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At the end of the session is quite interactive. So um we're gonna have people heckling out from the common bar. So please try and comment as much as you can and we'll make it as interactive as possible in a hybrid session. So this is your case today. You got Sally, a 40 year old female presented to Amy. She is clinically well, but presents to her with a letter to the triage nurse, letters from the GP and says she has very deranged LFT S. Please review and this can happen where the GP hasn't been able to get through to you. You're the general surgeon or the med reg on call. He just was all materializing with no history, no background, nothing but just some blood tests. Um My main thing with this is to start from fresh. So I don't want to leap in and everyone start asking about why do you have this blood test? What do you do actually get to know the patient as if you are the GP seeing her than the first time. This is the best way to treat these kind of histories. So when you speak to Sally, you actually realize the reason she saw her GP are the common symptoms of just chronic abdominal pain that she's feeling tired all the time. Um, very common with young women. They just kind of we plod along. Just accepting this is a symptom. She thought it was generalized bloating related to her hormones and her periods. And so has left it for quite a while. She's looking at having it for around 10 months or nearly a year. Just a dull ache, that kind of all over. It doesn't really bother her. She's just carrying on with life thought it was a normal thing, but she's just gone to the GP cos she's feeling really tired. I'm probing. She said, yeah, I've noticed my eyes are a bit itchy and swollen and my skin is itchy, but you're gonna move on and do a whole systems review cos as I say, you're meeting this woman for the first time. So always make sure you're going top to toe, especially in someone where they've mentioned your kind of introductory symptoms. LFT S are deranged. She should be looking at all your gi history, which you've mentioned the first section. So I want you to look at urine constipation, diarrhea, but really asking those probing questions. And she has said, well, I have noticed they're a bit pale and floaty as were all histories. I want you to watch your B symptoms. So these are unintentional weight loss, night sweats, these kind of things and with the night sweats, you can think of any infective kind of causes. So, fevers always come into that cos common things are common. So I'm hoping you can all start thinking about in your history. What are the key things to pick out here? So, obviously, we've done our um Socrates, we've really localized in, it's a right upper quadrant of pain, a long term chronic pain that's dull. She hasn't come in with anything new. She's been told to come in. So we don't have to hammer into the acute episode and we've looked at the generalized symptoms. But the main thing sticking out here is a pale and floaty stool with itchy skin are the main things to look at here. So we're signposting. I hope we're all getting used to this. So we're looking at what is her past medical history. She's got a low thyroid and rheumatoid arthritis. She's only 40. So, you know, there's quite a few conditions to have at this age things I've thrown in here just to keep you thinking, make you keep thinking in your drug history. Yes, these are the over the counter ones as well, but also any illicit substances. Now, cannabis oil, oil is obviously over the counter, but always probing in what is different because people can use herbal remedies. I have met a lady in A&E who was taking um, Thistle as a supplement and she ended up having significantly deranged LFT s because of it. So never think that at the end of the day, yes, it may be herbal, but it could still be toxic to the person. And so set off their liver, their kidneys allergies again. She's got none. She's got a family history of another autoimmune. She's got rheumatoid. She's got low thyroid. We're getting kind of a picture here that she is someone who is prone to these kinds of conditions. She drinks wine, 1 to 2 bottles where if you're looking at about, I don't know how many in a bottle of wine, let's say she's probably slightly exceeding or meeting. What is the recommended weekly allowance for alcohol? So nothing too significant. She's never smoked fish and active. Um So yeah, so these are the kind of things we're picking up in the history. We then move on as with any history. I hope you've got some differentials in your face. Uh in your minds, we're looking on to these kind of examination findings. Now, um our patient Sally has the left hand, the top picture and she has the beginning of the bottom, right? She doesn't have the picture in the middle that I'm sure you will know dip trends. But in the comments, I hope if some of you can start thinking about what these other three pictures are trying to depict. So if you can recognize these clinical signs, ok. So the easy one in the bottom right hand side is jaundice is sclero Tila ictus, sorry. My lateral Greek, whichever it is isn't very good. We're then looking, these are cholesterol deposits around the eyes and on the legs. So these are your example Asta. So looking at cholesterol deposits. So we're all kind of thinking where we're heading with this examination finding, we