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Finals Revision Series - Abdomen Lecture

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Summary

This upcoming on-demand teaching session dives into the critical areas of abdominal examination for medical professionals. Prepare to learn about the approach to the examination, type of questions to ask, systemic and peripheral findings, differentials, investigations, and management options to consider. Additionally, challenges such as Covid-19 and the importance of personalizing the examination will be discussed. For a comprehensive approach to abdominal examination, don't miss this presentation!
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Learning objectives

Learning Objectives: 1. Identify the importance of personalizing an abdominal examination based on a specific patient in the clinical setting. 2. Demonstrate an understanding of how to approach and utilize common abdominal examination tools. 3. Explain key demographic factors to consider when assessing abdominal conditions in a patient. 4. Explain common differential diagnoses in various abdominal regions. 5. Analyze the importance of considering conservative and surgical management strategies for abdominal complaints.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

34 paces has mentored it before Christmas, but unfortunately, I got held back at work. Um, so sorry for that. So basically, abdomen is a huge, huge topic. You've got the medical side, you've got the surgical side. And so I was kind of a bit stuck on where to go with this presentation. So I thought the best way to do it was B two gearing towards paces and just see what I thought would be the most useful, uh, situation. So the general theme of it will not be about the abdominal examination itself, because I think you guys will be able to just hand that out in the last two weeks. Everyone knows how to do that, and they'll know that inside out. But I think it's more about the approach that you have to the examination and then the type of questions. So it's not going to be extreme detailed about each disease that you might come across. But the type of questions that the examiners tend to ask after you've done the station. Um, I don't know for me when I did it, because it was the covid year. Uh, they didn't have real patient's. So it's a bit of a mix between if they had images for you guys or, um, if they have real patient's for you guys and I think either way it should work. Um, and I'm just going over the brief scenarios in each one. So in medicine and surgery, so in medicine, we've got the kidneys, liver, some stuff on organomegaly and inflammatory bowel disease. And the surgery. I've got some hernia. Stone is surgical scars and colonic receptions. So the fairly high yield stuff, um, it's not a very intense lecture. It's more about a mindset lecture. Um, so you walk into the lecture, and the first thing is your the lecture for you walk into your paces outside of the station. You've got a clinical case men yet, um, so that will give you the demographics of the patient. So hopefully like 53 year old gentleman called Mr Smith. Um, and then they might say it's a specific thing about his risk presentation. So it comes in with the right upper quadrant pain, and then that's all it says. Uh, now it's really important that before you go into that station that you think of yourself as a doctor. So it's not as a final year medical student, but as a doctor who is reviewing a patient and then presenting it to their consultant on that wardrobe. So that's how you should go into it, and it gives you a lot more confidence when you're doing it as well. Like I said, the abdominal examination everyone knows how to cram that in the last two weeks. Uh, so nothing that I'm gonna cover right here and it that differentiates you from everyone else Presentation in your liver. Your presentation is so so important because most of the time the examiners seen 10 people before you and they'll come to yours and they just don't give a crap about what you're doing In that examination, they don't care if you've looked at clubbing in the nails. I would still say do it and make sure that you're doing everything. But if you come across and you you say that, uh, this is Mr Smith, a 56 year old gentleman on general inspection, no peripheral stigmata of abdominal disease. On central closer inspection of the chest, there was an obvious midline laparotomy scar with abdominal distention it just like you. You can summarize it really nicely, and then they feel like they know that you've probably covered everything in the example, we'll give you a big, nice tick. Um, and then you've got your visors, which will follow a very easy format. So again, So let's go back to the presentation. So demographic. So, um, if you guys have problems remembering names, which I know, I always did, I always find the best way to do it was if it says Mr Smith on the outside of the examination station, I'd keep repeating it to myself throughout the station, and I'd use it in my examination. So I'll be like, Oh, Mr Smith, do you mind if I just have a look at your hands? And if you keep saying that, then by the end of the examination, because you said it four times five times you remember it and it just sounds a bit nicer and a bit more personalized. And as an examination like, as you would do with patient on the ward, Um, so, yeah, talk about the demographic of the patient. Nice summary Ethnicity is quite important. So, for example, if you think that they've got unlikely. But if you think that they've got sarcoid, then they might be of Afro Caribbean descent. Um, those kind of things are quite important. Or if they've got signs of diabetes, then them are probably of Indian or South Asian origin. Then those things are really, really important to mention. Um, you might want to talk about the obvious things that you might see. So deformities of the patient So pectus Karen Autumn or exc a bottom which will see even if they're actors. Often a lot of them will still have some sort of signs the size of the patient. So whether they look malnourished or if they're really big, then you might want to say they've got a large body habitus, which is a nice way of saying they're a bit Chubb's, um and then any scars that they have on their body. Um, now most of the actors will be 60 70 years old, maybe a bit younger, potentially. But if they are, they've probably got scars on them somewhere. So if they are, actors do mention the scars, and it does sound more impressive if it shows that you're actually making an effort. So it's not just you and an actor, but you are pretending that is a real patient. So it's quite important that you do that, then headline it with the main systemic findings and the peripheral findings. And then what I'd always do would, I would say, like to complete my examination. And I would say the the spiel that everyone says complete the examination and then I would move on to my impression of what the patient is. So I would say all of these things point towards my an impression of chronic liver disease. Um, and then I would move on to the investigations by myself. Now, the reason why I did that was because in the mark scheme that they have, there's there's a section the last one is like that they're competent, doesn't don't need prompting, and it often sounds a bit nicer if you just run into it. And it's almost like you've you've seen a patient at the end of a wardrobe, um, and you you're thinking about what you want to do next and how you want to treat that patient. And realistically, the consultant or the senior Reg is comparing you to f ones that basically on their ward on a daily basis. Um, you guys will be better than those f one's