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doing 70 Sergi today. It's our first section, and it's gonna be about general surgery. Yeah, so just a quick word from our sponsors. You guys have heard about medical protection already. And just quick. Shorter medal. They help us with all our certificates. A service recordings if you have any, uh, anything at all that you require, such as recording slight and everything. Everything is gonna be there. So please do feel in the feedback form, and you would get access to everything. Question. It are a fantastic question, bank. I'm sure you guys would have seen from the exam we had yesterday, uh, that it's very, very reproducible questions from there. So, um, if you guys are thinking of getting a membership, please, please use the court house keys 20 for 20% off your membership. We have a community. Also. I'm not gonna talk to much about this, but if you have any concerns, any any questions at all, join the community and ask and we'd be more than happy to help now. So this is what I've been waiting for for so long. It's been months and planning. We last time we thought that we could do it, but we couldn't, uh, this year we have managed to execute on. Hopefully, it just gets bigger After this, Um, we have had finished. You get ah, 66 collaboration. So far on, we are waiting on to more collaborations. Two more society still collaborate with so way have a whole surgical serious planet. And it's especially for medical students. It's final stitching, and then we have all skeeting as well with the same organization. So it's it's really going to be an amazing Siris covering everything. Surgery related to squish outer To be more British in your medical association burst Urology incision, UK National Surgical Teaching Society nine. Sick That's a neurosurgery and urology, Neurology, neurosurgery, Interest group and Walter Reed and in your surgical society for for helping us out in this collaboration. Uh, and we hope to see you in future sessions A swell. So just a quick few rules for the session. Please engage in the polls. We have five questions today. Today is not gonna be too longer Procession. The second part as I've been told, it's going to be slightly longer because it's gonna cover colorectal surgery. Today we have made the upper gi and general, a spot of general surgery. The session is going to be recorded if you don't want anything. Uh oh. Your interactions to be recorded. Please let us know and we'll remove it. And please, please share is a social. That'll be what? We're free platform. And we want to continue doing this for free to Please, please wait. Really, really appreciate. If you shared and follow and Sherice on all our socials And if you have any questions, feel free to email us today. We have the pleasure of being joined by doctor Deduction Raj Easy course surgical training, training in general surgery. So no better person to deliver the session itself. So I will hand it over to him to share his slight so that he can begin the session. Uh, just as is sharing size. Don't forget to join us for our biggest collaboration. Also with scrubbing, podcast and peer I Oh, they're going to do a case run through tomorrow at seven PM and it's gonna be amazing. It's a cardiology related case on it's gonna be really, really challenging some similar to the one that ninja. So, please, please feel free to join us. It's me. Just me a minute. I'm just trying to sort of this screen sharing thing. Sure. I think it is it the Do you see the full screen? I was just the power point. It's just about one that we see, you know. Yeah. Full screen now. Okay. All right. Thank you. Yeah. All right. Thanks for a moment on and thank you guys for having me. So I'm Dustin, Um, cause a trainee in Scotland. Nice to meet you guys in. Thanks for coming. So I'll do a tutorial on general surgery. So Part one will involve upper GI I and part to involve colorectal. Eso will be quite a shot lecture. And we have five questions. I would appreciate it if we can make this interactive. Um, so I'll be asking questions that we go low and just on survive the chapel. If you breathe, you can just come on, be doing three up to you guys, but hopefully can make this interactive. So, um, Lugar for the five questions first. So the first question. All right, so this is a topic that we're covering today. Um, so just a quick browse. True. And first question. So a 58 year old man presents his GP with dyspepsia and epigastric pain. Worse after eating, you mentioned that he has lost about 5 mg in the past month. What investigation? But your Crestor determine the course. So you can just going to pull? Yeah. All right, that's it. Okay, so just send the pool now, so we got most of the right answer. So Durant's is actually be so, um yep. So I called the nice, bright lines rate flags like, I don't fight it. Just weight loss and anyone each 55 years old. And both will need to be to have a scope to rule out cancer. Is anyone presented the GP with about 55 insulin weight loss, the spirit foot for two weeks off road to endoscopy. So we'll talk about peptic ulcer disease. Okay, so the definition is basically any painful. Fourth also is developing the line in the stomach and the duodenum. Okay, so the cause is of them. Should have learned in medical school. Quite popular. So infection, most commonly