got a bit of a headache but nothing else sinister. So, there's your history, any differentials anyone's got at the moment? Yeah, this way. Not asking. Thank you. Anything else. Common things. Why do people vomit virals? Yeah, he's 16. He's been sick six time. Anything else that can cause vomiting surgically? Yeah, he's a kid. Could be something. He's got general abdominal pain. Any other surgical causes your surgical society, most of you common is common to definitely a 60 year old boy. 100% want to vomiting is probably the first son and only son they'll have and they'll have tummy pain. So that's a really, really good one. Very justifiable. You're saying it's having small or less frequent, it could just be a slow pseudo obstruction. So all these things, you should kind of be having three differentials. DK A is obviously number one, they've got clue in there and patients will never tell you. My dad's actually a type one diabetic. They won't say, oh, my dad's actually got um, hypertension. They say, oh, they're on Ramipril and you're kind of going right. I'm gonna have to work it out. So finding those little clues are the ones that help you getting along. A 16 year old kid who's vomiting who's dehydrated, you're gonna end up doing a urine test on them and that will probably show your course. Yeah. So we move on to examination. We went through this last week, but there are main things to get through with your examination. I want to make sure you start off at the end of the bed, we get too drilled down. But when you go into exams, I was trying to hear from the other day, you should be to show the exam that you're thinking about. You really looking down all by the bed, looking at that catheter, looking at the signs above the bed. It's easy marks in my final year. It was just a s you had to look in the drawer and there was a salbutamol inhaler. You have to look around to really make a point. You look at him, but he's a kid. They compensate till they're really ill. I know he's 16, technically an adult, but they're young. You really wanna make sure you've checked everything looking at him from the end of the bed and his mum is usually the one who's gonna tell you he's sick. So we look a bit closer. These are some of your other stigmata by the bed. What's this? Yeah, blood, blood in his vomit. So we're thinking, is this going to be he's got some form of a lesion in his stomach or is this just a mallory wise tear? Is this something else? So is it got to start thinking of these? Am I getting worried. Now, do I start? Have to think about blood products? All these little clothes. This one dries. Yeah, it's gonna be shown dry mucosal membranes. Um, it's hard to tell in real life. The tongue is the best they say to look in the mouth. I have never seen any dryness in someone's mouth. You can see their tongue. It is one of my pet peeves on a Jerry's ward where there will be a, someone who's dehydrated and there's no mouth care. If you ever are on Jerry's wards. Please, please please help the nurses with that because see someone bleeding from their mouth, from my dry tongue. It just, it breaks my heart. So that's the other one. And then this one, what's he smelling there? But it is what? Uh pear breath. Yeah, sweet smelling breath again. Never smelt it. I just checked the bloods but that's me being lazy. It's something they'll tell you in the exams. I've never seen it in real life again. Don't know those who didn't attend the other day. Not trust have electronic notes. I worked in six F one F two. Everything's paper. So this is how you should be drawing it at one point. Tenderness. It just shows when, if he was to Tio on the ward you would flick open, you can see exactly where he started. And as a general surgeon F one F two, I was, this is the stuff that comes your bread and butter. So him, he's just gonna say it's generalized all over mainly epigastric. Going towards the left upper quadrant associated with the vomiting. Nothing more, nothing less. Ok. Anyone remember how to complete an abdominal exam? I gave an acronym to those who were there on Tuesday. Sorry. You know. Yeah. Dri. Yeah. Yeah. And some, oh you were kind of a gold star then her, there's the clue. So D ra rectal examination, D dipstick hernia or to do with your hernias. And he's a boy, we mentioned torsion. So yeah. So you wanna examine the external genitalia. So this is his urine. It comes back positive for ketones, po positive for glucose. We already kind of knew what our diagnosis was but moving on, these are his bloods. I'll put some reference ranges up there. Does anyone pick anything out? It's odd. He said your feet is a bit down and is high. His urea is high. Is it proportional to his creatinine dehydration? So there are two cases where your urea is disproportionately raised to your creatinine dehydration is one upper gi bleed is the other because you're having your protein meals. They are the two examples if you ever get an M CQ and you see urea is 15 point something and your creatinine is a little bit raise like 80. That disproportionate rise is due to dehydration or your protein meals. So it's a very easy one just to help spot and on the walls that helps you with your fluid prescriptions. He's also mildly got a bit of a raised CRP. Is it bothering you? Not really, I'd say with normal white cells, this is just, he's irritated. He's a bit inflamed because he's been throwing up eight times. Um, always use your bloods to help dig your sepsis. Yes, it'll go red on your bloods. But you've got to look at the clinical picture. You'd want to be asking what was his new score, especially in the kid bloods are not the most accurate thing. Go on the clinical assessment more than anything. This is his venous blood gas. How are we feeling on that? No good. Why is it not good? It's very acidotic is it? Which type is it? Why? Mhm. Uh His it is. Yeah. OK. CO2 is low bicarb is low. So they're the two things. This is how you differentiate. So always start. So I start with your oxygen because it's the easiest thing to know. This is the thing that's gonna kill them. So this is on Rimer. As we can see up here, we're kind of going, this is a bit low but you kind of go and you've got eight in your head as your figure for your oxygen. So less than eight is a type one respiratory failure. OK. It's a VBG. So we're not that worried but I'm just, yeah, it is. So don't worry, this is why fat to be low on this as well. But