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General Surgery & Peri-Operative Care SBA session

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Summary

Join this unique on-demand teaching session run by three final year medical students from the University of Aberdeen who have designed this session to provide relevant content tailored for your final MLA exams, with doctor-guided weekly discussions on different specialties each time. Tonight, FY2 Doctor Ankit will delve into general surgery and perioperative care, with an emphasis on diagnosis, investigation, and management, valuable for written exams and OSCEs. This interactive session will not hold back from addressing and dissecting the complexities of common medical situations and their optimal management strategies. Be prepared for engaging activities like answering SBA questions online, with the opportunity to share additional knowledge in the chat and contribute to everyone's learning.

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Description

Join our General Surgery & Peri-Operative Care SBA session designed specifically for medical finals, conducted by Dr. Ankit Gupta (FY2), who brings his practical surgical experience to the teaching session. Engage in high yield MLA finals styles questions, with levels of difficulty increasing with each round. Benefit from crucial clinical insights provided by instructors who have themselves worked in the specialty they teach. This session will not only test your knowledge, but also offer you a real-world perspective of general surgery & peri-operative care, making it highly relevant and beneficial for your medical finals studying.

Learning objectives

  1. By the end of the session, participants will be able to differentiate between the various types of hernias based on diagnostic cues and patient presentation.
  2. Attendees will be able to correctly identify and describe different types of stomas, including their typical location, appearance, and output.
  3. Participants will gain an understanding of strategies for situational problem-solving and clinical decision making in the context of surgical and perioperative care.
  4. Contributors will understand common perioperative complications and their management, enhancing their ability to provide appropriate care for patients.
  5. By the end of the teaching session, attendees will have a greater understanding of general surgical conditions and will feel more confident in approaching these in their final MLA exams and in clinical practice.
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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.

Hi, everyone. We'll just give a few minutes for people to turn up and then we'll start. Ok. So, hi, everyone. I'm Emma and just to start off. So just a quick introduction. So we are three final year medical students from the University of Aberdeen. So it's Emma and Brian's here as well. And Jan's also running it with us, but he's not here tonight. So we just started this revision series after setting our finals last year with the aim of providing some useful and some relevant content for you guys tailored to passing your upcoming final MLA exams. So we're running these sessions roughly weekly at the moment covering a different specialty each time and each time they'll adopt an SBA approach and they'll ma mainly be run by doctors, some by us, but mainly by doctors covering the session for you. So we have an fy two doctor tonight here to cover the questions with you. So, moving on, this is just a little bit of information about what other sessions we have to cover coming up in the future and the way we do these sessions, there'll be 18 SBA questions and we split them into three ses three sections. So the first round is easy then medium, then hard questions. And this is also just a little side on becoming an ambassador of the crash quarter finals team. So it just gives you instructions about what to do. So it's roughly just to email us with it around 200 words about why you'd want to do it. And moving on, this is just how to keep up to date with all of our teaching sessions. There's a QR code for everyone to scan on Instagram, Facebook and Nick, just some house rules. So we just ask that everyone goes on mute and pop your questions in the chat and we monitor the chat at all times and we'll feed them back to the doctor running the session for him to answer your question. And these are just our learning objectives for tonight. So at this point, we'll just pass on to Ankit the fy two running the session and hand it over to him. So we hope you enjoy. Perfect. Thank you for that, sir. My name is Ankit. I'm one of the um academic foundation doctors. I'm currently based in Leeds. Um So today we'll be going through general surgery and perioperative care. So I'm currently on general surgery at the minute. Um And my interest is in, is in surgery as well. So we've got a bunch of questions to go through. Um And we've got these learning objectives as well. So we'll try and tackle a broad range of questions because I'm aware that you guys need to know, need to know quite a lot for finals. Um And essentially the main thing will be diagnosis, investigation and management, which is the most appropriate thing for final year medical students and people sitting their finals. But it will also be quite applicable to people sitting on skis as well. So we'll try and build in um, a couple of stuff that links into both the written exams as well as the Os Keys. And then hopefully you guys will be able to retain a fair amount of information for when you start work because all of it, believe it or not is, is fairly relevant when you, when you start work as a doctor. So, um, we'll go ahead, so we'll start off. So the way that it'll work is we'll present a question. Um We'll give you 30 seconds or so and we'll put a poll on the screen. So, um, you'll be able to vote for your answer, have a, have a go at telling us what you think. Um And I'll keep asking questions as well. So I think that, that you guys will get the most out of firstly answering the questions. But if you guys are able to share any additional knowledge in the chat, so if I ask a question and you're able to answer, that's perfect. Cos it's just making sure that the memories are being updated in your head. And I think it's a, it's a good way of, of embedding knowledge in your mind. So we'll try that. Don't be shy, don't be afraid that it's gonna be a stupid answer, I think. Just go for it. Um, and I, I'm sure you guys will be absolutely fine. So, so we'll go for it. Um Any questions after the end of each question, let me know in the chat or, and, and these guys will very kindly have a look as well. So we've got question one. So we've got a 52 year old lady presents to the GP and she reports a painless mass in the groin area. So on examination, a mass is noted on coughing. So it is below and lateral to the pubic tubercle. So what's the most likely diagnosis from these four options? Ok. Yeah, so good. We got quite a few good responses there if we can try maybe for a couple more. Just so. Yeah, perfect. That's absolutely fine. So 18 responses. So 66% of you said femoral hernia, which is excellent. So that's the correct answer. And 33% or a third of you said inguinal