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All right, we'll make a start. So um welcome everyone to session three of Osk Express. Um Good to see you all back again. This week we are joined by the lovely doctor Nash Maraj who is an fy one and uh he's gonna be talking you through postoperative care stations and how to approach complications in surgical patients. So before I hand over to him, I will just introduce the rest of the team for people who are joining us for the first time. So um it's essentially a group of fy one doctors and then um me who are putting together these series, you know, these sessions to basically talk you through common final stations, how to approach them um kind of common presentations which could crop up uh the the top tips for OS technique. And then also we'll just talk you through example cases in, in the stations. Um And then over the course of the the next now eight weeks, we will also be providing you cases on aussies.com, which you can do after the sessions and whilst we are preparing you for, ay there is those are the common theme um you know, to be a, a safe practicing fy one. But we do have to just pop this disclaimer up here whilst we are a, you know, an educational resource to help you with sys. We are, we're not medical advice. Um We're not here to replace university teaching, so we take no responsibility for um any outcomes from the session. Um All the, all the, all the sessions are peer reviewed, but if you do notice any errors with the content, please get in touch and let us know and we'll change that straight away. So like I said, in today's session, we'll be having a look at postoperative care complications in surgical patients and then we'll have a little Q and A at the end for any general S TFA Q. So with that, I will hand over to doctor Nash um and he'll start off with postoperative care. Hello. Good, nice. Everyone. Can you all hear me? Ok, and we'll see if the chest is working. Yeah, got a little thumbs up. Ok, cool. Um, my chat is just, I think running a bit slow. So give me ok. I think that's fine. So, uh today I will be covering the two sessions that are, you know, very surgery focused. The first one is uh, oh, let me do some introductions. My name is a um, I am an F one in northwest right now. I am in Warrington, which is one of the Manchester D GH. Um I went to Leicester, obviously. Uh and I've been doing, you know, like sort of pa teaching since third year. This is my first lecture as a doctor. So I'm actually, you know, a bit, a bit about that. Um And I really hope you guys can enjoy this lecture and get something out of it. So I'll be covering the two sessions that are very surgery focused. The first one being the postoperative care station and the second one being complications in surgical patients. Now with the postoperative care station, uh really and truly is a, a source of um you know, Morph Fluids Station. Now, Lester has a thing against, you know, you prescribing 0.9% sodium chloride three times for the day. Um and they are very strict on the fluid regimen that you are going to be prescribing for patients. My number one advice for the station would be to go on that example, document that they have post it on blackboard uh and just work through that case, um just with a blank sheet of paper, work through that case and see if you understand their thought, thought process behind it. Um because they have like their very particular way of prescribing POSTOP fluids. And even though, I mean, a behold actually works on boards and in real life, um it is how you get the marks for the station. So the session is separated into 25 minutes sections. The first five minutes is reviewing any available documentation and explaining to the examiner how you would approach the situation. Um If you go through this, you know, the the fluid prescription and you think to yourself. Oh yeah, you know, it is just very easy. Uh three about food regimen. Um The amount of documentation that's going to be available in the station is the stressful part. Um You are going to have to read through pages and pages and pages and pages and pages of documentation to figure out what's going on. Um There was no one in our ay last year who was able to, you know, have a very full complete understanding of everything because it was just like such a volume of information that they give you um for you to then, you know, read very quickly, try to digest the information and come up with a proper regimen for the patients. Um the best way to focus to, you know, try to get on top of that is to read BBC news articles every day and try to skim skim, read them as quickly as you can maybe pick out some key points. Um That's like what I think would probably work. Uh So you have the documentation being reviewed and then you have to speak to the examiner a bit about, you know, um in the example that they gave it was analgesia. In my case, it's both postop nausea and vomiting. And then the second five minutes would be, you know, discussing a fluid balance and then your regimen. So exam criteria, um this is what an excellent student would be. So, ask the examiner appropriate questions. Um Yeah, you can see it although to the examiner if you want, but they aren't gonna give you marks, but it is under mark scheme. Um but if you want to shoot them out your thought process and sometimes it'll guide you um a little bit if you go off track, go off track. Sorry. Um So as you can see, you know, asking the examiner appropriate questions, so you need to have that ability to when you're approaching the examiner have the ability to say. Ok, well, what am I looking for? Well, no, what am I looking for an examination? You say something like, you know, what is their refill time? When was their last set of observations done? Um If they do have a catheter in how well is the catheter draining stuff like that? Um And then interprets investigations, users clinical reasoning, um recognizes that analgesia is not working in my case. Obviously, it's postoperative nausea and vomiting. Um and then, you know, assessing dehydration status and giving a um appropriate fluid regimen. So we will start with my case. Um I put together some uh documents I will give you guys maybe two minutes uh to, you know, scan this QR code, get documents up. Um There may be a bit of one or two tiny spelling errors on those. Um Please forgive me for that. Um But yeah, if you can scan the QR code, you will be taken to a Google Drive with a couple of documents which pales into comparison of um the amount of information you'll be given in the actual station. You know, I was trying to replicate as best as I could. Yes. So it's a QR code. If you scan the QR code, uh it should be working. It attracted yesterday, I can check it again. Yeah, so it's up. Um, there's a, an adult drug chart, drug chart. Sorry, I'm very sorry. Um, an adult and patients on uh anesthetic chart and obs chart, preanesthetic and a note. Thank you, Nadie. Thank you. So for the sake of time because we have a lot of sight to go through. Um, I'll just get started. So you have Mrs Gilmore. She's a 45 year old lady and she is admitted to the same day surgery, um unit for an elective laparoscopic cholecystectomy. So first thing I'll jump out for this case is that one. It's an elective case, meaning that this patient was admitted in a nonacute set and it would have been planned for months in advance. Ideally, patients who are coming in for a same day surgery are medically optimized. There's no ongoing, you know, medical therapies. Um, you know, stuff like hemoglobin is, you know, up there, uh your BP is very well monitored. Your liver enzymes are very well monitored and essentially just like nothing too acute. So in this case, you know, you have to put down in your head as she was previously well before she was admitted into hospital. So at 5 p.m. sorry, at 3 p.m. 20. Yes. So they're saying that Susan hasn't been able to keep any food or drink down following the procedure. Uh According to the operation notes, she should have restarted eating and drinking as normal following the procedure. How would you approach this patients and address the nursing staffs concern? So, first off, uh I just want to ask, uh if anyone could tell me, you know, usually when this postoperative nausea and vomiting start following the procedure two days. So it's anywhere within 24 to 48 hours. Um and patients who are high risk of uh POSTOP nausea and vomiting or patients who have had previous procedures where they develop postoperative nausea and vomiting. So it's kind of, you know, a key indication um that they may develop POSTOP nausea and vomiting again. Um If you guys take your mind back to year four in your obs and station, you know, when we were learning about hyperemesis, gravidarum. Um One of the key things was, you know, anyone can be vomiting. But if you're vomiting enough that your electrolytes starts to become deranged or if you're vomiting enough that you're, that you're beginning to lose weight. That's when you get very, very concerned. So when you know how, how the decision will work is that you'll be given this introduction, you know, how will you approach these patients and how will you address the nursing staff concerns? Um This is your time to show up to the examiner. So you need to be able to imagine sort of a scenario where you are the ent doctor. Um and you are gonna speak to the nurse, so you're going to speak to the patient. So I have a couple of points here um on the next slide regarding what you would do. So approaching this uh you know, scenario, you need to let the examiner know that you will have a very thorough understanding of the patient. So you have to review all the documentation that's available in front of you. Um including the preanesthetic workup operative notes, in particular, the postoperative plan. Um surgeons are very particular about when patients should be starting back eating and drinking. Um The type of antibiotics that they should be on um went to a MP no bowls being opened. Um Stuff like that. Also, looking at the drug chart is really, really, really important. Looking at your fluid balance is also important. Um The EWS score, obviously