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Uh huh. Just gonna share my screen. Guys. Oh, Martha Project said let me scan just one sec. Can you ask me? Gain? No. Yeah. No, it's not. Let me. Why don't you just share the screen from your computer? Let me. Sorry, guys. One second. Try now. Yeah. Um, I like to welcome you all to a brand new weapon. A session that's been created Long side, back to the suture. Um, this weapon, our surgical course consists off, uh, full webinar sessions where we cover through urological emergencies to, you know, emergency and general search gram emergencies. Things that you would expect for Unefon an F two to come across during a time while you're in hospital. So this is a very quick and comprehensive guide, Teo, What you would be expecting to know during your F one F two years, uh, in the UK. Um, this This team consists of myself. Does she? We've got, uh, Martha. Hey, uh, I've also got another master on the other side on, so thank you for joining with us today on. I hope to prove this surgical webinar sessions will be very useful for you. And at the end of each weapon a session? Um, you'll be able to get certificates for attending the the these teaching sessions on Dove course like to say, a big thank you for metal for giving us the platform to create and give set figures for you. So just before we start the presentation, just want to. And I just wanted to let you know that we want to make this more interactive. Eso I'm We're trying. We're gonna try and ask you a lot of questions during the presentation. Some people are always, uh, you know, don't be side. Please do answer on and definitely make this lesson a bit more interactive. So without further ado, today's webinar session will be on urologic emergencies. So I've done urology as a job on It's a fantastic specialty. I would definitely encourage people to do it. Ah, it's very interesting. A lot of complex surgeries on just management off the disease itself is very interesting. Now there are multiple neurologic emergencies, and I think one thing during medical is that, you know, we just get slightly tour from the books kind of thing. But I think hopefully this session will give you a better understanding off the different types of urologic emergencies. So case one, we've we've got a 78 year old gentleman is presented emergency department where painless macroscopic you materia with some plots. So he's basically passing wine red blood by with the urine with clots it describes of no dysuria or urinary frequency. But he has noticed that he's lost around about 8 kg of weight over the last two months. And just for you to be aware he is a milk off 40 pack years now, the question of mosque is what's your approach on? What should friendship diagnosis for this patient? Well, I'll just start off with the differential diagnosis. Yeah, so one of them is yet bladder cancer is one of the differential diagnosis uti All right, so, um, I'll just kind of continue onward said the main approach when you see such patient is where for a patient is coming in to the emergency department with frank, you mature and clots. The first thing you need to do is first assess the patient clinically by the aid BCD approach. Starting off with a raise away, working your way down now, a couple of things that you need to look out for Is the patient hemodynamically stable? Is the patient hypertensive tachycardia on? But I think one thing you need to look at, how much blood is he losing? But, you know, with his urine, uh, in the case that he is stable, it's important to get a detailed history. Um, one of them, you know, ask him for how long this problem has been going on is a short is a long history, um, important to get a drug history. Why someone might be on a double pack. Such a Z Adoxa ban or picks band for PE's EFS are the only warfrin for F any sort of metallic heart valve. It's really important to find out if they're on any sort of anti coagulation. And it all second thing you need to think about is also making sure to ask a smoking history, Um, especially in ladder in blood T CC's transitional cell carcinoma you worry about, you know, it's very it's very much associated with smoking at important people who work in industries who work in pain industries and so on. There's a lot of industrial costs indigence associated with urological malignancies, specifically about a TCC again on blood. TCC is the most common bladder cancer that you would come across. Now it's important to examine, uh ah and exclude any sort of abdominal suprapubic masses in such places. Patients and also you do a digital rectal examination to assess the prostate. Anyone can give me an idea of what you would expect on a digital rectal examination. If you're querying a prostate malignancy of some sort, you can also don't want Iraq clear. You don't any fear. Uh, so yes. So you Yeah, so you're Technically, it's a large prostate. Doesn't necessarily. Yep. So you can get a nodule, a prostate, something. What they say you know will not texture off the prostate when it's quite firm. Yep. Well done. Um, so that's what you would be expecting in the case of someone who's got a, you know, a life of prostate malignancy, Of course, if it's enlarged, but it's smooth and you think of the behavior, Um, and in such patients, the most important thing to do is, of course, instead of three week after and start irrigation, uh, important to check the hemoglobin. Remember, if the hemoglobin is less than 80 and they're actively bleeding. Please do get a group and save and make sure to start transfusing the patient if they're very hypertensive. Important fluid resuscitation is very important, making sure they keep their me an arterial pressure up on. In any case, when you know, despite everything that you're doing with fluid resuscitation, that doesn't work and they're still dropping a BP, then I to you need to be called immediately along with the senior urologists. Um, now a couple of other tests that you would have to send off a year and dip on a urine M c and s because you guys can cause microscopic hematuria as well on important to send the urine off the samples because you might be able to see malignant cells. Like I said, group and save is very much important. Transfuse if it's necessary. Stop any Don't any sort of anti crime Lintz doac swore friends aspirin. The bedroom stopped your antibody therapies before stopping them. Just make sure to find out why they're on specific medications. In the case where there are, you know, you just have to kind of be aware of what what they are taking for and then for anyone who comes in with you. Material, uh, they would most definitely require an outpatient flexible cystoscopy on if they're bleeding. You know, if they're holding out quite a bit, then definitely inpatient ct urogram. Now the reason you could do an inpatient, flexible cystoscopy, you know, to try and figure out if we can see anything but most of the time if they're bleeding there and then it's very unlike that you be able to see anything anyway. Um, so whenever you have hematuria on, always, always, always important, you know, to rule out malignancy before anything else that's very important, especially in elderly people. Hematuria is always a malignancy until proven otherwise, especially in the patient we've got in this case, you know, an elderly gentleman, a history of unintentional weight loss. Painless. See materia. You know, this often suggests an underlying malignancy, most common being love, cause you think about bladder TCC transitional cell carcinoma. But don't forget, you can also get renal cell carcinoma is which can present with human sure as well, like have in have explained UTI can cause microscopic hematuria stones can cause he material important. A certain if they've had any sort of recent to ur BT's to appease studio beauties. Basic. Answer you through a resection