for the reason that you're you're just sitting your final so your knowledge will be better so automatically you have a really nice base to compare it off. So you need to make sure that you're doing the things that F ones are doing currently. So the way that they move on to investigations and then they might suggest things that they might want to do. Um, so when you talk about investigations, always start small, so bedside stuff. So whether that's doing a little clinical examination laboratory stuff. So whether you're doing bloods and then procedures, whether that's an acidic tap and you're looking at, say, patient's got a really distended abdomen and you're looking at their serum albumin and the city's gradient. So the saag gradient, Um, and then if the the clinical vignette mentions anything about, um, so say, for example, upper gi bleeding, you might want to just throw in a piece of evidence based tool. So, uh, the Glatch Glasgow Blatchford score, um, so you might want to say that you would calculate that as well. So these are things or how you're going to personalize your station based on that patient directly in front of you. The vibe ear's are very easy, and people get very stressed about them. But they're not. They're not hard at all the imperial exams. They just want you to know the really common things. And they want you to know it really, really well. So whether that means differential. So with the differentials, I would always come up with 32 very, very common ones that you you can't miss. You don't want to miss. And then I'd always pre face and say in a rare condition that I might want to rule out would be something like human Chromatosis or Wilson's disease. So when you do those kind of things, it just shows that you know what the the General Box standard stuff is. And you're also thinking about wider stuff. If you give them 34 common ones, then it doesn't make you stand out at all. Um, there's no reason why you need to stand out. You can just cruise through all of this as well. But the reason why I was suggesting is because it gives you a bit confidence when you're going into F one, Uh, when you know that you've done well in your finals, and it's like probably the only thing in your life that you can control because you've been shipped off to the highlands or somewhere. Uh, so it might be nice for you for you to have some control of your life. Um, investigation. So how are you gonna investigate this patient? So again, start from bedside. Move on. After that, they might ask you about the management so very basic stuff. So you're going to talk about conservative medical and surgical management, And if you just headline each one so I would conservatively manage them with analgesia and then medically, you might want to give them spironolactone or something, and then surgical, you might want to do a tap or whatnot. Um, complications are quite a common one. And then after that, realistically, you've had seven minutes of the abdominal station. You've had two minutes going through all of these things. They might ask you a random question, which you might find a bit difficult. That's quite normal. Um, and realistically, there's There's there's not much yield and getting that last one right. I don't think it'll make much of a difference to you. So I wouldn't stress too much about the fibers as long as you've got a fairly good knowledge base. If you prep well for the Pacers examination overall. So if you've got a good knowledge of the really bog standard stuff, you'll be fine in the written papers as well. So it's quite a nice one to get through if the clinical vignette talks about pain and it's an actor then divided by quadrants or by the nine areas and think about each of the organs that are involved. So you've got in your right upper right upper region, you've got your liver, so you might want to talk about uh, hepatocellular carcinoma. You might want to talk about abscesses. Uh, you might want to talk about gall bladder problems, and that will be your acute cholecystitis your colon Joe itis um, Then if you're looking onto the left hand side, you might want to talk about your spleen. So if it's a chronic thing, then you might think human genome is. If it's more of acute pain, then you would talk about, say, a lacerations, for example. And then you've got your bog standard stuff. So your appendicitis is and your right lower quadrant. Um And then in the left iliac fossa, try and talk about things like diverticulitis. And obviously you've got your cancers as well, which will always be there. Now it's really important that if it's a female that you always consider the guy any differentials. So, for example, you talk about it's the reason why this is so important and why they might mark you down is because if they see that you haven't considered it and you have you say you're an S H O covering a general surgery ward. They'll be a bit worried if a lady comes in with right, a lot of fossil pain and you haven't ruled out ectopic tor shins and cyst ruptures. So it's really important that you whatever you do in the Garda station, um, just make sure that you consider those in the abdominal station that you consider the guy any differentials. Um all right, so the first question, if you guys just want to tell me what these are, they're two separate pictures of two different patient's. Um, I've got the chat up, and if you guys just want to give me a few suggestions of what you can see and what you What does that tell you about the patient? Um, there's gonna be quite a lot of questions like this, which So I'm hoping that you guys are just firing away some sort of question of answers, so I'll wait for a couple of minutes. Let me go. Awesome. Awesome. Really good. Okay, so yes. So the one on the left is, uh, the fistula suggesting hemodialysis or some really good. Alex. Um um and then, Yeah, Daniela. Amazing. So it's a Tesio on the right. Um, well, it's kind of a test, So basically, there's a few different types of tunneled central line. So this one in particular is a Hickman line. Um, so if you look so the one on the left, the way that I would talk about each of these so they might show you a picture or, for example, Well, hopefully for you guys, they might have real patient's. So the image on the left, uh, arteriovenous fistula, you might say that this is a surgically made arteriovenous fistula. And the image on the right shows a tunnel tunnel central line in keeping with a Hickman line. And if you look really carefully, you can see the line you go underneath a Navy in vain itself. Um, I basically what that shows is that this patient like you guys said, has been having some sort of hemodialysis. Uh, so the Hickman line is usually used as a more of a temporary measure, but still long term as a line goes, as far as lines goes, so maybe a year or so a V fistulas tend to go on for a bit longer. Um, and it does show that this patient has probably got, uh, some element of end stage renal failure. Um, overall. So it's quite an important thing. If you really want to push it further. You might say the most common causes of end stage renal failure are things like diabetes, hypertension, and then more rare causes Would be, uh, well, adult polycystic kidney disease, for example. Uh, which is a nice way of like rounding off those things? Um, important to never take blood just for you guys. When your F one's never take blood from a Navy fistula. Um, there's a chance of introducing infection and it clots. And then the surgeon will be really pissed off at you if you clot ab fistula. Okay, so definition of end stage renal failure. So CKD stage five or the need for renal replacement therapy. Now, the reason why I'm talking about the kidneys in this particular one was because I was