Computer generated transcript

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

Hello, welcome everybody um to the first session of um the final year series um surgery session. And I'm really pleased that we have our surgical lead doctor Cameron Green all here. Um and he would be um leading the session, um and I'll give the stage to him. Excellent. Okay, so, good evening guys. Thank you so much for joining. Um and welcome to the first um surgical part of the final year series and where today we'll be chatting about kind of surgical history taking and I'm thankful, joined by a few friends who are um also um doctors and tonight. So I'm joined by Dr Suzanne Bar Wise Monroe Dr Gabrielle Slater and Doctor Anne Caldwell. Um, so we're actually all a group of fy twos. Um and I am okay. Yeah. Yeah. So, um yeah, so my name's Cameron Green Whole. I studied medicine at the University of Aberdeen and graduated in 2021 along with the three other doctors who are helping with the session. Am I integrated in physiology and my B S C from 2018 to 2019. I'm currently working. Um I've just started new job like all the other F one's and two's today. I'm currently just moved to Infectious Diseases in Lanarkshire, which is outside of Glasgow. I just finished up a G P job and I'm hopefully thinking about applying for course surgical training in 2023. However, I think I need to grow my application a little bit more. And so I'm hopefully thinking of doing a clinical development, fell year as well next year. Um I'm kind of in my spare time. I enjoy playing hockey. I play for a team in Glasgow and I played at Uni Joy going for runs and I like to meet up with my friends. Okay. So, yeah, so kind of the main structure of today's webinar will, will be going to go through basic surgical history taking and for kind of final year off ski level. Um So looking at the basics and then looking at kind of questions you should ask and, and kind of interesting points and things you should think about when you're going into our skis and prior to going into our skis and then to kind of finish up and to kind of get all of our everything we've kind of spoken about during the session. Well, and the three other doctors are going to help with some case based um presentations and basically kind of acting like it is an Oscar. Obviously, we're not, we won't be able to see them, but it's just to kind of get in your head how you'd go about asking the questions and things. Okay. Um So the first thing and I think basically, probably most people will know in this um webinar tonight is when, when it's taken a history and taking the history of presenting complaint, Socrates is a really good way to go about it. Um So if it follows the outcome, Sokrati, so site onset character, radiation associated symptoms, timing, exacerbating slash alleviating factors and severity. Okay. So firstly, so the way we're going to kind of talk through Socrates and how you go about it in an Oscar to start with, we'll be using it for as the history presenting complaint, way of going through it, but we're going to use it for kind of abdominal masses and distention. So if you have an Aussie scenario where this is what the patient presented with and we're going to talk through how you go through that using this um structure and also kind of different points you can think about during that as well. Okay. So, firstly, kind of site. Um the first question you want to ask is where is the lump? And so where is the problem essentially and that you're having and can, can you point to it? Is there, is there, is there a specific area that is causing you pain? Um however, or is it kind of general, is it you can't really point it to anywhere you, you don't know where is you're asking the patient, where is the lump essentially then moving on to onset? Um, so you want to know how long they've been feeling like this? How long they've had this pain? Or, or maybe swelling? Did it come on suddenly or, or has it been coming on for a couple of weeks? Has, has, have you noticed it for a while? And now you're kind of just thinking about coming into the doctors to see what's going on and uh kind of adding following on from that. How is it noticed? Had someone said to you, oh, you've got a bit kind of swelling of your tummy or you're looking a bit swollen or, or did it just kind of come on suddenly it's just been sore really suddenly and you're kind of worried about it or you kinda want to know, is this becoming a bit gradual? Is it, uh, your clothes become a bit tighter recently or, you know, if things don't fit you as well, because just a bit swollen, more swollen than usual, you want to kind of get to know about why this has come about. Okay. So they kind of then you move on to see. So the character of the pain. So, is it focal or is it generalized? Is it focal? Can you, can you kind of market to a specific area of your body? Are you able to point to it or is it generalized if you got kind of generalized tummy? Pain or generalized abdominal tenderness does everywhere, just feel a little bit off and you, and you can't quite kind of point to a specific area um then moving on to the a part of it. So the associated symptoms so that producing any local symptoms, like swelling or have you got an abscess or anything like that? Um Is there, is there a specific pain somewhere? Is it in your umbilical region or is it in your right iliac fossa? You kind of want to know, is there pain coming other places as well? And is there any other kind of lumps or bumps on your, on your body that you're aware of that maybe aren't as big but, but you are certainly kind of aware that they exist. And then I think another kind of big part to look at is systemic symptoms. So, have you lost weight recently? Have you just been off, off your food and you're, you're losing weight and you're just diet isn't gray and yet you don't fancy eating as much and you're just feeling general malaise just generally run down and feeling just rubbish recently or kind of more kind of cool erectile focus if you had a bit of a change in bowel habit, have