helicobacter pylori have your drugs. That is non steroidals steroids, stress smoking alcohol, and quite rare. But it can also cause peptic ulcer disease. Something on insulin jealousy syndrome otherwise has gastric Norma's. I've only seen one case in my last two years in training, so it's quite rare. But it does happen. So, um, things that note stress is quite a main cause for peptic ulcer disease. You'd be surprised to find out that many a few medical treatment for one every two years because of stress and off coffee during a shift, you tend to, um, come in the peptic ulcer disease, so be watchful. So if you just look up for a sec peptic ulcer disease. Like I said, man covers gastric ulcers and the blood. You know, also typically the history for your exams and or skis. The pain is quite related to meals and was after meals. You know it's, on the other hand, is relieved by meals. Not often the case, when you see patients in any D on the warts because patient to say that it was after meals before meals but you, when you go and do a scope, you'll find that it doesn't really match the history of the exams. Just keep a note that you know if it's after meals. Desperate gastric also tends to be relieved by meals. Tends to be most likely 20. No ulcers. And, um, like I mentioned earlier Diagnosis Gold Standard would be endoscopy and biopsy. Um, you can do a close tests when they do a scope, so you can take a sample of tissue on go for CLO test, which stands for campylobacter like organism. It's been a microscope and that will. It used to look out for Helicobacter treatment. So mostly medical. So based on what the algae. So if it's Helicobacter just most often the case you do Cipro therapy. Um, anyone can tell me right in the trap. What? The triple therapy antibiotic regime. It's most commonly Well, in order to come online and tell me what the triple therapy is No. Yeah. You know, I don't see you. Yep. So rightfully so. So's usually amoxicillin, Claritin, mice and metronidazole. And ofcourse, don't forget your PPI spell such a form. I prefer pen tip ago. Um, so, yeah, that's a very common question to be asking all ski so machine in triple therapy. Well, the usual therapy for two weeks, and then you re assess the deal for antigen test to see him. Batteries. Kid Surgical treatment is a professional building up one and been rock, too. So they're formed gastrectomy and do the neck Tiny's. You don't need to know this for your medical school or skis or finals, but it's quite good, you know, for MRCS exams when you're sitting for membership. Exactly. Tone. Okay, right. So this is a picture. Definitely from the web. So, um, as you can see, you can see it kind of punched out lesions on the scope. You can see a break in the mucosa, and you can see it's white fibrosis sick and see that it's quite a bad peptic ulcer. So these patients at high risk off myelin transformation yesterday and you know carcinomas. We need to biopsy that lesion. Okay, so anyone can tell me the complications of peptic ulcer disease besides mountain and see, like I mentioned earlier, very common complications of peptic ulcer disease. Yep. Perforation bleeding. You're up a job. Perforation, Molina. Yep. That's part of your bleeding. You can have him a 10 ounces on Molina strictures. Yep, it's quite rare. So yet, like someone mentioned strictures so strictures can cause gastric upset obstruction um, and that can cause, uh, mountain cedar on Barretts. Yeah, Cancer. Thank you. All right, So there's a quick run true for peptic ulcer disease. So the second question So a 48 year old gentleman presents the e d with worsening epigastric pee really into the back along side north and vomiting upon further questioning. Get Mr Drinking. It can still be every day on physical examination. Epigastric tenderness upon palpation and bruising present around the flats. Given the likely diagnosis, what is the problem? Is sign present on physical examination. Abdomen nation, I think when you click the chat, but in the on seconds revealed, pull it. Sorry. So it might be with keeping it on the question for a bit and then moving it. Thank you. Right. So I'll just end the pool. Most of you got the right answer. My, my, my mistake Up here, it's 40. You're right. Answer. So all right. So yeah, it's a great Turness sign. So, um, flank proof languishing. It's otherwise. And a great honor sign signifies retroperitoneal hemorrhage. It's commonly seen in the magic pancreatitis or ruptured ectopic pregnancy. Prick trivia. It was initially discovered by a gastro a gynecologist. Um, and he seemed a free total doctor. Great owner. And he, um, was the one who discovered it when he saw a patient object. Optic pregnancy. But you get You can see that in the spirit ruptures, humor, pancreatitis and your pregnancy. So I'll just go true. It d if anyone anyone can. Just typing. What? Those signs for colons signed, You know where? See them? Quick tip. It's quite similar to greatness. Yep, yep, Their umbilical. What about Rosenstein? You know which condition. Yeah. Good. And the site is Murphy's sign? Yep. Cool. It's a status. And Schwarz Taxane. Uh huh. Very good. If so, someone asked when you see Colin So Cullen sign and great and assigned the resent humor it retro parental hemorrhage. So, Colin, scientifically see around the umbilical area of periumbilical hemorrhage, you can see