asked about this in my of Ivers. Um, so it's just a bit of recall bias here. So again, like we said, so always start off with two of the most common ones. So diabetes, hypertension, and then you can talk about your rarer stuff. So your renal artery stenosis, your polycystic in your disease, any drugs that might be involved multiple myeloma and then amyloidosis. So amyloidosis and sarcoid you can pretty much safer anything as a rare cause because they're both infiltrative diseases, and they cause everything. Um, and it's important just to understand how e g f r is related to describing the stages of CKD. Okay, anyone have any complications of chronic renal failure? Uh, list any as many as you want. It doesn't matter if it's stupid or not just if you can list a few and I will refresh the chat in a couple of minutes. A second or two. Oh, awesome. Awesome. Really, really good. Perfect. Okay, so a lot of people saying electrolyte abnormalities, vitamin D synthesis, electrolyte abnormality, anemia, hypertension. Really good. Really, really good. Fantastic. So these are the type of questions that they asked, so they're very standard. But once you've asked, answered, like a couple of them, you you kind of get a bit stuck. So it's nice to know, like, the bog standard stuff in a lot of detail. Uh, so, yeah. So cardiovascular disease. So if you've got any sort of renal failure, you're I think 50% more likely to die from a heart attack. Hypertension. You've got disruption of the renal and rennin angiotensin system. Um, you've got renal osteodystrophy, which is basically any sort of bone disease as a secondary result of having a renal problems. So, for example, secondary hyperparathyroidism. Uh, you might get renal Austria district you later on fluids, you get a Dema electrolyte disturbances. So hypochelemia like you guys said, um oh, uh, sorry. What's the difference between Hickman and Tassio? Okay, So it's basically the number of lumens that go in and the type of. Basically, Hickman and Tesio are both kind of companies that make the lines, so it's very difficult to say what they are. Um, so as long as you say that Hickman and Tesio and then I think groshong are both all three of them are tunneled lines that can be used for dialysis. I think that's the extent If you're a bit of a renal nerd, then you might want to go into that bit more. I personally do not know. Um, there's also a portacath, which is often used in kids as well, which is almost like a little round disk that you will have, and that's also used for dialysis as well. Um, and it's the type of lines that go in, um, so you'll find two or three lines coming off. This one's only got two. Uh, you also might have a vast cath, for example, which tends to go into the groin, and that's not tunneled at all. Uh, the reason why you would want to tunnel this, because it means it's less likely to have infection overall, Um, and you can use it for a longer period of time. Um, yeah, anemia. Because you've got, um basically, you've got lack of e p o so erythropoietin. And then that's why you get it. And then leg restlessness is because of uremia and sensory loss. Okay. No worries. Okay, um, this is the so the last question I wasn't asked this question. I did get asked in my finals. So what are the indications for renal replacement therapy? And I think that's a pretty fair question, but I got stuck on this one because I was an idiot. Um, so do you guys want to give that a go? Awesome. Awesome. Daniela and Charis really, really good, so I can't actually remember. Okay, I forgot why I put this guy in, but it's just because the guy looked very angry when I didn't say anything. Um, so it's a bit of a quick picture, and it's not very relevant, but anyway, um so yes, like you guys said Uremia in particular, it's not going to be a uremia of, like 30 with no other effects. It has to be the effects of uremia that, like that might you might consider renal replacement therapy. So, for example, encephalopathy or pericarditis, because one of the main causes of pericarditis is actually a uremia refractory hypochelemia. So you've tried your insulin decks. You've tried your salbutamol NEBs 23 times. You might have even tried lokelma, which is a potassium binder. Um, and then it didn't work. Uh, refractory pulmonary edema. So they're really, really breathless. The kidneys are shot. You've given them a couple of doses of ferries in mind. But you know that furosemide it's going to ruin their kidneys anyway, So as a result, you decide. Let's let's just put them on a filter. Let's get all that fluid off them, and basically, you put them on a filter for 24 hours and you're, um, say 100 and 50 miles per hour, and that's how you do it. Now. The important thing that you need to remember which you'll probably find if you have any I t. U jobs or if you've been on I t U before, is that when you're taking off that much fluid, you don't want to, like crash their BP in the process because obviously they're going to have problems coping with their BP. Um, refractory metabolic acidosis. Um, which is Yeah, that's pretty self explanatory. And then drugs. So if you've got anything really, really nephrotoxic, um, that you can't clear your kidneys are already poor. Then you'd want to get rid of that in your system. A lot of, uh, for example, poisonings as well. You might also want to, um, do a breathing replacement therapy if if it's not improving their condition. Okay, um, I think this was quite a funny joke. Spot diagnosis. Um, if you guys want to give that a go, there are two separate lesion's I know. Refresh in a second for you guys. Awesome. Perfect. Yeah, OK, so often they'll ask you things like, uh, what are the signs of chronic liver disease that you'll see? And you're like, Oh, I can list all of these. Um, and then they'll ask you for differentials for each of those symptoms. So, for example, So this is what I mean by in this lecture. It's it's more about the the way that the Examiner might think, um, so you can kind of tailor your revision to to what they might do rather than the actual content itself. being, uh, something that you would want to revise from. So, for example, this is spider animus, like you said, and the one on the on the right is a cherry hemangioma or cherry angioma. Um, so you'll often find cherry angiomas tend to be in any old person, especially of Caucasian descent. Um, and then Spider Nieve, I you? If you have more than four, so five or more, then you're going to have it's It's probably a pathological. You can also get it in things like using the combined oral contraceptive pill or pregnancy So they might ask you, What's the differential for a Spider Nevis? And then what are some other causes? Spied an IV? I and then you kind of stumble there and you need to ask. You need to basically go into a tiny bit more. Um, and then how can you tell the difference? So you press down on the spine. Numerous. It will fill up um, and usually you'll find it in the distribution of the superior vena cava, which so you'll normally find it on the trunk as opposed to the abdomen, which is quite an important thing that they like asking um, and then cherry angiomas are just completely benign. And they're just abnormal proliferation of blood vessels. Um, okay, So what are the common causes of chronic liver disease? I don't want to go over this with you guys. I think you guys consider okay in spc. Know? So that's variable. Yeah. So it's unlikely to be in the S P C distribution. It's normally on their abdomen, but it can also be on the trunk. Um, I don't know about the number of the number of them, so I think I think if it's still, if it's if it's four or more, then it will still be It can be associated with pregnancy as well. Um, so yeah. Yeah, exactly. Um, okay, so