any recent bloods and a fluid prescription charts, um obviously in the station's case. So when you are the F one, you, if a, if a nurse raises a concern. You need to approach this nurse and ask them, you know, what exactly are you concerned about? Um And at this point, the nurse will give you uh their understanding of this patients presenting complaints. Um And the examinable sort of actors are, you know, mimicking barriers. So you can ask questions, seems like, you know, how long has this patient been vomiting for? Um And then you can also ask stuff like, you know, is there any blood and you vomit? Um What about bottles? Are they able to open their bottles? Um What about uh keeping any food down at all, keeping any liquids down at all um previous, you know IV food prescriptions? So in a sense of you know what to get, what you need to see to get marks on how you would approach your patient. It's very much a red flag. So you need to be looking out for when you're speaking to the examiner. So the examiner will ask you something like, you know, what do you want to know from this history? What do you want to know from this examination? Um And we, we know that the examination is going to come afterwards. So you need to do mood assessment. So focus your questions on the source of history. Um So again, it's just like it s quitters for any of the presenting complaints. So when did it start? Has it been constant and in particular for vomiting, you need to find out the volume of vomit. Is it bilious? Is it fecal in nature? Um And what medication has she been, you know, having to help with this vomiting? Um, sorry, this is quite a really slide. Uh You will tell me later on when you get these slides for her. So, uh I have it written here, Red Flags, um, worried about something like a postoperative obstruction um on ili um any metabolic disorders. Uh and then assessing the impact uh on recovery from surgery is also quite important actually. So, one of the things with postoperative nausea and vomiting is if you have a, if you have a patient who is constantly, constantly vomiting on board and you have a patient with, you know, multiple port sites or if they have a laparotomy scar or a hysterectomy scar or anything like that, wound healing becomes dramatically affected because your tissues are essentially coming apart and coming together and coming apart and coming together. Um And therefore it will affect the ability to recover post surgery as well. So what interventions would you do? Um You know, you take some time to review the documentation in my station. I had spent maybe three minutes um reading through everything and I still wasn't able to get everything done. Um And the consultant was most likely ask you why. So in the example that they gave um on, on blackboard, it was about pain in particular pain that was not being managed properly. In my example, I included postoperative nausea and vomiting. Um When the examiner asks you why in the station, you need to have the ability to clinically correlate the information that the examiner is presenting to you with the information available in the documentation. So from your reading, you should have come up with a, you know, sort of understanding why is my patients having this POSTOP nausea and vomiting? Uh or you know, why is my patient in constant pain? And one of the things that you will definitely have to look at is the drug chart and medication administration. Um A key thing to keep in mind is just because a patient is prescribed something does not mean that it is going into their system. It does not mean that they have been giving, given that medication. So if, if you guys had a chance to review any of the documentation I placed on that separate link, um you would have seen these two documents. The first is a uh regular meds chart. So just their um regular prescriptions and the second is their fluid balance chart. So on the, based on, you know, prescription, you can see the day how paracetamol going there is no route on that prescription chart. Um You know, for extra points, you could have asked the examiner, you know, what route are you guessing this paracetamol? Is it IV or is it oral? Um And then you can see that this patient is also prescribed cyclizine po three times a day. Um, and it's recorded as being given three times over the last 24 hours. So the reason that included this very particular, you know, case and this medication is because this is the exact type of thing that you bring in the station. Um, you need to have the ability to look at this drug chart and look at the information that the examiner is giving you and come up with the, you know, conclusion that, well, they have been vomiting, as we can see from the fluid balance chart here. They have been vomiting almost every hour. Uh, they've been vomiting and they've also been given their po medication. So you just have to think about it. You know, is that medication, is that tablet really staying in the stomach? Are you really having any therapeutic effect from having that tablet being given orally? Uh And you know, at that point, the exam will be, yeah. Well, good, good to know. Um, that you also know why they are having this POSTOP nausea and vomiting. Despite the fact that they have been prescribed antiemetics, I know the examiner will ask what would you like to do about these patients? So we if you do documentation, we spoke to the examiner about any red flags. Um, the examiner would have told you, you know, uh it is just normal vomiting, no blood, um, no cough opening. Bowels, well, passing wind. Ok. Bowel is not opening because obviously, um, no stool there because no food is yet. So passing wind. So we know that isn't, you know, something like an Alius. Uh, and then reviewing these two documents, you can put together that. Ok. Well, this patient is prescribed an antiheat. However, it is an oral antiheat and this patient is vomiting every single hour, meaning that most likely this antiheat is not having its therapeutic effect. So just in the chat, um, because I feel like I'm talking everyone's head off. Um, what would you do for this patient who has vomited? Uh, 12345677 times since this morning? What interventions would you let the examiner know about how would you manage these patients? Someone said IV mm little by mo Yeah, the resuscitation DV gi like it. I like it. I like it. Send you to be out. Yeah. So, um we noted this patient should have been eating and drinking as normally according to the POSTOP surgery notes here, um, they aren't able to eat or keep anything down. Um, and if you had asked the examiner, the examiner would have said there isn't any food in the vomit. It's just completely bile. Now, um, and then we need to consider what do we do about this po medication? We need to give it via different routes. Um This is when you have to put your you know, five years as well. You guys do the pharmacology exam, I think sometime in January. So um you put out knowledge, you know, you just apply that knowledge. So we know that cyclizine you can give it im you can also give it IV. Um So you can switch that medication and someone mentioned a V VG that's really, really important. Um So a VV gy electrolytes. Yeah. Hypercare. Yeah. So lactate levels are important. Um electrolytes imbalance. Yeah. So if we're going truly off of electrolytes, you do a full blood count and using ease. Um the BG is mainly to check lactate levels and you want to make sure that the patient is an extremely acidotic. Um However, we know that vomiting leads to what uh electrolyte abnormality. Thank you. Kind of famous. If you're vomiting all the time, you'll end up with hypokalemia, hypochloremia, metabolic metabolic alkalosis. Yep. Thank you. So you will end up put in alkalosis and the best way to go about seeing this patient is metabolically alkalotic or acidotic is by doing an ABG instead of a VBG. But A VBG is always useful if you want to check lactic levels. Um You know, in patients with severe sepsis who is presenting lus following an open um abdominal. Uh I don't think you have sorry if I said that previously, but if a patient does have a like it, um it doesn't always mean sepsis, what it means is that somewhere in your body, you aren't receiving oxygenated blood, um, in a patient who, so obviously we are looking at, you know, this post of nausea and vomiting and I have put it in your mind from the very get go. That is this post of nausea and vomiting. If a patient had this level of, um, you know, sort of upset following surgery, you do your full blood count, you're looking for inflammatory markers as well and you'll do an examination of the tummy. Are they extremely tender? Is there any signs of, you know, any perforation that was um done during the procedure? Something like a bile leak. Um, it is quite common in cholecystectomies. So if, if lactate was, it would be pointing you towards a different, you know, sort of halfway down, you know, a simple postoperative nausea and vomiting. So when you are doing, uh, uh your ABG, you look for any signs of alkalosis because if you are vomiting enough that it actually affects your acid base balance, it is very severe and any metabolic abnormalities need to be raised would have seen you immediately. You can try your best as an F one, but it needs to go to either an acid or A R um from there. So, monitoring this patient, you do a full set of bloods again, you do A L um you do an ABG, uh you would consider putting in a R tube in and if there was anything like a cough if there was anything like a chest um respiratory examination. So, hearing crackles all about, you start worrying about something like an aspiration pneumonia. Um And at that point, you order something like a chest X ray. Um For now, I think for gestation, the most important thing that they would want you to do. Um, after I went on that very long tangent about possible sepsis following elective cholecystectomy from bile leak is actually just changing the medication from an oral medication to an IV medication. Um, the station isn't about management. It's about, you know, fluid prescriptions and simple interventions. So you will do your oral medication change to IV medication. So you go from