then move on to this. So this is how I would detect something where I'm a palpate in the abdomen where she's got both plateau and splenomegaly. So this is how I draw it. If I was doing paper larking, the key thing which I think I mentioned in the first session is how you palpate the liver and spleen. And what people don't do is fully cut in. So your hand should be going like this and really going down sharp to have the organ hitting the edge. Otherwise you're just not gonna, if you're coming in at a 45 degree angle, you're never gonna feel the edge. You want to kind of sweep under the tissue and then it's making sure you're doing it to the right time as they breathe in diaphragm flattens and you'll get the hitting. So that is the main thing. It's also in your gi um examinations in your abdo exams to make sure you don't forget this, which is the hepatic flap. You can also have it in kidney disease with uremia. But it's the main thing. It's quite a flapping of the hands and it's make sure they have their elbows outstretched when you examine this. So you've got a history and an examination in this case. So your differentials should be quite clear. I'll give you a couple of minutes online just to think about what differentials should be going on in your mind. Just to confirm she does have the flap, she does have the flap. You can, I can feel the liver and the spleen. So um no need to comment online. We're gonna break down what are differentials. So I'm gonna focus on the symptoms. The main things that I picked out in this history and examination. She's got itching and she's tired. So we're thinking, ok, why is the itching is the build up of bilirubin in the blood levels leading to that itching of the skin and fatigue is very indicative you can have tired of all the time for many reasons. But autoimmune, she's got rheumatoid arthritis, history of Sjogren's. She's just at these risk factors for something else going on. We've got these yellow changes th pigmentation again, she's jaundiced. We know we're going to be focusing in on the pathology of the liver. She's got both spleen enlargement and liver. So we know this is quite a progressed cirrhosis because we're having that multi ordinary failure. The other one you could look at is you want to look at a cardiac history as well. Um Just to see if there's anything else going on any other forms of failure. And then we've got the showing of the cholesterol deposits where I showed you the xanthelasma around her eyes on her legs. And then we're also looking that she had the pale floaty stool. So then we could also think of obstructive causes anything cool in that cholestasis, that lack of flow in the biliary tree. You're not moving these products bright. So these are the differentials all helping me build my head. So, autoimmune problem within the liver, we're looking at a woman as well. So we're looking at PBC, your primary biliary cirrhosis. If you have that, you can then also move on to your PSC, which is a sclerosing. Cholangitis. Common is common. Most common causes of cirrhosis. You can look at an alcoholic and fatty associated. You can probe into her diet. She probably doesn't have any signs of N AFL D but she says two bottles of wine a week. Is she fibbing? Could it be an alcoholic cause any other cause? You've got pale floaty stool, a chronic dull pain. If it was going more to her back, I'd be worried about pancreatic cancer. So make sure you're getting act or an ultrasound to look at the biliary tree. And then again, we look common is common. It could just be an obstructive stone. So they're the main differentials I would have in my mind. So with this in mind, you want some tests. So the first thing you're gonna do is some blood tests and we've already said the GP has printed off the LFT S. These are the, what they show. So I've given you some reference ranges so you can break these down. So Bilirubin is 78 we know she's jaundice. There is argument to say uh what level of bilirubin is when jaundice becomes um clinically deceptible. They say around 7080. Some people say lower, but that is usually where you start to get the sign of jaundice. Her inr is high and her cholesterol is high and we're looking at the T and the AP are significantly significantly raised. So what do these all mean? So these are enzymes associated with the liver, your ALP and your GGT, if it was somewhere else, it may be about stagnation in the tract. So you're looking at your PSA then, but because her GGT is high that it's specific for in the liver as it helps you suggest it's an intra liver cause there are about five main functions of the liver and this can help you break down is what's gonna go wrong in these patients. So, um I don't know if anyone's mentioned this before. So I'll give you all a second just to think about it before I tell you a spoiler. But these bloods help suggest what the five main roles in my head are for the liver. Mhm Exactly that. So picking more at the coagulation, what does your liver produce it produces your clotting factors. It's a synthetic organ, it produces things, it also helps break down things. You've got to think. In this case, you may look at albumin, it helps break down those metabolism, that products of the body, it also stores things, it stores your sugars. So it's important in your diabetic management. So you want to make sure you're getting a blood sugar on this