you've got ethanol. Obviously, it's your main one. You've got any sort of hepatitis? Um, that will will lead to, um so your cirrhosis and then eventually path PSA. And then you've got quite important nonalcoholic fatty liver disease. Um, so you'll have that in the absence of any sort of, uh, you've got deranged LFTs without any sort of alcoholic history, and then you've got the rarer conditions which are also associated with So Wilson's for example, uh, in your examination, it might might present with a young person whose got Parkinson's like features or neurological disturbances and then also, uh, liver problems. Liver problems tend to come really late. Hemochromotosis also that, um and then these are the stuff that you need to make sure that you're you can list off absolutely rapidly, so I would go through them. So if they ask you the signs of chronic liver disease, you can say in the hands I would see this, um, and then in the face ID See this? So Terry's nails is something that I found while I was revising for this for this examination. Um, for this lecture, I actually didn't know what they were, but it's basically where you get a large red spot of it on on the distal portion, and then you get whiteness in the middle. Um, and they often if they keep asking you for signs and the hands, then you just might want to go through a few of them. I think of just butchered do patient's contracture as a name. So despite nearby gynecomastia loss of hair so anything that basically with liver function and liver problems. You tend to get poor estrogen regulation, and then as a result, you get gynecomastia and loss of hair. Um, and then you'll also get hepatomegaly and splenomegaly as well. Okay. Um, okay. Do we know what the features of decompensated liver disease are? You guys can just drop them in the chat. Yeah, really good, too. Anyway. Awesome. Yeah. Encephalopathy, jaundice, society splenomegaly. Yeah. You guys are sick. OK, cool. Fine. Um, and then any complications of chronic liver disease. So these are the kind of questions that they tend to ask, and they get a bit confusing when you're in that situation. Yeah. And what you'll know. Yeah, exactly. Clotting as well. Clotting is very, very important. Malnutrition? Yep. So it's important. So decompensated anything which is a decompensated condition basically means you're living with a problem for a long time. So you might have had liver disease for 10 years, Let's say and you're stable, you're not having any problems with it. But then all of a sudden, whether you've had a little chest infection, you've been pushed over the edge, and your body is no longer able to cope with how crap the function of that organ is, um, and as a result, you'll get an acute on chronic picture. So Decompensated liver disease. You get jaundice, edema, bruising because your clotting is shot because of all the all the basically all your coagulation factors and your platelets are produced in the liver. So if you're not getting that done, then you'll get bruising. You getting careful opathy because you're not able to clear out all the uremia and then you'll get fetal hip Atticus as well. So those are the features of decompensate liver disease again. So Decompensated heart failure, for example, someone who's got heart failure for many years and then suddenly something pushes them over the edge, and then they suddenly get loads of fluid on their lungs, for example, and then complications. You'll find that there's a lot of overlap. Often they might ask you after asking you about the complications they might ask, How are you going to treat and so bleeding? You might want to give vitamin K derivatives. You might want to give, uh, prothrombin, uh, complexes. You might even want to do a liver transplant later on down the line. Um, ascites. You would give things like spironolactone. Um, if they've got something like spontaneous bacterial peritonitis, then you would want to make sure that you get rid of all that kind of stuff. Um, so you would give them spironolactone, and you'd also give them refer mixing as well. Um, and you'd also give them ciprofloxacin sometimes. Um, and then in cuff allopathy, you basically want them to pull out all their high urea, so you would give them loads of lactulose, uh, to get rid of it all, uh, seizures you just managed normally. So with lorazepam, Um, and you're trying to avoid any sort of hepatotoxic benzos and then cerebral edema you might want to give with mannitol. Okay, uh, this was another question that I would often see in the old paces examinations. Vernick is as well. You are really good. Um, so how do you know whether you're whether what you're feeling is the liver or the spleen? So can you guys tell me and it sounds like a really stupid question. But then when you're trying to verbalize it, you kind of get a bit stuck. So if you guys wanna okay, just connecting to the chop. Uh, awesome. Awesome. really, really good. Uh, not being liver and large is vertically largest. I've only okay. Really good, Alex. Really good. Uh, Jed, that's really important. The notch is extremely important. Um, I'm not sure if you got if any of you guys have done surgery at Mary's, you'll find that these tend to be the questions that they ask because they're the guys who run your final stations. Um, so that's where I got this one from, uh, Hepatomegaly. So the way that you describe it is how many fingerbreadths below the costal margin? Is it how it moves when you when you breathe, is delta because smooth, tender pulsatile you might. So if it's not smooth, you might think something more like a path cellular carcinoma. But generally, what tends to happen is HCC. So when you get a really scerotic liver, you lose all your your tissue. You're healthy tissue, and so it tends to be a bit smaller than than that. So if you've got very advanced disease, it can often be a bit smaller pulsatile. Because if you've got any sort of congestive heart failure, it can often be a pulsatile liver. Um, I've written that twice moves inferior and inspiration, uh, causes. So they'll then ask what are the causes of this big liver? Or at the end of the examination with the actor, they will just say you find, like, a very large mass in the right upper quadrant. What? What might be the cause of that? So again, human chromatolysis, great hemochromatosis, hematological conditions, viral condition. So Hep B say see all of those kind of things and then the investigations. So this one is quite important. So if they've given you a sign, then you need to again break it down. Start from really small things. So you would want to do bloods. You want to look at their LFTs? And I'm sure they rammed into you guys a lot. And they asked you a lot of questions in the path exam about what's the most important thing for, um, liver function and you take prothrombin time or albumin? Prothrombin time is better, but that's really important to mention in this exam, because this is where you show that this is where your knowledge is. Um, you might wanna do an abdominal ultrasound. So if you think that there's an abscess there at all cts less used MRI as you can use and then biopsies. And then, if you're really, really bougie, you might want to talk about what staining you do. So like, if you think it's amyloidosis, you talk about the Congo staining or whatnot, and that's where you show off. So with each investigation that you talk about, you'd want to make sure that you justify why you're doing it instead of just saying bloods and saying FBC you and you don't do that. Just talk about I would want to look at the clotting for this reason to look, to look at the liver synthetic function. I would want to do an abdominal ultrasound just in case there's any sign of abscess