hernia. So we'll go through the differences. So femoral hernia is inferior and lateral to the pubic tubercle. So this is what was described in the stent. So you'll typically see this on past med or ques questions. So the the the location of the hernia is really, really important. So typically, a femoral hernia will be inferior and lateral to the pubic cubicle and inguinal hernia will be superior and medial. So it's really important to be able to distinguish those two hernias, obviously an umbilical hernia, none of you went for which is great. Um It's not in the region of the umbilicus, but there's also this other differential that we need to consider, which is a Safina varix, which is a dilation of the saphenous vein in the groin. And that can also mimic a lump. So it can mimic a hernia. So it's something to be, it's something to consider in your differentials. Um But that's this will typically have a bluish tinge to it as well. So we would expect there to be other examination findings as well. So obviously, this isn't a complete list of hernias. So there are some other hernias such as an incisional hernia. So where a patient has had previous surgery, there may be a hernia through that defect where they've had their wound repaired. And there's also something called a spigelian hernia as well, which is um so the transverse abdominis fascia, the uh small intestine or or abdominal contents protrudes through a weakness in that fascia. So that's called a spigelian hernia. And there's also something called aictis hernia, which is essentially a bit of small bowel that's incarcerated within the hernia. So something to be really important or something to be really aware of because it's really important. And the thing with femoral hernias is you want to pick them up quickly, um, because they have a much higher risk of strangulation than inguinal hernias do. So, something to be aware of if you're, if you're on surgical placements and, and typically f for femoral, they're more common in females than they are in males. Ok. So well done. So we'll go to the next one. So number two, so we've got a 45 year old woman with a history of you seeing undergo surgery and a stoma is created as part of the treatment plan. So during the POSTOP assessment, you observe that the stoma is in the right iliac fossa and is spouted from the sti it's from the skin. The stoma has a liquid output. So what type of stoma does this patient have? And if we can try and get everybody to answer, it's anonymous, so you might as well pick. Yes. So we'll try and get a few more responses so everybody can have a go at answering. Yeah. Ok. All right. So I think the majority of you have answered. Um Don't worry if you haven't. So it's a tricky question. Um and something that a lot of people get confused on so we can go through it so well done to those people that put B ileostomy. So it is in fact, an ileostomy. So ileostomies are typically located in the right iliac fossa. Um So I remember this, that is that ileostomies are very, very or the terminal ilium is very, very closely related to the appendix. The appendix is typically in the right iliac fossa. And so if you have a stoma in the right iliac fossa, that's likely to be an ileostomy. So, something that's being secreted from the small bowel, if you have a stone on the left hand side, it's much more likely to be a colostomy and that will be typically flushed with the skin. Um So I'm sure you guys know the reason why an ileostomy is spouted is because the liquid content that it produces is very, very irritant to the skin. So it needs to be spouted so that there's minimal irritation to the surrounding skin. If it was flush and the contents are in contact with the skin, it would cause a lot of erythema and possibly some cellulitis as well. So it's an important differentiator between the two. So either of these stomas can be loop or they can be end. So a loop basically means is that you get a loop of bowels a bit like my finger. Um And then you chop that bit off. So you essentially get two holes. So one either side and most of the time they are the, the plan is to reverse them or to, to um make it back to normal at some stage or another, it's just, it's looped it's a loop colostomy just for the time being just to allow the rest of the bowel to recover in the meantime, whereas an end colostomy or an end ileostomy is much more likely to be permanent and people are left with stoma bags, either in the right iliac fossa or the left iliac fossa, um from a, from an end from an end colostomy or an end ileostomy and they will just produce outputs into that bag and they'll have to change that back. Um Another type of stoma that we haven't talked about is a urostomy. So this is a urinary stoma. Um And this is essentially where the ureter are planted into the abdominal wall. So you'll get urine coming out of that and this can typically be anywhere loca it can be located anywhere on the abdomen, but you'll notice that the output is very, very liquid, as you can imagine. It's from the kidneys compared to the ileostomy and the colostomy. Um So well done to those of you that got it right. Um And hopefully it makes a bit more sense to those of you that put some of the other options good. So number three, so you've got a 15 year old boy presents the e presents the ed with sudden onset left testicular pain. So the pain started a few hours ago and it's associated with nausea and vomiting. So, on examination, the left testicle is swollen and positioned higher than the right there is a loss of remister reflex on the right on the left hand side. Sorry. So what do you think is the most appropriate management something? Ok. So before we move on to the next slide, um, so there's quite a divide on this question I can see. So a couple of people have put some different options. So in the chats, if you're feeling brave enough, I think, go for it. So, and does anybody know or does anybody have any differentials in mind? What would you be thinking if you saw this stem? Yeah, exactly. So good. So, so perfect. So the main thing that we would be thinking is torsion. Perfect. So good. So people are thinking the right thing. So we would be thinking torsion. So I think you've all got the diagnosis on point, which is excellent. So this is a urological emergency. So something that we need to address basically immediately because there's the risk that if the testicle is torted, we're going to lose blood supply. So the critical window is, is typically termed six hours. So we need to be able to operate on this within six hours. So the issue with this question is that it's not asking for a diagnosis, it's asking for the management. And we know that from the stem that the torsion is likely on the left side. So we've got a lot of cremasteric reflex on the left side, we've got severe left testicular pain, the left testicle is swollen and it's positioned higher. So it's all pointing towards a left sided torsion. So most people actually put d which was urgent unilateral, left sided orchidopexy. But the answer is going to be a, so it's going to be a bilateral solution. So the reason for this is is that if we operate, we inside the scrotum and if we fix both of the testicles, then there's a much, much lower chance that anything like this will happen