of bladder tumors or onto up his transfer through a section of prostates. With these, after these operations, you're basically just, you know, kind of getting rid of whatever into Arby's. When they have large prostates, you're basically shaving off the prostate, which will cause bleeding. So you have to always think about these cases on with radiation cystitis you can get him a cheerio on Black of said. Stones can cause it, I think, when dividing in material was divided into macroscopic and gross on. These are some of the nice guidelines that GP is often follow, you know, in patients who are in an outpatient clinic, settings for patients who are over 45 with unexplained visible hematuria gross. Immature without UTI are persistent bacteria. You know they need to be referred to a humanitarian clinic where they will do an outpatient, flexible cystoscopy, where you kind of go in into my urethra into the bladder to look around to see if there's any sort of you know any sort of odd shape or mass or whatever is suggest malignancy of any sort on for those age of a 60 year with microscopic hematuria. Always refer them to a human. Sure, a clinic for the possibility off cancer. Now just some extra information. If a tumor is identified, I think, via a CT urogram or on after an outpatient flexible cystoscopy, you would end up doing a CT staging scan, which involves a CT, chest, abdomen and pelvis, to look for the presence of any sort of local invasion into other organs on to see if there's metastatic spread elsewhere. Too long is wherever is it could be. And of course, patients who do have come in with cancer. They'll have a huge MG discussion involving colleges urologists on both course, the next ologist and he said, any tests to see you know what? You know what in what we can do for these patients, for sure, in a love for low grade tumor is to our beauty, is very good. Um, of course, if there's invasive bladder cancer, you'd have to either do a partial radical mastectomies with topical infergen opera fees. Lymphadenectomy. He's on, in fact, that the real story counter hospitalists is one of the biggest, largest prostectomy and cystectomy centers in the UK They do a lot of robotic surgeries. It's really cool with the dementia machines and definitely very complex surgery. That very complex surgery. That's very interesting. Onda course is about. It's very unfortunate when you do have metastatic disease, and then we just have to speak to the oncologist and see what we can do for these patients. Um, that's Hematuria's Ah, very quick, brief overview of hematuria. I'm just going to go to this. I mean, does anyone have any questions on human Geritol? Oh, okay, Perfect. All right. If there's any questions, do asked me to stop me in the middle and I'll be able to onto the questions that you have. Um, now, case to your left, one on the ward and you've been called to review a 67 year old patient. Now he's presented, basically, is complaining of not being able to pass urine for the last 12 hours with severe low abdominal pain. There's no radiation of the pain. There's no relieving or exacerbating factors. You're definitely come across this quite a bit. He's got a background, no pas medical history, but he hasn't been explaining that he's had Roger West Thing off lower urinary tract symptoms of the past month, including frequency poor stream nocturia Bye to sign the stables. There's no hemodynamic instability. Um, on just moving on on examination, you find that he's got distended powerful bladder with super pubic tenderness, and you decide to do a digital rectal examination shows he's got an enlarged prostate. What's your initial diagnosis, guys? And we'll just fire away. Yep. So it's got bph. Um, you have been on prostatic have a pleasure, but what's causing the distended, palpable bulla surgery through? Um, yeah. So there we go. Yeah. So not being able to pass urine. Well done. Um So what you think of is acute urinary retention? Um so for go on the clinical history that we've got here in a patient who's got a cute abdomen, but they're hemodynamically stable with a distended, palpable bladder. You'd think off on acute urinary Oh, urinary retention. Picture on to get a confirmative diagnosis bladder stand as Georgia Georgia, Georgia has mentioned on the chat. So it keeps me running a retention. So you have well, you have urinary retention. Where you have chronic and acute urine retention is that inability to pass urine on down with the difference between acute and chronic is that do is defined as a new onset inability to posture, and that's associated with pain and discomfort. Whereas in chronic retention, you don't have pain. A tall but not you don't have the ability to pass urine on you. Be surprised some gentle some elderly chops come in with over liter off of an overeater of residual volume on, you know, without any sort of pain. Now it most company effects men, right, Felicio, because, you know, be benign. Prostatic hyperplasia is the most common cause off. You're on a river tension in men. A soon as we, you know, get over in a past 50 55 years old. Um, on. I think you know the incidence off BPH risers, and it's a common problem that most men do face. Uh, you have to always think about prostate cancer, causing your in your retention as well. You can do get urethra strictures. Now, One question I forgot to ask you is does he think you you you're in retention does not commonly I rarely effects females. Do you know in any instances where it can. So we're talking about BPH. And prostate cancer is the most common cause of urinary retention in men. But what can so but Mr about pregnancy say it's urethra strictures? Syria through stretches. Ah, and traumatic bottom. Yeah, so eight from a traumatic injury to the urethra or any sort of like. And sclerosis, all of them can cause urethra fibrosis, leading to the formation of urethra strictures on this can. This can cause females to present where the, you know, retention. But you very rarely see it. Of course, patients who have got bladder cancer or is some sort of cancer that's causing, you know, you know, if they have blood clots that can cause clot retention, huge has a very common cause. You'd see this in in yeah, puffiness. You'd see in, um, in the elderly and the geriatric wards. A lot of patients who end up having constipation's end up going into cute room room retention. So for these patients, put a catheter in, get a force for animal, let it come out and talk them. Two days later. Power stop urine retention. You see that very often you end up seeing people go home with catheters. Onda course neurological causes multiple sclerosis. Parkinson's, called a quinine, is very important that something that will cover tomorrow on peripheral neuropathy. All right, so get retention is basically an ability posture and associated with pain. Um, now, with chronic retention, like I said of patients who present with acute on chronic retention, what it means is that they usually have, you know, low urine tract symptoms. You know where they have, um, frequency nocturia poor stream. But then they can present with acute pain. And this usually happens because when there's, you know, when Depp that they are accumulating large volumes off of urine in the bladder. And that's why you see these gentlemen come in with a liter off urine in the bladder, you'd see, like I said it distended, powerful bladder with super pubic tenderness. And it's important to always do a PR just test the prostate and to check for constipation now, acute retention or chronic retention, the know you treat it is basically just catheterized. Now a lot of people end up going for the 12 and 14 French. I think people are scared of the 16 French, probably because it's the biggest size, but I would always don't bother with the 12 and don't bother with a 14. Just start off with the 16 French. Um, there is no