in an arterial less than eight, you type one, greater than six, you're type two. So always start with that bit first before you move on to your acidosis, then you bring in your base excess and your bicarb. And then you're thinking this is, oh, it's a metabolic. If this CO2 is greater than six, this is going to be, they could be compensating or it could be a mixed acidotic picture. So that's how you start to work this out. Then you go to your lactate, ketones, lactate and they're the pretty much main ones you need to know for your metabolic acidosis lactate isn't that high. But we know because of his urine that's been positive for ketones where it's coming from and his glucose is 2525 is not good. He has got sugar in his blood. You want to make sure we are getting some proper control of this sooner rather than later. How often do you do gasses? You going? Mm. 74 if it's in? Yeah. So the guidelines, do you, are you still sort sepsis? Six? Take three, give through, right. I'm gonna ruin your lives. It's been updated and for my exams you have to learn the new sepsis six which is all, everything is within the hour. Have you heard all of that? Yeah. So you are titr your fluid assessment based on hourly lactates. So that is an easy again, new change to sepsis because we used to say, give fluids, assess them. Now it's all within the hour. So you should be doing hourly lactates and bringing that down and changing your venous bug a with your fluid assessments because obviously DK A, what we're giving fluids flow is fluids. So that is the one that is the trick for your venous blood gasses. You should be doing hourly lactates in this kid of this age. You may be doing more frequently as you say, cos it's A&E we have this machines in there but hour is probably what I'd have in my head. Yeah. Any questions about gasses and we never done a cap gas? Mm. Very weird. So you'll go to a gas machine. It'll be new and a new trust and I haven't even signed onto it here. Cos that's too short. But you basically have a little pet. So you pin prick and then you use a bit of pressure, include it in a little clear tube and that's what you use for a cat gas and it goes under the same needle. But it's basically like you have to use pressure to do that. It's a good one to practice because you could be the only doctor impede journey as it is quite frequently in other trusts. So you will be abandoned a lot of the time anyways, we already got the diagnosis who has seen a patient with BK. Anyone managed it. No, no. So as I've already said the main thing you're going to be doing is fluids. This is quite a nice trust London. But for your exams, normal Saline, you just want a crystalloid that is going to help dilute their bloods. Bring down the acidosis that we've got. There will be in protocols, especially in kids where they'll give you on your fluid assessments. But your main thing is I say I'd have an hour in your head. So you're giving a stat bag. So this is for about 30 minutes in a young kid. You can be very quick with a liter, reassessing. Make sure you're managing their BP and their lactate and keep doing that doing fluid assessments. You want to catheterize them. You want a constant fluid assessment chart. This is someone who's dehydrated, very sick. You're going to be doing lots and lots of fluids and escalating early. What happens if you keep giving normal saline, they'll be coming. You can do what was normal on this or I A some hot hypokalemic. OK. All right. So yeah, you flush out all your potassium and when you have your potassium going then you're gonna get cardiac abnormalities. It's not what you wanna do. So this is why again, you're doing your regular venous blood gasses, cos you're gonna get your potassium on there and that way you can know, oh, in this bag, am I gonna put 40 K cl in there? So again, this is why you need regular, regular monitoring. So this is the acidosis we've attacked. Have we done anything with the diabetes yet? What we're gonna do is got a blood sugar of 25. Let me, it's insulin. Yeah, definitely short or long acting, short, short. Yeah. So it's usually a rapid but just say short acting. Um, you can give a stat unit, they say it's naught 0.1 units per kilogram per hour. I'm not sure on those numbers, there is usually a policy but just for your exams, you should be saying I'd want to administer as per trust guidance, short acting insulin and monitoring that blood glucose with regular BMS, all the gasses. You're constantly reassessing. As I say, if they're vomiting as well with doing a dehydration assessment with their fluids to help relieve that obstruction. You could consider an NG and referring to the specialist. They are top three fluids with keeping on potassium insulin specialist. That is DK A any questions? Yeah, we just heard s hernial orif external genitalia rectal exam, dipstick urine. So when you're presenting your abdominal examination, say today, I examined Duncan a 16 year old patient. He presented with excessive vomiting and abdominal pain on um examination from the end of the bed. I noted that he had blood in his sick bowl. He had pa breath and he was looking clinically dehydrated. Um on palpation, there was generalized abdominal tenderness on deep and superficial palpation with no hepato or splenomegaly and that on auscultation, bowel sounds are present. So, in conclusion, I met Duncan today, a 16 year old patient who presented with abdominal pain following vomiting to complete this examination. I want to make sure I've examined his hand orifices and his external genitalia because I'm worried about testicular torsion. I'd want to do apr exam and then complete with the dipstick of the urine done. And that is all your whole presentation in two minutes. But it sounds like I've done it. I've turned up on the wards cos now it's a number generator to get a job. You just need to learn what you need to know to be a doctor. Everything I learned from med school did not help me when everyone was dying of COVID. So turn up, get in the doctors, get in this mindset cos it's the most you'll learn in your time today and think the things what's gonna benefit the patient. Yeah. Anything else? It's just insulin you don't give. So this is in the acute phase. So this is you as the F one N A&E you would be starting with a senior, a fixed rate or a stat depending on the policy. I wouldn't, you could do a sliding scale as well, which would help with