in the future. So instead of just fixing the testicle that it's torted, we obviously do that. So we do that and then we fix it to the skin, but we also fix the other testicle to the skin. And this is primarily just to reduce the incidence of this condition happening again. So it's a tricky question, but it's something that's really important to be aware of. So if you're asked this in finals, at least, you know, now, um that you would, you would treat both sides, which isn't something that really happens in surgery, you don't really treat both sides if one side is wrong. But in urology, this is a, this is a one off procedure. So you actually do both testicles at the same time. So you treat them both um primarily for the reason that something like this could have very easily happened again. And so obviously, you've minimize that risk whilst you're already exploring the scrotum anyway. So it is a tricky question well done to those of you that were able to guess the diagnosis or, or make the diagnosis. Management is a bit tricky. Um, but hopefully that makes a little bit of sense. Um, if you've got any questions, obviously feel free to ask in the chat. Ok. But well done. So. Number four, so Mister Jones, a 38 year old male presents to Ed with complaints of painful rectal bleeding. So he reports experiencing intermittent episodes of bright red blood in his stool for the past three weeks, he describes the pain as sharp and localized around the anal area. So no changes in bowel habits or weight loss. Uh On examination, there is tenderness and induration around the anal verge. So what's the diagnosis? Ok. So most of you answered, which is great. So there's a bit of a divide again. So most people have gone for C which is excellent. Um A couple of people have put a and a couple of people have put D as well. So we'll go through why? So hemorrhoids. So, in this case, so hemorrhoids typically are painless. Do you know when hemorrhoids are going to be painful? And don't worry if you don't. So when would be the time that we would expect hemorrhoids to be painful? What state would they have to be in? So, external can still be painful. So, hemorrhoids are by definition sort of um dilated blood vessels. Exactly. Ky perfect good. So they're going to be thrombosed. So, when they're thrombosed or when they lose that blood supply, then they typically become painful. But normally we would expect hemorrhoids to be completely painless. So people generally only realize they've got hemorrhoids when they wipe their bottom essentially. Or if they not, or if they look in the um, toilet pan after, after they've been for a poop that they would notice blood, but normally we would expect these to be completely painless, er unless they're THS as we said, so excellent. So in this case, we can rule out hemorrhoids. So it's most likely not going to be that colorectal cancer. This guy's a young chap um and his colorectal cancer is typically painless again. So none of you put that, which is excellent. So, anal fissure anal fistula. So this is where it gets a little bit confusing. Um So if we go on to the next slide, we can talk about it a little bit. So in terms of exam technique, if you see painful rectal bleeding, I would immediately think anal fissure. So a fissure is a tear in a, in a surface. So it's a tear basically in the endothelium or the mucosal surface of the anus. And so if you tear something, it's likely going to be very, very painful. So this is going to cause painful rectal bleeding, fistula. So the definition of a fistula is the connection or the abnormal connection between two epithelialized surfaces or which are hollow. Um So a fistula is basically the anus canal um connecting to another part of the body, which it shouldn't be connected to. So it's an abnormal connection or an abnormal way for some things to pass through. And this is typically where infections can occur, sepsis can occur. And so that's managed with things like setons, which is a um a cotton wall that basically goes through the fissure and, and blocks it off just to drain away any infection there. Um But obviously, that's not within the scope of this talk. So this is just a diagnosis. So if we see painless rectal bleeding, we can think hemorrhoids, colorectal cancer or anal fistula, but in the point of painful rectal bleeding, we think fissure. Um So yes, difficult question but well done to those of you that got it and hopefully it makes a bit more sense as to why it's a fissure and, and not the others, but well done. Uh of course, any questions feel free to ask. So, number five, so Missus Adams, a 50 year old, 50 year old woman presents to Ed with severe right upper quadrant pain that radiates to her back. So she reports nausea, vomiting and intolerance to fatty foods. So, on physical exam, Murphy's sinus positive and there's tenderness over the gallbladder area. So, what's the most appropriate next step? So give you guys a bit of time to think about this one So give it a few more seconds. Ok. So again, a divided question, but that's the purpose of these questions. They're meant to be challenging. Um, so we've got from the question that it's cholecystitis. Um, so it's, it's about what we do next. So a couple of you have put administration of I IV antibiotics. So we wouldn't normally typically treat cholecystitis with antibiotics. So there's a sort of step, step wise progression. So we've got Bilary colic, we've got uh cholecystitis and then we've got cholangitis. So in typic, so typically in cholecystitis, we've got inflammation of the gallbladder. Um, and often you'll see in past me, questions and, and, and questions when you do your finals that the stem contains very relevant but limited information. So in this case, we can tell it's not cholangitis because she's not, she's not feverish, she doesn't have a temperature. Um, and there's no evidence of jaundice. So we're not concerned at the minute that this, that's that this infection is widespread or even infection that this is an infection of some sort. So this currently is just gallstones, irritating the gallbladder. So we're not concerned that there's jaundice. We're not concerned that there's an obstructive obstructive pattern to this er, picture bilirubin is not going to be high, she's not jaundiced, there's no fever, she's not septic. So at the minute, we've got cholecystitis. So the next thing that many of you have actually fixed correctly is going to be to perform an ultrasound. And we do this before we administer IV antibiotics. And the rationale for this is, is that if we perform the ultrasound, this will tell us whether there's any uh evidence of obstruction. In which case, we need to treat with IV antibiotics. But in this case, we don't. So there's no evidence of infection and typically, in questions, you'll see that's where it's trying to trip you up. So if there is no evidence that there's a systemic infection, no temperature spikes, no rye gauze, no fevers, then you don't treat. Obviously, the whole point of antimicrobial stewardship is just to be safe with your prescribing. So if there's an, if there's an incident or a case where you don't need to prescribe, you would you would stay away from prescribing. So, so well done to those of you that got perform an ultrasound. So that would be the