you become, become a bit more constipated recently or you're not going to the toilet as regularly as you would, or, or have you having kind of diarrheal episodes that you don't really experience normally have quite a regular bowel movement. What is there a change? You, have you got diarrhea of your constipation and anorexia again? You just off your food? You don't fancy eating completely off or any fevers recently. Um, have you feel yourself getting hot in the past few days? Are you burning up any temperatures that isn't normal for you? And then, yeah, are you having any night sweats? Are you, uh, is that something new that, that doesn't really happen recently? But recently you started sort of sweating in bed. Is that something? So, yeah, you just want to get more information from the patient. Okay. Um So the next part we'd go onto is the, so I kind of associated symptoms. There is like the seven efs I'm sure again, I'm a lot you may have heard of, of abdominal uh, abdominal mass and what the cause of them might be. So these seven s can be potential causes, um, of an abdominal mass. So first we kind of want to look at there any signs of bowel obstruction, any, any flatted this, are you, are you passing gas or is there colicky abdominal pain, pain that kind of comes and goes? Are you vomiting? Um, or having your absolute constipation where you can't pass any wind? You don't have any bowel movements, um, or your abdomen distended is the, is the patient abdomen noticeably more swollen than it used to be. And then again, like, are there any kind of changes in bowel habit or rectal bleeding. So, at this point, you kind of want to think and especially in fy one, you want to rule out the causes of bio obstruction. Um So then another kind of cause would be the second death would be fee. She's. So, are you constipated? Is it, is this kind of pain in your tummy or is this swelling related to um, feces build up or you might be constipated? The third effort, fluid accumulation. So, um you want to know is there ascites um or like causing explanted of the die from or are there other kind of features suggesting liver disease and like particularly portal hypertension? So are they jaundiced? Have you got any hematemesis? You might be thinking about viruses, they got any dilated veins in their abdomen, any rectal bleeding which might suggest hemorrhoids. So, yeah, are there any symptoms of jaundice or of an email? Um So then the fourth F would be fat. So, is it just that they put on weight recently? Is is that the reason why they, they've noted this swelling? Okay. So the fifth f um would be is fetus. So again, two female patient, is there any chance you could be pregnant? You haven't realized when was your last menstrual period? Um Are you using appropriate contraception? You, you want to know about that? So that could be a potential cause. Um then the next is food. So are there any signs of malabsorption? E G like diarrhea? Are your stools pale? Are they bulky? Are they offensive smelling? Um, do your stools float in the toilet? Are they quite difficult to flush away? Um, so, so, and when you're thinking about food, sometimes celiac disease is a cause of abdominal extensions, you might want to think about that. And, and then obviously, and then the seventh of this flipping Great Masses which I, I've read in the number a few books. So, um, are there any Gynie or genital urinary symptoms? Are you having pain when you're peeing? And are you going to toilet more often than normal or you can't hold your bladder? Um, are you having any blood in your urine? And then you want to know if you're having any vaginal bleeding, if it's a female patient? And, and then I think just another thing is I notice is there any kind of associated leg swelling dvts virus, ah, cities? So, anything like that? Okay. So the timing and the duration. So is the next part of the Socrates acronym? So, is it enlarging? Is the mass enlarging? Is it staying the same? Is it getting smaller? How long has this gotten over? What time courses this changed over? What time courses the mask gotten larger or has it, has it stayed the same? You noticed it a couple weeks ago and it, and it stayed the same or has it kind of growing over the last few weeks, months or your, your abdomen coming a bit more distended over the last few weeks and months, then you want to know if they kind of exacerbating alleviating factors. So, what makes them feel better or what that makes them feel worse? So, would passing a bowel movement that take away the pain or if they set up? Right. Would it take away the pain or do they have to lie flat? Would that, would that take away the pain or would that even move the mass about, would it disappear? Um, is it, is it worse after eating? Is there, are you having pain after eating or you having pain when you, when you're hungry? And that kind of looks into Peptic and Judy no ulcers as well. So you want to think about that and then kind of moving on to the severity of the pain. So, just asking the patient outright, what, how would you rate the pain out of 10? So once it's actually not too bad at all or the mass isn't bothering you too much or 10? Being awful. It's agony. I can't control the pain or the swelling is just so awful. Like, I don't know what's going on. So you want to kind of get to grips of how the patient is feeling to kind of see, seeing almost kind of rating how serious the situation is okay. So then another big part of our skis is the, the ice acronym, which I personally like to, to do at the end of the history of presenting complaint. So, asking the patient ideas, what do they think is going on? Do they have any idea they read up? Have they Googled anything that they think might be the issue that maybe they'd like to kind of rule out or is there anything that they're actually concerned about? Is there anything that they're particularly worried at my duty? Do they think it's, they've got bowel cancer? Is there a reason why they think they might have bowel cancer or are they just concerned about something that's that, that their friend