patient. Obviously, the easy one that we will think of and why we think of alcohol, it helps filter out your toxins. And it then also finally has an immunological support in the body. So they're the five things, storage toxins, metabolism, synthesis and immunology. They're the main five functions in my head of the liver. There's lots of things it does, but they are the ways I break it down in my head. So advocacy, as I said, I nr is very deranged. So we want to be doing a full clotting screen and looking at what we can do to help sports patient if they are at risk of bleeding. The next thing you do as I've floated and already mentioned to you in the past is that I'm worried about this patient having an autoimmune thing. Best thing to pick out anything to do with autoimmune disease. You're looking at antibodies, what do they have that's raised? So we obviously this her sister has tro so these are the antibodies. I'll take a picture of this because these are the common ones for CQ that they do ask and the associated disease. But the main one we're looking for, my main difference that I mentioned is PBC, where it's your anti mitochondrial antibodies, which is actually present in 95% of cases. So that is the main diagnostic test. I'd be going for this patient. Yes. But as I have mentioned already, this is something wrong with inside the liver. So the only way if you want to purely diagnose, even though it's a very sensitive test, the antimitochondrial is to take a biopsy which would show some noncaseating granulomatous inflammation, which would be very supportive of a PBC, which is what this is. And this is just another table. You may want to take a picture for your notes that help me break down what are the differences between your PBC and your PSE management of this? So at first it's supportive. The main thing I wanna have at home is this patient is very sick. She's left this for 10 months and jaundice, it is a late sign of this disease. And so we're looking at going more to the bottom of this table in our management, but we start off with managing the symptoms. So you're itching, you want to give those medications to the top. She's at risk of osteoporosis and Adex of her fat soluble vitamins. So you're thinking about supporting those as well because of her cholesterol levels being affected. And then you've got your su oxic acid, which can help decrease those high end range LFT S. But it's not gonna affect her. In this case, this is the Mercedes Benz scar at the top, right, which is indicative of those who had a liver transplant, it can come back because it's autoimmune. We're never gonna cure it. You can try and suppress it as you do with all transplants, but no treatment is perfect. But in this case with, and the fact she's developed jaundice, she's very far down the line in her disease pathway. And so this would be the definitive management for this patient. So that's the case. That's the first one. Just a bit more of a medical kind of side of gastro of these patients. What are the things to look for? Always think in these young patients who've got a history of autoimmune. What are the b best tests and what can I actually do for them? The short term, don't just focus on the blood test, see the bigger picture. They're the main takeaways here. So, onto the MC Qs now, I actually did a uh actual quiz for this one. So you can fill it all in private yourselves. Um I haven't got access to, to this anymore, so I won't see your schools, but I'll give you a few minutes just to sit through the questions, see how you do. Um And then I'll go through and explain them all in a few minutes, but take your time. No rush. I'll just give you a good time. If it doesn't come up, we will just go through the questions. No working. I might put the up, ok. They have trying to put the C in the, I put the link in the chat. I did this quite a while ago. This is when I made it originally, so I've lost access but it should work. I checked it the other day. Sure. Four days, Sweden. I, I've got someone from the North De District Hospital. One mark a in. That's fine. Ok. I think that's enough time to go through the questions. So, as you may see if you did, I'm sure you all got them. All right. But if there were any, you got wrong, there are some explanations there, but we're just going to extract it a bit further. This is the first question. You've got a 30 year old IBD U with a history of TB who develops watery diarrhea. Now, the key things to pick out on this one because obviously we're writing exam times to pick out the key things in here. Intravenous drug user with a history of TB. The main thing that should be one in the back of your head. This is some with HIV, maybe even with an AIDS, defining illness because it's not normal at first to be picking up TB. So I'd be concerned that they have got opportunistic bacteria and these infections are atypical for the new normal population group. So that helps in broad things out watery diarrhea. He's losing a lot of fluid with no abdominal pain. So it's not gonna be IBS. Uh, we've got no history of any medications. And also if he's an opioid addict with IBD U that usually causes constipation and if it was overflow, then it wouldn't be watery, you'd be having just that typical diarrhea. So we move on to our infections. Well, e coli and salmonella are very common. So that leaves you with sea, which is your breakdown. And that is