next step in in defining that this is actually cholecystitis. And based on those ultrasound findings, we'll come further management for, but for the time being, we don't need to give any IV antibiotics. And a couple of you put immediate cholecystectomy. So this is quite rare. Um This is actually very rarely done even in the case of cholangitis. So if there is widespread infection, you would typically treat first. So it's very unlikely in in some cases that it's going to be immediately life threatening. So what you do is obviously, you've got a gallbladder and cholangitis that's very, very inflamed, very, very irritated and that's caused widespread infection. So, the immediate thing to do in cholangitis is to treat the primary infection. So you bombard them with antibiotics. IV antibiotics such as coamoxiclav. And once that inflammation has settled down a little bit, then you proceed to cholecystectomy because by that time, the gallbladder will be a little less friable and it will be much, much safer to operate on 5 to 7 days down the line than it is to operate on a very, very tense and very, very irritated gallbladder. So that's why you typically don't do a cholecystectomy straight away. Ok. But well done, well done. So, Mister Thompson, a six year old six year old man has recently undergone a gastrectomy for the treatment of gastric cancer. He now presents with symptoms, suggestive of post gastrectomy syndrome including early b satiety bloating and diarrhea. So, what's the best management approach? Ok. Sorry, I'm aware p for purposes of time, we'll try and get through these quickly. So if you can put an answer down as to what you think it would be good. So, absolutely. So most of you have put a so intramuscular vitamin B12 supplementation which is spot on. Um So the important thing that we need to consider is is that this guy has had a gastrectomy and within the stomach, you produce intrinsic factor which interacts with B12. And so if we don't have that there's very, very little point of actually giving oral vitamin B12 because it most likely won't be absorbed if, if there's no stomach or it won't be interacting with the intrinsic factor. So, if we give it intramuscularly, it's much more likely to enter the bloodstream and therefore to have an effect on our B12 levels. So, absolutely, we would go with IM um a couple of you have put d so dietary modifications, it's a similar thing. So again, it's being uh so it's, it's taken in B12 orally and if we do that, obviously, we don't have a stomach. So it's much, much less likely to actually have an effect. So Im is the, is the best in this case. So, really important to pay attention to what surgeries they've had a and this can play quite a big part in, in, in your answer. Um But well done to those people that got it. So round two. So hopefully no questions from that. But obviously, if you've got questions, feel free to ask, if not, we'll go on to round two. So they'll ramp up a little bit. Um But you're doing really well. So, so we'll keep it going. So we've got number one. So a 64 year old man presents the ed with vomiting, abdominal pain and distension for the last 24 hours on examination. There's generalized abdominal tenderness with high pitched bowel sounds. These are his observations and we've got act performed below. So what's the most likely diagnosis in this case? Ok. So wait until we have 20 or so responses. Uh It's a tough question. So don't worry if, if, if it's a complete gas, we can go through it. Ok. So, um, good. So again, cause a bit of a divide. Um, most people have put small bowel obstruction or large bowel obstruction. So it's equally split. Um, and a couple of people have put A and B as well. So we'll go through it. So A so ischemic colitis, so ischemic colitis very typically on exam questions is pain out of proportion to examination findings. You typically don't really get abdominal distension. Um You don't really have generalized abdominal tenderness and there's no high pitched bowel sounds, you'll just have generally normal bowel sounds. So it's just the pain. That's the most aggravating thing in ischemic colitis. So you'll typically have that picture and ischemic colitis won't show the CT image that we've seen here and we'll talk a little bit about the CT image. So the CT image shows some sort of bowel obstruction, which you guys have been able to identify. It's just whether it's small or large. So I can see why a fair few people have put large bowel obstruction. Um Some of you might have looked at the top near the liver. Um So there's an area there that's quite dilated. So that's the stomach and we can see on the left hand side that there's some dilated bowel, but there's also some central, centrally dilated bowel loops as well. So, this is in fact, small bowel obstruction. So, small bowel obstruction, most likely if you were to see it on abdominal x-ray, it's centrally located and you would get vomiting much more before you would get constipation. And that's typical. That's just because of the anatomy. So, uh, the small bowel is, is proximal to the large bowel. So if you eat something, it's much more likely to come up quicker than it is for large bowel obstruction because it takes a longer time for the food to go through the small bowel and then to reach the large bowel and then come all the way back up again. Um Which is why you get constipation a little bit later in small bowel obstruction and a lot more earlier in large bowel obstruction. So, really important to pay attention to the timings and what they tell you in, in the stem. So even if we couldn't interpret the CT, we can see that this patient had vomiting. Um, and vomiting is again, much more likely in small bowel obstruction. So, a few clues to try and differentiate the two, um, abdominal x-ray wise again, a very, very common question. So, small bowel obstruction, as we talked about centrally located, large bowel obstruction around the perimeter of the abdomen, small bowel um, has p PreQue circularis, um, which so lines that traverse the entire length of the bowel, um, large bowel obstruction just has that house stress, so, so small indentations on the edges of the bowel. Um But yes, hopefully that makes sense. So, again, a difficult question, but really well done. Um And some things that can cause small bowel obstruction are things like adhesions. Large bowel obstruction typically is caused by cancer. Um And volvulus is as well. So cecal and sigmoid, volvulus so good, well done. Perfect. So we'll go on to the next one. So we've got a 48 year old man who is due to undergo a laparotomy for small bowel obstruction. So what's the most appropriate airway management method? So this is a bit of anesthetics as well. So what do you think spot on? So I don't think we need to really spend too much time on it. So nearly everybody got it. So a few people didn't. So if this patient is undergoing a laparotomy for small bowel obstruction, it most likely means that they've been aspirating or they've been vomiting. So there's a very high risk that that vomit or that aspirate can enter the wrong way so it can go into the lungs. Um So we want to be as definitive in our airway management as possible. So we wouldn't use an LMA A because it's not a definitive method. So definitive just