has? You, you want to kind of get to grips with that? And then the last one expectations I do feel in kind of in clinical practice. It's a bit of a strange question to ask and I feel you kind of have to kind of get to grips with if, whether it's kind of an appropriate question to ask the patient, I feel myself anyway. But an off ski scenario, it gets you marks to ask the expectation. So, at the end of the day, what would you like to get out of this consultation? Would you like to know what's going on or would you like a blood test or what do you want to see be the outcome of today's consultation? So, Ice is a very important thing and it's not to, um, miss out even what at all times in all skis, I learned a university if you ask, is there anything worrying them? And they say one thing, it might be good to say, is there anything else worrying you because it can be an extra mark there as well, which you kind of don't really realize about? Okay. Yeah. So moving on to past medical history. So is there any history of any previous hospital admission's or operations, illnesses, especially maybe abdominal disorders or operations they've had in the past? And if so we may be, if you have time, you want to know this is probably more in clinical practice. But what year, what, how was the diagnosis made? Um, that can be good questions to ask. Um Is there any history of inflammatory bowel disease? Have they got crones and they got ulcerative colitis? Have they got kind of maybe at that point, maybe I think there's a family history of that. Um Is there any history of any Gynie problems? So such as fibroids, ovarian cysts all kind of ruling out different masses that might be causing distention of the abdomen. And then again, just the other things to rule out. Is there any hernias mile descended test is history of abdominal aortic aneurysms. Um So yeah, that, that's getting a good past medical history. Okay. So drug history, what medical, what medications are they currently taking? It's good to know what dose they're on. Are they on a high dose? You're on a low dose. What reason are you on it? Why, why we prescribe this, re prescribed it in hospital or were you prescribed it in the G P practice? Getting to know why they're on this for what condition are they on? Um for certain patiently compliance. Do, do they take it every day or do they kind of take it as and when they remember or as and when required and when they feel they need to take it and, and do they have any side effects or have they just started a drug? And is it recently? Um, yeah, so, uh, compliant. Any side effects. So they just started it and they've just suddenly started having these kind of strange pain, their tummy or have they have these side effects for a number of, number of years? They've just gotten on with it. Um, and then again, over the counter herbal medications catch a point in Oscars just to know and, and clinical practice. Good to ask. And they take anything that wouldn't be prescribed by a doctor or are they taking things that they just buy in the pharmacy? And then, and, and then at this point I probably asked about drug allergies as well. So, have they got any drug allergies? And, and if they do it's kind of good to, to get to grips with how severe it is. What happens when you get this? Do you get swollen lip, swollen tongue or do you just feel a bit rubbish. It's, it's good to kind of know the level of severity of the allergy. Okay. Um, yeah. So then smoking, social history, it's, it's good to go smoking. So, how often do they smoke? Have they, are they a smoker? When did they last smoke? Are they an ex smoker? And if they are an ex smoker, how many years did they smoke for? And how many cigarettes did they, did they smoke a day? And then that gives you the chance to work out the number of pack years and kind of to, to show risk of as to how risky they're smoking behavior has been getting alcohol. What do they drink? How many units do they even drink? Are they a social drinker or do they drink every night of the week? Are they drinking a beer or a glass of wine every night? Are they drinking a bottle of vodka every night? It's good to kind of get to grips as to where, how much they're drinking. Um, and, and then recreational drugs. And do they take anything like that, like cocaine or anything like other than that? Um, and then an overseas travel history. It can just to get a quick question. Have you been overseas recently? Ruling out things like highlighted cyst or high data, high dated cysts, um, can be a good thing. And then occupation are they, do they work in a construction site and they're heavy lifting and putting them at increased risk of hernias or have they worked with certain dies in laboratories or in, in factories? It's, it's good to kind of get to grips of that and, and getting social history. You, you kind of want to know what their limitations are due to this. Can they, is it, are they living in the house and they're struggling to walk up the stairs now or are they having to get their husband or wife to do a lot of things for them or have they had to phone their GP to get some, some time off work? Are they currently off work because of this? And, uh, do they have any certain hobbies that might have led to this? Just these questions are good and yes. So, and again, the kind of main thing and then at the end of that would be how does it interfere with your life, um, with your walking? Can you walk up a flight of stairs? Can you work anymore? Can you still manage the task you to do at work or you still turning up for work? Are you sleeping at night? Is the pain so bad that you're not, you're not able to sleep or you're waking up and doing it during the night? Because because of the pain. Okay. Yeah. So then family history, are there any diseases or illnesses that run in the family? Um, is there a family history of any malignancies? Um, any, if, if they've got kind of blood in their stool and they've got some abdominal pain, is there any history of bowel cancer, um, or have they had any kind of infectious contacts recently that