your fluids. But the main thing is make sure whatever your trust policy says. Yes. What is sliding scale? I've heard so many good question because you'll be prescribing it. Day one but I wouldn't be surprised. So what it is is a short acting insulin co prescribed with fluids. It will have hourly plans for the nurses. So it's literally a chart that has time boxes in it where they have to put in the BM. They give an either insulin with glucose to bring up the blood sugar they can do or they're bringing just normal. So sodium chloride to bring it down based on ABM. So you'll be prescribing, give normal cell line of BM is greater than 10 glucose. So 5% dextrose was less than 10. This is me, this is what I did in Southend. This may be a difference in different trusts and then you can consider insulins all based on titrating to your BM. So is it kind of like P RN? No, it's a set variable rate chart. So if you look it up on CLP Sirna, it comes up as this little box that says variable rate and so the nurses can choose how much they give based on the policy. It will tell them what they should be giving. But your main thing is thinking the fluids and what BM is going to be your threshold. I went for 10 cos it's round and easy for the nurses. Some go for 11 because that is technically what you're aiming for in the patient, but I just went for ease. But the main thing is a sliding scale compared to a fixed rate is that you're going by the BMA fixed rate. Insulin is you're just constantly giving insulin to cover them for, let's say pre op surgery. Thank you. Yes, sir. A all right, I've spoken enough. It's your turn now. I haven't been able to do the online QR code because they wanted me to pay for it and I refused so you can jot them down. We'll just go through each question at a time and yeah, work it through. OK. Safe space. This is your first question? OK. OK. OK. Yes. Mhm. OK. Horrible question. Yeah, everyone happy is ready to go through it. OK. We won't expose the answers. We'll work it through. So, diff diffuse Goiter. This is a very common presentation. Everyone know what Goiter is child definition. So yeah, diffuse swelling of the neck is actually goiter. So it's all across. So you just basically got someone with a massive lump. You wouldn't find that in usually a lymphoma. So that's why you can exclude that because it's more, more localized or in a, just a nodule or a thyroglossal cyst. So that's how we can start narrowing it down antibodies. It's a classic M CQ one that I used to hate anyone know exactly what it is off the top do. So, which is your most common one on the board. What is, what will you be saying in your clinics? Most commonly, everyone thinks it's great. It's actually multinodular goiter, which is just someone who has basically got a long term effect. And n thyroxine your graves disease is people with the autoimmune. So, they're your type one diabetic. So, usually that's what you see on this one. That's why it could be this because she's got a background of type one diabetes. Other ones, any other auto means that's what you're thinking of your graves and the other one, you know, which also has autoimmune diseases. huh? Hashimoto's exactly. So we're already down to two because we've got the clear word in there. Graves disease. The autoimmune antibody is anti TSH. And so the answer for this one was Hashimoto's. So the clues are this always think diffuse goiter. OK. I've got generalized swelling. So it's all inflamed. So that narrows you down. Then you go. Oh, ok. She's got autoimmune, narrows it down and it's TP O so Hashimotos with this one des, um, is painful. So always think if they're saying a painful swelling, it's more to do with devis much rarer. But the other two, they, you autoimmune associated happy with that one. Roughly there were a lot more the faces have gone down a bit since I started the questions. OK. Next one. Thank you. OK. Happier with this one. No. Oh OK. Has anyone seen the picture of the cushing out person? Anyone really brave and wants to shout out the answer. Correct. All you've gotta think is they're a Roy person. So they've got swelling they're big, they're storing fat, they've got thin skin, any think of anyone who's on steroids, it's all fat, less muscle, thin skin, parathesia. It's more to do with your Addison's just because of the different fluctuations. So that is more one of the signs you'll get clinically. Yeah. Moon face, Buffalo, interscapular fat pads, proxim myom myopathy also happens in thyroid disease. So how do you test that in your thyroid exam? Proximal myopathy with their arms across from their body. So that's how you see cos they're using their call them. So they've got that proximal myopathy. So, yeah, and that's why again, looking from the end of the bed is really important cos this could be a young kid who's been taking genic steroids and you can see they've got thin skin, they've got these signs and that will help you if they are deteriorate on the end of the line. Ok. Next one. OK. Sure. Three. I know these are hard, don't worry. OK. Everyone had a thought, everyone happy. No idea. OK. Let's break it down. OK. This is what you're gonna do. This is what you're underlining. Ok. So they've got a BP of 250/100 and 50. Is that normal? Is that worrying you? What are you thinking of the back of your brain? But more than more than hypertension, more than that because you know, 100 100 and 40 is hypertension. The Yes, malignant hypertension. What do you get malignant hypertension in clues. This is an endocrinology, pheochromocytoma, which is an adrenal gland cancer usually happens in younger people and people with genetic causes. So, yes, we've got that one. So we know that's probably what they've got. They've also previously had a thyroid cancer and an aortic aneurysm. What kind of patients get all of these conditions? They are young with an aortic aneurysm. What does that? Do you think they've got normal tissues, connective tissue disease? So, what is a common one where you get? What's the, one of the syndromes? Marfan's? So we've got some Marfan's thyroid cancer and a phay toma. What could it be correct? Men? Two B. So this is how you break it down men. One is your pituitary adenoma. So this is someone with your bitemporal hemianopia. So they're the ones you think about. They also have pancreatic tumors and parathyroid. So we know it's not men. One. That's out. We're down to men two A and two B