different techniques, you know, that you need to use when I trying to put a 16 or 4 14 French. Just use a 16 French and then work your way up. I think it's important to notice that for patients who have residual volume of less and won beater and normal kidney function, it just means that they have like to get a large BPH. Start him on treatment tamsulosin, an alpha blocker, and you can start them on finasteride as well. 5 mg you took. You know, remove the catheter in 5 to 10 days, and if they're fine, then the tamsulosin is doing its job. If they still go back into retention, then they need to be referred to urology to discuss about the possibilities of a transurethral resection of the prostate, where you shave off the prostate. For patients who have a residual volume of greater than 1 m or have arranged kidney functions, these people need to be admitted to hospital because, of course they have a naked eye they likely chance that bill need a long term caster to accessory nerve function because that risk of post obstructive diuresis uh, which basically means once you put a cast er in and they use the bladder decompresses rapidly. But the body's then goes into kind of it goes into overdrive when it starts producing large volumes off your urine. On what happens is that if you don't monitor the urine output and match with, you know with fluid input, what then ends up happening is that they can go into a KYW that as well. So it's important always for patients who have large residual volume is too monitor how much urine that passing out and if to replace, half the urine output that's lost with fluids. But that's something that you would come across, you know, that the urologist will do themselves, uh, and you know, urology isn't without catheters, and we've got a two week after. I'm not sure if you can see marrow, but to a captures the box standard CAFTA you've got. This is the first channel where the urine a strain, and this is a port where you ah inject 10 mills of saline solution to inflate the balloon, which would keep the catheter in place. And it's generally I think the one misconception is Do not shove down the catheter like it's, I don't know, a hammer or something like that because the last thing you want to do is create something we call a false passage where you know you're going. You know you could. Technically, I just kind of create a new passage. Um, and a horror story of Once we came a question. Urology, Will is a patient who had the past medical history of who had previously had prostate cancer, who had brachytherapy and came in with, ah, with hematuria with clot retention. I mean, a patient who's had brachytherapy there. Their pelvic floor would be very friable, very fragile. And what's ended up happening is that people have had multiple goes at catheterizing this patient, and they basically created a false passage board way up into his rectum and kind of perfect it. So you know this. I think the one thing is be gentle with catheters. Don't try to shut them down, and if you can't do it, then get senior support of the urologists. Most important, thing. Not this green one. Here. This is a team and tipped catheter. Now the reason why it's curved and it's hard is because they had to obstructions that you would usually see they're so they're using to obstruction two points off different session, this first bit here. The the bulbous Kroto Junction is where the first no obstruction but difficulty you'll come across the way to bypass. It is keeping this the Penis perpendicular to straighten up. But the second one will be here at the Urethra Junction here, and you know, there's no way to 222 manipulated. So what the demon tipped catheter is because it's curved, it basically slides under and goes in. It's very useful catheter. And if because you have a three week after for irrigation, one really cool thing is, if you can't get it with the TV on tip, then you can use something called a true My God, Why? Which is really awesome guidewires the usual hydrophilic, which means that you know they're fine with water. Um, you just put the God wife through into the bladder on. If it's in the blood, it will just go inside and just kind of stay within the blood, and all you need to do is just insert a catheter over the GUIDEWIRE into the blood. And it wouldn't just naturally go in the case that there is any false passage is what ends up happening is that rumor. Why comes back out of the Penis? So that means that you know, you've got in the first passage. So you take the tremor guidewire out and then retry again to try and see if it goes inside. Now that sometimes can fail because at the end of their putting, a catheter is a bind procedure. So what better way than using a flexible cystoscopy to go by under direct vision and then inserted Custer by the cystoscopy. Um, so, yeah, that's a few techniques on on CAFTA's, but wide just say it's tough with 16 French, it's the easiest one. Um, and I think I think it's just very difficult to do a femur caster. Most of the nurses are quite professional doing it, so just let them do it. Um, all right, Without further ado, I just let Master's just continue with the next. Any questions? So far, guys, No. All right, this Fine. We will continue. Um, was then so here. My case. Um, so we go a nine year old boy, the percents with a two hour history of the stickler pain, and he's a sudden onset. Okay? And I would like to put that on capital letters. Sad and onset. No recent trauma, no lower urinary tract symptoms settles and no UTI or anything. No fever on the pain is 10 out of 10 separate e. So what are you thinking? Hear about any suggestions? While you may concern on a 19 year old patient with sudden onset escrow skating pain lovely. So we go already. Quality answer is yes. The answer is the stick alert Ocean. You guys are correct. So moving on into the next, it's like the stick your tongue shin is dad. So Okay, so we never want to encounter while we're on call on neurology. But it's nothing to be a scared, Uh, but it's a really important topic, especially on Children's. Okay, So my recommendations here is always always when we go someone refer, but any to us always rule out to stick right. Ocean, please. On it, in any doubt. Do please just escalate to the SPR. Okay? There are being a low instance that done people actually hard to ciguatoxin. And it was no, it's collected. So they said, it's a big thing. Okay, so do please escalate when it is needed. So basically, the secret ocean as defined is quite simple. So there is a twisting on the spermatic cord, and that makes ah, loss of blood supply the coast ischemia, an infection. So that is the recent worries. An emergency on the recent by the state and touching a chorus because the recently increased mobility of this testicle something real important. And I've noticed that Ah Lord off the junior doctors don't go into detail is to always ask the parents if we got any Children's for something called a bell. Clapper is the form it e I kept, So I go into the next slide to show you a little bit more. So essentially bells couple deformity is a congenital DC's on. It seemed to happen, actually, quite often is average is 125 patients on is you can see here on the image this normal testicle. We've got this called scrotum around the testicle on we go. Something called the Tunica Vaginalis. In the case of patients with bells clapper thesis, Tunica vaginalis goes all the way up. Which coast? There, testicle to light or recently on. What is important to know is that this is a disease that happen on both the testicle. So it's bilateral. Okay, so that is something important to keep in mind on these body causes. There testicle mobilized like it is loud, then too freely swing and twists around. Okay, is no fix. So that is quite important. And it was a lot of people knows about it is quite important on jam patients. All right, so moving into history, I'd really detail history is important. Especially if you're on the middle of the night and you're gonna put your phone and call the SVR on course of the place to a thorough history. Um, as we read explain, it tend to a core point often on John boys. So teenagers of genitals on, uh, the main main, um so keep he had his is always a side and on statistical pay. Okay, It's really likely that a patient I've got up history or 48. I was off 72 hours. Testicular pain booby. You know, physical attraction. The pain is excruciating. And pay a instability. Sorry. 