might have made this like a viral illness that they're having? Is there a reason? Is there other family members at home that aren't particularly well at the moment? Um, if urinary symptoms or, or paying around the loin area, is there any family history of kidney disease like polycystic kidney disease? Um So it's good to work out whether or not how the patient are the parents, patients', parents still alive. And if they are, do they have any medical editions if they're not alive? If they sadly passed? And what, what was the causing of this or do they have any Children with any medical diseases or any illnesses? Okay. So, yeah, I think this is a really good diagram in which I found I used it through your day as well for exams and things and it takes the albumin to nine different sections. And it kind of if you're asked at the end of uh of uh Oscar Station differential diagnosis and, and say they, they have, they're having right lumber pain and you've examined them and it's, and it's right. Lumber pain. Then you could be your two differentials could be pound of writer. So you're a tear, a coke. So just having these ideas in your head. And having this picture of this diagram can be can be a good thing just to kind of turn to if you're kind of put on the spot in an exam and remembering this picture. So yeah, I really recommend using this. Okay. So yeah, so moving on. So what, what investigations would you like to do a common question at the maybe towards the end of an Oscar station. So I'd like to get some bloods and listing the blood that you want. So full blood count E S are blood film. The examiner might say why do you want these? So full blood count can show us anemia of chronic disease or if they've got polycythemia and the full blood kind of raised white cell count can, can point to things like diverticular disease, reno infections, empyema and the goal of the gallbladder. Yes. Our is a good marker. Malignancy and chronic inflammation and blood films can be used in blood disorders and, and things like hepatosplenomegaly then moving onto biochem. So you're using these, I can look at how, how, how dehydrated are they? If they've been vomiting, um can look at their gallbladder and issues there more so kind of liver function test there. But you know, in a renal lesions or obstructions can be used for the using these calcium's in a good one and kind of um carcinomas glucose. Um If you've got a patient who's got an alcohol um, history, think about pancreatitis or pancreatic cancers. CRP is a marker of infection. It's used kind of everywhere. LFTs, liver lesion's Mex, low albumin and ascites. Um and your families as well for pancreatitis and then P S A for a gentleman um who's coming in with prostatic symptoms. It's a good thing to, to look at and to, to think of maybe prostate cancer. Then urine, is there another great test that sometimes people forget about my cross pay culture and sensitivities. Um, hematuria you want to see. Is there any renal cell cancer, bladder tumor's? Is there puss cells? And and then another great thing for urine and it's uh it was in my final Oskin 50 or was uh pregnancy test. So beta HCG pregnancy test is always really important to, to have an investigation, especially if it's a women of childbearing age with abdominal pain. Okay. And then they, they might want to know about radiology and any radiological and investigation you'd like to do. So, whether it be a chest X ray um can look at, can tell you things about congestive heart failure and Mets or an abdominal X ray. If you're thinking about bowel obstruction or constipation or Reno reno or you're a Terek calculi, then trans abdominal or trans vaginal ultrasound scans can look at organomegaly like triple A's cysts in large bladder's or variant or uterine lesion's. Then a CT abdomen plus or minus. The use of a guided biopsy can look for carcinomas or collections assists, particularly in like surgical surgical wards. And then again, I decided to West kind of further investigations. I'm not sure if you'd probably be asked this in 1/5 year or final year off ski. I, I, I certainly wasn't, but again, just to be aware of the other investigations that you might use in a surgical scenario. Okay. So we've come to our first case and with Doctor Barr was Monroe is going to be helping with this one. So, um, the next patient on the surgical assessment unit is a 22 year old female named Susie. Um, so you're the surgical S H 01 call. He'll be myself. Suzy is the patient you have accepted referral from a GP due to having pain in the right iliac fossa. So I'll be now and I will now be the surgical S H O. My colleague, Suzy is the patient I wanted to get you from Suzie. Um, so, well, if you just have a listen in here and tell us what you and we'll go through it together. So I'm just getting there just like me. Okay. So, yeah, so Susie, are you on? Ok. So, um, so what's brought you in today? Um, I've just got this really bad pain in kind of like the right lower side of my tummy. Okay. Okay. And when, when did that start? Um, yesterday lunchtime I was out for lunch and kind of stood up to go and leave and it just started suddenly. Okay. So it came on suddenly. Okay. And how would you describe the pain? And it's really quite bad and it's just been there the whole time since it started. Okay. So she said constant, it's constantly there. It's not stop, it's not been intermittent. No. Okay. And do you mind telling me, has the pain radiated anywhere? No, it just kind of started maybe like in the middle around my belly button. Uh, but it doesn't go anywhere else. Okay. And, and the pain doesn't radiate down to like your, your groin region or anything like that. No. Okay. So you said you have pain in your, and your kind of lower? Right? Tummy? Yeah. Do you, have you had, had any pain in your, in your shoulder area? And? Yeah. Well, I've had some pain in my right shoulder but I was playing netball last week and it started then. So I kind of what I like fell over when I was playing netball. So I feel like it's been from that. I didn't really put it down to this