basically means that it pro it forms a proper seal around the airway. So anything that is regurgitated up from the stomach can't actually enter the airway. So the only thing that does that is an endotracheal intubation um or a tracheostomy. But tracheostomies are obviously very, very much further down the line. We would do an et intubation first. Um So we can measure this through a bunch of ways. Um So we can measure the waveform capnography, we can auscultate the chest, we can look for bilateral air entry and air and chest expansion. Um But the most important thing is that waveform, so that CO2 waveform. So the most appropriate thing here is that et intubation, an oropharyngeal airway wouldn't be appropriate for a surgery. Um but it is appropriate in a patient that's relatively unconscious, that has a reduced G CS, but you need an interim airway measure. So we wouldn't use it for a procedure. Um So Waldens to those, have you got et intubation? And laryngeal mask is a very easy um sort of not mistake but next option to go with. Um But in this case, it's a high risk procedure, we want to be having a definitive airway management. So good, well done, well done. So, number 3, 62 year old woman presents to ed with left lower abdominal pain and altered bowel habits including constipation and intermittent episodes of diarrhea. She's had two episodes of rectal bleeding. So she's tender over the left dilator fossa, no signs of peritonitis. These are her obs and her bloods are normal except from a mildly raised C RP. So considering the diagnosis, what's the most appropriate initial management? Ok. So good. So, so this is, so this is one that's caused a lot of people out it looks like. Um and I can completely see why. So any ideas about what we're thinking as a diagnosis, so it's tricky. Um but any ideas, cancer is absolutely a differential. Diverticular disease is absolutely a differential as well. So perfect. So those are the Yeah, perfect. So those are the main things that we're thinking. So we're thinking either cancer or diverticular disease. So, in this case, um so we can see that they've got two episodes of rectal bleeding, they are tender over the like left iliac fossa. They haven't got any signs of peritonitis, they're stable and bloods are normal. So given that the bloods are normal and obviously, there's the altered bowel habits, we are thinking more diverticular disease. So typically in cancer, you will have patients that have anemia. So this is a longstanding thing. So cancer obviously needs a good blood supply to be able to grow. And so this will some this will be something that happens over months. So you will generally have anemia of chronic disease to some extent. So there are obviously, these questions are very, very tricky. So they're designed to catch people out, but in this case, it's diverticular disease. So we're not going to be offering colonoscopy. Um We're not concerned that this patient has bowel cancer simply because they don't really meet the criteria of having colonoscopy. So, colonoscopy is typically given to patients that have iron deficiency anemia of unknown origin, essentially and also patients that have an altered bowel habits. So you would be completely right to think that colonoscopy is a good initial management for this patient. But given that we actually don't have any anemia, she is tender in the left lower quadrant. This is very, very typical of diverticular disease and maybe in this case, diverticulitis which is an inflammation of some of those diverticulum or out pouches typically of the sigmoid colon. So in this case, we would just increase dietary fiber intake and this would be ma this would be managed conservatively, which is what, which is what you see exactly in clinical practice as well. So this would be something that patients get sent home with. Um and they don't need to be admitted for antibiotics. Um They just are managed very, very conservatively and they tend to do very, very well. Um So, yes, absolutely. Cancer is a, is a very, very good diagnosis to think of if this was an AUS station spot on. Um but just writtens can be quite annoying, but this would be diverticular to so well into those of you that got it. So this one's AAA bit of a read. Um So we've got MBA, 45 year old woman presents with a recent diagnosis. Of breast cancer. She has a painless lump in her right breast. No significant past medical history, nonsmoker consumes alcohol. Occasionally, family history is negative for breast cancer. So, a mammogram showed a 2.5 centimeter irregular mass in the right upper quadrant of the breast. Ultrasound confirms a hypoechoic mass with irregular borders and core needle biopsy. So the main thing that's positive here is her two. So what would you want to start on this patient? So good. So a lot of people have put the right answer um which is b so we've got trastuzumab uh which is an, sometimes it's also called Herceptin. Um And so you'll see it in, in questions as Herceptin, which makes it a lot easier. So her Herceptin and her two breast cancer. So it makes it a little bit easier to be able to get the answer from that. Um But yes, absolutely. So this is something that can be targeted with biologics. So it's proven that this is her two receptor positive. So if we give something that targets those receptors, it's very, very likely to work. So we target this breast cancer with Herceptin. Um if it happens to be another form of breast cancer. So one where it's estrogen and progesterone receptor positive, we can give tamoxifen um as well. So in this case, we don't need to go for a mastectomy straight away adjuvance, ra radiotherapy adjuvance means that we give it alongside something else So in this case, it's likely to be wrong anyway because it's not suggesting that, that, well, that C is not suggesting that it's being added to anything else. And D she's got a negative family history. Um Her two is, is a, is a mutation that happens. So there's no indication to actually undergo genetic counseling um and testing for BRCA one, BRCA two because we already know that this is a, a her two receptor positive um breast cancer. So there's no indication to go to undergo all of that testing. Ok. But really, really good. So Miss C so a 60 year old female is scheduled for an elective cholecystectomy due to symptomatic gallstones. She's, she's got a past medical history of well controlled hypertension and type two diabetes, both managed with medications. She denies any history of cardiac or pulmonary issues. She's a nonsmoker and consumes alcohol occasionally. So this is her pre op assessment. So what a ss a score would you give this patient? Yeah, so a couple more and then we can talk about it. All right. So A SA can be quite difficult. Um but we'll try and break it down. So, so well done to those of you that got A SA two. So this is indeed an A SA two patient. So a SA one typically you actually never really get them in real life. Um, most people will have some sort of alcohol use which already puts them at So it'll be more than minimal, which already puts them at an A SA two, a lot of people smoke and, and very few patients are actually a SA who wants it. Very, very few patients are completely, completely. Well, um, most, most patients will be a SA two. So A SA two is things that