sometimes they should have bought great and and call and sign. But sometimes I guess you wanted them either Columns of returns. But it's ah signifies either a magic pancreatitis, all project topic. So if you see those, think about building that tummy. Okay, so we'll talk about acute pancreatitis, right? So keep pancreatitis like the name It's basically means inflammation. The pancreas, um, the Creon call feet just actually seen medical school lunch in medical school have classically epigastric pain going to the back simply because of the increased risk of perpetual Bertoni. Oh, you get fever, you get tachycardia, you get a gastric tenderness. Um, on examination of the tummy and you get great and colored sign again, it's quite read. To see them clinically on the world for an emergency department is quite red, but it's quite common. And exams and your books. So what did you know? Um, the causes are. And if you've memorized in the morning, I get smashed. Um, so good to know for your skis, MRCS and for life basically went Any consultant surgeon gets moody, and it has to ask you because of pancreatitis. Um, you want to just read a lot what I get smashed then for Yeah, right. So Okay, so it's idiopathic. Good. Good. So I'm sure most of you guys probably know the answer. Okay. Don't ever mention scope and bites. When a consultant ask you what the cause is our because that will lead you down a rabbit hole that you don't want to enter. Um, okay, but yes. Coping. Scoping for them. Uh, I just mentioned goal from that goes to most common cause is that you see, while this compressive list, All right, so yeah. So, like, so basically, since idiopathic goals don't have trauma steroids in mom's or two immune, and then you have your foot being bites your high book calcemia or hyperlipidemia hypertriglyceridemia as you are seeping your drugs, it's good to know that, um, how do you, um, diagnosed? Um, so basically blood test you do your blood test, you do it for the count everything into a serum. Emily's you going to do a light case? It's quite hard to request a light piece on the water any D, but I believe it's quite sensitive is usually three times Theopylline it off normal. So anything less than three times it's highly unlikely to be pancreatitis. Um, you can do a light piece because it's more sensitive. More specific tip typically last longer, but you don't have to request them underwater. You can do a ultrasound abdomen to look out for the cost. Saving about Goldstone's chicken Look for changes Instead of gallstone disease, you can do a CT of abdomen. Pelvis. It's quite rare. If you do it, there should be a suspicion off. Probably necrotic pancreatitis. So because Actos usually clinical diagnosis based on good history, good examination and blood test. So you don't need a CT to tell you that you have pancreatitis? Um, you can use course. Um, you can use a glass every scores. Yeah, the squatting and use. You can use that ransom you can, actually, too. But for your skis and finals and MRCS, you need to, you know, roughly every schools for pancreatitis. Okay, um, management is usually conservative. You have to admit the patient award. Um, keep them on IV fluids. Give them adequate algesia. Um, textbooks always say avoid morphine because morphine kind off causes contraction of the sphincter or die, and that can worsen the pain. But in real life, you'll always get them or, um, off the hydrocodone. Um, and you give them any ground? Doesn't really care. Doesn't really matter, but give them analgesia. Give them anti medics if they're vomiting. Um, and if they're worsening despite fluids and anti medics and painkillers, you should have a high suspicion off. Necrotizing pancreatitis. Patient presented that really unwell? Um, you should definitely let your senior snow ready. Stroke? Nothing. Go for a CT, and then you go to each year. I see you for money tree. Okay. So, I mean, um, as an F one on general surgery, you'll come across pancreatitis a lot of times. You know, after one or two months in during surgery, it's be the fingertips. Basically have to manage. My appetite is just fluids. Antiemetics algesia. That's it. And watching week. Okay, So quick. Picture on Colin. Sign and return a sign. So Colin's sign, like I mentioned paraumbilical cretinous is on the flank. Um, and always think about different gels besides hepatitis. All right, so complications of pancreatitis. Can anyone tell me what the common complications are if you just run the trip? Yep. Diabetes pseudocyst fluid collection. Okay. Rds. Okay. Radius liquid effecting my crosis. Okay. Right. So when someone asked you about complications can always divide and divide into early and late complications so early would be pseudocyst to be very pancreatic fluid collection. Could be rds. Could be pancreatic necrosis. Um, could be the I see, uh, late complications to be chronic pancreatitis and that can result in our type two diabetes, like someone mentioned earlier because chronic inflammation of the pancreas can lead to destruction for either of Langerhans cells. And so your beat yourself up destroyed and you lied to type two diabetes to be in patients with chronic pancreatitis, so we have to watch out for that. But most commonly, the early signs of look out for any complications look out for is the RDS um think rejected assist and also peripancreatic