oral um, cyclizine to IV cyclizine. There isn't a set, you know, antiemetic that you do. I know usually postoperative nausea and vomiting is on. Um, some, you know, surgeons there, some anesthetists like to use cyclizine instead. Um, it's all just based on trust guidelines really. But, you know, you find a way to get that medication in them IV um, or iron, you consider an angio tube for a patient who is vomiting quite a lot. And the reason is because this X ray here is a nasty, nasty aspiration pneumonia. And you don't want a patient who came in with a, um, completely, well, before the procedure for an elective cholecystectomy to end up with an aspiration pneumonia and staying in hospital and then rechecking bloods in particular for this patient. You're looking for low potassium levels and your chloride abnormalities as well. Um And then obviously, you're looking for anything like signs of upset, um like inflammatory markers being raised a spike in white blood cells. Um But we'll speak about that more in the postoperative station, postoperative complication station. So that's the first five minutes where you review documentation, following review of documentation, you um Essentially, the examiner will ask you, why do you think this is happening? Um And then from there, you give an intervention, a very simple intervention usually. Um And you move on. Uh as I said before, the most difficult part of the station is the share volume of information that they gave you. Um We had a patient who went to ICU and then came out and it was really, really stressful. Um I do think it is because in reality, food prescriptions is very simple once you follow the um pathway that they have given you. So then you need to make it a bit more confusing. Uh in my mind, I think. So that's the first five minutes. And in uh keeping time in mind, I will move on now to your second five minutes of the station. So you help, you know that this patient um has the correct interventions going in and the examiner will now ask you, OK. Well, you know, can you talk me through doing a fluid balance assessment for this patient? Now at no point, did I, you know, formally a fluid balance assessment? A in fact, it was on, on placement in year three when an F one from another, um, trust moved to less obviously, um, showed me how to actually do a full balance assessment. Um, in reality, it's very much like a normal, a normal examination. Um, meaning that you start at your bedside and you move from the hands to the limbs, both hands to the arms, to the neck, to the face and then in the tummy and the legs. So just, you know, sort of thinking about where fluid is in your body. Does anyone want to, you know, sort of show any ideas what could be important on a patient's bedside that may indicate, you know, any fluid abnormalities. It's quite obvious actually BP. Yeah. Yeah. So if it is, and you want to know why do they have a cast and why are we so closely monitoring food input output? Um or you need to figure out, is this a long term? So, um did they have something like a sepsis? Sto is a really good one? Um Yeah, and you need to always check the SOMA output. When was the last time was changed or check your notes to see when was changed? Also the type of um you know, material that's coming out of the, is it very watery? Is it quite solid? Um And then a very simple one is actually just like dissipation of IV fluids running. Um, yeah, if you have IV fluids running, then something is up because you aren't able to maintain your fluid balance by oral intake. So we've decided to, you know, give you IV fluids. So everything that has said is also correct your psy, the character JVP, mucous membranes. Yep. So I like to look at it from, you know, you start with your hands and you go up to any hands. You look for any cold peripheries, very, very cold peripheries. That means that you aren't perfusing. Well, um you do put a refill time, very, very important. Anything more than two seconds is a red flag. Um You check the pulse when you're dehydrated, your pulse will increase. Um And then you check your BP, you move up to your neck, you look at anything that could extend a JVP, any signs of heart failure or fluid overload. Um And then you look at your face as well. You look at the uh mucous membranes, you have a look at your eyes. Um you look for any dry mucous membranes, any dry tongue. Um And then in terms of your chest, if they are looking food overloaded, you have a quick listen to the chest, but I wouldn't say, you know, it's the number one priority. Um And then you can have a feel of your tummy as well. See if there's any ascites on your tummy that's really important because if fluid is being filled up in your tummy, then you aren't getting fluid to your normal tissues. And then you can finally, and the examination by looking at their legs, um, edema is really important because um the amount of volume that patients can hold in their lower limbs is absolutely horrendous. So you need to figure out where this fluid is going in. Um Also if at some point during that examination, you know, the examiner said to you, ok, well, during this examination, in response to you explain what fluid assessment you do, the examiner says something like, well, you know that they have bilateral pitting edema all the way up to the hips. It immediately changes the way you're going to prescribe fluids because that sort of indicates that there is um you know, heart failure aspect to this. So your kidney disease aspect to this patient. So you just need to, you know, mention some things in in the notes, you know, just go from there. So through prescriptions, um massive massive um sorts of documents that we have here, a nice flow chart. Um You can see that fluid assessment is the very first one which we just spoke about. And then fluid resuscitation comes down here. You have a completely different station related to fluid resuscitation and that's like, you know, your at station. So for the station, this one isn't important. Um The ones you focus on is routine maintenance or replacement of um replacement and redistribution. This patient in the station is most likely going to need routine maintenance or simple replacement. Nothing dramatic. That would require you to speak to the renal team or to a senior because they want to have you, um you know, sort of show off the fact that you can prescribe fluids for a patient under one. So when we look at maintenance fluids, I know we've done this millions of times in ef three and EF four. However, as I said before, they in less so they have a completely different way of prescribing fluids. They're very particular about the um electrolytes that they want you to prescribe. They want you to keep very, very closely to the standards that they have here. And if you overshoot these standards, you know, given, giving more than one m minimal per kilogram, you're putting yourself in a bit of danger for some scrutiny from the examiners. Um If you want some extra brownie points, you can say stuff like, you know, after I give my routine IV maintenance flus, I will then reassess and monitor patients, you know, stuff like that. So uh that's where we're at. Everyone knows you use the upper limits as well. So it would be 30 mL per kilogram. You don't use the 25 years, 30. Um you have the one minimal of sodium potassium and chloride. Often people forget to put chloride in their calculations just 40 marks you need to be chloride and even though it may not seem the chloride is the most important thing in the world. Um And then finally glucose 50 to 100 g a day and replacements, I won't spend too much time on the slide because this is sort of, you know, severe replacement deficits. So these are the prescriptions that are available to you. Um You have 0.9% sodium chloride, 4% dextrose slash 0.18% sodium chloride, 5% dextrose and a half in solution. What I will say from the get go is um in their documentation in their example, they rarely, rarely, rarely used 0.9% sodium chloride. And that's because patients end up having, you know, maybe twice or three times the amount of sodium that they need. Um true IV fluids. And I think it's something that, you know, on your board and in real life and when you're at placement, no one really takes that into consideration. But Leicester for some reason has released, you know, this document saying, you know, we really do need to start focusing on these electrolytes. And as a result, they have used this 4% dextro 0.18% sodium chloride the most. Um I used this prescription in my exam as well because it gives you the flexibility of getting a high volume of fluid in them while maintaining adequate sodium levels, you know, not overshooting sodium quite, quite um a lot because if you think about it, a patient who's getting 1 L of 0.9% sodium chloride needs to be 100 and 54 kg, you know, at the get go. So that's quite difficult to come across anyway. But um we'll speak about that a bit more. Um Before I move on to the next. Oh, wait, never mind. So this patient's weight is 85 kg. Um If you have a pen and a paper, you can write that down and tell me what you would do in this case. Um Before we move on, um I have my prescription, there's no correct prescription, there's no wrong prescription in the station. All you need to do is justify the examiner. Why you decided to prescribe this. And um if the examiner questions you, you know, you show that you have the ability to weigh off the positives versus negatives um of your prescription. So I'll, I'll give you guys uh should I say two minutes? Um This is their fluid balance chart over a 24 hour period. Um So they are in a positive 100 ml fluid balance and these are the prescriptions that you can use in your exam. So I'll give two minutes. Uh It's an 85 kg patient. Ok. So in the interest of time, I'm just gonna move on now. So I asked you guys to do that prescription initially because I didn't want you all to see these um lab findings. So the reason I asked you to do that is because I want you to now look at your prescription that you have. Um And then based on these lab findings, in particular, this potassium level of 3.2 um what would you do differently for this patient? So we