or anything amenable to drainage, um, and then biopsy to understand the histopathology of what's going on. So, for example, if I thought there was an infiltrative disease such as amyloidosis and then they don't ask you any questions, because then when you're talking about niche hista path, you probably know more about it than they do, even if you don't OK, Splenomegaly. Uh, what are the causes of it? Can we give any so yeah, exactly like you guys said. Not dull to percussion. Uh, and then it moves to the right iliac fossa on inspiration. It's more like when you're breathing, but just in general inspiration. Awesome. Yeah, Yeah, really good. Um, I actually didn't put EBV in there, but yes, uh, mono will cause it. Um, so again. So, yes, Planet sequestration. You have you got any sort of sick or Southern? It's probably going to cause it any sort of long term hematological condition. So you've got Yeah, malaria. Gaucher's disease. Awesome. You guys are sick. Ok, Really, really good. Um, yeah. Any sort of chronic hematological malignancy your blood can't take anymore. Gets pulled somewhere. Goes to the spleen, infective endocarditis. That's a really important one. And it's probably one of the more. I think it's something like 50 to 60 patient to with infective endocarditis have, uh, an element of splenomegaly Felty syndrome. So that's the one which it register associated with rheumatoid arthritis. So again, So you talk about the three most 23 more common causes. Then you talk about one rarer one just to sound really cool. Um, yeah. Polycythemia vera really important as well. Uh, so you felt healthy syndromic, arthritis, splenomegaly and the neutropenia. And as just tired of symptoms that you'll get, um, and again. So the investigations that you do so like we said, we'll talk about the blood we'll talk about, but importantly, because you're tailoring it more towards the hematological stuff that you were considering, you might want to do a blood film in that point. So instead of just saying blood, you talk about blood film and you would want to have a look at. So if you think it's CML doesn't have a left shift progression, you'd want to do an autoimmune screen. So, um, if you would want to do a dat screen, for example uh, CTS ultrasounds, usually quite good and Daniela like you, said Polycythemia Vera. So that's associated with Jack, too, and then Jeff and whatnot. Um, so those are really important things that you might want to consider if you if you really want to push it a bit further. Um, most of the time it's someone who's not, um, someone who's not associated with the abdomen, so you'll probably have someone I don't know. Like a respiratory consultant examining the abdominal station so As soon as you start talking about stuff they don't know, they think that you're really good, and then they'll push it a bit further. Um, inflammatory bowel disease. I think you guys get this drilled into you a bit too much. I don't want to go into this too much, but it is something that comes up often, and they'll ask you the differences between ulcerative colitis and Crohns disease. And then you'll have to talk about the differences in the presentation of it and then the differences in the histopathology of it. And then, if you really can talk about how you would manage it. And that's really important because, for example, in ulcerative colitis that the management will be a bit different from Crone's disease. So you've got your topical missile, lysine's crone's disease. You've got your infliximab, and you're really hardcore biologics, which you would want to use. Um, so it's important just to to make sure that you can talk about each one of these aspects of the disease. Um, they will put this into a lot of the time, and then almost all of the time, if they're talking about one specific disease, disease process. So, for example, even if it's something like rheumatoid, um, they'll ask you the extra articular manifestations of all the extra intestinal manifestations. And then you should name three or four. So you might say in the eyes, I'll see the anterior uveitis or whatnot or uveitis uh, in the skin you might see erythema nodosa, um, or pyoderma gangrenosum. Obviously, there's a lot of overlap between all these inflammatory bowel diseases and the skin changes that you might see. Um and then later on, they might talk about the complications of each one. So you see, definitely way more associated with adenocarcinoma. You're 50 to 60 times more likely to get a cancer if you've got you. See, uh, crones, you'll get your complications such as fishes and abscesses. So basically, because it's transmural and it goes all the way through the wall, you're going to get problems with it, forming services with other epithelial layers. Okay, so that was the medical abdomen in a really, really quick way. Those were four areas which I think are probably going to come up, and then you might want to just have a look at this a day before the exam. The surgical abdomen is I don't know. There There might be a few things that you might want to talk about here. So hernia. So basically a protrusion of a viscous through somewhere where it's not meant to go, usually through an anatomical defect. Um, if they are asking you about hernias, they potentially could ask you about specific anatomical locations. Um, so for example, uh, inguinal canal, Hessel box triangle and then the femoral canal. So I've written them out for you here. I don't think they're likely to give you anything on say, for example, Richter's hernias, uh, spaghetti inns or operators. But if you know about them, doesn't doesn't harm you at all. Um, so I would just have a look at this may be very, pretty low yield stuff. Maybe one question for it, Um, And if you just remember this a couple of days before the exam, then I think you'll be fine really with it. Um, the important thing is just to know inguinal hernias and femoral hernias and how to differentiate the two of them. So inguinal hernias, The way that I remember it is I am. And I think, uh, doctor Darcy? Darcy? No, not Darcy. Uh, profit. Mirza. That's the one problem as a West, uh, thingy got where it's called. Anyway, He, um, did told me this, so he was basically, like, England or other way. I remember as I am so inguinal is above and medial to the pubic tubercle. And then femoral is just the opposite. So it's instead of above, and medial, it's below. And lateral so football, whatever that means. Um then they know the difference between direct and indirect hernias. Um, so you basically put your finger on the midpoint of the inguinal ligament? Um, easier way to do it is 1.5 centimeters above the femoral pulse. If you want to do that in the exam and then ask them to cough. So in the Abdo exam, if you're you're doing really well for time, then whilst you're feeling the tummy, you can just throw in a few cool things, like putting your hand. They're asking them to cough feeling around the area, and then they'll be like, Oh, this person's not just following geeky medics or, for example, if they've come in with right upper quadrant pain, you put your hand underneath the sub costal margin. You ask them to take a big, deep breath in, and then you see that their Murphy's positive. Most of the actors won't have that much in depth knowledge. But if you're specifically asking for those things, I think they'll be impressed. Uh, yeah, West Mid. Yeah. Thanks, Daniel. Uh uh, Yeah, so that's quite important to know. Um And then what else was there? So for example, appendicitis. You would want to know your rose. Think signs your so assigned. And if you're coming in with a patient with right, um, lower quadrant pain and you're doing you're asking them to do a psoas sign or the rustling sign. Then