pain. Okay. But you still have the pain in the shoulder just now. Yeah, I do. Okay. Okay. And is there any kind of history of any injury to the tummy recently that you've had? Okay? Fine. And are you having any other symptoms at the moment? Um, no, I don't think so. I, I just feel a bit rubbish, like I feel a wee bit sick, but okay. So you're not nauseous or any vomiting? Um, I feel a little bit sick but I haven't been sick. Okay. And any fever, I'm not that I've noticed. Okay. And is your tummy swollen? Um, I don't think so. Okay. And have you, have you still got an appetite at the moment? Not really. I think I've just been feeling quite sick. Okay. And your bladder got your water works, going to the toilet. Is there any issues there? Um, no, no problems when passing urine? Okay. But, uh, obviously you're a young female. Is there any vaginal discharge you're having? Yeah, I've been having a bit of like dark redness but I think I'm on the week off of my pill. So. Okay, I think that might be due to that. Okay. Okay. Fine. So do you know when your last period was? I think the last time I came off the pill was like six weeks ago. Okay. Okay. Fine, fine. Um, and does anything make the pain worse? Um, any movement? So I've literally been bedbound. Okay. And does anything make it better? Just lying in bed lying still? Okay. And have you taken anything for the pain? Um, yeah, I've tried Ibuprofen. Okay. And has it, has it worked? No, it didn't do much at all. Okay. And if you ring the pain between one and 10 and one being like fine and 10 being pretty awful. How would you, how would you rate it? Probably nine? Do you think you could sleep with the level of pain? No, I have not slept at all. Okay. Okay. Fine. And maybe on taking your past medical history. Have you ever had any operations? Um, no. So you've ever been to hostel before? No. Okay. And any other kind of history do you think might be relevant? No, I did. I have always had quite heavy periods. That's why I went on the pill in the first place. Okay. Did you see your GP about that? Um, yeah, I did. Okay. And do you, do you suffer from any drug allergies? Um, no, not that I'm aware of. Okay and sorry, just going back to the pill. So, um, you said you're on holiday and you missed it? How many days did you, did you miss it for, um, like 2222 days in a row? Yeah. Okay. Fine. I'm just moving on. Do you, do you have any, um, do you want to tell me a bit about your family life? Do you have, do you live at home? And? Yeah, I live in a flat, um, with one of my friends. Okay. Okay. Fine. And have you been on abroad recently? Yeah, I am. That was when I actually missed the pill. I just because of all the like whirlwind being away. I was in, I be tha with my boyfriend. Okay. Okay. And did you did you eat anything there that might have caused you to be? Yeah, I did, I had a couple of days of a bit of a dodgy tummy kind of being bit sick. And, like, when I went to the toilet wasn't very nice. Um, I think it was because of some milk that I had at breakfast time. Okay. And do you smoke? Yeah, I do. How many do you smoke? Um, about 10? Okay. And how many, since what age would you have you smoked from? 15? Fine? Okay. And do you drink alcohol? Yeah, I do a bit. Okay. How much would you, would you drink on average on a week? Probably about, I drink wine mostly and probably like five glasses, but they're quite big glasses. Okay. That's fine. And do you have any other family history? Um, well, my grand had bowel cancer and my granddad died from a heart attack? Okay. Other than that, not much that I'm aware of. Okay. Okay. And do you have any ideas of what might be going on? Um, I'm a little bit worried about the bleeding and things. Okay. And obviously I've still got my appendix so maybe something to do with that. So maybe the thought of appendicitis concerning you. Yeah, a bit because I've kind of read that this, this is where the pain usually is when you have an appendicitis. Okay, and asking, you know, what would you like to come out of this? Consultation today. I think I just want the pain to get better because it's so bad at the moment and I need some sleep. Okay. That's great. Thank you very much uh Susie for your help there. That's the end of that. So I'm just going to talk through um that just now. So this case um illustrates well, the importance of taking a structured, an accurate history kind of in any patient that presents with acute abdominal pain. So kind of early on in this, in this um in this history, your mind is probably kind of drawn a little bit to the thought that she has acute appendicitis um due to her having right sided um acute abdominal pain. Then however, kind of further questioning the history of you is that she wrote take her pill whilst on holiday with her friends who included her boyfriend. Um One they didn't ask if she's been sexually active since then or anything like that. I I didn't mean to ask that, but this kind of together with the fact that she's noticed some dark red vaginal bleeding and her last withdrawal bleed is late does add another differential as a ruptured ectopic pregnancy, the top of my differential diagnosis. Now, um so there's obviously noncompliance from the patient with the pill. And I think that the diarrhea and vomiting on this was on holiday might again kind of make your head turn a little bit as to what's going on Um Again, in Oscar scenario, you might be asked what the differential diagnosis are. So of a female, it could be pelvic inflammatory disease or an ovarian accident such as a rupture, Torgyan hemorrhage, pen decided to be there a miscarriage, even things like Crohn's disease. However, these are all kind of less likely at this stage and this case is not ectopic pregnancy until proved otherwise because of the severity and the consequences, Quance the consequences of missing such a diagnosis. Um And I think a question I got asked in my final, you're off ski at with a similar situation to this is what would be the one test in this situation that would be most appropriate if, if at the time and it would be a urine