collection. So it's quite good to know about the early complications. Pancreatitis. Okay, the third question. All right, So 75 year old man presents to the surgical OPD we joined It's weight loss and loss of appetite for the past three weeks. He denies any abdominal PT however it states is urine dark in color. And it's still that the appeal on examination a non tender problem asks president right hypochondrium, which tumor marker would eat your diagnosis. Okay, so and the pools, it is a mix between 80 and see. Um, we'll get back to you on there, but it's in the pool. Right? So the answer would be see. So, um, so you're also fetoprotein is classically known for hepatocellular carcinoma. So dissipation, as you can see from the history he presented with Sign the obstructive John, This, um Why, you see, that's because, yes, you're really dark in color and stuff which appear colic. A pill so classically obstructive John days. And if you're thinking about nontender out for mass, which is not painful, do you think about something sinister? That pancreatic cancer? The nontender couple of mass could be an enlarged gall bladder, and that is a sign known as corporate. See a sign, Of course. His law. You stay there. Any non tender, palpable mass gold bladder rules are Goldstone's. It should be either Critics CEO Cholangiocarcinoma and the tumor marker, which is quite specific for pancreatic cancer, is seeing 99. Okay, so, um, alpha fetoprotein, like I mentioned earlier, is for hepatocellular carcinoma. It was quite specific for another form of tumor. You can tell me what What kind of tumor? It's also useful. Elevated working. Yeah. You see, like I mentioned, yeah, testicles were looking for Yeah, usually. Same normal. Okay. What do you see? A useful costly and brian costing. And Brian and DJ Colorectal good 19 nineties usually use for pancreatic. What about? See a 15 3 breasts. Good and s 100. Very good. Well, normal. Yep. So, I mean, when I was a medical student, see? And put me quite a tricky, be hard to memorize. Help. Remember the tumor markers? So he told me. Basically, see in 1999 inverted horizontally, he looks like a pancreas. And 15, 33 and inverted horizontally. It looks like a breast. I know. Um, it's a tricky, but yeah, if you have any heart, remember, the cause is, um you can use that. Okay, so we'll talk about in pretty consulate on about for right now. I will talk about John this. Okay, so there's three types of jaundice, so days prehepatic hepatic and posthepatic causes jaundice. So you're prediabetic course of John days. If your hemolytic anemia is so, if your G six PD your sickle cell anemia as you're here, they're free for psychosis. Basically, blood cells breaking up, Releasing, um, uh, him hemoglobin in. That's breaking down to believe body and Billy Rubin eventually. So it's quite common to get John different hemolytic anemia. Okay, So hepatic causes would be your viral hepatitis for any hepatitis a B or C can present with John this, um, you sick and get John difficult or doing your hepatitis drugs. Paracetamol overdose. You can get John different. Um, quite rare. But you can see them. Um, when you look in EDS. And if I want to refer you to, you can see they should come in the John district. Percent more bottles. So, um, and inherited the soreness so you can get critical managers and Gilbert syndrome again. Those are quite rare you can find in books and exams, but it's good to know so quickly. And I just basically a deficiency in the liver. Enzyme used to congregate believer Been Who can Gilbert syndrome? It's basically a syndrome where there is, um, deficiency in excreting bilirubin. So patients with low but syndrome tend to be asymptomatic, and it didn't prevent with mild effect. Um, attic John this and we do blood tests. The bilirubin be slightly high. Uh, Gilbert symptom to present medications who undergoing stress patients who are fasting. So it's good. Good to know, for example, so usually patients who presented Johnny's due to stress across Singleton Detrol, but syndrome and doing to do anything for them. It's just inherited. Posthepatic causes. So like Imagine leaping critics. C is quite notorious. Cholangiocarcinoma is and strictures, I felt. So you go on. If you go on the Apidra HPV words. If you see a patient who looks like Homer Simpson, who looks really yellow, and if they're not complaining of King just itchiness, the patient most likely has pancreatic see a cholangiocarcinoma, It's quite said, really, because once patients present John, this is a late stage, so you can't do anything about it basically, is just chemotherapy. Okay, right. So Billy Rubin cycle. I'm sure people in different 1st 2nd year of medical school intend to pop up again when you sit for Marcia's exams. Unfortunately, um, there's no easy way of going about it. You have to have to read it, understand it and learn alone about it. So, basically, in simple terms, um, it starts off with your regular cells breaking down in the speeding, releasing hemoglobin for him. And then that breaks down to Billy Burden. And if any times breaking down to believe nobody and a bilirubin, then goes your liver cells cup for cells and gets conjugated because uncontradicted Billy Rubin is not what the PSA Little so once better been, gets contributed. Um, it comes with two soluble. So then gets released into your bile