cos we know they've got the pheochromocytoma and the thyroid cancer. Does anyone know the difference between A and B three? Like it's like two things? Yeah. Yeah. Yeah. So basically the morphin noid is in B A. They also get the hyperthyroidism and the parathyroid. So that's the difference. That's how you know that one. VHL. Do you know what that stands for? Yep. And in that one. Yes, you get the pheochromocytoma. That's why that was, could have an option. But they don't when you get the thyroid and they, they get cysts. So if you've got someone who's got palpable kidneys, they're the ones who you're thinking more. That is the cause and NF one O2 neurofibromatosis, it also can get a pheochromocytoma. But these are the people, you know the freckle complexion cafe au Lait, heard of that. That is more your NF one. So with this, with the excluding the aortic aneurysm is your differential here because you know, someone's got elastic and that is how you get through to the Marfans. I've never seen any of these, but you do have to let them. Sorry, someone online is just asking. Ok. So men two, both of them have your pheochromocytoma and your thyroid medullary carcinoma. A is your hyperparathyroidism, hyperthyroidism or B is your Marino? So as soon as you've got a Marino hepatis, that's where you think you'd be right? Next one. Yes, I OK. C horrible cos it's a bit tricky, right? The key here. And this is what you'll find with your MC KS and I only worked out in my final year is picking out what they actually want from you because technically all of these are correct. These are all used in your diagnosis, but it's the best diagnostic test. Cos what are we thinking of? We've got bitemporal he and worsening headaches, uh adenoma. So we're thinking of a tumor in the brain. Take all of this away. You're not reading the question, what will the neurosurgeon ask you for any with the brain tumor? That's the answer. So this has all freaked you out. Oh, it really has freaked us out. But when you go, when you go back to the basics, we've got a tumor. What we need is an MRI head with pituitary adenomas, fundoscopy is part of your initial clerking. Look in your eyes, cos someone's got a visual defect. You're going to do your cranial nerve examination. What diagnose it though? Well, because you know, you know, in your head, what they're getting at this is a very bound or what they're asking for. When you go to your CT head and your MRI head, our CT is good for swellings. Not really, they can see big things really good for. How big is your patrus gland plus with pain, anything soft tissues, MRI. Um I like orthopedics. So what do I want an MRI for anything soft tissue, any knees? That's when we like an MRI. But then if you look at CT S, you look for the blood since you have acute strokes. This is the best one. That's when you go for your CT head. Nice guidelines. You're in any, that's more what you're going for mass effects. MRI head will diagnose what it is. What's it's involving, this is your best diagnostic test. So we know it's a tumor, cortisol prolactin, all your hormones, how many of these are secretory. I'm leading you there, cough and the cough and not function. Most of them even less. I think from what I've gathered are, they don't produce much. You just get these mass effects. What is the majority of hormones produced by these in half? Protin? So, what symptoms would they be presented with as well to these headaches and bioral? They've got prolactin releasing and there's too much. What was that? Someone said it, right. No. So that is your main thing. So this is my next test. 9 a.m. cortisol is more when you're looking for your insufficiencies where people aren't producing their cortisol. So you think of adrenal issues? These are the two I'd want. But yes, you could have a high proacting and FSH, but you could have a tumor producing that anywhere. This is the best diagnostic test. Any other questions? Do you know how you treat pituitary? Can cancers fe excision? That is the common one they go for again. Never seen it. This is your last question. So, don't worry, you've got through the worst of it. And I just, this, you, it's good. Ok. Yeah, I just like himself. Yeah. No. Anyone feeling competent. See. No. So I initially wanted it to be seen. But Metformin also you do can stop the morning of surgery and by books, me going back cos actually I continue Metformin in real life, but by the books, is it all of them Metformin because the side effect it just, it is lactic acidosis dehydration and glycoside is again when you stop because of hypoglycemia. We've already got a few sliding scales and it right. Check your books. My books may be different. I went back through my notes to minutes question. But in real life, my main one is glipiZIDE and it is a whole stop start regime that is in most trusts. So when I clock people to admit them, I'm always double checking because your other ones, you think your ace inhibitors, that's pretty much it you can do. Is it the case in all trust or with Metformin or is it again go to your notes because it's the books and I went to my books cos my original answer was safe for the books from my notes from med school have been clear that Metformin should be stopped before GF and before contrast and in case of tissue hypoxia and a EGFR less than 30 they're the contraindications to when you stop Metformin when we just drop to a fixed rate instead. Um So this is someone where you're admitting them for an elective procedure. So if someone was acutely unwell, so they're dehydrated, needing their touch you about medications and they're not being managed, that's when you're going to your fixed rate. Again, surgery, safer sliding scale, fixed rate is a very niche point in acute diabetic management. In the perioperative surgical patient, we stick to sliding scales because we're temporarily giving trauma to that patient. So the safest thing for me as a prescriber is cos if I leave the room overnight and I go home, it could have a hype overnight. So by doing a sliding scale, I've covered myself. I don't understand when you lose fixed rate instead of a sliding scale because is a sliding scale always just having that security that you're essentially doing the insulin, you're adjusting the insulin based off of their BM. So why would you do fix rate? Endocrinologists do it. So this is someone who was more stable in someone you're trying to get them on a regime