10 out. Tend. And they're always coming. Complaining off notion moment in. Okay, on. They always will say, I've never experienced this testicular pain before, but saddle then actually have experienced these. That is what we call actually torsion detorsion. Okay. Ah, really important to some impatience and especially for female doctors. Give me a little bit and confident Will do. Please do. A thorough examination has for assistance in the case you needed, but literally was just looking for If one testicle lies Heidger than the other one where the reason is or isn't a lie, we shall, um, those power pay for tenderness around the epidermis on there are two really important test to do. I'm pretty sure maturity or you guys will be aware on the crevices. Very reflect, um, sign that in this special will be asked then. So it's just when we just sort of rub on the part of the thigh and then the state testicle will go out. It's normal part off, you know, off the cream, it's a reflex. But in patients off of course, the secret ocean. This will be absent on DA. The prince sign is, um, assigned with. It's really see and give us really good inside to differentiate between the secret ocean or epidemiologic itis on. It's really religious Left this cold or scrotum on hospice patient. Is the pain improve? If the pain has improved, that means, you know, there's a negative print size, meaning like there is. You know, there is no testicular. Torsion is more, um, off. Um, evidently, more kite is in this case, Um, I suspend before the key factory on this patient is deciding on statistical a pain on the patients with the people in the mark. I t states inflammational the evidence of epididymitis basically, and there is a gradual onset. They will complain, or fever on day will complain or low where urinary tract, um, signs as well. Um, always has for sexual history of this patient's on our bicycle eat since I'm uncomfortable, but it is need it on, um, a spot off that, um, examinations. We should always is a neuro in deep urine and CNs you reach of fell on Bloods. Ah, there is a lot of instances it that any Just refer patients without these basic investigation and just something that we need to make sure. Um, but they're done. We can sometimes do an ultrasound off the testicles just to make a comfort just to confirm that. I know. Said, oh, to rule out the diagnosis, but in it doesn't always happen on I don't know. It will really depend on where you work. But sand the hospitals are ultrasounds are quite limited. And it's actually quite difficult to get that on a period off six hour gap. Okay? Because after that and move onwards into my next life on, um, as I just mentioned here, all suspected to seek a large torsion, they should go down to theaters within that gap within a period of time off six hours. Okay. Eso even any doubt if you ah, doubting yourself with this? Maybe, you know, just always tell you someone to ask someone to escalate. If you're the f one, just escalate today. So show at least someone with more experience than my kind of give a little bit more insight. Okay, um, the treatment that we use in this case it's always been lateral. Okay, though pexy and they're going to go into the tell by basically it means making an incision on the growing area. Bilaterally, we identify the testicle we preserve this much accord on, uh, we just literally fix, like, the testicle down this called Crowton to the fascia. Okay on, then. I know they're all the most. So, uh, one second. Okay, puff it. So the reason why you do buy like sherry, So the reason why you do bilateral is because weapons is in people who have bell clapper deformity. What ends up happening is is that they look like models. Explain. They usually have this congenital defect on both sides. So you wanna make sure that both of them are fixed? Not even in patients who don't have the bell clapper deformity. You would still fix them because, you know, there is a likelihood that the second one can talk, and you don't want someone You know where you have both testicles? Kind of, You know, kind of a nice I explained before. Sorry. Ah ha. Nobody didn't see your question. Well, um, as I explained before, we tend to happen a lot off the patients that come with the sickle it ocean. They have the experience that what I explained before torturing the television. So they've got a history. So they are prone for the second one testicle to actually have an acute ocean, it swells. So that's why we do it. Bilateral on one thing. So I would add, is you know you're down during the operation you're fixating the testicles of what we call a three point fixation where you fix the testicles to the medio, inferior on lateral part off the doctors fashions what we call it to fix it to keep it in place. And while we're down that you must just get both of them done just to make sure that you know the testicles stay viable though we do these vexations. One of the things that we do consent for is that, you know, despite fixating the the testicles they can sometimes still a tall, you know, it's still, you know, twist. So there's one of the things that when you do consent a patient, you can't. You have to say there is a like, a chance of recurrence of caution, So there's a lot of things when you consented. Patient need to do. But whenever you go, and you always fixate them bilaterally, all right? Okay. Cool anymore. Or the questions about that. I just opened my shut box so I can see dances. I think everything is fine. Okay. Perfect. I'll continue. Yeah. So the next case I shows is called paraphimosis on, uh, afraid you will encounter this quite a lot. Um, sorry, my bad guys. Eso I'm pretty sure more so. You are a well, a world power pharmacies, and it's an inability to place back or restrict the foreskin over. The plan on this can cause a tight constricted by around the glance on it's actually this reduces the mountain off Penis return on this least to edema and swelling on. Um, as you know, edema and swelling can lead to peanut lyski mia, if less and treated. Okay, there are a lot of risk factors, but the most common ones are fine. Mostest in swelling, catheter on, bull hiding or button on. Um, besides this, but there is the information of the glands Penis on, um, the prep use. Okay. They will just kind with presentation and increased swelling and pain. And surprisingly majority of patients come with paraphimosis is that have had a viral load history of this complaint off. So, you know, it's high for a skin for a long time on Sunday, then I quite a shame for two can't hospital. They will only come in their own need. Um, so it was quite interesting, and I saw actually, the heat, something he will in contact quite often. Um, normally, what we will do is the same sort of thing. We will prepare the patients to theater. Um, anyhow, because I'm afraid sometimes we can do something called a man with digestion on. I do want to emphasize cyst. There is a big myth around the world that if we can put sun, you know, um, look, a solution on top or san start off lidocaine on top, or sand off jelly solution and talk that can help us treat tractor for a skin. But the answer is no. So please, guys don't do that. Especially, um, I've seen some of my colleagues doing that and then escalate into the S P. R S p. A. Getting mad because you can