know what the maintenance potassium is, we know what the maintenance sodium is, the maintenance fluids. Um But now we know that this patient is in a potassium deficit, a very small potassium deficit. Um How would you modify your prescription? Um Would you do something drastically different? Would you just change the amount of potassium that you added in one bag? Would you do it over a certain period of time or would you do it, you know, just immediately in that single bag, you just increase, you know, from 20 millimoles of potassium to 40 millimoles of potassium. So, uh if you just take some time to just reflect on whatever prescription you had before, now that you know that he so she does have a, a hypokalemia, uh what would you have done differently for this patient? All righty. Oh, so when you get to this point in the station, the examiner will ask you to work out for them. You have a little calculator, the examiner will ask you to work out for them, the patient's daily requirements and you need to be able to work it out quite orally and quite easily. Um I don't know about you guys. I get very flustered with maths when I'm stressed. So um II spend a lot of time practicing photos station. So you have um 85 kg by 30 which is 2500 and 50. Then you have sodium which is 85 and then you have potassium which is 85. However, we're going to aim for 100 millimoles because she is currently at 3.2. I would say that if you have a patient who is in a deficit, um aim for 20 millimoles above what their usual maintenance dose is. If you go for 40 millimoles above your risk of, you know, giving a patient weigh too much potassium IV uh And then you have the chloride calculation which you cannot forget. Um And then the glucose calculation 50 to 100 in 24 hours. So this was my prescription. I just put a small note here because I just checked it. This should be so chloride should actually be 177. I apologize. Um About that. Uh That was my error. I think I just changed it last minute. So in my prescription, I thought this would be useful because this is how they want it to be prescribed. Um You need to write your name blah, blah, blah, blah, blah blah 1 L. And then the medicine that is the addition, which is the potassium is your potassium chloride which is blah, blah blah. And then the dose is the 40 millimoles or the 20 millimoles. Um And then IV and then you do it over eight hours, eight by 4, 28 by 324. Um Yeah. Yeah. Yeah. So that's over 24 hours and then you sign um and then after you do this prescription, you then need to calculate the electrolytes from this prescription. So there's two different, you know, calculations they will do in the station. One for the daily requirement to show off to the examiner and then one to show the examiner um how much you've actually given the patient. So in my patient, I have given them um 2500 milli milliliters, I've given them 77 millimoles of sodium, um 100 and 77 of chloride, potassium 100 millimoles and glucose, 100 millimoles and you just need to add them up using this section. So that is my prescription. Do you? Yeah. Yeah, you do take into consideration. So the insensible losses was actually part of this of the fluid balance. Your insensible losses need to be part of your fluid balance. Um There will be a note when you are about to prescribe and it will say um accounting for ongoing sensible insensible losses of blah, blah, blah. So when you do your fluid balance, you need to add it in. Um no No, no, it is not already noted in your charts. I included this in here for you guys. Um Sorry about that. So they will give you this source of chart here and then you add and the insensible losses and then you come up to this, but it'll have like ample space and everything. All right. Yeah, exactly. Same unity. So this is just my prescription. There's many ways to prescribe it. Um If you want to use this as like, you know, an example of uh how to actually write you fluid prescriptions and make sure that you write it in the actual fluid prescription chart, not in like something like regular meds or anything like that, you know. So just moving on now to some common teams in POSTOP care, essentially, there's two things that they can bring for this patient because the patient needs to be know by mouth and one will be a patient in severe pain. Um POSTOP or one will be a patient who is having postoperative nausea and vomiting. So I'm just gonna briefly briefly discuss both of them. So, postoperative nausea and vomiting, going back to the basics of it, you know, you have your vomiting sensor and so many different aspects of the human body control this vomiting center. Um one of them being medication. So when you're thinking about POSTOP nausea and vomiting, think about patients who are at risk of developing POSTOP nausea and vomiting. Um These are patients who, you know, have existing electrolyte abnormalities, liver abnormalities, um and patients who have longer surgeries as well. Uh When you think about reducing the risk of patients developing POSTOP nausea and vomiting, intraoperative steroids is quite common. Um to give you give an induction dose of steroids um during surgery. Uh and then you also need to adequately hydrate the patient during surgery, shorter surgery times is also important. Um And we also discussed, you know, um the fact that patients who are having postoperative nausea and vomiting have a risk of wound dehiscence. Yeah. So essentially, I looked at the document that they gave for you guys and it does say that they will not ask you to assume, um that the patient will have. So they will ask you to assume the insensible losses. They won't ask you to assume X amount of onfi from a sto or they will not ask you to assume X amount of output from vomiting. Um So it's based on that fluid chart you given, which obviously makes it very difficult, but given the case, you have to separate that now from the fluid shot in front of you. Um and then treat the second part of the S as. Ok. Well, this is the fluid prescription that I'm doing given this 24 hour time frame um that we had previously for this fluid balance. Um They don't expect you to do anything drastic like, you know, account for a decreasing um you know, decreasing volume of uh vomit that the patient is going to be having um postoperatively. Now, do you change the prescription? So you look at the fluid balance that they give you in front of you over the 24 hours, you are the insensible losses and then you work from that um nothing too complicated um following that. So POSTOP nausea and vomiting, you know, risk of incidence, electrolyte abnormalities, et cetera, et cetera. Um And you always approach as patients in a fashion. Uh And then as we spoke about before you do some bloods um including HV, Maori W are very, very, very, very, very common um in patients who are vomiting quite a lot, it's gonna appear as streaks of blood, it won't be coffee ground vomiting, it will be streaks of blood that they are bringing up. Um And then as I said here, the arterial blood gas for the metabolic alkalosis um considered an NG tube alert registrar consultant if abnormalities are there. Um This is a slide from uh NHS Law School, one of those hospitals up there. I thought it was quite useful um in terms of the drug uh class and then the route and dose and then any comments that they had on it. Um in reality, once the drug is being delivered, uh oh and truly, it should be fine. Uh Now we are going to talk a bit about patient control analgesia because for my si was given feedback, which said, does not know about patient control analgesia question mark. And I realized that I did not know much about it in reality. So patient control analgesia, there is essentially two types of them. Um And I do think that, you know, a lot of us did not perform well in our ay for fifth year and less likes to bring to sort of topics that people don't do well in. They bring it back um to prove to examiners and like, you know, whoever that, you know, we actually did teach them this this time. So there's two types of uh patient control analgesia and are very particular about it. The first one is a bolus dose of PCA. Um Usually it is morphine, it could be given IV in our station, it was given epidural. Um And what that type of PCA is, is a single dose of morphine that the patient has control of um and whatever during pain and they can have, you know, 2.5 mgs of morphine. Um What I would say is in patients who are, you know, are using their PCA quite often in that sense, they will be um eligible to have a the second type of patient, patient controlled analgesia, which is patient control analgesia where there is a standard basal dose of analgesia, which only uh anesthetics. And the acute pain team can actually prescribe them lesser. Um I did not know that before. So I have the two charts here. This is from the chart um which I actually had never seen before prior to this. So the as required medicines, um this is the one that I was talking about, this is a bolus dose which you as an F one would be able to prescribe and you'll see that the, whenever they do do a bolus dose, it will be documented here. Um And then if they did a second bolus dose, it will be documented here and then blah, blah, blah, blah, blah, blah. Um And then the second type of PC is, as you can see here, it says uh back infusion, 0.50 to 5 mL S per hour and only an anesthetist can actually prescribe this medication. So if you do get something on patient control analgesia have that in the back of your mind that you as an fent can give the bolus dose. But if they need continuous patient controlled analgesia, it needs to be a senior. Um which I think was the answer to oh because they kept asking why this patient was in pain. So the answer was, you know, they needed a specialist review for their patient control analgesia um to essentially add on a background um infusion. Yeah. So that is patient control analgesia review the anesthetic charts. Consider what you Oh yeah. Consider the patient actually understands told to use PC. It's just like asthma, um you know, you tell them to click the button and then they get locked off for a period of time. Some patients, you know, may not