why it is this infection cos it's an opportunistic, it's a rare one and you'll see all the sports. So just for your notes, this is something that just to help break down the kind of presentations you get with your acute diarrheas based on the pathogens, the kind of things they get. Question two. So in this case, got a 45 year old male with a history of alcohol excess with too much history. Uh when he's pale as well was the other thing to pick out here, intermittent severe abdominal pain, diarrhea, which is p pale as well and foul smelling and hot flashes. So we've got someone who isn't digesting properly. They've got that stare to hear. And so we're looking at someone who's got some form of malfunction in the biliary absorption of the body. Now, the fact he's pale makes you think OK. This is not a jaundiced individual. This isn't someone who is cirrhotic. And so it would help exclude A&E then we could just look at malabsorption. But um, we're looking at well here that he's got severe abdominal pain so it could help with this one. But the main thing here is looking at alcohol excess and we've got this history of severe abdominal pain with three months. We're not acute, we're chronic. And so that leaves us with d chronic pancreatitis. That was the answer for that one question three. So we've got a 59 year old gentleman who's been diagnosed with peptic disease. He's positive for H pylori. This is one, unfortunately, it's not one to break down. It's just very simple one to remember the answer is e so the main way to remember is pak 500. So it helps with your doses. So your pack is your ppi amoxicillin and Clarithromycin. However, you can also have is your PPI metroNIDAZOLE and Clarithromycin. And that is why D is wrong. But yeah, two prescriptions just to learn very common. Obviously, no os is the safe thing to say as I would refer to my trust guidelines, but this is one that's been floating around for a while as the mainstay of treatment on to question four. So you've got someone with arthritis. He's on Celecoxib long term, he's got brown lumpy vomit. So it's an NSAID Celecoxib. But those of you who did not know. Um, so what are you gonna be at risk of here where you've got your peptic disease and your inflammation? Yes. It could be esophagitis and gout if it was just pain. But we're looking at here, brown lumpy vomit. We're getting digestion of the bleed. And so we're looking at duodenal ulcers, the lights will stay if I'm lucky if anyone's heard of a curling ulcer before. I don't know if you have, this is a kind of peptic ulcer that occurs following burns injuries. Um, and esophageal cancer, it wouldn't be associated with a drug history. You'd again have someone who is unintentionally losing weight, he's probably had, if it's a lower third or your adenocarcinoma, you'd have a history of your Barrett's and if it was an upper third esophageal cancer, they'd have a significant history of smoking. But as those are missing in the history, we've got some brown up and vomit digesting blood. This is what it's a question five. We've got someone with smelly breath, halitosis and difficulty swallowing and a lump on the side of his neck. So, breaking these things down again, if you haven't heard a plumber, Vinson, this is the Web syndrome where you're going to have your adhesions called strictures in the esophagus, which is why you would have your difficulty swallowing. You wouldn't specifically have a lump in the side of the neck. Killian's dehiscence is otherwise known as your pharyngeal pouch nut. Crocker esophagus is a motility disorder of the esophagus where you get the spasms along the esophagus, you would have the difficulty swallowing. But again, lump wouldn't be recognized. A rolling hiatus. Hernia is one coming through at the diaphragm. So again, you can have dysphasia, you can have difficulty swallowing. You wouldn't have a smelly breath in the lump and a lipo. Yes, we've finally got a lump. This is a soft lump. Would it be likely to cause obstruction of the esophagus and smelly breath? It's very unlikely as a subcutaneous soft benign lump. And so that leaves us with b your pharyngeal pouch, which is where you're getting your breakdown in your constriction, muscles of the pharynx. And that is why you're getting these symptoms and the lump. Ok. And final question, we've got someone with ascites. He's got all the signs of, to be honest, clubbing, chronic liver failure. And the key thing here is he's got a sag of greater than 1.1. The answer should have all been quite easy is d because any time the s is greater than 1.1 it is a hepatic cause whenever it's less than 1.1 it's other. So that's when you're looking at your metastatic and your infective causes. So that is the main thing here and they are the MC QS C. We're on to our scenario. Now, this is going to be quite hard because if this one's quite an interactive one, usually I bring props but we're trying online cos I didn't wanna move the schedule. So this is your case today. The more comments on the chat, the better. I know there's a bit of an internet delay but try as hard as you can. So your case online you've got Ashley who's an alcoholic and intravenous drug user who was admitted to the Gastro ward by, as a general medical patient because she was brought in by ambulance for an overdose. The nurses have just pulled the emergency buzzer and you were the only f one on ward. You come