realize is a special say it is sort of a tight squeeze on. If you have got a little bit of jelly solution, there you go glucose eyes or going to sort of make the work a lot, you know, more difficult. So please be sensible. There's no such a thing. What I would recommend from experience is this patient's has explained before. They will try to push it to can't hospital. Some of them have been seen by the GP, and then they're sort of forced. But the deep it from here to the hospital, so do please keep good, um, and and Asia in Austin my the pain, the smashed you can't before you a 10 mile of reduction spect protocol on our hospital. Everything various, we just sort of try one or twice a lease. And if this fellow's then do we just moved into dorsalis cleat? Okay, something real important is ah that you may Sure that your spine what the procedure. Anyway, when we consider patients, we going to details unfortunately dot So resplendent there we just do a small cart on the foreskin on um, we just retract on. He doesn't really look aesthetically nice. So when the patients tend to wake up in the morning to all our after anesthesia. They get surprised because we didn't do something called a full superstition. Some patients, we can do it but is a lot faster for us to do a door. So a split. Okay. You want to say something? Come in one day just to add on the door. Cicely is the reason why you do. The door slit is it's very difficult to perform circumcision on someone who's got a lot of swelling around it. So if you do it the second decisions, very. It's been nine. Impossible to form, you know, basically performed the surgery and in stitch everything back because everything will be quite swollen. So what you do is you perform the doors slip, allow the pain the prettiest to retract, let the swelling. Um, um, you know, reducing go away. And they don't come as an elective patient to have a circumcision there afterwards. No. Right. All right. Okay. So I think we're moving on to the next case. The margins. You see, uh uh, I know we named that serious Is the urology emergencies, and I'm not appreciate this ones are the most common waas. But we just wanted to make a mentioned on one second. So my joy, Children time patient Will will go for some concession, as I splaying. I mean, I didn't want to sort of put a picture here. If you can type in Google dorsal, a split incision, then you will sort of figure out what I mean, But it doesn't look aesthetically nice, eh? So this patient has to say have been suffering with these require a while, So we just do some concession anyway, okay? Ah, yeah. So we're just moving into Martha. Perfect. No worries. That's fine. We're moving into martyr now as to say we use know, like a pro, but your mem emergency. But I felt was something really important on that You will encounter quite often. So just leave with you. Mata. You see the presentation on a second? Yes. My presentation. No. One second Monta way. Yeah, we do. We love him. Okay, then I will Look, I would run true. Sorry. So that we have got in the world, maybe? No, just Okay. Okay. So you are in any. You're one of the junior doctors for support. It's already then presented my side for my thumb. I'm one of the after doctor said trial. Sorry. Working with Martha and Ashy eso. The first case, um, is the last, most common neurological emergency that you can count A surgical? Um, junior, especially obviously when you're larking a patient's in any so 67 year old female presented to the emergency department with a 12 hour history of blowing toe growing pain with associated nausea and vomiting and temperature spy come around 39.5. Observe the shots. Um, they actually showed that she has got, uh, type look. And Shauna and, uh, keep our gum. Oh, Okay. Just one second. I'm gonna put too dear. Yeah, but that was not gonna be my on my Any question of George question is going to be another one that you should know. Okay, So what's your approach now? It's fine. Door. Just Yeah. So I'm not asking about it. That I notice is I'm asking a water approach. So you are deaf one or you have two doctors right to any. You got disease, sir, from this patient, which is in excruciating pain describing an intensity, um, bladder's kind of bloods and urine. Dipstick. Substance. Six. Um, ultrasound of keep the nasal. How do you approach patients? Um, when they come in to any, any clinical, Um, I'm not asking a for our investigation. Some a B c d. Good. Very good. Um, so you started with your a b c A v City approach. Always a Remember that. I mean, she's talking, So yes, there with their part and going to be you listen to the lungs. So they're both clears. Find a heart. Sounds, um you might have a chronic atrial fibrilation. Also, you might feel dizzy. Regular pulse, and then you Are you going into D? Any extension him? So, Danny, expecially what you're going to do, it is obviously the abdomen. And you're also gonna check, um, for the back here, also going under NASA, and you're also going to check something else doing at the abdominal examination. So if if the patient is stable, you take obviously detail, history and clinical examination. It is very important. Um, in this case, when you've got the fish and said, that is ah, um that is our Oh, that is coming with a such a a day in with flu does something which is a life threatening which is a a rupture the triple A What we usually do clean ically to check for a run for a triple A. It is to track for parts of the master inside the abdomen. And this is really important. Um, after a day, uh, when you're going to actually ask for all the bloods and so on and you see an immovable of being dropped and that you are still thinking and this will be a triple A, you don't care. It's the moment about her renal cortical. You think about the Triple A because the patient will actually die because of the Triple A. But you ask for an old gentlese city. Our program, in that case, is just to exclude a a true break because it's really important, Isaiah and actually last it up and in our hospital and that the last week, one of our deficiency, it was actually waiting them in the in a DEA in the area. He was waiting to see us, um, and it was coming on with the back, you know, with the low in pain on. But he just went into cardiac arrest. So we need to start to the CPR. Uh uh, in the waiting area Billion in. So it's a really important. Ah, screwed any weight and, uh, do professional will be your detail Easter in casing, which deficiently stable. You have done your examination full doing in the eight weeks you have excluded that reason. Know triple A cleaning early and then you're thinking these might be some finger. Also, which investigations are you gonna Hasker in the first? See stance? Um, John just it is. Yes. Which investigation second? Gonna ask if we have them. Your examination. You have a PICC in your history of us about the past medical, least for your stream. Might have a chronic a half fine. The total hip replacement the last year. Okay, I am. You're taking the allergies Have taken the drug history the most difficult. She drinks hyper whole urges more, some fine. Which investigations are you gonna ask him? I'm not speaking about imagesa. I'm just speaking about a parking an investigation. Love us. Very good. So which loved to six, actually. Am I gonna ask in the first system? So that is gonna give me straight away and know so use any the CBC? Okay. Yeah, so usually usually a any as already perform of the BG. So I venous blood gas and that will tell your ex which tells you more or less The what the patient is is so it will tell you the pH but from a venous blonder are you for the patient is in lactic acidosis. So you will get you will attract the lactate in this case because the patient is actually quite a just got a racing temperature. So what we're thinking it is also possible infection. And I don't know, I'm going