of controlling their blood sugars. This is someone who's maybe not very responsive. Um I have seen it done on the diabetes ward. I've never seen it done. I've never prescribed it myself. Um And for your answers, it's a very niche cause I think the majority of places you just need to know when you're starting your short acting, long acting, your fixed rates are just for those acute presentations of diabetes when they're stable. So they're not acidotic, they're not dehydrated. OK. Right. So this bit I'm really gonna need people to heckle at me. Heckle ideas. Nothing is a bad idea because this is going to be your scenario. OK? Because you're on the diabetes ward. This is the f one I didn't know there would be so many comments otherwise I would have stolen some stuff, but we're gonna go through an informal sim. So this is your patient. I want you to throw out how you're gonna manage them. Ok. So I'm your nurse. I'll give you anything you'll need and any answers you need. Ok. So doctors, doctors, we've got a patient on the ward there snoring and I can't rouse them. What I'll be here for? II don't want to talk to about what they're here for. They're snoring. I can't wake them up doctor I think. Am I pulling the alarm? What am I doing? What serv oximeter? Ok. So the pulse that 7071. Yeah. Oxygen 71%. Yeah. Come on, Brian. Wake up. Brian. Can't wake you up, Brian. Yeah. So jaw thrust. He's not snoring anymore but he's still not waking up. Um Let me look, I'll get the suction for you doctor. So there's a bit of secretions but there's nothing in there. You're correct. Yeah. Ok. So you put an MP down. Um How do you measure an MP from your nose to? Ok. So we've got you size seven doctor. I'll just put that down for you. Let me help. Ok. He's still snoring when we let go of the jaw thrust. Perfect. Yeah, I'll wet that on for you doctor. Don't worry. Oh his thats coming up now he still snoring. He's still snoring. How is his respiratory pa? It's very agitated, as I say, snoring. It's slow respirate. It's quite force breathing, pupils are equal amounts of light. He's alive. No, I mean, my life. You? Oh, yeah. No, there's no trauma. The patient was admitted a couple, uh, earlier today from A&E, we haven't really got much handover about him. Um, miss that. Yeah, I can. Yeah. Yeah. Yeah. These are all good things. So, you're alone. So, let's go to, not a good trust this way. Let's go to my D DH, I'm alone for 40 patients. Can I stand here the whole time? This is Brian. He's a big, big lad. He's been going to the gym. Yeah. So what you're gonna say to the nurse quickly pull the buzzer. Let's get some help going here. But do we just hold this forever. A ps hard to hard, soft to soft. Heard that measuring slide on, on the pallet. Get around. Oh, stop snoring and your admission, your oxygen. Oh going up even further. His s are now 90 better. But yes, there was an A B you mentioned just to recap before we go any further. The main thing with your airway is to keep reassessing. So the first thing you plug on is your non rebreather mask and your sax probe and you keep reassessing it as you go along that way, you're thinking your head and fixing the thing that can kill them. So, yeah, that is the best way to think about it. Oh, let there be light. When would you not want to do a head tilt, chin lift, c spine injury is exactly that. So they're in the collar, it's quite hard when they're in the collar. So you'll see if you go to any trauma calls. The Anestis can sometimes just hold the c spine and they'll do the jaw test at the same time and that OTP will be helping them NPO P then go into your eye gels. I haven't seen an anime user in years. I like the um I had a lady who was quite agitated c spine injury and a need to give her an easy life. Kept giving her loss of morphine. So she was fully a overdosed and I'm there managing my c spine and um an airway mo I only got to be, but the fact, luckily I had a traumas with me was holding c spine. But you know, that is the point as soon as you're managing an airway Paul Butter, as soon as someone's saying, snoring, you're an F one called buzzer. No one has ever crossed that. You pull the buzzer. I like one person that needs to ST shout at me. But I was right to because I was one F two on my own. You're not legally supposed to be on your own to do these things. They're paid to do the airway support, get them down there. Is. What does that mean? So your arrest team, has anyone attended an arrest? Yeah, but it was there was a lot going on, there was a lot going on. So as, again, very chance of trust, I've only been cos I did medicine in my first two jobs as F one cos I wanted to get my medicine out way, moved to surgery on the arrest team in that trust, similar things you will have two registrars. One is the reg for the wards. One is the clerking reg, one of those would be the team leader for all arrest course peri arrest and cardiac arrest. The number you put down is the four twos, 2222. And that gets in there. If you then put out an airway A that, that's when you get the anesthetic coming down. Different. Cool. That can be in some place. It's called a blue cool purple. Cool is the G ones. But all you need to say is I'm putting out per arrest, arrest. People know what you're saying there next, you've got a couple of I MT ssh O sa couple of F ones. And that is your arrest team in that. As I say, you've got your team leader, then you've got another reg you can help lead the F one. Usually one is on taking the notes. So say you're in a rush, you need someone to take time. It's a simple thing. Someone needs to be documenting every time you get those drugs. School is my favorite job. And then the other F one job. Is usually getting the access here. I would assume like it was in Mary's in trauma centers, there is a ACP trained person for access and they usually get the logical Cannulas. But your rest team should be about six people with a team leader who is a medical reg you will all be a trained. So technically you can all run it. But no, that is your arrest for ay purposes. Stick to saying I want to put out an arrest. Cool or a peri arrest. Cool. And that way like with this one, you're worried about airway, I want the anesthesist. It's a very fair thing to say you're showing. I'm thinking what's safe. But yeah, that's the main ones for airways and whenever there's an airway call, someone never uh if you're managing an airway, you're already