around the corner and you see this, what do you do? And the answer is not panic. The answer is we're going to start assessing this patient as per A to E. Now if you've ever seen the vomit bowl, so imagine the toilet bowl. Obviously, this is a pitch from the internet, but a vomit bowl has inside it, the actual volume of blood, she's filled that volume of bulb. So you were looking at she's already lost 500 mils like that of blood. So what I'd put out straight away is a major hemorrhage protocol. You are on f one likely on the ward. So the first thing you need is help because you do not have enough hands to help. Look after this patient and when they start bleeding, she's got a lot going on. It can go wrong quickly. I can't see this one. Have you changed a couple slides. Nope, just tap, see if I can go back to it wouldn't be a session without technical difficulties. Yeah. Or we have the technical difficulties. Start thinking ahead of how you would manage an upper gi bleed, quickly. Stop sharing the screen and Licia. Bye. Yeah, let's get that sharing. Lovely. So, back on this is what you see if you couldn't see it online before she's filled up a vomit bowl of blood. We're at 500 mils, the buzz has already been pulled but making sure you're getting one of your nurses. So the first thing you say while you're supporting this patient, you as the doctor, you should say to whoever is spare, not the most senior nurse cos you're going to need help is that you can say I need you to call up, I put a peri arrest, call out. You can get the medical team here and say with a patient who has just vomited 500 mils of blood. And like I said, and then you, this next thing you do is also you can ask them if you're going to lose a large amount of blood, it's early. So then what I need to do to put out that major hemorrhage protocol. So before we get onto that, we should break down our A to E so as always, we're going to introduce ourselves to the patient and we'll say Ashley, hi, I'm Charlotte. I'm one of the surgeons um Can you, are you right? And you just try and engage with her? Are you all right? She'll kind of nod at you. She's kind of got blood drawing out of her mouth, but she's kind of say. Yeah. Yeah. Yeah. So we know the airway is patent. This is someone who is acutely unwell. So it should be rolling off the tongue now that I want to be able to play, fitting a non rebreather mask with 50 L of oxygen to this patient and getting saturations. Um She's so distressed. The sats probably just falling off. You, you're not getting any sats at all. What this sign shows on the left or the right, even for your screens is when you're trying to listen to her chest breathing, her respirate is very high. It's 35 which is the nurse is calculating a full set of s as you're asking as you go along, you're gonna consider you wanting a gas cos someone who's acutely unwell. But again, she's very distressed. She's feeling sick. She's leaning over. You're not able to get to her wrist at the moment. We want to consider a chest X ray cos we've already given oxygen. We can say this and we could think of any intrathoracic causes. You wanna listen to the chest, her Shakira is central, which is all you can feel and you know, trying to listen, but you, you can't hit anything. You don't know if that's because of the distress of the team or anything else. Your breathing. All you really know is that you've put her on oxygen where she's got blood all in the mask and she's not trying to pull it off. She's getting agitated and you've got a respirator for 35. So there's not much you can do at this stage. There's not much you can do. The main thing we want to get onto here. We've got blood is circulation. So you're trying to do a peripheral capillary, refill, slow, it's delayed. You don't know what you're doing. You're getting your heart rate. It's coming back about 100 and 20 100 and 25 moving up the arm as we have been doing, we want to get large four access. I've been hammering this into you, but these are our veins. This is our arms. What was the key thing in the history? Ashley is an intravenous drug user. She has used all her veins for herself. She's also acutely unwell. She's peripherally shutting down. So you'll be trying to get access. I would be surprised if you can get it. So we're not getting any bloods and we're trying to get a BP cuff on her and the readings coming back as 90/60 you're going in the back of your head. I've seen blood. I've got a hypotensive tachycardic patient. What do I need? I need to give her some blood or at least some fluids to try and improve her. You've got nothing. So, the main thing I want you to think about online if we could have someone come, what are you gonna do? You can't get any access in. You've got a very trained, you've been to all the courses, you know what to do. But what do you need to do? You cannot get cannula in, please come in in the section if anyone knows. Yeah, access is what exactly that IO lines now, these are great. I've only used one once and they're very easy to use. I don't know if anyone of you are aware online where you can usually secure this access so you can use the Tibial Crest. So you feel, you feel the tibial tuberosity and you go below, you go directly on and you drill straight into bone, you pull out, you can take blood, you can take gas which we've been trying to get for ages, but actually wouldn't let you and