are basically well controlled. So if you see well controlled diabetes, well controlled hypertensive disease, well controlled asthma, something like that, that is going to be an A SA two patient. So in this case, we've got a well controlled diabetic and a well controlled hypertensive lady and she's got a BMI of 32. So that fits into this category. Um, an A SA three is somebody that's got severe systemic disease. So if a patient has had a, a history of MRI or um a cerebrovascular accident, something that was longer than three months ago. So it's still a severe systemic disease. It's likely to leave them with some residual deficits, um or poorly controlled diabetes, hypertensive disease, something like that. And that will fit into a SA three. So this patient wouldn't be a SA three because her things are well controlled. A SA four are things that are more recent and a bit more of a threat to life. Um So all of these things here that we can see. So a recent CV ATI A and coronary artery disease, things like that. But then things like valvulopathy whilst they might not be causing symptoms. They have the potential to cause something very, very life threatening. So they would be a SA four patients. A SA five patients are patients that are not expected to survive either with or without the operation. So they're catastrophic brain hemorrhages, catastrophic intraabdominal hemorrhages such as abdominal aortic aneurysms and things like that. And A SA six is, is brain dead patients. Um Obviously, you typically won't see the A SA um scoring system used on those patients. Um But it's just a category that you need to be aware of. Um So good, so well done. So basically, this patient has well controlled um conditions. So she's an A SA two lady. Good. So, Mister Patel, a 55 year old man presents the ed with severe epigastric pain radiating to his back. He has nausea and vomiting over the past 24 hours. His medical history incl includes heavy alcohol consumption and recent binge drinking. So on examination, he has jaundice and there is tenderness on the upper abdomen and palpation. So what's the most appropriate next step? So I'll wait for a few more responses. Um But give it a go. What do you think? Ok, good. So any ideas what the diagnosis could be in this case is anybody brave enough to put in the chat, what they're thinking or what a differential would be? Yeah. Spot on good. So this is very, very likely to be pancreatitis. Um So something. So an inflammation of the pancreas most likely in this case related to alcohol use. So, pancreatitis most commonly is caused by gallstones or alcohol. Um And in this case, it's very, very clear that it's most likely to become. So it's most likely to be alcohol. So this is a case of alcoholic, acute pancreatitis. Um So the next thing that we would do is we would do a so perform blood tests including amylase and lipase. So a couple of you put BC and D um but the main thing that we need to do is we need to perform this test to actually confirm that it is that it is um pancreatitis. So we need to actually diagnose that condition in the first place. So, amylase and lipase both are very, very important. They're both made by the liver, they're both secreted by the liver. And so if we measure those enzymes and if they're so typically more than three times the upper limits of normal, then we can, we can basically definitively conclude that this is a, in fact, a pancreatitis attack. Um a couple of you put Glasgow Emory score. Perfect. So that's the, that's the method of er measuring the severity of pancreatitis. But in order to do that, we need to perform the blood test first. So the blood tests will include some parameters that are useful for the Glasgow score such as LDH Albumin urea um and things like that. So, we need to perform those bloods. First, ultrasound might come a little bit later on if we're concerned that this is due to gallstones. But in the case of pancreatitis, we're not typically going to not going to do an ultrasound from the offset because it'll just show us that it's just the pancreas that is inflamed and nothing else. So, we're not too concerned about doing an ultrasound, um, and act for the same reason unless we're suspecting pancreatic necrosis. W in which case, we would do act abdomen and pelvis with contrast. But for anything else, we can diagnose it clinically and off bloods. Um so well done to those of you that got it. So it was a tough question. So any questions at all? Um apologies, I may run a little bit over time, so feel free to leave whenever you, whenever you want. Um I'll try and whiz through these final questions. Um If you've got no questions, I guess we can, we can start. So these are pretty hard, but we'll give them a go. So a 23 year old man presents to Ed after drinking heavily the night before. So he's vomited multiple times and has reported that he saw fresh blood the last time he vomited, he has severe chest pain. Um and he's also got crackling, feeling on palpation of his er chest. These are his obs. So, what diagnostic investigation should you do? Yes. So we'll try and Whizz through these if we can. So I don't want to push you. But what's your instinct? Great. So thank, thank you for um voting so quickly. Um I'll give it a couple more seconds and we'll talk about it. All right, perfect. So a lot of people have put b um and we'll talk about w the answer. So what is the diagnosis in this case, do you know? So what are we thinking? What are some differentials? So tough for anybody have any guesses, esophageal vi viruses? Mallory wise. Too much coughing. Yeah. Mallory wise. Ok. Anything else? Mallery wise. Very, very reasonable. Good. So perfect. So Bohar, so a couple of you have said Boar's disease or Boh syndrome. Yes. Spot on. So this is Bohar and the reason we know it's Bohar. So mallory wise. So, Mallory Weiss similar stem. So you would get fresh blood typically after heavily drinking just because you're retching. So you'd hear um, the inner lining of the esophagus and that starts to bleed. So you get fresh blood, but there's additional things on this examination. So he's got severe chest pain, which you can get a mallory wise, but it's typically retrosternal because the esophagus is retrosternal. But we've also got this crackling feeling on palpation. So a couple of you might know, so this will be crepitus and do you know what this crepitus is due to? So what's the sort of word for or term for it? So this is quite um tough. So, don't worry if you don't know. Perfect. Yes. Spot on, spot on. Really good. So this is surgical emphysema or subcutaneous emphysema. So we've torn the esophagus basically. So bh syndrome is a tear in the esophagus. So we've tore the esophagus and we've got air that's escaping from the esophagus into the thorax. And so this will mean that whenever we palpate the chest, we're feeling this sort of bubble wrap texture. Um when you palpate the chest and it is very classical bubble wrap. So if you ever get the chance to feel it on placement, um do you won't forget it? So this is air underneath the subcutaneous tissues and air, sometimes you can see it on X ray as striations of the pectoral muscle. So you wouldn't normally see that on an X ray, but it's where it's air where it's not meant to be. So the reason you don't do an