out of your depth. So we're on to breathing. As I say, it's a very low risk rate. So that's picked up to 93%. Now, what is this diagram demonstrating? Thank you. Yeah. So he's got coarse crackles on the right hand base for your A two. The best way to address any patient is start the arm. If you start the arm for every case, you're thinking I've covered everything. So start with the airway end of the bed. There's snoring, secretions, getting that suction in early is a good thing to do. Look, take out any obvious obstructions, teeth. If it's a trauma call, caid your airways, non rebreath. Always every case. I don't care if they've got CO PD 50 m, cos the hypoxia will kill them. You then move on to breathing. We worried about your sats Probon. You're going up the arm. I'm thinking here we said earlier. ABG that way, you'll never forget it. Whenever you're thinking of any oxygen compromise, you need an arterial blood gas. What's the other test I want in breathing? If anyone who's got a breathing difficulty, portable chest X ray again, what your informal job will be in a perusal it. Get calling radiology and getting portable x-rays to come around. Anyone with breathing. Always get that x-ray. It's tiny radiation but it will give you loads of answers they could have per you can see it on a chest X ray. Always good to have. Then you're moving up the arm again thinking oh nothing more up here JVP. Now I'm thinking of respiratory rate. I've got to hear. Then I'm looking at the chest wall, I'm taking down the gown, maintaining dignity. You always say that your exams, but to fully expose the patient by maintaining dignity. It's also not to let them get too cold. Cos coldness also is that terrible triad, what's gonna kill them acidosis hyperthermia? So you look at the chest, you see he's not really moving his chest, you'll then do your expansion. You will be cut your six zones quickly. But and then you also take six signs and here he's got right lower lobe course crepitations. So, we're already thinking in our head or what could be going on here if it's, if it's both sides, we're thinking, oh, is it fluid overload or something else going on? Is he an edema? Has he got fusions? But it's one side, one sided. Course, crepitations sounds like a pneumonia but we move on to circulation again. Start at the arm. First thing you do, you're gonna hold that hand. You forget how simple things are. But in the hand, they're clammy, you're already going, they're a bit sick or are they cold? Are they peripherally shut down? This is a trauma case where the thing is peripheral cap refill, peripheral cap refill is a bit rubbish in a trauma sick patient, central cap refill is the one you should always be checking again. We're going up the arm. We've already got the ABG we're at here or we also a heart rate down here. So we wanna make sure we're asking the nurse in real life. I'll say, can I please get a full set of observations for your exams? Need to say your observation. So in airway, I want that proton in breathing. What is the respiratory rate in circulation? What's the heart rate? What's the BP recycling every time you give any fluids? Large cannulas both and cubital fossa. What bloods do we wanna take off in this patient? Yeah. Mm What were we thinking? Of the diagnosis is of this. Yeah, never ever hit go again. Is your new sepsis within the hour. Get every culture you can fusion culture, urine culture, do a full septic screen. Blood culture is definitely one you've gotta take at this point because how long does the blood culture take to come back? Two days. I'm waiting on some cultures from theater that take 5 to 7 days. Bone cultures take ages. So the sooner you get them the better and then you'll actually be able to treat what's going on because we've got a lot of resistance bugs around there, especially in this day and age. So getting those cultures early means we can target the therapy better again. So we've done that. We're off for a BP. It's 95/57 what we're gonna want to give Brian at this point of what? Yeah, someone's got the money at the front there with the plasma life, right? We're gonna give a bonus. How much are we giving him? No, Bryan's 25 year old body builder. That yeah. Um 250 mils does nothing even in the little old ladies, we still give it. It really does nothing in him. I put up a liter for your exams, say 500 mils. But again, because you just have to pass your exams. I'm gonna say the exam question real life. Pop the bag because it takes ages unless you've got someone who's really hypotensive where we're squeezing the bag, we're squeezing the blood in. But the liter that's not, we know he's gonna need fluids. He's not. Well, at that point, every time we put up fluids, I want a catheter in. It's something that I've picked up, the more I've got along is fluid balance is so, so essential, especially for understanding your patient. And then you're thinking again, de your examiner. I'm thinking about what could happen cos I could overload this patient, I could dehydrate him. It's just another form of monitoring again, like a chest X ray for breathing. What test would I always always want for circulation? EC G? So again, where I'm working on my chest, we've done the BP, we're reassessing that every time we do something we reassess, we don't move on to D until I'm happy with C go up the neck. Again, we've got J BP cardiac monitoring. So I want formal cardiac monitoring and a formal ECG 12 lead both all the time cardiac monitor. So cardiac monitoring is your continuous in A&E where you're on three stickers and you can see the heart rate all the time. And then a formal 12 L UG is the full one. So they're two separate things and you have to both are put on, but you say both and it just shows again, I've been down to any, I know what I'm looking for. I want continuous monitoring and I want to check all the leads. And then we're at the chest, we look at the chest wall again, central papillary refill, and then we fill the apex beat and we can auscultate for heart sounds which are one plus two. This is your eg happy, not happy. It's just a sinus tach here. Fast leaves. You're looking along. So always start with the DCG one and three reaching leaving. So you can see your axis deviation. Then I go to my num bottom strip rate and rhythm 300 divided by big squares. So we're at 100 and 50 roughly P waves regular. We know we've got rate, rhythm, no access deviation, then