and gets reabsorbed in the bloodstream into the kidneys, whereby it's converted to your ability Order for your billing and that gives your in your cross that yellow color. Okay, in the gut, your billion is broken down into the stock of a billion by bacteria in the large bowel. I'm sorry in the small bubble, and that gives, um, you're the classical color of feces. It is either brown orangish. Okay. And then you have enterohepatic cycle, where by your bile acids and your bile will get reabsorbed in the island, the terminal terminal island and gets recycled back in the liver. Okay, So, um, as if f I want to If i to us a surgical trainee, the most common question would be asked Issue know in which surgical condition which patients will be prone to having this cycle destructed any one time only which condition? It's mostly to lead to a destruction of the intrahepatic cycle. No. Uh, your buds. Yeah, groans. Goldstone's so basically dances Crooms. So because Crone's affect the whole elementary candle from your mouth to the anus so and only croons with contrast surgery. They'll go through something called Terminal Island resection and basically your island resected. So when that happens, you don't have feel intrahepatic cycle going on. So these patients tend to have medication given to them to, um, replenish your bile acids to sweat. It's got good to know because patients present with science off by elicit emergency. Let's get diarrhea. Um, you know, we lost. So it's good to consultations have gone through, um, you know, under section on What? What could happen? Okay, No, two seconds. Right. Symptoms of John days. Um, you get quite intense itching with John. Dizzy Get interests, which is elevated the sclera. You get a change in your colored urine? Just quite dark yellow. Um, and you get pills too again. They'll still do get it If it's obstructive. John, this If you get something like viral hepatitis Apria or have the packet forms of John this you get very dark urine. But your stool be will be unchanged. You can get Don't know pain and fever depends again. If you have hepatitis C, you have cholangitis. You can get done. A pain fever. Okay. All right. So how do you treat John days? And how do you diagnose them for the criteria is basically, is if you think that President in your serum Bilirubin at least 35. Micro move. So, um, I mean, you don't have to know the clinical value, but it's good to know how you diagnose them. Um, blood test. You do LFTs through a function test yesterday. Billy Rubin. You'll do a full liver screen for thinking about medical course is to go to him in hepatitis Oh, our primary biliary. Cirrhosis of promise Claritin cholangitis. You get up in the abdomen to look out for Goldstone's, um, you can do a CT to look out for tumors like it off the pancreas, tumor or cholangiocarcinoma or alternatively, Janice agents like us, we like to, um, recipe. Oh, yeah. Sippy mrcb. It's kind of MRI of the biliary tree. Yes, it is mostly therapeutic. You can do it diagnostic, but you can see the therapeutic. If it's a gallstone in the common bile duct, you can do a center up to me, then there and take out the stone. Okay, so management of John Days. So basically, you have to investigate the course. You can just leave it. So, um, in the meantime, you can give patients antihistamines because patients are coming intense itching we can give them cholesterol is a drug for hyperlipidemia, but also been proven to show that it relieves intense itching You to join this, you can give them that you can also give them. You can also do ERCPs conventional year. If that's called stones, um, causing doing this. Thank you. Any questions? Just call populate in the chair after lecture. All right, The next question So a 48 year old lady you strained? Sorry. So my screen Full street. One minute. Yeah. Sorry. Ah. 48 year old lady presented TD. Worst thing, right? Upper quadrant pain. According to her, the pain comes typically after having heavy meals, the Penis colicky in nature. And she admits to having nausea along with a P. She denies fever in any of the symptoms on examination. Know joined this present. How was she? Has right up according tendency upon examination Abdomen, what is the first line investigation after routine blood test? Yeah. All right. Let's just send it there so most of your right eye and say, see shit the results. All right. Okay, so the ultra very abdomen genocide It's quite straightforward. If you're untreatable, anything after examining, then after some. And then if you don't know if you control the after ultrasound to a city, So, yeah, the first time. It's always ultrasound to look out for Goldstone's okay, for this patient have possibly Murphy's sign one exemption abdomen. And that is quite indicated for acute cholecystitis ping, right. Definition simply means inflammation. The called bladder and thing that I take this information so quite straightforward. The common causes are that they're three. You can divide into three. Anyone ask you what causes that divide them makes you look more slick and more efficient. So, um, they're calculus, a calculus and infective. So calculus, as in stones, stones, non stone infection. So the calcalist bit so they're treating front of the stones. Most common is cholesterol stones those yellow stools have seen in after cholecystectomy and the pigment