they'll if you're like, I'm going to push down hard on the left hand side. Does it hurt on your right? Then they know exactly what you're doing, and you can put that into your examination and say, this was negative. This was positive. It's almost never actually positive, and you'll never see it in clinical practice. But it's nice to put in, um, difference between the two. So England or hernias are common in both men and women, so inguinal hernias are still more common in women than femoral hernias. But femoral hernias as a whole are more common in women. And the problem with that is it's much more likely to strike strangulate as well. Um, make sure you know the sorry. Make sure you know the differences between a, uh, incarcerated hernia and strangulated hernia. So basically incarcerated basically means that you just can't reduce it back into the back through the defect that it came from. Strangulating means that it's now cut off the blood supply. Um and then that's that's the problem with that. They do tend to like to ask those sorts of questions. And then if they really want to push you about hernias, they might ask you about Rick to Tonia. So you might want to say, that was, uh, where you get a trap hman of the anti mesenteric border of the colon. Um, you don't even need to know what that means. You just remembered it from a flashcard, but you'll sound a bit better the examining of the hernia. Um, if if it is a hernia, if it's a real patient, I don't know if you guys what it is. Uh, make sure you would offer to examine the scrotum so indirect tend to go into the scrotum. Uh, maybe listen for bowel sounds over it. If it's on the abdomen, maybe don't Don't put your step on someone's balls. If, if you think the scrotal involvement probably a bit grim. Um, then talk about if it's reducible incarcerated, strangulated and then the cough impulsive is there or not? So, um, for example, I think for femoral hernia if if there isn't well, if there's a difference between, uh, often ephemeral hernia can be, uh, confused with a safrinha varix, which is a type of a bit of like a almost like a varicose vein, but like it looks like a lump in the femoral triangle. Uh, so it's something that you would want to consider, especially in someone who's got varicose veins already. So any sort of elderly woman you probably have. You probably put that into your differentials as well. OK, moving onto Stoner's definition artificial union between conduits between the outside and the inside, So exterior ization diversion, decompression feeding and lavage, um, are the indications for a stoma? Uh, this was asked for me in my exam, Um, in my surgical station so lavage would be, uh, that's That's the one, which is probably the hardest for you guys to understand. So basically, there's a There's something called Appendix Costa Me, which is unusual in a child. They bring out part of the bowel into the umbilicus, and then you can basically give them enemies through that, um, feeding. So your your pegs, your gastrostomy tubes, your judge tubes, all that kind of stuff are types of stoners decompression. So you've got a really large sigmoid cancer, and you're about to blow. So you basically bring out part of the bowel into the surface to decompress the bowel and let air up diversion. So if you've got something like fecal peritonitis, you want to move the bowel away from that area and then move it to the top and make sure that's coming out in a certain way. And then exterior or ization is similar to everything else, basically, just bringing out part of the bowel to the surface so you can get stuff out. Um, examination. If they give you a patient with a stoma, um, then make sure that they're standing when you do it, and then examine them when they're lying down as well. Take the bag off like don't be afraid to take it off. I'm sure they'll want you to do that or offer to take it off for that patient. Have a look at the site. Have a look at the appearance. Pop it around the stoma because often you can get a sort of, uh, can you repeat what savages? Yeah, so there's, um, there's a type of There's one specific case which I know of, where where lavage is used. And it's basically it's called an appendix costumey, and it's used for Children obstruction, bowel, and you give them enemies for it. So it's You bring up the bowel to the surface, usually around the umbilicus around the belly button, and then you push enemies through it, and then it helps them relieve their bowels. Uh, so it's a good way of doing that. I've never seen it before. Um, but when I was looking up, indications for a stone with that was one of the things that came up. So probably something that you might want to mention. Um, yeah. So the content of the stone is really important. Even If you don't know what it is, just describe it. So it's brown. It's green. It's It's like the consistency of it. Uh, the appearance in particular is how healthy the stoner looks. So especially when you've got a brand new stone formation, You would want to make sure that the tissue around it isn't really dark, black and necrotic. So it's important that you have a look at it and make it look. Make sure it looks healthy. So any sort of pink stoma is very, very healthy. Um, the site so left Elliott Foster. Right? Iliac fossa. Uh, sometimes you might have different tubes coming off them, and I'll show you what that means in a second. Okay, so now can you guys tell me what each of these stoners like represents or what is? Please, uh, refresh it in one a couple of minutes or so. Awesome. Fine. Really good. Yeah. So these are the most bog standard ones that you'll get asked. So the one on the left is an ileostomy. The one on the right is a colostomy. The reason why you can tell the difference. Um awesome. Yeah. Perfect. Yeah. So the reason why you can tell. The difference is because ileostomy is the small bowel content is really, really irritant to the skin and the actual stoner itself. And so often what can happen is if it's too small a stump. It can mean that irritates the skin and can call wound dehiscent and then a dermatitis around the stoma itself. And so it's important to make it spouted as possible. Um, the usually you'll find it in the right. Iliac fossa. Uh, yeah, yeah, yeah, Exactly. Yeah. So if you if you said something like that Danny other that it's a colostomy from a Hartman's, you could definitely say that would be the case. Uh, it's not the only case I wouldn't say. It's definitely that, uh, from a hartman's procedure. But you might want to say that it could be associated with that. Um, so, for example, it might be associated with a pan proctor colectomy or whatever. In that case, um, yeah, so spouted. You get really nice like fluid coming from it. Um, the one on the right, You're going to get more. So basically, you've got more time for the feces to go through the bowel transit. You get loads of absorption of all the water. And so the consistency is drier, and it's more stool like, so look like, basically inside of their Um okay, the next one. Do we know what this is? Yeah. Double loop. Ileostomy. Perfect. Yeah. Brilliant. WB ileostomy can sometimes get confused with some sort of like a prolapse. But this is normal. You're basically cutting the ileum into two. And you're bringing up both ends. One is to decompress the bowel so the distal end is decompressed, and one is for all the bowel contents to come out. And if you see this you're thinking, Oh, this person's probably going to have a reversal very soon. Um and then they'll probably in 1 to 2 years. Once the bowel has settled down, once all the inflammation has gone down, they'll probably open them up and close them again. Which makes it nice for the patient and better quality of care. Okay. And