pregnancy test. So beta HCG urine test um to rule out an ectopic pregnancy. Okay. So yes, before we move on to the next role play, there's a question from Co Peka. Um appreciate a great teaching. Can I ask if this case leads towards Gynie? Will we be expected to take full Gynie history? Yeah. So in my um finally, Rosky, I I kind of took this case because it was very similar to the case we had in our final your Rosky, but it wasn't really again, the history, I think the time limits of Oscars, you kind of do have to ask some questions cause obviously the history going to lead you in different directions. It's never going to be completely straightforward as it, even as a hospital. Um So asking a few of the guy, any questions are quite important if they're on the pill, when was your last period? Especially tell you a women of childbearing age. Um So, so I wouldn't say you expect to have a full gaining history. But if, if that's where the kind of history leads to asking a few questions that can help narrow out the differential is good. Yeah, sounds good. We could uh we found, um I will send the uh the feedback form in the middle of your role play. Yes. So how can we move on? Oh, sorry, sorry. Um So yeah, so as I said, that's the differentials. Okay. So, um the second case, um Annie is about jaundice. So Annie's a 65 year old female who has been sent via GP just having jaundice that the patient feels has got worse. Her husband's noticed it and she's also feeling quite nauseous. Um, one of the doctors, um Dr Gabrielle will be taking the history from Annie. And so I'm, I'm going to kind of treat this like a bit of an Oscar scenario where I'll be the examiner and I might stop Gabby and Gabriel at different points to ask her some, some questions. Okay. Our um, Doctor Slate and Dr Caldwell and the uh hi there. So I'm just going to start with taking a history. Um So if we start with an E, so, hello, Anne. My name is Gabrielle Slater and I'm one of the doctors here. And can I find a bit about what's brought you in today? Yeah, of course. So, I've come to see you today because over the last kind of week or two my skin's been getting kind of progressively more yellow. Um, I didn't think it was too bad but my husband said it was getting worse, especially in kind of the whites of my eyes. Um, I've also been noticing I'm getting some tummy pain as well. Okay. Um, if we just take those things each in turn, so when did you or your husband first start to notice this yellowing of your skin and eyes? I think just under a fortnight ago. Okay. And if you've been particularly unwell recently or how have you been feeling prior to the yellowness of the skin? No, no, I've actually felt quite well, actually nothing in particular I can think of. Okay. And I know you mentioned the tummy pain that you've been experiencing. Um, so what came first? When, what did you notice? Um, it's kind of hard to, because it kind of came on gradually but it was kind of intermittent pain that was coming or going. And now that I think about it, my, my bowels have been a wee bit off as well associated with it. Okay. Um, what do you mean by your bills have been off if they diarrhea or constipation. What do you mean by that? I know this sounds really bizarre but I just think that a wee bit of a weird color. Okay. But what sort of color have you noticed there? Quite pale? And how's your urine looking just now? Um, now you say it actually it's quite dark but other than that, I've not noticed anything different. Okay. And no burning sensation when you're passing urine herb. No, no, nothing like that. Not that. No. Okay. And if you felt feverish at all, no, no, not at all. Okay. So if we just go back to the tummy pain, if that's ok. So where specifically would you say the pain is in your tummy? It's kind of on the right kind of upper side of my tummy just under my ribs. Okay. And when did you first start to notice that pain? It's quite hard to save. I'd say it's probably been there for a few months, kind of on and off. Okay. And if you had to describe the pain, how would you say it? Does? Is it sharp and it kind of catches your breath or is it just a constant dull ache that's there all the time? Um, it can be quite sharp because when it comes on, it just kind of stops me in my tracks and I can't really do anything when it's happening. Okay. And does that pain go anywhere? Does it ready anywhere else in your body or does it stay quite localize? Um, I do suffer with some back pain and kind of my bit of my right shoulder. But I don't know if that's related. Okay. And when the pain comes on, do you feel sick at all or are you vomiting with the pain? Is there anything else that you've noticed? Yeah, I do actually feel sick but I've never actually vomited good. And how frequently would you say your experience in this type of pain? It's gotten worse over the last few months. I'd say when it started I was having it kind of once a week or so, but now I think I'm getting it at least once or twice a day. Okay. And is there anything that brings this pain on? Um, it seems like you've been having it for quite some time. Now, is there anything that triggers it, would you say, or? Yeah, I think I've kind of worked out that if I eat a really big dinner I get the pain, it's more sore and it lasts a wee bit longer. So, to be honest, I've not really been eating much at all because of how bad the pain is. And it makes me feel quite sick as well. And is there a particular food groups or anything in particular that you eat that seems to trigger it, or is it just any meal? Um, to be honest, any meal, but larger meals would make it worse? Okay. And if you were to say that 10 is the worst pain you've ever felt and zero is no pain at all. Where would you rank it out of 10? Um, right now I'd say it's a seven but it can fluctuate it. Okay. Okay. That's good to know. Thank you very much. Hi. Sorry, I just like to interrupt you. Uh, their doctor slater. Can you hear me? All right. Um, so what other parts of the history would you think would be important to cover? So you would want to cover in