you can give fluids. The thing is, is it's very painful to give fluids to this. So as soon as you get access, try and get your normal cannulas in. Does anyone recognize what this kit is on the right? Mhm Nothing in the comments. OK. So this is a central line kit. So the last thing to collapse if you're struggling to get blood. So you're not worried about access. If it wasn't this patient, you could go for a fem stab, but you could use a femoral line. You can use the jugular vein or your subclavian to get central access anesthetics. Love doing this cos you also get monitoring through this. So you can also take your bloods. But this is another way if you're struggling with peripheral access, you can move to central access if you're, they're not sick enough to warrant an I AM. So if you've got the access, you've got put in either a central line, an IO or you've done a femtab just to get some arterial blood. What blood test would you like to request? So we've got someone with an upper gi bleed. The first thing I hope is rolling off the tongue is you want a full blood count. We wanna know how much she's lost. We wanna gas for a quick read. So you can see her electrolytes her lactate to help realize how unwell she is. Um And to look at her electrolytes cos you're about to get pumping fluids and you, I'm hoping you need blood products or what you need. Is it a group of save and a cross match for upper gi bleed? You should be cross matching around six units and remember to do a group of AV and cross match. You need two samples taken by two at two different times, at least 15 minutes apart, depending on the lab and they must be hand signed. So in an emergency, it's making sure you get those two groups saved done early, but group of safe take time. And the only thing this patient needs right now is blood. She's thrown up again. There's another 300 mils all splattered on the curtains. We need blood. We're also going to do cos we're worried about this patient, liver function tests and clotting again. The main thing I want you to say is your full blood count and your six units to be cross matched. But she's just throwing up again, we can't wait. What we need is this a major hemorrhage protocol? So this is again a very interesting thing. And I learned this on the job in my first um arrest call when I was dealing with in a maternal, it was a postpartum bleed. And what you need to do is called the porters and no one ever teaches you this. But this is the main thing is to put out the major hemorrhage call. What does it actually do? It calls two people. It calls the porters to go and get their thing of their products depending on the trust. It could be just packed red blood cells, your F FP pack one pack two. But it also lets you speak to the hematologist and they can help authorize and give you advice on what bloods you should be giving, which pack is the right one. So if you look at this one, you can have the first pack. It's got five units of red cells, five units of F FP, which you should be alternating. So we give you red pack cells and your F FP, you can squeeze this blood into her if she's strutting down and becoming hypotensive. Um And then it may also think in trauma, you can use a pool of platelets. Um The main thing with trauma that can help and I don't know if any of you have seen or you've been in placement is a TEG, which is a specific way of blood tests that you take, that helps project what clotting factors this patient has and helps you specifically titrate what bloods is very helpful in trauma. But in this case, we're just going to replace like for like we want bloods and we want volume and that is why you're going to alternate your FBC S and your FF PS with your clotting factors, which are all in your F FP. But yes, the main thing is calling them out directly. And again, this may be putting out the 222 twos. It's just checking with your trust. So we've put out the major hemorrhage protocol. We've got access, we've taken our bloods going to the lab at this point as we've got access. Is there anything beyond blood you'd like to give, given the history of actually being an IVD U alcoholic? Um I hope you can think online, I'll give you a second before I spoil it So it's about thinking of your call, what can help and it's these medications here. I don't know if there were comments online. So you've got your tele and your ciprofloxacin because we're thinking in this patient, she's got a variceal bleed. She hasn't had a history of peptic ulcer disease. There's no brown lump, you vomit. So in those kind of patients, you may be giving IV PPIs and keep them nil by mouth to help with that. But the main thing here is we want to try and stop this bleed as much as we can. So tele pre is a spin vasopressor and then you want to give your prophylactic antibiotics because we know that we're going to have some issues here with this patient being at risk and we may need surgery at this point. The other thing that everyone forgets in circulation beyond also, I want to hammer home every time you give something within the first time you give your fluid challenge, your first bag of blood. I want new BP. I want a new heart rate. Always recheck. Every intervention, always recheck before you progress. Is this a catheter? We have got someone who's fluid depleted. We're going to need continuous fluid assessment and catheterizing is the best way to do that. But