what are these two? Well, okay, I stupidly left all the labels on the one on the right. What's the one on the left? This one's a bit harder. OK? Really good thinking. Alex and Daniel, a nice a little conduit. Okay, uh, is the same as D functioning or ileostomy? Yes, exactly. A charity is the same as D functioning ileostomy. Um okay, so it's not actually a feeding tube, so this one's a bit more difficult. So the one on the left is basically part of the I'll, um so it looks very similar to all the stuff that we're looking at before, but from it they've brought out to pipes. Um, and those two pipes is basically it's just a urostomy, um, and the way what they normally call So Danielle was correct in saying that it's a urostomy, and it's a ileal conduit. So basically, it's, uh, the the ureters of the contents of the ureters are coming out through an eye a little bit. Um, the reason why you do that. So let's think about you've got your kidneys, you've got your your Etta's, you've got your bladder, and then you've got your urethra. So when you've got, say, a cancer of the bladder, you take out the whole bladder and you'll take out the urethra, and then you'll have your your Etta's coming out, and they need to drain somewhere. So you bring them out into the abdominal surface. And then that's where you get all your P coming out differences. You'll probably get a lot of Balkans in coming out and also urine coming out of there. So it's often very, very confusing when you do see it, Um, and it will be a very complex procedure leading to that in the first place. The one on the right, the one that I wanted to talk about was the mucous fistula. So that's often done after say, for example, a Hartman's procedure where it's an emergency procedure, you've removed the sigmoid colon, and you need to decompress the rectal stump. Now that's extremely important. There are a few ways that you can decompress the rectal stump in clinical practice. What you might want to do is you put a flatus tube up there and basically allows air to come out of that rectal stump. If it's really, really bad and the stomach looks horrendous, then you can sometimes bring up the mucous fistula and that decompresses the bowel from that way. And then the way that my consultant used to do it when I was an F one is that every day I'd have to give one of the We had loads of cranes patient's. We'd have to give them a PR exam, and you basically put your finger in there and, like, push around all the borders of the like the rectum, and you just get this horrible, gooey gush of fluid and probably be like 203 100 mils. Now you can imagine it smells horrible, terrible thing. But if that was building up in the rectal stump, it can often blow, and the whole rectal stump is lost. As a result of that, you can't actually reinvesting most the two pieces together. So it's really, really important that you keep all the bowel bowel pressures right, because obviously they are fixed areas. They will explode if there's too much pressure in them. So your ostomy and then the mucous fistula. So, yeah, it's urostomy with the Ali will come to it. Uh, this is just something that you might want to have in your examination as a cheat sheet. You'll find that as you go through your revision, you'll find that some specific, uh, stones are useful at specific receptions. Um, you don't need to know them in too much detail. The one that I definitely know the most is the Hartmann's procedure, because it's so, so common. Um, and the reason why is because, uh, we'll talk about Hartman's procedure in a second. But basically what it is is you remove the sigmoid colon. Um, and the sigmoid colon is the highest pressure area of the abdomen of the colon, so it's the most likely to burst. When it burst. You'll get vehicle peritonitis. So the first thing to do is to remove that area, check it out, and then, uh, so up the other areas and let the bowel rest, and you usually let it rest for a while. So maybe a year or so before you reverse the problem in the first place. Complications of stoners. Um, So what can you think of? I'll give you a couple of minutes just to have a think about this one and think about how you might want to answer this in the exam as well. Okay, Okay. Let's go through Charis. Awesome. Okay. Infection, Closure of the stoma. Paris Normal infection, obstruction. Yeah. Infection. Obstruction. Yeah, Awesome. Fine. Um, when you're talking about this So the examiners like really brilliantly. They move on to the complications, any sort of procedure that that's involved, whether that be a surgery, whether that be any sort of, um, like, I don't know, an acidic tap or a plural tap anything like that. Talk about the structures around it, and then make sure you find ways of structuring your your answer. So it's no good just listing off three random things. It makes no sense to the Examiner, and it doesn't feel very structured. Uh, now, if you're if you take your time, you break it down and say Complications. Stoma could be early complications or late complications. Um, and then you name one or two for each one. It sounds like you've been listing for years and years because you structured it so well. Uh, if you just list to, then they could ask you for more and more. And when you lose that structure, it's very hard to come up with ideas. Uh, so the way I used to do it was early and late so early would be hemorrhage, ischemia, high out, but parasternal abscess stomal retraction. So hemorrhage. Self explanatory. Leading a lot from there. Basically, when you're doing any sort of reception. Your your clipping off the blood supply to that area, the bowel. If you don't do it well, it can often hemorrhage and come out ischemia. If it loses blood supply to the smaller area supplying the stoma itself, you can get a necrotic area, and that's often dying, and you'll have to take them back to theater. High output Stoma. When you guys are F one, you're gonna see this quite a lot. So it's basically a patient comes in. They've got a stoma, and it's just continuously producing fluid, as you can imagine, especially if it's like an ileostomy. For example, there's loads of electrolytes are being absorbed in the small bowel. Um, and if you're not getting that, you're going to get loads of crap coming out in there and you're gonna become hyperkalemic. You're gonna be probably hyperchloremia as well. You'll lose all your magnesium as well, and as a result, you'll get massive electrolyte abnormalities. So the way to treat that is to give things that will slow the bowel down. So things like Imodium so the para mide, or codeine phosphate, for example, is often used for reducing the amount of your bowel is producing, and then you'll want to make sure that you replace all the electrolytes as well. Uh, so they might say, Well, what? Some complications. They want you to say High output stoma. And then they'll ask you, How do you treat that? Um, and the more the more you answer, the more they'll probably ask you a few questions, especially if they're running out of questions. Um, often you'll find if it's like someone who's like a GP and they don't really know much, then you're just going to sit in silence for a couple of minutes. But that's fine as well. You can have a nice chat with, uh, late. Uh, like you guys said Hernias, obstructions, dermatitis. So that's what we were talking about with the ileostomy and then, uh, all the other stuff. So prolapse, stenosis, fish sellers, uh, important to know that often ileostomies kind of look like they're prolapse, but they're not. It's just a really long spout, and that's normal surgical scars. Um, for those who don't want to do surgery, this can often be the bane of your life. Um, so do you guys want to tell me any of the ones