stones, which are usually brown or black, um, due to bile and also infection. And they're mixed owns, which is you get a mixture of cholesterol and PSA pigments don't usually black. Most commonly it's cholesterol stone that you see me take. A patient called Byetta Out. A calculus course is is quite red, but that's happened is usually in patients with hypercholesterolemia lipidemia. You can get something less cholesterol polyposis, which is basically a polyp meet up and tired of Questran. Um, it's quite it's quite red, but it's fascinating. You see one so and you still get something called diverticula specific all better, which is basically an outpouching to call by the wall, which causes inflammation. The whole bladder. I've not seen one. It's quite red, but it does happen. Infection. Most commonly, you have few infective agent, So you have equal I your clip seller, Um, in your streptococcal. It stopped because the callous in some Manella equal and capsule is the most common organisms, causing cholecystitis. If you have infective course is happening, then you should be quite variable Collin dry just developing later on. So these patients should be started on some sex immediately, and antibiotics, fluids, um, and BP support. So be quite Mary of that, especially, you know, snf I one on general surgery, they separated, but anything anyone present it fever except to six immediately. I mean, investigations. Like I mentioned earlier. I'm concerned of basic blood tests. You can do your food that count your liver function test you're using east and also see are being elected. You can get erections. Extra abdominal x ray. Um, why I mentioned erections. X rays? Because patients presenting with the right upper quadrant being always mean girls don't have to rule out other sister causes like a perforation. Perfect, viscous to do it erections, X ray to look out for and the dye from abdominal X ray. You can do an abdominal X ray, and sometimes you can see a calcification of stones. President X ray if you read, but you can feel it. Sometimes after sounds the gold standard, you can do them. Um, we like to request MRCB because you can see you can look at the anatomy of the biliary tree, can look where the stones are and that can eat operative planning. You can do something that has PCI See the weapons percutane. It's transplanted cholangiogram. Um, my hospital does it, but some schools didn't do it, so it depends on where you are. And again, I mentioned your CP can do boat can do it other diagnostic and also but therapeutic and speak. And you guys can also do a high dose scan, which is quite red. Not done. Now this one has a medical student. He's doing dandy, but I don't think Do it now this, um but good to know, for exams management, um, colitis like this should be managed with antibiotics, So insurance after six. So give your fluids, antibiotics and also mg divisions actively vomiting. And, of course, don't forget. Oh, geez. Yeah. Okay. Surgical treatment. You can do a laparoscopic or open cholecystectomy. Go standing now. This electric scopic faster healing time. Better cosmetic outcomes. Um, but we can convert an open cholecystectomy this perforation or just empire, not the whole bladder. So it depends on what you find when you in your data. Um, you got to do something with the hot cholecystectomy. Can even tell me what a heart cholecystectomy it's anyways come across it to him. Yep. Yep. Someone mentioned surgery during that mission. That's a hot cholecystectomy is basically a cholecystectomy done when a patient presents Initially with your policy status is usually done because the patients quite septic. They're quite unwell, and usually they're usually hypotensive, septic shock and usually a cholecystectomy. Then they're on the same day. Um, they can result in poor outcomes. Usually patients who have complications down the road, they can have perforation again by leaks. Um, so it's really done, but it does happen. Um, okay, So the classical ways of how your treatment is that usually patient, country cholecystitis you give them antibiotics and then two weeks later you do a cholecystectomy. So that's what's known as in political a sec to me, where you give antibiotics for two for two weeks, get the vision, come back and then you're going to call better. But you still have cases where you do a hot cholecystectomy where occasions quite unwell. Um, you need to take the garbage out. Then there. Okay, right, right. Movie sign. So movies. It's basically examination, and you pop it the right costal margin and this rebound tenderness. When you do so, patients tend to flick and you tend to grow any clean. You do that so basically, when you take deep breaths and the inflamed liver marginal come into contact with your hand, and that's what painful so that's positive. Murphy, sign for cholecystitis. I don't know what boys signs for. I mean for your cystitis, but Hamilton weighs what it is. Well, could response hypoalgesia the scapula? Yeah. Um, you don't do them in real life. You don't actually look out for it. Um, but consultants are quite at the wrong one to us about boys. Scientists. Good to know. Okay. Oh, so definitely mothers distinctly about sepsis. Six. So seeing that you guys are forth and 50 and medical students, or even that your medical students and when you enter, if I won 76 will be the bread and