to ask for all the rest off the investigation and which are what we call a former blood. So the ones that they use and it to the laboratory, not the one that you make at the point of their fasting, which are the full blood count. They're important. Yes, sir. Use And he is really important. And the CRP, that's the one of the most important inflammatory markers so that you can have in this case you might actually have that that obviously this year he will actually be increasing. So we arrived to the value is is the other reason I called you Come So this is the most common neurological presentations, and the name arena follicle refers to severe pain that results from the obstruction of the stone inside the renal system. Oh, obviously white and gives pain because you've got to do is a stone inside the ureter. This is gonna obstructed the floor viewer in. And obviously you're gonna have that All of the anatomical portion above the sono will suffer from this obstruction of bruising pain. Um, and it comes in waves, and it most commonly affects men with a rich of a treat wanna and toes over 65. And now the question would be why men and not so much women. It's, um, if you were does a question. So the worry a try or came, So it's gonna affect the more men, uh, was a women, and they've got the one a hormone which is progesterone on them that is gonna delay it. The writers. So obviously the writers, they're actually bit more flexible. The one in women want comfort to the one in men. So there is an increased risk er off the stone obstructing and not passing through fully the ureters. Because the writers of men are stiffer and they're not so flat. Cymbalta has the women just because they don't have a progesterone. Her majority of end of the electrical trucks, the bathroom to wanting to women. Majority of the soul numb are made up of from calcium. Um, yeah, And the risk factors are gonna be saturations or Chris solicitation. So there any risk factors are going to be dehydration. A. This is actually very common. And so that's why it is always a side when someone has got a really nice cord. It could please a drink of water hyperkal story, um, and, uh, hydroxyurea. And in these two cases, you have got also some a familiar syndrome and that might lead a toe hyper cancer area, which means increase the excretion of calcium in the urine and Doctory a over books. It's old inside the urine and the levator levels off for your case in them in the urine. So these usually it is in gotta. So the tremor's common area So we're stone will impact. They are the tree John Chansa. That is where diameter off the you're ever is More first one is the trouble ureter conjunction on, uh which is indeed just at the beginning of a off the ureter after a doctor. The second one. It is that today how the brain the political bring is exactly where the ureteric first over g r India car stories, um, not productive. He's a just before the ent bring the blood for so at the domestic a unitary in Japan. So the presentation, the most common presentation it is of a patient coming with the flank pain that moves it down to the ground in a pretty it actually refers to the to the location of the stone and that it goes from up to down, so lying to grow in pe in a folic in nature. So coming in waves dark on some pain with a piece of increased pain, pain can radiate to the testes in manner and to the world but in women and there might be associating in no shots or vomiting them. So sometimes there might be, indeed, the blood in the urine, um, and the examination of me reveal up flank tenderness. Um uh, usually at the university, they always a talus. Sorry, Mohammed. I'm just your the different colored massive rise. It was merely and we have really? So I'm going to go up. Um, they got a bastard. So they actually cross over here. You are actually write that. This is the pelvic brim. Um, anatomically speaking here, you've got to your common iliac artery is, um okay, um and you're going to be gone. A little bastards. Some in this point in time, um, which is the second most common point them. It's a day not western. And it's the same point. Is the family combretum? Um okay, now you go. So and sometimes, obviously, you can have the summer blood in the urine, which is what we call a hematoma. The eye. It might be microscope because after my to take within a urine dipstick or the muscles topic, this is just because obviously, the stone will pass through the ureter, and obviously the PSA will cause a some. It's creation of the the lining of mucosa off the ureter, opposing blood them on examination on the reveal of flank and earnest for about you guys. But we have studied in my university. There's so called the Giordano sign where you literally well, user, your your list of your feast. Uh, and you check for standard NASA in the part of their temporal area, which track in the day from the reason and you referred pain over there. So question analyst? Yeah, I think it's the Giordano sign just called in different ways. Anyway, you news? Is that the story? So you're in deep from blood. It might be positive. There might also be the presence of sometimes some of the, um off the nitrates and over locus I. It's because indeed results one bacterial, which is a protest mirabilis. So which is one of the most common of meth you're gonna Asmanex causes UTI. It is also cause of for kidney stones. So enough days you will also find nitrates allow. Besides the urine dip, it's actually not so important for unit and Lampa levels That is actually really important to check for blood. After that, we saw the former blood. So if we see using is therapy else to manually case in the because obviously you would like to check for any possible clothes off these urinary stones. So the x ray feel? No, we never actually asked for it. Um, because it's not really good. Uh, You can only see one type of the stones, which are the radio over stone so you can't see the rod you lose and funnel, so there is no reason for you to ask for it. You'll waste time because of this medication is to wait only for going for an X A, and you will also where you would also waste the money, even if that's not so expensive and extra. But still, second one ultrasound, we do not to use it. 25 stones in the first cyst on some first of all it because it is a parent or dependent sac on that, it is really wanted to check for the presence of our journey. Froze is sometimes it can't identify stones because it it's not really sensitive. And the ultrasound also, it can't really check the exact location off the stone. And sometimes that you might need to know where exactly. Okay, did the stones inside the urethra I have got This is, you know, contrast. Will you be? This is the gold standard, So always ask for it. Um, it will tell you the size A, which is really important for the management and the location. And obviously it will also tell you about the presence of the hydronephrosis. Is no. Hydronephrosis is. That is a measure of obstruction. It reflects the degree of obstruction and usually correlate with the renal. Um, so possibly fresh diagnoses. Um, it will be a uniformity. Is, um then it will be a rupture Triple A up in decided never to try. It is, um, and in an apologetic public pregnancy rupture deceased. We're in a very unfortunate. So when you actually find that that's the reason we have decided that to do ultrasound. It is the operator dependent. But in case of a woman not always asking for your indeed for within the bit hcg because you would like to track you for the person that has actually had a neck topic pregnancy? Yeah. And in this case, you would refer to die in him in a Gerson. Obviously, you also need to rule out a very unfortunate a rupture deceased. And the gold standard or four days is not a city. It's actually no. And the foot up in decide is, um, you would wider a nutrition resticking Stan. Okay, so, no, just