O GD in this case is if, is because if you've torn the esophagus, then there's a theoretical risk that you'll actually push the scope through the tear. And if you push it through the tear, you can obviously interact with the lungs, you can interact with the heart and then it is devastating. So you would avoid an O GD in all circumstances. So that's a contraindication. In this case, we wouldn't do that. So what we would do in this case is we would do act contrast swallow, they would have some sort of contrast to swallow. It's fine if it leaks because then we can tell where that leak is going. And if it leaks into the thorax, we know that they've torn their esophagus basically. So we need to be able to make that diagnosis. So if we see a chest X ray here, um a couple of things that you couldn't, can see. Um So, II know you can't see my cursor but around the heart, sometimes there's a sort of second border and that's termed pneumo media sinum. So that's air basically within the pericardium and the mediastinal sac and the heart. So, and, and, and air shouldn't normally be there and you'll get subcutaneous emphysema as we talked about. So, air sort of showing its striations in the peck muscles and sometimes you might get air underneath the diaphragm as well, depending on the level of the location of the tear. Um So surgical management is typically standard, we obviously need to repair that tear as quickly as possible, but sometimes things like IV antibiotics and that and um fluids can be, can be, er, an alternative if it's a very, very small tear, but it is something that carries a very high mortality and morbidity rate. Um So good. So very, very tough question. Uh well done to those of you that got it and hopefully it makes a bit more sense to um those of you that picked another option or an O GD, for example, really good. So tough question. Um We've got a 56 year old man has undergone a potentially curative esophagectomy for carcinoma. So, what's the best long term feeding option for this patient? So, give it a few more seconds. All right, perfect. So most people have gone for D. Um So the right answer in this case is B and I'll explain why. So A and D we can basically rule out straight away. Um So this patient has had an esophagectomy and for a nasogastric tube and a peg tube, what we do is we basically insert it. So a peg tube is endoscopically inserted. So we actually put a camera down the throat into the stomach and then we put the tube in through the tummy. So it's just giving us an idea of if we're in the right location or not, but if we don't have an esophagus, then that's impossible. So we can't do D and we can't put a nasal gastric tube in because they've had an esophagectomy. So saying, so an esophagectomy is basically, so ectomy means the removal of something. So in this case, it's the removal of the esophagus most likely secondary to a cancer of, of some sort. So it's removal of the esophagus, whether that's partial or whole. Um It doesn't matter too much. Um But yes, this is removal of the esophagus surgically, hopefully, that makes sense. Um So a feeding ginos toomy in this case is best because we don't have to do it endoscopically. So we don't have to put a camera down and we can feed them through their abdomen. So typically, this is done at the time of the operation. So at the time that they remove the esophagus, they put this ginos toomy tube in at the same time. Um And so that's the best way of basically bypassing the stomach, but also feeding directly into the intestines. And that's the best way of absorbing um, vitamins and minerals from, from whatever you're feeding them TPM typically isn't used long term. So it's something that's used as an interim measure. Um And so that's not a great long term option in this case. Um But hopefully that makes sense. Yes, absolutely. Sorry. I know I'm running over a little bit but feel free if you need to be off. Um I should be done very, very, very soon. So I think we've got a couple more and then we're basically done. So, number three. So we've got a 55 year old man with type two diabetes is scheduled for elective surgery. So he's on SITagliptin. The surgery is planned for the next day. So what should you do with the regards to his SITagliptin? Ok. So again, a question that's caused a little bit of divide. Um But most of you have put the correct answer. Um which is a, so it's continuous aglypt as normal Um, so, absolutely. So in this case, we continue this as normal. So this can be taken during the procedure and there's not that many risks. So some of you might be, you're thinking of Metformin, which has its own rules in, in, in, in surgery and it's quite complex. So we won't cover it. Um, but the main reason we, we, we won't talk about it is there's rules with how long the operation is, how many meals you miss and then therefore whether to withhold the Metformin and, and, and so on and so forth. But in this case, with SITagliptin, we continue it as normal. Um And diabetic control is very important perioperatively. So high glucose levels can actually have a very bad outcome on surgery. So it can increase the risk of wound, breakdown, wound dehiscence, which is basically tearing a part of the wound. It can have an effect on morbidity after the operation and mortality rates after the operation. So it's really, really important that it's controlled well. So diabetic optimization is very, very important before surgery. Um So good, so well done to those of you that got it. So this is just continue as normal and, and this is the nice guidance as well. Um Alicia. So, so the reason it isn't peg is because of the camera needing to go down the esophagus, but patient has had it removed. Absolutely yes, perfect. So, same reason for the nasogastric tube, we can't actually do anything endoscopically because there's no esophagus. Um And obviously, if they've had an eso esophagectomy, the stomach is likely to be anastomosed to either the proximal throat or the distal throat or the, or a very proximal portion of the esophagus. So there is AAA suture line and there's a risk that if you poke an endoscope through that it might tear apart the suture line. So anything to do with the esophagus and, and, and poking a camera through there is not going to be an option. So it's contraindicated. Perfect. Uh So I think it's two more questions or three more questions. So, Miss Johnson, a 65 year old woman is scheduled to undergo surgery for a hip replacement. She has a metallic heart valve. So one should she discontinue unfractionated heparin? So this is just a, a factual recall question. Uh So what do you think? OK. OK. So again, caused a bit of a divide. Um So I can see most people have put b so in this case, so unfractionated Heparin. Um So not something that you'll typically see people on. Um but does anybody know what it can be reversed by? So what's the reversal agent for unfractionated heparin? So if somebody needs emergency theater, they've taken an unfractionated heparin dose quite recently. Um What can we give to reverse the effects of that? So, not vit K. So Vit K is typically warfarin. So protamine. Exactly. So protamine sulfates are well done. So in this case, so the answer is, is a, is a bit different to what a lot of you guys are thinking. So the the answer in