that you know, uh, you can just say is there's b is that doesn't need to be in any order and just list them off. And we are coming to an end soon, so there's only a couple more slides, so you hopefully won't be too bored, OK? Really good, Tanya. Anyone else want to give a go for any of the others? Okay, just gonna refresh it one more time. Yeah. Awesome. OK, so, uh so basically, um doesn't actually show the Rutherford Morrison scar here, but really good thought process. Rutherford Morrison Scar is like the hockey stick one, and that's more associated with, like, a renal transplant. Sub cost all. We are really good. Uh, so let's go through it. So a is a midline incision, so it's a midline laparotomy scar. You'll usually see it going around the umbilicus. Sometimes you might see a patient, especially the older patient's who've had surgery from the old school surgeons. They might have a paramedian scar, which is which is B, um, and that's often for sort of renal access or sometimes asplenic access. It's not really used anymore because you can basically sever a bunch of nerves in that area, which can be pretty detrimental to the way you recover. Um, so that's B C is cockers scar, so you can get a cocker scar either on the left hand side for, say, splenic access. Or you might get on the right hand side for, say, a gallbladder removal, especially if they're laproscopic. And it's really, really hard to do. There's loads of adhesions. It's a crappy bladder. Then you'll want to probably do, uh, make it open. D is a rooftop incision or a chevron, and that's often used for really good access for liver transplants or Whipple surgery. You can often get a Mercedes Benz scar, which is where it's also got like a thoracotomy scar on top of it as well. E is just a like a flank left blank scar. Releford Morrison would be around that area, but it's like more of a curvy shaped um, F so f is a gridiron scar. The way that I tell the difference between so gridiron and lands is F and G. Um, lands is landscape, so it's like straight, so that's a nice way of remembering what G is and then f is basic gridiron, and it's like a 90 degree to McBurney's point. Um, so it's like a nice straight one. Um, and then h is a Pfannenstiel incision. So that might be anything to do with your cesarean sections. Was the most common. And if you see it in a guy, it's often bladder surgery. Um, so they needed open access. Um, if you have real patient's and they have a few dots around them, um, and they look like they're in a very organized space. Then you would probably think that they're laproscopic port, and I wouldn't rule it out. So if they did bring patient's in you and you only see two scars or you only see one scar, I would still suggest it as a laparoscopic ports car. So you'll find that, for example, diagnostic surgeries, for example, like if you're trying to diagnose endometriosis, for example, you'd only find, like, one or two ports cars. Um, you've got some really cool people, I think, uh, Mr Paraskevi A in Saint Mary, he does a Lap coli through 11 port incision through the umbilicus. Uh, so you get some really cool ones. So it's always worth mentioning. And then you can maybe pre face and say it's not as many ports cars as I would expect, but that's where you usually expect them to go. And then the trocar is usually inserted around the belly button so you can have a closer look at the belly button itself. OK, surgical resections. Um, if you don't want to be a surgeon, this is a bit annoying and you guys get a bit, um, worried about this, but it's pretty easy, right, Hemicolectomy. So you've got a cancer on the right side of your colon, so and you seek him your ascending colon. You remove that bit so you remove this whole area. You've got an extended right hemicolectomy. So now your cancer is somewhere in the transverse colon, and instead of saying is the transverse colectomy. For some reason, they call an extended right and they take a right, and they take part of that that transverse colon off, and it's usually up to the splenic flexure left hemicolectomy self explanatory. You can remove this part of the colon apartments procedure, so this is the one where we're talking about it before, usually using an emergency. So you got your sigmoid colon here because of the bendy shape of it. It's kind of like a toilet, and it's really high pressure area, so it's more likely to burst, especially an abdominal trauma. And so you remove that part of the sigmoid. You bring this part of the rectum to the surface so you might get a mucous fistula. Or you might just sew it up and leave it in there. And then you bring this part to the surface, and that's known as an end colostomy. Um, and that's an emergency. So it's basically just removal of the sigmoid colon. Anterior resections are basically if you've got some anterior sections and abdominal. Perennial receptions are two different types of surgery for rectal cancers, so it's important that you differentiate the colon, the rectum and the anus, and I know that sounds really simple, but it's really like the surgeries are different, depending where which part of the bowel is affected. So if you've got the rectum affected and it's really, really close to the anal margin, you have to do an abdominal perennial resection, which involves removing a bunch of lymph nodes from the outside of the rectum as well, because that's why they normally spread, because the lymph node supply to all of these areas is different. And if any of you want to do the MRCS, that's going to be the bane of your life. To try and remember all the different types of lymph nodes and where it spreads to um, and then an anterior section is just removal of So you say, if the if the cancer is I think it's more than five centimeters away from the anal Verge, then you can remove that part of the rectum, and then you can sit back up often at the same surgery. Sub total Colectomy is basically for things such as ulcerative colitis, so you'll find that most patient's with you see will have a surgery or currencies. You will have a surgery, uh, in Ulster colitis. You've got most of your colon affected. It's going to be continuous. And if you say have it in the sigma and and the descending colon, then um, they'll remove that part. If you have it in all of the parts of the colon but not the rectum, then they'll do something called a sub total colectomy where you've got your eye, Liam here. So that's the ileum there, and then you'll just keep your rectum. So you take everything else away, and then you got a pan proctocolectomy, which is where you take everything away and you bring up part of the ileum to it. Um, with crone's disease, obviously, the more you take away, it doesn't really make a difference, because you can get anywhere from the mouth to the anus. Uh, so it can often re occur even if you get it. But the prognosis for patients who have had a pan proctocolectomy with ulcerative colitis is actually very, very good. Thank you for listening. Um, I only kept a turn our because I never used to be able to concentrate for more than an hour. If you guys don't mind filling out some feedback, it can be as harsh as you want. Um, if you didn't think that was useful, if you wanted to like you to go in a different direction or you're expecting something else, please do let me know. It is quite useful for me as well. Um, and thank you. Thank you so much for giving this election. Um, do you guys have any questions at all? What you mean? Um, And if you have any questions about applying to Manchester or coming to Manchester as well, let me know. Um, I have all the bad things to say about it, but you can let me know, all right? I don't think there are any questions. Okay. Is that okay? That's fine. Thanks so much.