particular any pre existing medical conditions, particularly, um, conditions that they regularly see your GP for, because that can guide you in terms of their background and what they're likely to present with in particularly previous hospital admission's, um, in particular when taking a surgical history as to whether or not they've had any previous abdominal surgery and is this can ultimately affect management, um, of patient's if they have any previous scars at any perhaps, um, adhesions, I would include that in my question. So I'll probably go and ask Anne that herself. So, Anne, is there any medical conditions that you regularly see your GP? And have you ever had any previous surgeries before? Um, so when I was a teenager, I think I got my appendix out and the only other times were the birth of my two Children? Okay. Are you taking any regular medication just now? Honey. Um, I take one tablet for my BP. I can't remember the name but I've been on it for years and I don't take anything else. Ok. No. Over the counter medication. No. Okay. And any allergies that we need to know about. No, not none that I know of. And any allergies to anything other than medication, including food as allergies. No. No. Okay. I'm just gonna speak a wee bit about your social history. No, Annie. Just get a bigger picture about what's going on. Um, so do you drink at all? Um, yeah, I would usually drink with my dinner. Okay. And when you say you usually drink with your dinner, how much are you drinking? I'll probably just a glass of wine with my t, okay. How long does the bottle last you? Um, a couple of days, I'd say okay. And do you smoke at all? Uh, no, I've never smoked. Never smoked. Okay. And I do apologize for this question, but we do have to ask everyone, is there any recreational drug use? No, no, no. Okay. And anything that runs in the family that we need to know about? Um, no, not that I can think of. Okay. And if you don't mind me asking how is the health of your parents? Yeah. No, they're well, they keep very well good. Good. Okay. Doctor said I'm going to interrupt you again. So what clinical examination would be most interested in performing here? So, particularly an abdominal examination, focusing on the board. Sorry to interrupt here. Um If I'm sorry to interrupt you, tutors, um if you are not speaking, if you could turn off the camera, sorry, turn off the speaker, I think there's a lot of interference but yeah, I will turn off. Okay. Sorry doctor. You can still hear me. Yeah, I can hear you. What clinical signs would you be looking for in the patient? Uh So well, firstly focusing on the nine quadrants and with deep palpitation thing, you would most people to help people, I'm getting a lot of background noise and okay. Yeah, doctor. So you want to keep going. I'm not sure if anyone else is getting the background noise, that should be it sorted. Please let me know if not. And so you want to focus on clinical signs um in particular looking for things that might point you towards the diagnosis. Um So particularly this patient is telling you that they've noticed the yellowing of their skin. So you would want to kind of show objective evidence of that. So looking at the skin, particularly the arms and the trunk tend to be the kind of first areas that you could notice it. Um often it can be quite difficult to pick up jaundice in the skin and the most sensitive area to look for it is the Scalia. So lifting up the patient's up in Ireland and getting them to look down and to expose maximum part of the sclera is good, um, feeling for lymphadenopathy, including all the chains. And if you're worried about a potential underlying malignancy, is there any lymph nodes that are up? And you would want to palpate the leverage and to ensure there's not a palpable liver edge and to explain why the patient might be presenting and you would want to feel for the spleen. However, it's important to note that the spleen is actually only palpable when it's twice the size. So you can't fully comment on whether or not the um you have splenomegaly unless it's twice its size. Another sign which is extremely important, particularly in Anne's cases, Murphy sign which will go on to discuss in due course. Okay. Can you hear me? Alright. Is there an interference? No, that's fine. Okay. Um So, moving on then. Um so on general assessment, Mrs Murphy sitting on her bed, she's clearly John Nixon looks quite uncomfortable. Her vital signs are quite normal. They are normal and the patient's fully orientated. There know adjuncts around the bed, patient is overweight. However, there's no palpable lymphadenopathy. Um So on examination, you notice there's no significant abdominal distension, um palpations, no, no organomegaly, no masses. She's tender in the right upper quadrant. Um She's Murphy signed positive. Um There's percussion, there's tenderness over the right upper quadrant and on auscultation, biosensor present. So you wanna quickly a few just quick fire questions, Dr Slater. So just tell me what Murphy's sign is. Yeah. And so Murphy sign is a sign that's elicited by asking the patient to breathe out and then gently placing the hand below the costal margin of the right side in the midclavicular line at the approximate location of where the gallbladder would be. The patient is then instructed to breathe in. And normally during inspiration, the abdominal contents are pushed down as the diaphragm moves down. But if the patient kind of stops breathing in and winches with a with a catch, that's a positive test. So ideally, what I like to do is I put my hand down directly before below the right rib cage. Ask the patient's take a deep breath in and then out and then I push my hand up towards the rib cage and then say, and breathe in again. And if that elicits any pain or kind of catch on their breath, then it would prove to me that Murphy's sign is positive in order to conclude that it's definitely positive. If you repeat the same on the other side, on the left hand side, it should not show the same illicit response of pain. Um and therefore it would be a