understand that completely. Um And then always consult anesthetics. Um You can also use the anesthetics a lot if someone is AM and then you don't have paracetamol, why not give them some paracetamol, you know, um that is the fluid station uh for you. I'm sorry if I wister out really quickly, I'm just conscious of the time. Um So I think what I will do is I will see many questions for the end of the lecture. Um And what we can do is take a cheeky 30 minute break now because I am trying to finish at 830. Um I hope that we do not um finish too late but aiming for air 30 if we need to um do do do, I'm not too sure what you mean by that. Uh So the amount of electrolytes lost is, you know, assumed from the most recent uh user that you collect from the patient. So in this patient, we can tell that she was bombing over a 24 hour period. And um s if you drop your email, I will ask when record to email you feedback form. That is very kind of you. I really appreciate it. Um diagram from a nice chart. For example, it's just a diagram Yep. So the bolus doses can be prescribed by the affluents. But if you need a background basal dose of PC, it's only a specialist. I can prescribe that. Um So in terms of electrolyte losses, guys, what we need to think about is, as I said before, with the, if you're given a fluid balance chart, that's a fluid balance chart in front of you and you operate on that 24 hours, you also need to operate on the electrolytes that you have in front of you as well. Um And those electrolytes will be the most recent electrolytes. You aren't expected as the F one to account for anything in advance of that or you are expected to do, prescribe um and correct a very simple electrolyte abnormality. Um Electrolyte abnormalities are very intense, it's very easy to mess up. Um And I don't think that they're going to bring something like a hyperemia. I don't think that it will bring something like a hyponatremia for you. Um It would be a very simple um potassium deficit if they bring it at all um as it did in the example as well. So in the example, they weren't accounting for, you know, any ongoing losses. Um Well, that was a pain example, but they also stated explicitly, you aren't meant to be accounting for any ongoing losses from anything like diarrhea or anything like vomiting or anything like so output. So keep in mind just the electrolytes in front of you and the um fluid balance shots in front of you and go from there. So, what I will do is I will do a two-minute break instead. Um And then we will move on to the complications in a surgical patient. Um There are three cases, hopefully spending about 10 minutes in each case. Um And I would be asking lots and lots and lots of questions and then we can do a cheeky Q and A afterwards, um, for you guys. Yeah. So I'm just gonna take two minutes to stop to our hearing and, uh, I will speak to you guys in two minutes. Mhm. Mhm. Right. I am back and ready to go. Um, just because I want you guys to have a good evening when I'm gone. So, complications in a surgical patient, um, it can vary how to bring the station. They may give you a patient who is POSTOP and having a complication. They may give you a patient who has just recently, recently, recently been seen by the surgical team awaiting treatments and then they have a complication. Um, remember when you're thinking about surgery, there's a three main types of surgery really. There's to, um, there's urology and then there is gen, um, S and guides, you know. Yeah, but, you know, it can definitely come up, I guess oncology, but like, you know. Right. So, you know, when we were in med school, those are the ones that we kind of look out for. And then each specialty has a very common um surgical complications with their postop i, with their, you know, perforated bowel leading to sepsis with their anastomotic leaks leading to sepsis with their bile leaks leading to sepsis. You know, and then urology with any scarring, any uh tear to the ureter, any prostatic problems or any bleeding, um and passing urine. Uh and then, you know, which will almost always be compartment syndrome um or a acute ischemic, like that's kind of going towards vascular, but, you know, so top tips, uh 10 minutes session focuses on utilizing your knowledge from your surgical blocks. Um surgical history taking, when you do a surgical history, you need to focus on, you know, just that surgery, um you know, asking questions about how they've been getting on following the procedure is really important. Um One of their baselines usually like um is there any sort of intense blood loss in things like uh see, you know, if there's a open fracture or in gi if there's a gi bleed? Um and then social history as well, you know, how, how well is this patient? Does it really make sense operating on them? Um That's going along sort of a a grades. So basic surgical procedures, you need to have a good knowledge of um because the complications are, you know, tied to these procedures um including year four procedures. So you need to have a good understanding of, you know, any, any procedures that you came across in gynecology, um you should be able to uh discuss with the patient because it's considered in this, you know, surgical complication. Um And then you should be able to, you know, come up with some differentials and management in acute scenarios. Notice that is a acute scenario because um most of the time if it is a severe surgical complication, they may be quiet, excuse me, they may require surgery once again. So the first five minutes review available documentation usually just a paragraph in this, it is not a lot of information that you get, it's usually just a paragraph, the EWS score. Um and then you speak to the patient, get a good history from the patient in three minutes time. Um discuss any examination that you would like to perform um with the examiner and the examiner will give you the findings of that examination and interpret an investigation. Um More than likely it's going to be an X ray or it's going to be an ECG. Um If they wanna be nice, they may give you some blood but you know, first five minutes is a very quick history. Um I the examiner what examination findings or positive slash negative. Um and then do an interpretation of investigation. The next five minutes is you review all the results available to you that stuff like blood work cultures and you feel the imaging, you look at their drug chart, you look at their fluid balance chart. Um and then you have to clinically correlate the examination findings to you what the entire scenario was about um to come up with a diagnosis and then you know, discuss management. So just a bit about surgical histories I have here aim for three minutes, practice for your friends. When you are speaking to your patients. There is no need for a drastic opening question like, oh, how can I help you today? Um You are going to be given a paragraph which says that this patient has a new onset, right? Iliac fossa pain um with pr bleeding and you then need to figure out, oh, well, where where does this patient fit in? So no need to do a really big open question. A focus history is always focus on a single symptom really on the history of presenting complaints, especially important to clarify timelines in surgery. Why? Because you know, ischemia takes its time to act and stuff like, you know, when last did to eat and drink is also quite important if they need to go into theater again past medical history, as I said before, anything that would affect their A sa grade dramatically. Um diabetes, immunocompromised patients, anemia, prostatic diseases, all of these things really do impact emergency surgery. Um And therefore, if it is a complication of a patient, you know, we need to be aware of it social history wise, smoking and drinking is the bane of, of bowel healing if you ever do an anastomosis on a patient who smokes and drinks. Um and has hypercholesterolemia essentially metabolic syndrome. They are at a very, very, very high risk of something like an anastomotic leak. Um The reason being any diseases which affect the vascular vascular system, essentially affect tissue healing and as a result, they will not be healing as they should. Um post surgery. So um fully structure the usual um history focus on a single symptom, define a timeline. Um Think about social history in terms of smoking, any comorbidities that you need to be aware of. Um and then go from there, you'll be given a single investigation during your first five minutes. Um And you also need to speak to the examiner about the examination, the examinations that are quite common. Obviously, the abdominal exam, the respiratory exam and joint exams look for you move for joint exams and I would add in to a vascular assessment for any M SK exam that you're going to be doing. Um I wouldn't, I wouldn't necessarily say, you know, do a peripheral vascular exam unless you know, almost and that it was going to be an ischemic limb. Um But, you know, so you have to think through these exams in your mind and when you're speaking to the examiner, they will ask you what are you looking for when you were doing this abdominal exam. So you aren't going to be having like, you know, a nice social conversation of, oh, I'm checking your hand for any hepatic flap. You know, it's like, you know, I'm checking the abdomen to see if there's any rigidity. Uh I'm checking the abdomen, see if may sign is positive, you know, something like that. So sessions, I have three sessions. Um I am going to try my best to get through them in time. So we will start off with the first session. Um Let me not skip the sl second session time. Um We will start with the first session. Um A left hemicolectomy. So you have Jeremy. Um He is a 67 year old gentleman. Um He attended hospital three days ago for an elective left hemicolectomy two days POSTOP. He complains of severe abdominal pain which prevents him from sitting still or even thinking straight again. Like the last case that I said he came in for an elective left hemicolectomy. So this is a patient who was previously fit and well prior to admission because surgeons love having people medically optimized before they operate. So