don't tell her little better he's into do. It wasn't important. Was just the degree of the kidney congestion. Yes, it's important. Um, but actually, cities kind of will give you more information about our it done, and you'll try some itself from messages. Come is much more sensitive and much more specific it and you would trust around them. So in that case that we would recommend it to go for a city. Can you be? It's developed always upon in the clinical scenario and, uh, on your patients characteristic Yeah. Uh, yes and no. So it is a much more immediate Oh, yes, you're right that you actually take a last time to do another ultrasound. But first of all, did you try some? You can't get it over night. Um, and if you're a night, you will ask for a CT scan. Uh, I'm not sure about to the hospital, but we don't have anyone that can actually report for money and ultrasound. Um, um, so you would go for a CT scan? Um, then I'm, uh yes, it is. It's much more spacey. And so you would, uh, you will actually ask it did that actually, for that that you can ask for a Nutra some. Maybe there is not a problem. But in the case in which you have a, for example, a female, I would ask the friend which was running the casing, which I've got a female love a younger female, uh, that she might be praying. And the or, for example, she might be in there. Appear the and they do. Ultrasound will actually help me understand. Officials got a ruptured cyst that order know William Portion, and they too. Let me to exclude the diesel from every night for a week. Um, these are what I would use it for no time. Productive. So here we haven't got a CT scan. Now we have got two slices on the six and anyone tell me what the hair grows in the city manager on the left side. The shore stones? Um, yes, carpooling exact feeling. So these are balanced. I kind of try. And then on the right side the what are what? Can you see it? So can you see my mom was smart phone? Yeah. Okay. So what? I'm I'm pointing over here. No, not yet. Renal. Some every night. So they're picked up from factor that also will the super red eye grounds a meaning that they are on atomical. Ah, hired on the kidney. Oh, no, the spleen. It's more up and it's on the left side. Doesn't It's over here. This is that so This is the right side. This is the anterior. This is the left side. And this is the posterior part. Um, yeah, they're not cortex that we cannot treat. That is very nice cortex. And the dessert is more in black. It is actually the, um the medulla. And what's over here? These are gray is in Yeah, So it's actually a generic Roses are in our tell discernible. This is inside. Here they stand in the Yes, it's a it's a vest. And it It's the hydronephrosis exam, ms, because it is bilateral. So desire to stones have actually cause a bilateral hydronephrosis. So a biologic obstruct on them. Just run to a CT scan. A. So, just to recap, aware of sad, Uh, this is the anterior part of the city's on, and these are just the maze. Very basic. That's one year last posterior was you conceal to that cramp and then you've got your right side. Um, after death from gonna show you over here. So desire to keep your kidneys wanna. And kidney number two This is your very first a bra. Okay, I am. This is actually your Ortho, which is and not and no contrast the city, as we said before. So you're not gonna see contrast in your arteries and the arteries will appear great because they don't have any contrast. Okay, Yeah, You can see some part of the front as well here. It's full of bowel. Um, all about around. And this is all of fact, Okay? And the r D Moscow's But these are just the basic. And just to point out which are the structure, since I desiccates can but one, you will actually be in the Kleenex or in your spittle. You will actually see a lot of the city Stan and the your I will get the use of three on, but it would be much easier now. Do you want that? You know, throwing something from drugs are anti emetics for announcement vomiting or we usually give the cycle and then a 50 mg up up to three times a day. Evidence of infection. So obviously, how How am I gonna speculum reason? Evidence of infection. I'm gonna check this year. First clinical status on the patient. She's a spike in temperature. Okay, Worth of count is up with the neutrophilia syrup. Ease up. Evidence of an infection. I'm going to start him on antibiotics, and you're gonna fool of the protocol of your hospital. Obviously, before doing all of these, you would actually have got in the urine. Um, see a PSA, and you're going to start the You're a patient to straight away within a number below dispatch point in my yard. And as soon as your culture of the urine will be back, you will in our the choice of antibiotics within the sensitivity of the culture, we're going to give up the fluids because most commonly, these patients are gonna be dehydrated. Then you've got the conservative management, but not obstructing stone. Um, you can let him go home with the once the pain is controlled and you're going to repeat the city. Can you be intraware some? And you can also start him on the medical expensive therapy, which is a food from solution, which is an alpha blocker for a stash in before Sandy. And then you go for surgery and tree cases up bilateral complete obstruction. Also, as in the case off the city scan, put obstruction of the study that achy the name or in case of Monica, why do you start with the way the spectrum antibiotics country with for the cultures? No. Uh, so as soon as you see that this is actually true for all the patients and that they have both been infection and bacterial infection. So when you've got a patient that clinically resembles a bacterial infection that the blood's, um so the food blood counts so that works. That's count is gonna be up. Um, with the neutrophil. Yeah. Can you hear me? I know. Oh, okay. Three model. We just lost you on afraid then you might have lost connection. Sorry, guys. Sorry, guys have been lost The connection now for two seconds and everything and jumped. Um, that's my Norris sign. Corn deviated. There you go. Okay. Can you see their screen? Um, Martha. Yeah, yeah, yeah, that's perfect. You know, I am. So the question was a wide Don't you wait a full dinner respect remitting biotic. The answer is no. This is not true only for the renal colic. This is true for everybody that has got a bacterial infection. So in in the UK, I'm not sure where you come from, but in the UK, what we do is a once that the patient is a clinically in. Ah, got that bacterial infection or so or he might be inception is, um so that has got to the criteria. But the S I s S o systemic inflammatory responses seemed drama. So I put in front tachycardia increasing the whites of pounds and so on. Even through this crowd, you're not use any more clinically, but we still use. What you're gonna do is that you're going to do your assessment, and after that, you're going to do what we call it the Subsys in six. This is a absolutely important. So Subsys in six, it means the six things um, you're gonna give oxygen if the patient needs oxygen, Okay, after death, going to get little measure mansa off the lactate level because there any, um, bacterial infection lack. Deduct it will go up, and these are obviously will cause a metabolic acidosis is, um, after that, you're going to get blood cultures before giving antibiotics, and you're gonna get the blood cultures. Okay, one another big boater on one of the big both. And you're going to get cultures from everywhere at that. Put it simply postoperative, all surgical patient you can, and like, a wound over here on the abdomen, a laparotomy, and they were going to get you're going to go with in this world. But you're going to take a culture from there before giving antibiotics after death that you're gonna you're gonna put a catheter and you're also going