we've done all of this. We're gonna move on to disability and exposure. So her BM is 14, which is high. Um which is very surprising for someone who if they are an alcoholic and have you, they're usually malnourished. She's not confused. She's got G CS 15 out of 15 and she's got a normal temperature. She's generally tender and she had, because we had a, a ultrasound walks with the gastro wall and I don't know if any of you have read an ultrasound before, but what we've got here is an enlarged liver. So we're thinking of someone who is in a form of liver failure. So this is our case, we're managing her, we're giving her blood. You go to discuss with your medical reg or the gastro reg cos what do we need? We need to get some specialist interventions. So the registrars asked you to call the boss and say what we need is we need to get them a scope to manage this and you're gonna hand over this patient. You've got someone who is hemodynamically unstable. These are the words I want you to be starting using into your SARS in the situation. The main thing to say is at the time the upper gi bleeds started the volume of blood you have lost, then you move on to your background. So you're going to say a bit about Ashley, what she came into hospital with what you did to manage her. So in this case, your assessment, what are her observations? Now, if you start lifting off all of her obs, you've got to bear in mind who's on the end of the phone, your boss will lose concentration. So, what I want you to use is your grades of shock. Now, I don't know if you've ever heard of your glasses of hemorrhagic shock? It's very easy to remember and a very easy one to help assess and it helps them understand how sick they are. So, in this case, the fact that she has dropped her BP, we know she's in class three or four. So we're actually looking at she's lost at least a liter and a half of blood. Now, I don't know if you remember the initial numbers I gave you, but her heart rate was 100 and 25 and her rest rate was 35 already. We know she's in class three. She's teaching on class four. We're getting worried about her. She's not confused at present. So she is still confusing her brain but she is anxious and confused, which means this is at risk. So these are the things we think about. So in my assessment, I would be saying about the fact that she is in a class. We shock and what we've done for her, the medications we've given that we've put out a major hemorrhage protocol. How many blood projects has she received so far? Any blood test the gas to let her know the lactate hp on that before we move on. And then in your recommendations, you say, I think this patient will benefit from endoscopic management of this variceal bleed, which is like this. So the main thing with variceal bleeds is you want two of certain ways to manage these bleeds. I've got some example there where you can ligate it or use sclerotherapy. You could, which is just some form of banding. The main thing is to b the viruses, you give adrenaline and you can directly use lasers, which is shown on the endoscopy, right is a bit of banding of the viruses to help tamper them and they'll just die away with the compression. If this is failing, then you move on to getting involved with general surgeons. And when we had it in my old trust in F two, if they were very sick, we used to say the general surgeon had to be in there. So the scope was done by the gastroenterologist in the theater. So if, if it went wrong, we could directly move to a procedure with the general surgeons. Um Well, if we're struggling to tampon on it, we can use this thing on the left. I don't know if any of you've seen this before again. My pronunciation is gonna be wrong. This is a S sts and Blakemore tube, which is basically a glorified catheter where you've got ballooning and you've got tampon of the viruses at the bottom and you're blocking the flow of blood into the stomach by putting that balloon in there. Thing on the right is a tips procedure which is a shunt between the portal, the systemic system. This could be done by interventional radiology. And is again, if the variceal bleeding is failing. But the whole thing is to pre prevent that backflow of blood into that system. So these are the main things of management for the system. The key takeaway message from this case, that is actually the end of the scenario is when you're looking at a catastrophic bleed is getting those volumes early making those right calls. You've got a buzzer already, but making sure the nurses have put out an emergency call to the medical team and understanding what it means to put out a major hemorrhage protocol. What your role is as a junior doctor and that is making the calls, getting the porters there speaking to him early and just getting blood in and thank you very much for coming. I'd really appreciate if you could all just do the feedback forms again. I know they're annoying, but I really appreciate it and it just helps me make these sessions better. Um, a couple of comments have been coming up recently about again. Me sharing the slides, unfortunately, um because I am just a doctor who's done this for lots of med schools. I don't know your exact syllabus. That's why I just kind of do this to help you think rather than being actual notes for your revision. But um I hope you're all enjoying it. We've only got a few sessions left. Um, so, yeah.