in terms of a history, um you're given this paragraph, uh this paragraph here. What type of stuff would you be asking these questions in your three minutes if anyone wants to be brief? Oh, actually, I'll give you guys some more information. So before you speak to the patient, this is his EWS score. And his food bo shot quick soccer to you. Yeah. Does this information that I give you guys the EWS score and fluid balance chart? Does it point towards anything? You know, this acute onset abdominal pain can sit still following his procedure? I know I'm not giving you guys much information. It's because I expected everyone to play. Oh, yeah, I'll ask about past medical history or I'll ask about radiation of the pain. Yeah. So Matthew is on correct lines. So, in your three minutes, what you want to do is always introduce yourself as usual. And guys like when you are in the, it's really good to introduce yourself as a doctor who is looking after the patients. Um, if you're in year five and you're still saying, you know, I'm a medical student. It does the of it really does change the exam or source of opinion. Um, I've had a feedback before where, you know, they always that I introduce myself as, you know, doctor looking after the patient rather than as a medical. So keeping those things in mind as well, you know, the way that you present yourself is always important. Um I gave this statement, you know, I understand you've been having some pain and tell me, can you tell me a bit more about that because I don't want to ask the patients, you know? Oh, how can I help? Um, I need to let the examiner know that this is a very quick history. I'm focusing on your pain and you tell me getting it going. When did it start? Does it ever go away? Have you been eating and drinking following your procedure? That's important. When last did you open your bottle slash pass urine? And is it the first time that you're having surgery? So, he says to you, you know, it's an acute onset, sharp stabbing pain in your lower abdomen started 45 minutes ago. Um, no radiation of the pain, eating and drinking as normal following the procedure, um, has not opened his bow as yet, but has passed when removed today. Under the surgeon's orders as fluid balance, no longer necessary. No urine production in four hours, no surgical history, medical history. He has hypertension, heart failure and prostatic hypertrophy. Your hypertrophy hyperplasia, isn't it? Um, hyperplasia? BPH? So, from this history, you know, very quickly, you find out that it is very acute. He recently added intervention done to him, which was removing in um, and once you remove the catheter, you need to monitor it to see if this patient is able to pass any urine. He says that he isn't able to pass any urine. So what would you do? Now, in terms of what examination do you think would, would be best for this patient and just to orient you, um, essentially a patient will be there. Um was saying you speak to that patient for three minutes after you finish your history. There will be no prompt saying, you know, three minutes is up. You need to decide when you've had enough information from your history. You turn back to the examiner and then you tell the examiner this is the examination I would like to perform or the examiner will ask you um, well, what examination would you like to perform? Um, abdominal focusing on the bladder? So what finding would you be looking for on an abdominal examination for this patient? Distension of what reroll and tenderness, keratosis? I think so. Yeah, distended bladder, super pubic tenderness slash pain. Yeah, I agree. I agree. I agree. So I think it's good to, you know, say something that you want to definitely look for um like the distended bladder and super tenderness. And then you also say something like a red flag that would point you towards a different. So you should be examined while you are looking for a um you know, acute urinary retention cause of this pain. You are also worried about something like a um you know, some sort of perforation or some sort of leak and therefore you'll also be looking for paraonis. So you cover your bases there essentially. Um So abdominal examination again, what are you looking for? A distended abdomen is usually an indication for obstruction, a rigid abdomen, indication for perforation, localized tenderness is inflammation. And you should always, you know, say something like, you know, I also examine the surgical sites, that's any signs of infection dehiscence. Um And then also look at any abdominal drains. Um, if they do have abdominal drains in, I always love this about um surgery. I love that you can see the nine areas of the abdomen and have an understanding of what organs lie below. Um I think it's absolutely fantastic and you always get like, you know, some flashy points if you can say, oh yeah. Um, a right hypochondric, you know, blah, blah, blah. So, yeah, just keep that in mind. And so we spoke about the, uh, you know, the history, the examination. I know they will give you an investigation to interpret it for these patients. They have done a bladder scan. Um, and this is the results of the bladder scan. So, can anyone tell me what the normal, you know, volume of urine you would expect to find in a bladder post void? Mhm. And then what's considered like a high volume where you're kind of like, oh, something is definitely wrong if this patient hasn't passed any urine as yet. Yeah, Grason and 500. Um, I have been like, sort of cautious and if someone hasn't opened their, um, open their, well, if someone hasn't passed urine, sorry. Um, and they have a about a scale of, and 350 they're feeling, you know, some pain, um, that I always consider putting a cat in any way because essentially they're just going to like, you know, fill up with fluid. So, after that, so you've interpreted correctly and the examiner will now ask you, you know, what do you think your diagnosis is? And you will see the diagnosis is most likely an acute urinary retention because he's having severe pain and he has a history of BPH and he's had GA and his blood has gone shows more than 500 more than 350 mL S. Um, so we're now only second five minutes, you're given some more information about your patients. You'll be given some bloods, you'll be given their regular medication. Um, and you will also be given a prescription chart, as I said previously, if you look at medication, you need to look at the actual prescription chart. Patients can be prescribed medication. It does not mean that they are actually taking that medication. You need to see that they have taken that medication by that, that they have by any. Um, see that it was given. So in the remaining time you find out that his regular meds are novorapid, Metformin to Lewin Calci two Ramipril Bisoprolol and then you'll be given this information and then look at your prescription chart and make sure that he's been taking his medication. Um, I have a set of bloods here for him. Um, anyone wanna point out anything abnormal in your bloods and if you do worried about it, I mean, there's definitely some abnormalities there Yeah, white cell and CRP talk too much about Jessica. Um, basically I included this because in surgery we, I be like, I'm in surgery right now. I'm in cardiology. But in surgery when you finish your procedure, essentially, your whole body is going to be inflamed. So, ACR P that is slightly elevated like 76 isn't something that would be too concerning and if you want to get, you know, some marks from the examiner, what you also can't see is you'll be looking at the trends of these results. So any abnormal finding, you always to look at the trend because a single snapshot of an investigation um carries little value when you have access to an entire trend of information. So, um, looking at white cells, you see, you know, day after surgery, white cells are extremely elevated and then they will come down. Um and then CRP will also be very elevated, they will come down. Um, platelets at times can be elevated because, you know, it's inflammatory response so they can come down. Um, and looking at uh the actual picture that we have for him, there's nothing that we know that is pointing towards the sign of infection. Um, his uh temperature has been stable through admission as well. Um And we know that your bladder is maintaining some fluid. Now, if we put a catheter in and then it does come come out that, you know, it's very, lots of pus lots of sediments, any blood don't be thinking more along your life of, you know, um a uti secondary to the acute urinary retention. But we haven't gotten there yet. All we know is that we're very worried about this acute presentation of the suprapubic pain that he's having not to worry about the fact that the white cells are slightly elevated and the CRP is slightly elevated. So the diagnosis, acute urinary retention. So you give the main differential and you need to justify why you think that is based on the entire scenario. Um And then I have it here, acute onset super pubic pain, no voiding for past medical history of BPH management. Um Think about what you would do as a ent doctor acutely for this patient. Um No, I would not give ibuprofen to any patient in reality. I think that's terrible what I can do. Oh, so no, um so acute management for these patients, they'll ask you, you know, what would you do? Um For brownie points, you can say at the bedside, this is what I'll do and then what I'll do after leaving this patient bedside will always be, you know, speak to seniors. So you can catheterize the patient immediately and then avoid emptying the bladder completely. This is something that I did not know during med school. If you have a bladder, that is more than 500 MLS full. If you avoid that very quickly, the patient can drop their BP quite easily. So you avoid it in segments. Um You can do like 500 then you can do 300 a couple, you know, like maybe an hour or two later. Um And then long term management, um cat out, as I said, for blood clots, repeat bloods including a PSA and discuss with urology. Um if the patient goes back into retention, um and then I have a little slide here just for a reminder of what prostatic