this case is six hours. Um So we this is 11 of the things that you will unfortunately have to rope plan. So typically unfractionated heparin is, is removed or is, is cleared from the circulation within two hours. So six hours is a generally safe time to be able to say that this patient is clear from heparin and and clear from anything that might make them bleed intraoperatively. Obviously, we talked about in the case that they've taken a recent dose, we can give protamine, but protamine comes with its own risks of anaphylaxis. And in some cases, it's actually um Proco uh anticoagulant, it has its own anticoagulant effects. Um So if there's not that much unfractionated heparin to go around. So if we actually give it maybe later, then maybe in four hours or so, it has its own anticoagulant effect. So it's really important to be aware of the timing of when patients get doses. Um So, yes, perfect. So there's a, there's a really nice guideline online um that tells you all of the um anticoagulant guidelines perioperatively and preoperatively. So it, it, it would be good to have a look at that. So it tells you things like warfarin and goa and aspirin and stuff. Um but well done to those of you that got six hours. So I think penultimate um so during a dental procedure, a 50 year old patient begins to exhibit symptoms of low class anesthesia toxicity. So he's agitated, confused and tremorous. His heart rate and BP is elevated and he complains of numbness around the mouth and tongue. So, what would you do next? Yeah, good. So this is a question that's basically asking you about reversal agents. Um So reversal agents is something that you need to be quite on the ball with. They're very, very easy marks to pick up. So s things like opioid toxicity give naloxone beta blocker overdose. You can give glucagon, um benzodiazepine overdose, you can give flumazenil blah, blah, blah, blah blah, there's so many um different reversal agents. But in this case, if we've got lo local anesthesia toxicity, we give b so IV lipid emulsion therapy. Um So you would some of you would be right, you say you would discontinue procedure and provide supplemental oxygen, but that's not going to be the most appropriate next step. So we know that this patient has local anesthesia toxicity. So it's best if we actually reverse that because then we know we're treating the condition that is causing all of these symptoms. So at the minute, um there's nothing in the in the stem to suggest that he needs additional oxygen. So he's got a high heart rate, he's got a high BP. Um but we know that giving oxygen to patients that don't need, it is actually more harmful than it is good. So it can produce free radicals and things that can be very, very damaging to the brain. So we don't give oxygen. In this case, there's no indication to do so. But we would treat that low anesthesia toxicity and it is with IV lipid emulsion therapy. So it's sometimes called intralipid intralipid 20%. Um and it's something that you need to be um very on the ball with, with, with regards to cardiovascular stability, so it can cause some cardiovascular effects. Um but well done to those of you that got it. That's really, really good. So Mr Davis, a 35 year old man presents the ed with severe abdominal pain, localized to the right lower quadrant. He has nausea, vomiting and fever. So there's rebound tenderness and guarding in the right iliac fossa. So, imaging studies reveal signs consistent with a ruptured appendicitis. So, what's the most appropriate next step? So the previous question we can, we can, we can go back to if you'd like uh a bit later on. So, spot on. So most people have got it, which is b so emergency surgical exploration and appendicectomy. So this is a burst appendix. So there's no point going ahead with conservative management, we're going to go ahead, open the abdomen and take the appendix out. So we know that it's ruptured. We know there's going to be peritonitis. We're going to have to treat them with antibiotics anyway. And this will typically be given in theater or in the anesthetic room just before they're about to go for theater. So, you're right. So we do, um, we do do immediate administration of broad spectrum antibiotics, but that's typically whilst they're already in theater. Um, so it's not something that we would wait about in Ed and, and give it. So we would just take them to the theater and they would need their appendix out straight away. So this is a, a surgical emergency. So they're perit, they're most likely going to be peritonitic. So they've got rebound tenderness, um, may have a very, very tense abdomen, they're most likely to be guarding. Um, so, yes, absolutely. You're completely right. In this case, a couple of you have put c so admit to hospital for observation and IV fluid resuscitation, which is a thing to do in the meantime, if you haven't suspected that it's burst. So it, there's no definitive answer that it's burst. This would probably be reasonable. Um, but they're likely not going to improve from that. So they're likely to be very, very septic. Um, and then ultimately we'll need to go to the theater anyway. Um, so good, well done. So I think that was the last question. So if we wouldn't mind, er, we'll go back to just quickly going back to the previous one. so this, so the answer to this one is IV lipid emulsion therapy. Sometimes you might see it in past med or ques meed as intralipid 20% or lipid emulsion. Um But they're all the same thing. So this is an antidote for local anesthetic tox toxicity. And it's really important to, to try and um maybe make a list of all of the things that you can overdose on and all of their antidotes. So it's a nice easy question to be able to pick marks upon in finals but well done. Um So I know I've waffled on for quite a bit. Um Hopefully that was useful. We've gone through quite a lot of questions. Some were very, very difficult. Um So you've done very, very well. Um Any questions you, obviously you can pop it in the chat. Hopefully, it provided you with you with some knowledge. Um And yes, I would very, very much appreciate if you could fill out the feedback form as well. That would really do a, a whole lot of good for me. Um And obviously I'll make improvements for next time as well. Um But any questions in the meantime, pop it in the chat, but otherwise if you could fill in the feedback form, then I assume you'd be free to go, I think, unless these guys want to say anything. Yeah, just thank you so much. Thank you for running really good and yeah, just if everyone can fill out the feedback form and then once it's filled out, we can send along the slides and the certificate and then just a note about the next session we have next week, which is covering and sp sessions and the QR code is just on the slide. But yeah, thank you so much again. Thank you for leading the session and yeah, let us know if you guys have any questions in the chat. Yeah, absolutely. No worries. Oh, I think you're speaking Bryant but I can't hear you. It's not working. Yeah, we'll just hang around for a couple more minutes to let everyone the, the feedback form and things. But yeah, I think Brian was just trying to say you can keep up to on our social media. We have it on Instagram and Facebook, et cetera. Ok? He said.