to give you the fluids up the thing that would in the car that that it's some people, they actually still use it. Some people don't use it and also depends upon the clinical area. And absolutely, you're gonna give broad spectrum antibiotics in the first hour. The first hour is what we call the golden hour. Um, for the first hour that you recognize that patient is in and is in steps is, um, you're going to give antibiotic brought this back from after the blood been taken, and this is because obviously, if you're going to give antibiotic before getting the blood cultures were gonna kilo the bacteria. And you're not gonna have the culture sensitivity, which is correct once that the sensitivity will be back, which is usually up to five days it can get. We're gonna narrow your antibiotic. So usually we started with in a bad season with the Tranxene, which is a broad spectrum, and then we're gonna narrow it down on the sensitivity, for example. Uh, I don't know. So if you look up with our house is a sensitive to a pharmacy globulin, we're going on our weight down to from oxygen over because you don't want to give it for a prolonged period of time. I brought this Bactrim antibiotic. Um, was these mean so that did not become a resistance up after so absolutely given by your day. Come in. This case is, um, after that pain, despite analgesia. So obviously you need to give him an optimal analgesia and presence of it. In fact, obstructing the cease a month, so complete obstruction and combine it with the fever a racing from a dream are So there are two ways of the performing answer. A surgery. That's another question. Sorry number. Okay, uh, and the first one is a Pick it up now, sniff. It also doesn't want it is a red rubber you're extending. Both are really good temporary measures to improve the renal function. But the first one, So the pickles announced nephrostomy is much more preferred in, in fact, it obstructive the system, which is also quite emergency because I gain it isn't so. This is the extracorporeal a shock, a wave lighter trips seem so this is actually is going to give a shocker waves with, you know, like the trip during is gonna make a fragments, um, off the the stone so that they're gonna be, but they're going to make it smaller and smaller, and they're gonna pass through the ureter, her PSA, and then they're gonna pass a trooper you were in on your patient after death to the definitely middle joint it is. And not ureteroscopy with the laser fragmentation. So you're gonna pass the widget and he's a ureter. You a tear off spooky red Red Live, and you're gonna make a fragment off these stones and that's productive. We're going to get the winning this bus. All the fragments off the stone and get them out. And let's see any question I see a red dot There are two. Make a drainage of generally frozen. See if we can't control the pain with the analogy is, um so this will be a pill called and I was in a frost. Oh, man. In this case, what you will actually do it is a to pass the within a nephrostomy. So it is like an opening them through the skin. Uh, and these is actually gonna make the obstruction a lesser obstructive. They're gonna actually freed obstruction on if I'm correct. Um, no. Which slides? Would you like me to repeat them, Adam, um, then actually wanna So this is the Okay, So this is the extracorporeal a shock away, but like, two trips him also where the ESWL. Um So what is gonna do your patients is gonna be lying down and then within a light, a trip deeper. This is gonna deliver shockwaves. Um, okay. To the kidney. The stone. Now, what is that gonna happen? Is that the stone? Due to these, a shock waves is gonna be smaller. Smaller is gonna be fragmented in a small pieces. Um, and the ones that this piece is there gonna be very, very tiny. These obviously they're gonna pass it by themselves, within in the urine. And they're gonna pass the true, the urine first inside the blood there. And then they're gonna be key out off the patient. Uh, patient is gonna pee them outside, but they're very, very tiny. So the the scope of the aim of the external extra extracorporeal the shockwave lithotripsy it is to make and the the Stones very tiny in order for the patient to pee them by himself on this is practically what it is. Um, and it is non invasive. But as it is all externalize for your life, we're not gonna enter weeding. And I use the ureteral MySpace or you're not gonna perform pick with. And I was never really the source to me, uh, before man that that she's just passing to the league report form, which is Post said it's ah, the Fick performed. So if you go on that, he will take it to the middle account. Okay? Yeah. Marty just riposted now. Lovely. Um, I think so. I know you have already done the fit back. The's will tell you to meddle. Account Santa, you. If you don't have an account with, then you might just need to quickly reduced the trick. It will be something quite simple. Just need to put your email name. Which hospital or theory you are on right now on. Uh, yeah, for this one. That I just, um, call the phone. They just can, um, kind of scan the cure cord. And they will tell you to the feedback as well. Okay, Yes. I was saying you mind me too quickly. Reduced it to meddle. Uh, you just need to put your name which Diener E and ah, a passport on then, um made a will give you acids to get your old your certificates and size so you don't lose it for life future. Okay, But you will at a magically your certificate against your certificate for today. We will be doing it this way because, uh, while load off our tendons, describe it, find it quite useful this way, and you can get your PSA difficult straight away. Okay, But do please message us on instagram. And if you go any sort of issues with Augusta May doses. Oh, making your account. We're here to help, and we will hopefully do. So. Okay, in regards to the link for tomorrow, we will be sending an email. Uh, tonight, probably on there I'm gonna be. So for the A and subscriber, some of it back to the future that have subscribed the owner, the website I will be sending an email, but obviously the link will also be poster on it to our Facebook page for toes that have not subscribe to the website or so you just need to go into our page. We're gonna put, um I think in few hours, Marta. Yeah, like in few hours we're gonna put to the next link. Uh, and two more. You're just gonna click on that on that will be the Lincoln for debt. More recession on for this one that follows us in instagram and just type Mexico you did today. And then we would just send you the lingers with it. All right? Any questions or any concerns? So anything else? All right, But if you would like something else to something more for tomorrow that we can improve, I know that there is no feedback for me, but just one on. All right? Yeah. Couple of people just say thank you. Thank you to you guys for joining us on. I'll say if this is all bent people. Thank you, Mark. Oh, people just, um, be looking forward to see you all tomorrow. So tomorrow we will have our lesson on orthopedic. That is quite interesting. And why useful for this one's there will be in coal. Um, as an f one f two unevenness a show, some will say So, uh, just spread the world. Just share with your contacts on. Just let us know if you go any sort of problem with the feet before we're here to help. All right. So, um, sorry. Someone dismissed me whether there's any way to get the slides. Well, a couple of people half. So what we will do is we have share on. We have records. So we have been recording this session, so we will probably be a load in it to or metal account. So you can just sort of go back on just what? Everything. And take notes from there. All right, so this will be a loaded on the platform. Any other questions? No. All right. Perfect. 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