we're going to move on to, we can look for any signs of Mos One Mobitz two, all these other things you're gonna look for in a sinus tachy. You can't really see it. Other things you can think of. In this case is he Perret, seek the things that could kill him is he hyperkalemic is the thing I'd really want to look for. Uh that tend to T waves high. 4h is four T otherwise it's always gonna nine times out of 10. It is a sinus tachy until we do the cardiac session and then it will be different things to do. But COVID where I did all my working nine times out of 10 was this, they would then potentially move into heart blocks and things. But at the initial sixth stage it's usually sound as tacky. But if you stick with 13, see if they're going into acute heart failure, two rate rhythm, then you look at the rest for any elevations and that's pretty much what you need to do when you're handed this and you're off and you're like this. What do I need to look for? If you just go 123, you're kind of there and then you wanna look for elevations, there's four things to look for. It's not the end of the world. And then you've already shown I can initially assess this patient. Now, we also took some bloods from the catheter we took here is the ABG that you asked for earlier. That's all of it. As I say, there's some 15 L of oxygen this good or is this bad one? You know, that's fine. Does anyone know how to interpret a ABG on oxygen? Like add 10 every liter or something? Uh very extra liter of oxygen? Your ot section 10, roughly. Yeah, rule of 10. So we're 100% oxygen. If he was healthy, it should be 90. So I take away 10. He's a bit hypoxic, he's not hypercapnic. So we know he's in type one respiratory failure. We can also tell that cos we've had to administer the oxygen in the first place and we knew his sats when he started at 72 but minus 10 from your percentage inspired oxygen is usually how you work out where you're at. I remember if you're not meeting those targets, you are in a form of respiratory failure. Um, his ph is fine. His bicarb is fine. So he's not compensated at the moment. So he must be quite cute. And he's got quite a mildly raised lactate. This is his next door of bloods. Mhm. Yeah. Last time that you thank. So we know he's got pneumonia. But what has he got now? He has got a bacterial because his neutrophils are high. What's the buzz word? And then you're gonna start ruining things off. He's got sepsis. It's your sepsis. Six. So I want to escalate to the senior within the hour. All of these things I'm taking my, I've already got my cultures. I've already got my lactate. I've already put cast in. So I'm doing a floor balance. I've already done all of it. Thank you examiner. You don't even need to ask me, what am I gonna give? I'm gonna give, what is, what are we gonna give? What's the perfect buzzword that makes me go. I'm going to give broad spectrum antibiotics as per trust guidelines within the hour. That is a sentence that will get you top top marks because I know, oh, she's read it. We give fluids based on hourly lactates. We give oxygen. There's your three takes and that's why by getting your circulation right? You've already matched your set to six. Yeah, that's the main one to look for um, any neutrophilia, we know it's bacterial more likely and then C RP greater than 100 I'm saying aseptic. But by his, I would have, we already knew the blood cultures, we're giving antibiotics pretty damn quickly. So we're already managing everything. He's, he's a, a see what I mean with your ear and questions for this one. His health there, they're fine. So they're in nine but he's got, they're normal sodium and potassium. No. Pretty low. Pretty low. Are we happy with those? Do you know how we manage those? Do you feel? Oh, just b honestly, as a co surgical trainee, it's been a while since the sort of medicine I would leave this to someone paid a lot more than me to do a med reg because I know, I don't know. In some cases it will be fluid restricting that will help bring them up. He hypoten. So we give him fluids. Do we give 40 K of minimal of K cl quickly? No. How quickly can we give 40 miles K cl it. So twenties, four hourly. I usually give 86 to 8 hourly. 40. Again, you can give things quickly, but that's up to the anesthetist. I'm calling people who know much more about these drugs more than me than I'm ever given this. I'm noticing it. I'm saying to the examiner. I want to either talk to them about what fluids to give is safe at the moment and fluid resuscitating. But I'm aware that I'm going to drive down his potassium and I'm going to want to give him some support with that. So uh you'll say, II will say I don't wanna manage this. So I don't wanna manage this. You guys definitely don't. So you're calling help at this point, but it just shows your examiner. I'm aware, I've noticed that there is hypokalemia. I am going to need med reg support ASAP to manage these fluids and these electrolytes because you could, he's already in a sinus tachy. If we start driving him potassium, you could rest, then you look through the notes and you see these are his blood tests from this morning. Just remember them, think about them in the back of your head. High ACTH low cortisone, think about them. But while we're thinking about that because you know, we're waiting for the med and we're coming for ages. This is we're gonna move on to disability. Never ever forget glucose, temperature, pupils, Apple or G CS. They're the fourth issue used to address people always forget temperature. They say don't ever forget glucose. So everyone ever forgets it. The temperature is really important, especially in a septic patient cos it's forming part of your knees. Um Brian, look, he's already got an airway. If we know we're supporting an airway, what is his G CS? Less than perfect. So we know we're gonna, we've all got the in coming. He's gonna need a formal airway. His eyes are no response. One. He's making sounds too and he's flexion. Um he's moving to pain. So he's about eight. So he's not too bad. He is recovering. This is the chest X ray you asked for. Are we happy with that on the lower side of the, the right side? Mhm. So we know his airway is not deviated, a pacification in the right lower lobe and there is no cardiac shift and I can't see any signs of a pneumothorax. That's in the acute things. Again, the 4h is forties, tension, pneumothorax is always in the back of my