on the prostatic looks like in BPH. So you have this, you know, inflammation, sorry about inflammation and hyperplasia that prevents the urine from coming down. And the only way to get through is really just by putting a cast in. So that's the case. Um a patient who went into acute urinary retention following their procedure, very easy to manage with a catheter, um brownie points for long term management, you know, doing some blood, getting a PSA done. Um speaking to urology about it if they were to go into retention again. Um I have two more cases. Uh I'll try my best to speed up a bit guy. Sorry about that. So you have your second patient. A total hip replacement, Ravi Rana. Um an 80 year old gentleman attending hospital five days ago for your right elective total hip replacement, five days POSTOP receiving rehabilitation care informs you that he feels more breathless than usual. So um a bit more information that they'll give you prior to speaking to your patients. You get their early warning score. A respirate of 23 start of 94 on air BP of 108 on 78. Uh pulse is a bit elevated temperature is fine. You have this POSTOP pelvic x-ray looks fine and you have the anesthetic pre op workup. Um So you can see that he has uh asthma, you can see that he has hypertension. Um He's under G A and it's for a right? Um Well, sorry, right. Osteoporosis. So, in your three minutes, what type of questions would you be asking this patient about this acute onset breathlessness that he has five days following his surgery? Trust me is a good one. Yeah. Hemoptysis is also a really good one. Cough is a really good one. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah, cool. So, um again, I did like this. Um, mobility is absolutely fantastic. Yeah. Yeah. Yeah. Palpitations. Yeah. So leg swelling really good. Um Three minutes. You do your introductions, I understand that you're feeling more breathless. So you introduce, you know this scenario, you let them know this is a symptom that we're going to be speaking about. Um, when did it start? Have you been coughing, brought up any blood? Do you have any chest pain? Um Have you been mobilizing after surgery? Um So patient tells you he woke up this morning feeling like he can't catch his breath. Sharp pain over his right lower rib with some inspiration. No cough overnight did bring up some blood, um, during a single coughing episode this morning, no temperatures. Previous cholecystectomy 33 years ago has been mobilizing with a physiotherapist twice a day for the last four days. Two. That was, yeah. How pain being controlled POSTOP is good. Um, so what examination would you do for these patients? I think it's quite obvious you would do a resp exam and on the resp exam, what in particular are you looking for? Check legs? I like it. I like it. Yeah. So rest the exam, you're worried about this because he had a single coughing episode. So you're looking for any signs of, you know, decreased air entry around your chest. You're looking for any signs of, you know, um wheeze because we know that he has asthma. So we want to see if there is a global wheeze throat. Is this breathlessness related to his asthma? Is it not related to his asthma? Um And then most importantly, I would say is checking your legs. So total hip replacement, any um you know, orthopedic surgery is a very, very, very, very, very, very, very high risk for DVTs. Absolutely notorious for them. Um So the appropriate examination that you would do is your breast exam. You're looking for stuff like using accessory muscles. If they are, then, you know, it's a sign of impending respiratory failure, percussion of the chest. You want to know if there's any effusion, wondering if there's any consolidation, breath zone, excuse me. Um any cause crackles indicating something like pneumonia and you wheeze indicating something like CO PD or asthma and then calves really important parts of the um respiratory examination, a unilateral swelling, erythema painful. And you will be given this image when you say, oh yeah, I'm going to be looking at his calves for any swelling. So you see this image, the examiner gives you this image and then the examiner gives you this investigation to interpret. And can anyone be brave enough to tell me what you think about it, please? Ok. So I'll just quickly go through the X ray. So you're looking at your airways, you can see the tracheas central. Um Yeah, you see the trachea essentially coming down. Um And then you can see the bronchi here and then you look at your lung feels nice and clear, nice and clear. And then you look at your costophrenic angles with the hot border. You can see the do left costophrenic angle is absolutely beautiful. The right costophrenic angle. Hm Not really matching up is it? Um So I included this because this is exactly the type of thing that they would love to do in a they would give you something that can throw you off. You know, everything is pointing towards one diagnosis and then they give you something that is pointing towards something else. In reality, I don't think this is a pleural effusion. I can still see very faintly, some uh penetration here going through very, very faintly. So I'm not too worried about that, but it isn't, you know, your B standard um normal chest X ray, but the clinical image that you have so far has all been pointing towards a DVT. No, nothing is stopping a patient from having both um A DVT and a right sided pleural effusion. But I don't think this is the major cause of concern so far. In addition to that, um, you have to look at the right lower rib with inspiration. Typically with a pleural effusion, you don't get a recent inspiration unless it is, you know, something like an M pe mo that's actually rubbing against the th membrane and very inflamed pulmonary vessels look larger. Um I have no idea about that. Absolutely no idea about that. Uh But sure. Um, so you finished off five minutes of the station, you're on to the second five minutes, you're on to the second five minutes and you're given more information of all your patients investigations wise. I have a list of investigations there. Um Sorry, a list of results there for you and you see his normal medication. So he's on amLODIPine, Ramipril, um Salbutamol Foster, uh which is just a, a steroid inhaler and you can see from his investigations, he's very slightly anemic, um, white blood cells are ok. Platelets are a little bit elevated. Again, CRP is a bit elevated again. EGFR is 88 of 6.8. A creatinine of 89. Again, very rarely would a patient be in hospital and have all investigations being absolutely crisp. Perfect you as an ent doctor needs to decide what exactly is actually going on. What's wrong with this patient? What can I do acutely? You aren't going to be able to, you know, an EGFR of a a, it is in the context of acute onset chest pain. Um was an inspiration uh with unilateral leg swelling, not really the, you know, cause for concern right now. So if you were to read this examiner and you say something like, you know, he is slightly anemic, um white blood cells are ok, platelets are slightly elevated, it gives you examined, you understand that you are able to see that something is wrong, but you are also focused on the overall clinical picture here are not aiming to, you know, do hematinics right now um to sort out this hemoglobin because you only have five minutes and the five minutes you need to use to help with the pe. So another investigation that you will get in this five minute is an E CG. Um If anyone wants to say briefly what's going on with this E CG um So it's just a sinus T um we can see P waves quite ly cure us is regular going on T waves there, nothing too scary. Um No ST depression um quite happy with his ECG I mean, there are patients with a pe usually will not stay ay anywhere. So at this point, the exam I will ask you, you know, what is your diagnosis? And you will see a pulmonary embolism secondary to a DVT. Um and then you need to clinically correlate it to the findings. So you, you see findings from history, um chest pain and he can point to was on inspiration, single episode of hemoptysis. Um respiratory exam revealed a clear chest and unilateral leg swelling and also the previous history of a total hip replacement. Um All pointing towards, you know, this DVT um slash P EI thought I made this case quite difficult because I did include, you know, a lot of information. So he could have been having an asthma exacerbation based on his history. I included that chest X ray would be very, you know, not too crisp and clear, right? Costophrenic. Um but he did not have a pleural infusion. So, managing post pe um you need to ask, is the patient hemodynamically stable. If the patient is not hemodynamically stable, which you will know by doing their BP and their heart rate, you need to traum the patient which is with players. Um I don't think they will ask you to do something like that. Um And if the patient is hemodynamically stable, then you will need to prescribe some, do a I do not recall them ever asking me the dose um for the do a really um I think you just need to know that it is a do a uh for, for the patient. And then so you know, that's your acute management and then further on what would you do, you will do a Doppler Doppler scan. Um You do a clotting profile, you do an ABG and then you can get some brownie points from saying that treatment is for 3 to 6 months. So does anyone want to let me know why you are doing ABG on this patient? This is kind of moving towards your e to E station. Yeah. Yeah, exactly. Julio. So um I would say maybe 10 more minutes if everyone can, please bear with me. I really apologize. Um So third case um uh diagno diagnostic laparoscopy. So you have Jan Jan Rasbo 29 year old woman attending a surgical assessment unit seven days after he after the elective diagnostic laparoscopy. Um She complains of pain and tenderness around her umbilical port site. So notice that I change the scenario each time I know that all these have been elective procedures which is fine, but you know, you're seeing patients in a surgical assessment unit rather than seeing them in a ward this time. Um So you're on the surgical assessment