positive sign. Excellent answer, Dr Slater, do you want to talk me through your differential diagnosis? Sure. So particularly with a patient who is obese presenting with post prandial pain. Um jaundice, um Murphy sign positive, I would be worried about acute cholecystitis which is consistent with the blood results with raced infection marker um alongside deranged LFTs. However, the blood results and um accompanied with John, this are displaying an obstructive pattern. So I worry about a potential stone in the bio dot particularly the CBD um in any patient that has joined us. And with a rising infection markers need to make sure that they're not potentially developing sepsis secondary to retain stone because the colon gitic which would warrant a potential urgent ercp to relieve this. Yep. Excellent answer doctors later. And finally, what investigations would you like? We've got the bloods and you, um you talked to them excellently, what other, um what's the investigation you like to do just now? So obviously, I'd like to do the blood results which well, I suppose guides further investigation and, but particularly for me, my main differential diagnosis is um an acute, acute close cystitis, which is inflammation of the gallbladder. And so the gold standard for that would be an abdominal ultrasound. Um You can do a CT abdomen pelvis, however, this is less sensitive that picking up golf stones, however, it can be used if suspecting other pathology. Um If the blood results are present are kind of shown towards a more obstructive pattern of jaundice and you're worried about a retained stone in the CBD. Ever want to consider an M R C P to review the biliary tree and see whether or not there's any CBD dilatation or stones that can be removed with ERCP. Fantastic, Dr Slater and the diagnosis in the end was acute colecystitis. Um That was an excellent history taking and you present your findings very well and you came to the differential diagnosis and the investigation. You, you really got them across very well. Thank you very much to both doctors later and Dr Caldwell for their help. Okay. Sorry, that's I'm back on. Sorry that's has gone through the to thank you so much um for all the doctors for helping, we actually have a question. So from um same back. So um they're asking for multiple symptoms like this. How many questions do you need to ask in history of presenting complaint for each symptom? Would you do a full Socrates for each symptom or do abdominal systemic inquiry to look for other symptoms? Um So yeah, that's a great question. I think the principle of it, especially in medical school Oscar is to work through Socrates. Um And that, that, that is the kind of main, the main way to get through history. And a lot of the time that the people that will be in all skis will be actors and they will have a list of symptoms that they're experiencing that will kind of help guide you towards differential diagnosis. So if they do come up at you with a lot of symptoms, obviously is a bit daunting and a bit confusing, but it's important to kind of let them have their, let them speak and try to get a couple of symptoms from them and just work through as long as you're working through an effective Socrates, even if you don't come to the final diagnosis in a, in a Noski, the fact you've done a structured history taking and you've done a good history presenting plane, they really can't fault you and, and having kind of logical and plan at the end of it, like, like you wouldn't kind of clinical and clinical practice of bloods and investigations. There'll always be something that will try and help you get diagnosis. Like in, in the situation with Dr Slater, there is the blood results. And so, so yeah, I wouldn't panic too much about a lot of different symptoms, just make sure you kind of following the Socrates and uh technique um and kind of moving on. Um So just, just to be important to not rule out any kind of medical causes abdominal pain. So obviously this is a surgical themed session, but it's important to be aware of cardiovascular causes m eyes and aortic dissection, respiratory causes pneumonias, um metabolic D K S. Addisonian crisis is um sickle cell crisis, hypercalcemia, different infections. So, gastroenteritis, um T B U T I S um and neurological causes like herpes or herpes zoster shingles just to be aware of other causes like that. Um as well. And yeah, okay, I think is that has come to the end there sorry Janis is is that the neck is there next laid I think is that has come to the end there? Yeah, so thank you so much, Doctor Green also. Uh is there an X rayed? I think that's it. Uh Let me see. Can you hear me? I think sorry. That's right. That's it done. That's it done. Thank you very much. Mm Let me see. So I'm so uh yeah, so uh I think is that has come to the end? Yeah, so thank you so much, Doctor Grail. So uh I think that's it. Uh Let me see. Can you hear me? I think? Yeah, sorry. That's right. That's it done. That's it done. Thank you very much. Um So yes, so we have actually got upcoming sessions in the surgical series um led by Doctor Greenhill. Um and he is very excited um to be teaching you guys again. So keep an eye on Facebook on a foundation program group 2023 to 2020 for Instagram and really looking forward to see all your feedback um because we really act on it and these tutors have used their own time outside work to teach you all. Um And we really hope that you take away from it. Um At 7 to 8 tonight, we have the P S A session six by Doctor Sona Patrician on medicine and surgery for the final year series. We also have upcoming um teaching next week on Dermatology. By Doctor Lift Davies. She will be the lead for the medical final series. Um We also have a foundation ranking talk in January 2023. So I hope to see you guys there too. Everyone who's taking the S J T this week or the next week's good luck. Um, and we hope to see you guys soon. Thank you so much. Thank you so much, Doctor Journal and um, Dr Slater, um, Dr Boris Morrow and Doctor Cow. Well, thank you so much. I'll, um, now stop the, okay.