head. They're the kind of things I'm looking for but always say what is obvious. But coming up, we've already been worried about the airway pa courier essential. So we're happy. Ok. So I showed you these bloods, you got a pneumonia for managing a sepsis. You've saved your life. Well done guys. But what caused him to go into this? Yes, he's got the pneumonia. But why is he not responsive cos people just you know he's Brian is 25. He's a bodybuilder. Why has this pneumonia knocked him off? How about you? Mm Just ankle. Why he is? He's a Roy boy. So what is it called where someone has gone into a crisis when he's taking too many steroids? I did anyone see that bit coming or do, are you just too worried about the cat? We were all focusing on the cap. That is what we should be doing because we're not endocrinologists. We're gonna manage what we can manage as F ones and L it's fluids, it's getting the bloods, it's getting the ball rolling, making the right calls early. Keep it to a structure. Not getting flustered if you don't only get to be, but you fully manage. B that's a pass in real life. They come by the time you're at bay. But you need to always remember, reassess, reassess don't progress until you're happy check that if that BP is now coming up, I can then move on to d then indeed. Or was he doing it? Like I didn't even do an examination on him. If I was to fully expose him or maintaining dignity, I'd check and see he's got thin skin and he's got all the signs of someone who's been cushingnoid cos he's been over taking steroids. The main thing is what's gonna kill him. And that is your ABC. Get really sick of what you're saying for that. So it rolls off the tongue. You'll be fine, you'll all smash it. I II understand why people are taking steroids and then you remove the steroids, then they crash. But I don't understand. So it's an insult on the body. So he has been supplementing it for so long as soon as his body has a greater demand, he's picked up a pneumonia COVID as well. His body's gonna drive, it can't cope and that's why it crashes down. So there's, it's that initial trauma, you have a, a dezone crisis, I say with literal trauma. So you could be stabbed, they could go into crisis and you need to give your cortisol, your hydrocortisone to supplement it. So as soon as you know, someone's on long term stories, always think they're gonna have surgery at some point, they could be coming in and they've just got appendicitis, they could have a crisis, any insult on the body. They're the ones who are prone cos their body can't cope. When do you ever get home all the time? Any, any maintenance fluid? I give Hartman's on wards. If I've got someone who's near by mouth, then we can cancel the surgery. I give Hartman's, it's a crystal age. You can give stat in an emergency. But in real life, what's in the cupboards is normal Saline. So that is what I say to give. It's not on any for him. I would want to give normal Saline with like the 40 KC in it because I want to control what electrolytes I'm putting in him. It's a great balance when he's better. It's a great maintenance fluid. If he's still not eating and drinking properly for the first case, apartments is good. Cos we're already thinking down the line. Once we've given him the initial resuscitation, I'm gonna maintain him. I'm thinking for the electrolytes, we're maintaining that osmotic stability as it should be in any acute. My two is normal saline. No blood. Ok. This is my old trust guideline. I quite liked how easy it was. I don't really like micro guide. This was quite clear to what to do based on your pneumonia treatment. So he's not confused. His urea was fine. His respiratory rate was fine. His BP was a bit low. So he's only got clerical one. So actually he'll be going on amoxicillin and then IV fluids and hydrocortisone. These are the main things that you're gonna have to give to supplement him. But that is just a easy way to think with your antibiotics and that is your long term management for him. But as the F one just keep him alive, by the time you're given the oxygen and you've put the AP down, you've done enough few exams. Stick to your structure. Always get a chest X ray. Whenever you're worried about breathing, always get an arterial blood gas and circulation. Always get a formal CG. That's him. I say to him and that is it. Hope you're not all too tired. Sorry, I have to gather feedback to prove you were here. Any questions, safe space. A lot of information, overload. Too much. Too little. That oh, a lot of bathing. No, I will show you at 10 to T waves because everyone thinks that was sinus tachy because you're getting that electric conduction. E CG. So the way I was taught it from the med reg is you shouldn't, you shouldn't be able to sit on it. It is so tall it is out of this world. You should, it would be going off the page. That is more like it. That's it. So, so tall. These are very good ones. It's usually on life in the fast lane is a bit better. So you get it higher than this in real life, it's higher. You've got QR S Widening. No, actually that one was better. Not X. No, this, that's more like it. See how tall it is. You're basically off the page. That is a tall 10 D. It's quite late in the day because we do blood so quickly. Now we don't pick up on it, but I have seen it and it is off the page. So the sinus tachy if we go back to the, so the QR S peaked, your T wave is actually Christ. Not that high. So it confuses it because it's that contraction. It's a fast electrical signal. But if the T wave, if you can sit on it, then it's fine. If it's all really peaked, it's not good. So it'll be at the top of the page happy. No other questions. There is one. How, how do you know it's from, uh, that's high. So they're your main things to look for. And it is the presentation of a hypotensive patient with those bloods with an electrolyte abnormality of a low sodium and a low potassium breath. We're just about to go grab the pizza and so just stay here two minutes. We'll bring it out. Yeah, it's not if someone say, do you see? Yeah. But you still, they, they all you can do is if you, are you safe then one? Ok. And they work because they wouldn't know when it's really right. Try it in real life. We did and I'd like to, I do. Thank you. Thank you so much not to do. But next week, yeah, that's all you're going to do is because even if you're there, no crash when you first see them, you.