unit, pain at the um umbilical port side for her um laparoscopy. So, what type of questions would you ask? This patient pain and side again you go through. So you keep it nice and simple. Nice and quick you ask about her, um, recovery over the last seven days because that's really important. She has had surgery one week ago. So she should be improving since that one week rather than, you know, deteriorating. You ask about stuff like blood. Um, if she has noticed any blood at your port side, you ask about stuff like temperatures. Um, you ask about stuff like any bowel leaving your port sides, any herniation. Um, you ask about if she is eating and drinking. Normally you ask about if she is passing urine, passing poo. Ok, as well. So, um, some more information for the station. Uh, her EWS score is three respirate of 22 a 96 on air BP 99 and 64 heart rate 1, 12 temperature of 38.4. Um, and she is eight and you got theater notes this time, the theater notes say that she has gone in for a diagnostic laparoscopy for endometriosis. Um, she's had a five year history of cyclical abdominal pain, dull, aching, cramping. Um, single instance of blood in the stool prompted invasive investigations. Um, she has a past medical history of hypercholesterolemia surgical history. She has an appendectomy in 2014, um, findings. Now it tells you that she has found that their phone, sorry, Endometrial po of Douglas sample sent for cystoscopy. I don't even think it is cystoscopy, biopsy for um follow up home. Once away from G A with DBC prophylaxis and gynecology, follow up fine. So we know our body patient, they were happy for us to go home once you woke up, no complaints. So wise and now that she's having this pain, um again with your introduction, introduce yourself as the F one understand you're having pain. When did it start any weeping from the wound? Fevers, eating and drinking, opening your bowles? She says to you that last night during her bandage change, she noticed some redness and pus. The skin is very hard and tender to touch around the side. She developed a fever last night comes and goes, um lost her appetite over the last 24 hours, very small volume of dark urine and you do an abdominal examination as usual. What I would say is we very much know that this is more pointing towards a problem with your wound. I would, you know, really highlight to the examiner that I would be inspecting the surgical site or three surgical sites for this port on for the port incisions because if one surgical site is infected, the chance that the others are infected is, you know, quite high because it's the same people I was operating. It's the same equipment, everything like that. So the examination wise, again, as I said before, you mention these things rigid abdomen localized tendinous surgical site. You look for any infections, any dehiscence and they will give you an image like this and you can tell the examiner um this doesn't look OK. It looks like there is some erythema or some pus. Um It looks quite angry. People love using a very angry, it's like, oh yeah, the wound is quite angry. Um And that kind of gives the indication that you know, more inflammation infection wise. Then you get a investigation um to interpret this investigation is an abdominal xray. Um Anyone wants to tell me what they would do for an Abdo x-ray or if anyone thinks this xray is all wrong. So if anything is wrong with his A Yeah, ABCD E everyone has a different ways of going about it. Um So you look for the any obvious air new peritoneum, anything like that. Um And then you would look for the bowel and you can see that this is a nice bow here coming down. This is your rectum here. Um You look for any calcifications, um any bony abnormalities as well, anything like that and you can't see anything drastically wrong with this abdominal x-ray. So it's a normal abdominal X ray and now you get to the second five minutes and they will give you, you know, some more information. Um So reviewing, they give you her regular meds. She's on atorvastatin 40 mill GS C OCP Calci paracetamol four times a day and you look at her bloods. Now, her white blood cells are 19.8 CRP is 273 lactase of 3.4 egfr of 55 creatinine, 190 urea elevated as well. So what I really wanted to highlight in this case is, you know, CRP rays and white cells, rays after procedure is expected, um you just put your body through major trauma, your body is going to respond to that in, in, in any way that it usually does in a patient who is 70 is postop spiking temperatures, um has a white cell count of 19. So anything, you know, above two, then what the normal range is and any CRP that's above 100 is, you know, alarming. Um And then you can see that she had, she now has an EGFR of 55. You can ask the examiner, has this been a chronic EGFR, you know, level? Is this new for this patient? Has she somehow developed an AK I in the last seven days which points towards a, you know, really severe diagnosis? And we know that she has a lactate of 3.4 which points you towards the diagnosis of a do, do sepsis. Um So two sofas used quite a lot in the surgery. Um, this is from uh med CALC. Uh So if the G CS is less than 15, it's a point if your Respi is greater than 22 it's a point and if the systolic is less than 100 it's a point. Um, anything more than two points, two or more points you always think about sepsis. Um, don't ever, you know, shy away from saying sepsis as an F one, it's completely fine to over treat a patient. Um, instead of, you know, being too modest and saying, oh, I'm not too sure if it is sepsis, um, it's better to if, if there is any indication for it start sepsis treatment. Um So, differentials for this patient would have been something like a hernia uh because she was having that pain when we did that surgical site examination, we would have seen if there was any bulging um a simple surgical site infection rather than a sepsis. Um And then for such incorrect analgesia prescription, um she's having abdominal pain POSTOP. Um and she's only on paracetamol. That's ok for some patients. It's not ok for other patients. Um So that could have also been a differential um sepsis six just included this, this should be rolling off you guys tongue very easily. By now, high flow oxygen, blood cultures, IV antibiotics, IV fluids, serial lactates catheterized patients, right? You so sorry about um you know, speeding through that last case there. Um I'm pretty sure everyone is quite up to date with CPS six. Anyway. Um I will do put the feedback on here for, well, sorry. First of all, we have the next session is on preoperative care on your 22nd next week. Um And I'll put the feedback code here. Um In the meantime, I can answer any questions related to these two sessions or a in general. Um I would really, really, really appreciate if you guys can leave me some feedback. Um It goes a long way, especially for my F one portfolio. Um And I do enjoy teaching, it's something I'm very passionate about. So I would love to, you know, get some feedback. So I will just stay on. Um I think you will stay on as well to just answer any questions um either regarding a lecture or regarding your upcoming Acies, uh all the best guys and practice reading BBC articles and coming up with your points because you need to read very, very quickly and you need to be able to digest that information very, very quickly as well. Um You think I am joking but I am not like you really need to practice reading. Yeah. Yeah, it is a lot of time to go through these stations. Um The cases aren't very complex as such. It's more the content in terms of reading the charts, the patient information, um operation notes, all of that is very heavy. So do practice your reading skills. And um once again, thank you very much for joining the session and thanks Nash for running through the two stations so beautifully. Any questions we're happy to take them and do fill out the feedback form for catch up content to follow afterwards. And me all, yeah, the three of us will stick around until um 845 and then uh we'll, we'll close the meeting. So if you have any questions you've got until then to, to send them over. Yeah, thank you, Nash, great session. Um I'll just go back to the potassium prescription really quickly. So in all patients, she um we looked at her electrolytes and her electrolytes, her potassium was 3.2 when the normal range for potassium, it should be 3.5 to 5.0. Um We know that her standard potassium, her maintenance potassium, the Mondini every single day is 85. Um we could have gone to 80 that would have been allowed in the exam. Um However, we know that she's in a slight deficit. I think it would be best to go maybe 20 millimoles above what they require in patients who are at a slight deficit. Um because that's what it did in the example case that they gave you in, in um on Blackburn. Um So that's why we went with 100. Um You will get one investigation in Cyprus um in the uh POSTOP session, but it does not stop them from giving you like, you know, an image to also look at or if they are, if there are two investigations, they will let you know which one that you need, need, need, need, need to interpret. So, yeah, the catch up content from last week's session should be on metal. Um I uploaded it the day after the day after the sessions, so it should be there if the catch up content's not there on metal and just drop me on a message and I'll look into it. But it should be though. Yeah. So the chloride prescription um is quite interesting. Um And I think it's something that people often forget when they are um looking at the fluids. So uh for her chloride levels, essentially, um we know that she's getting um 77, she's getting 77 of this essentially of chloride. Um because she's got uh 2 L and then half a liter. So she's getting 77 of chloride from there. And when you give potassium chloride, it's just that it's potassium chloride. So the amount of potassium that you give, which was 100 millimoles, you need to add it on to the chloride level because you've added in potassium chloride. So the 100 versus the 177 is actually just these irons here that came across plus. So that's, so you end up with the chloride of +177. No problem.