butter off your entire for life. So you should know this. So, basically, sepsis six week it started within one hour off the patient presented Presenting to you a sense of fever. Think about sepsis and start your success stick. So you give three Take trees your mantra. So give three. As you give antibiotics. If fluids and also oxygen, take three. You just can't drive for urine output blood tests, including cultures, and also tickle that gas after 11 A for lackey. So if you know this by heart when you started, If I want to If I too, um 24. I mean, safer life, for example. Also, Marcia's. Okay, a dachshund. Just give me one second. I just make a quick announcement on the chart. Yeah, you guys, it's more a handful. Mosque. Easy. I'm just adding a Google form to the chapped. It's just get extra information and feedback about our collaborative teaching s o. Please do fill this out. Okay. Thank you, guys. Sorry, Doctor Carroll. Thank you. Right. All right. So the final question Sorry keeps happening. Right? So 25 year old female patient comes to the clinic call up after a splenectomy fully erupted. It's been two months ago after road traffic collision. The registrar then proceeds to question you about any particular infection that she might be said. We'll do postsplenectomy it cleans. They're forgotten. All these micro biology in medical knowledge after starting surgical training. Um, yes, we actually will do. Which infection is this patient printer? Be all right. So I'll just ended their um So I think I moved onto the cursor after you guys started ports. We ask, so the answer. But you have you guys all right, So strep pneumonia. Um because most patients extremely vulnerable to encapsulate organisms. Can anyone write the check books? About what other? Against the North? Uh, capital, Give me. No. Yep. In him. Phyllis Me? Syria. Okay, Strep pneumonia is Roland. So clap Seller. Okay, so we'll talk about splenectomy. And so it's complications. Yeah. All right. So the function to the spleen anymore can tell me what the four different functions are, but still, basically, you know, breaks down. Reports ellzia and heels, Um, helps with encapsulated bacteria. Yeah. Yep, yep. Immune. Prevent infection. Good. Anything else it stores. Something else is Well, can you? Do you know what He Yep. Yep. Let's good. Okay. So, um, there's a name on it. Fish if I s h filtration, immunological storage and him out of places. So, um, filtration off your red blood cell for all red blood cells. After three months, it breaks down. So it filters out all the old report cells. Immunological function is it has anti body. Has it starts antibodies as well. So g m e d immunoglobulins. And it's tossed. Um um, important. You know, trickle function, storage your platelets. Um, it's quite a important organ. May stop platelets and hematopoiesis is so it functions in red blood cell production, especially newborn babies, before your bone marrow takes over, the spleen functions in human two places. Okay, so it's just good to know North talks about the speed except when it's injured or ruptured during the trauma. But it's got some of the functions are Let's go. And I think someone I think someone want mentioned about, uh, destroying capital gains. Since, of course, the right answers. Well, indications of splenectomy. Anyone Tell me what the tree was. Common indications are one. It's foma. Other two. Yeah. All right. So trauma from a nation sickle cell just drew So sickle cell crisis can cause hypo spin is, um So if you're spilling and largest, um, because it's been a megaly and you can have symptoms. Did that do to them to strangle the sickle cell? Um, so you can take up to speed the treat. Hyper spin is, um, melon and see not mountain and see off the spleen. Proceed but mountain. And he suggests leukemias. Lymphoma. So acute leukemias for CML cll can cost. You know, Maglie, um so you can take up to speed. Um, for the purchase Fel Leukemias. Okay, Complications. Austin ectomy. Um, so that's kind into the question asked earlier. So like I mentioned, there are girly in late complications. So early complications anything to do with any surgical question is if anyone are stable complications, infection, bleeding should be a talk to, um really complications. It is for everything. So infection bleeding. You always school right with that other things which is quite red gastric Stasis. You can also pancreatitis does happen, but I'm not seeing them late complications can have a fistula, which is basically a normal connection between two Patillo services working up in protective Still a to the year speed. You can have Trumbo cytosis. So this is quite a common complication because patients can they're high risk of developing DBT and the portal vein thrombosis. So patients who have had a splenectomy shit this doesn't aspirin, okay to prevent those. And you can get something known as an oxy or overwhelming postsplenectomy infection, just which can be caused by intoxicated organisms. Okay, we'll talk about I'll see after this, right. So upset. Otherwise known, is warming. Post anatomy infection is basically a serial former sepsis. So anyone present anyone for the history of splenectomy. Um, usually within 23 months in the coming fever or flu like symptoms you should be quite cautious about and obviously developing. So symptoms look out for, ah, flu like illness like headache, little achy vomiting and four fever. When you see them, you should just start yourself to 6 to 8 a week in former registrar stuff that step to 6 ft away. Investigations As part of the 76 you can do your blood test. Um, you can do FBC using easy lefties. You see our people cultures times two and you can do that gets elected and catheterized Amanti output. So body accepts of six your treatment. So basically the treatment for an obviously, because of the organisms, capsulated usually respond quite well to perspective. Beetle activities. Antibiotics, which is usually of insulins. So, um, can be is the most commonly used antibiotic. Okay, so patients who are allergic to penicillin can get it through my zing or Claritin. My things are macrolite, um, so you can start them on that and then you monitor them. Okay, This patients can be quite unwell. Usually they can go into septic shock and they're usually go taste your I see for traffic support. So be very a Europe that Okay, So if your surgical trainee in your steam clinic and someone comes to you, um, with fever and if it's connected me a few months ago, that's your first differential. And me the patient's CT. Okay, um and yet postpone acne Patients should have antibiotic prophylaxis for two years after it's back to me, um, went back to give. Like, Imagine, this is a pen be or every time I sing If if you're allergic to penicillin, you have to get them lifelong and you by Texas, you know, suppressed. So if they they have active cancer under going to chemotherapy or the HIV, or if they're definitely diabetic from antibiotics and vaccinations for those organisms, so and we'll flu vaccine um, and will you makoko back? See? And we'll major cocoa backseat. Okay, make sure that you received Also, the GP should be rare bills, and they should make sure that they get their vaccines on time every year. And it's a regular follow up. And I believe I mean, I don't see them all the time. I did it and it just took it that they have a bracelet. You had a recent thing that they're, you know, suppress. And they have had a splenectomy because you travel. They shouldn't travel to military a prune areas because the spleen functions. Suck wrist, um, the malaria against, um, So patients with connective who have malaria do tend to be quite unwell. Cool. They do. Okay, so just a quick talk to you about pancreatic. See, these lights go to see a row. And it was his size of this good, though from him. But thank you in. So let's talk about talk about pancreatic cancer because we had a question about pancreatic cancer. So, um, the respect is up. Smoking age, chronic hepatitis, being overweight, being diabetic, it's well, and you have your inherited syndrome, such as your kitchen PCC or lynch syndrome, your polyposis syndrome, and anyone with broccoli one or two mutation. And if your men immense symptoms know your men, one meant to win meant to be. Okay, trickle features like I mentioned you get painless. John. This, uh, quality is low. Um, so basically states that anyone with a long about the gallbladder is not And, uh, it's usually, um, did you cancer on call stools? Someone raise your hand, Gory she any questions? Or if she that's fine, I think you can carry on all right. So weight loss is getting a doctor in and deal stools because instructive in nature can get diabetes. It's quite a late sign, but you can get them some patients that present with new onset diabetes. And you do investigations, and you find out the F tumor, which is quite said, step diarrhea and can get triggered a sign of mountain. See diagnosis. Um, CT scans. The key you can do after sound but is usually operate operative dependence or seek is quite accurate. Can get your classic double duct sign ultrasound. I'm not seeing them, but your reader, graphics and radiologist might tell you what this um, mrcb a pet skin and then you'll see in 1993. Treatment usually will be both. So if if you do your TNM staging and the patient has teach one thing, critics see which is quite rare, usually business present with stage two of these three, you can do peoples, but once the station states tree, there's nobody will be posted just rely on chemotherapy in politics Care Okay, yeah dot If treatment looking like mentioned here, you can do chemo radio against the inserts stent because the humeral struck the bowel duct that can lead to worsening. Doing this and you can just put a stent into relief obstruction just to make life easier for the patient. But ultimately it's just related care. It is a quick run through book pancreatic cancer, so I think that should be us. If you have any questions, you can. Fantastic. I just I just wanted to take this opportunity to, um, send the the research from way work quite hard. Yeah, we'll go through all the questions slowly. We were quite hard to organize. His collaboration would love to see your feedback on the collaboration as a whole and whether it helps, you know. So just send a a feedback from on the on the chat again. We'd be really, really, incredibly grateful if if you could, you could feel that in, because it really helps us assess whether what we're doing is right. What we're doing is wrong, and it really helps us in understanding how we can improve our policy is and our medical education itself. So I just sent through the form on D in the chat