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So I'm Hannah. I'm an F two at the moment. I was an F one here in, um, in Swindon working. Let see. Um So this is a four part series. The first one is gonna be on lower G I and then we've got upper G I um urology and then ent we might, depending, I think you guys, a lot of you guys are here for four weeks. Some of you a bit longer there potential to do things like surgical skills or to if you guys are interested, but we'll start with just these four and see how they go. Um This is all sponsored by the MD, which is why we've got pizza. Very kind. So, uh with you. So we're gonna cover basic anatomy, um, acute presentations. This is mostly focus on some of the things you're either gonna see on call, um, or what you're gonna be called to the wards about and how you're gonna manage those once you're when you're called there. Um, and then a brief bit of operating principles, obviously, that's not gonna be your main focus as juniors, but you'll be assisting and things to know for that. So, something with a K hot. Any of you guys have co um, yeah, this is the pen. There you go a moment. She's so right. Is everyone joined? Do you want to join you? Trouble? Oh, ready. So, it's only about 30. Well, that's about 10 infections. Um, yeah. Oh, so starting off with, what does the S MA supply? So this should all be vaguely start easy. Some little hard. So, so the next two questions, which I'm sure you can guess what they're gonna be. Um But the SMA is obviously the second branch um of um the the, the gastrointestinal system next month. So this uh have you all done cahoots before? I thank you doctor. Um It marks you on speed as well. How quickly you want to? So come on in. Got one. Yes, I see the I MA oh And then, so this last question, we'll probably give it away. That would take me to the front. OK. Yeah, if you wanna join the last minute, the pins. Yeah. Put some OK. And stable top player now. So what part of the duodenum? So we kind of said that we know it's supplied by both celiac trunk and the sma. Um So which it is, which part of the duodenum is only suli by the celiac trunk in most people are these all making sense of anatomy back from second year, right? So now a bit about the venous drainage. So this is not as often spoken about, I think as I know about the arterial side a bit more tricky. So this is um most of the time the be strain follows the um arterial side, this is supposed to be a bit more specific. So again, we're talking about that lower part of the duodenum. Excellent. OK. So this is mostly useful when you're interpreting x-rays. So the thinking about what you're looking for in in testing, what are the key features that you notice? A small intestine? Large? Oh, we got different leaderboard now, kids. OK. Yeah. Um Nice. OK. Where, so again, back down to slightly easier questions. Hopefully you'll get this one. Nice. I I can't remember what the fi oh the five symbol streak of three. So similar to that other one about the small intestine. Now, what's the large intestines? Yeah, so we're talking about with these kind of long a bit. OK. Nice. Um So people putting the strap, those are the kind of um bands that go around it rather than the fully uh Yeah. Oh OK. And that day slightly giving away what our first topic will be on but where does it come from? What's that space? Most of you getting that one last couple. So there's a set rule that you can tell often you use it to you look at x-rays and sizing. So down the back. So is it 35712336945, 10 15. So, yeah, so 369 rule of, um, yeah, what you're looking for, if you see a abdominal x-ray inside, in between the small and large bowel, there's the, you're either looking for three centimeters or nine centimeters. It's bigger than that. The instructor? Ok. Where is the transition point? Nice. Oh, and then last one? Just for a bit of fun. What is this on the x-ray? You see it? Is that any bigger, a little symbol here? What is that? So that was a piercing of this? I remember in one of my exams they put, I think it was a nipple piercing that you have to identify. Um So it does come up occasionally, at least in my university's exams, right? So the winner of this was, it's the third place we have X second jade and first place was next. Who was, who came that a price? Well done you up? OK. So now the anatomy side of things is done. Let's go back two, the four. OK. So effect in this, we're gonna go through two mutations um that you're likely as I said to see on call or um be called to on the wards when you're a junior. I think. So, MRI, we've got F ones and then a mixture of fourth to sixth year. Is that right? Anyone any different to that? Cool. OK. So first one is appendicitis. So this is the most common thing you're gonna surgical, um, presentation you're gonna be dealing with in terms of what causes it, it's not exactly understood fully. So, there's a few theories. One of the most common ones is called a fecalith. Has anyone heard of fecalith? It's effectively a little bit of poo that gets stuck in that, um, stuff in the appendix and then leads to a build up of the general core which inflam it, that causes the nerve stimulation which is gonna cause the pain. Um And you're gonna get the immune response. That's the most common. Some of the other ones are, some people think it might be seeds that get stuck um or an immune response particularly in Children. Um I cells the um Right. OK. So this is quite interactive. We've got lots of questions. So hoping to hear a bit more from you. What if we do nothing if someone presented with abdominal pain, they've got an appendicitis likely. What if, what if you do nothing? What will happen to that patient? Rupture? Yeah, like rupture. Anything else you got rupture? You got sepsis? Yeah. Um So yeah, rupture sepsis. They could die effectively. There is the ongoing and I think since COVID where more of them were managed conservatively with just antibiotics, there's a bit more of a question of how you manage them. Um I know that there was one patient you presented, she had it three months ago and then just had this abdominal mass which again, they were just continuing to treat with antibiotics. Um, but yeah, so along with the rupture, you could get ischemia, um, and a rupture is effectively a bowel perforation, not just of the appendix, it's the whole bowel that's then, um, could potentially leak out. Um. Right. So I'm gonna go through these presentations in terms of initial management to do, to make it safe and how you're gonna confirm the diagnosis. So your initial bit is always gonna be your history, your exam um escalating early, obviously talking this as a junior getting your s getting your um to come see them making safe what you can start on the ward if you're suspecting this. Um and what you should be thinking about how you should be investigating what you could be ordering and then how you're gonna actually confirm that it is an appendicitis in this case. So how are these patients presenting? What are they gonna come in with pain? Where abouts pain? Right. Yeah. Yeah. MS point vomiting. Yeah. Anything else? Fevers, fevers. Yeah. How are you going to differentiate? So all of those could be diverticulitis on the right side or what? How else are you going to tell that this is about 10 with the pain. Often they describe it as epigastric moving to the right iliac fossa. So yeah, the moving pain, they often they don't feel like eating. You kind of can ask them. Oh, when did you last eat enough? And in terms of surgery. They've eaten actually a little while ago because they haven't felt like eating at all. There is a family history. I mean, I haven't seen this article about that much but there is apparently a link, um, with first degree relatives having appendicitis. So, now on your examination, what are you gonna be finding? And you'll know the difference between pain and tenderness. Yeah. What's the difference? Yeah. So, yeah, exactly. Pain is what the patient's going to tell you. Tenderness is when you push on the abdomen, they say they're tender uh um or like they are an actual kind of pain because that's where the tenderness comes in. So that's where, so your history is going to show right lip fossa pain, but your examination is going to show right lip fossa tenderness. Um It's going to be rebound tenderness. So the pressing in and then releasing um and then guarding. It's I don't know if anyone's felt guarding, but it's something that once you feel it, you get what it is versus the pa the patient kind of voluntarily tensing their muscles. Um There is a difference. You can, once you kind of examine more patients, you're gonna see it, more ross wings and so os and you'll know anything about those. Yeah. So it's all about getting, it's the peritonitis and kind of showing that stretching. So I've got some videos crossing sign is found in acute appendicis. It is a variation on to, to perform this sent, press slowly and gently into the left, lower quadrant of the abdomen, they quickly release your pain, sudden the pain in the right, lower quadrant and with positive sign. Ok, Tom, I'm going to palpate the left, lower quadrant down here with quick release and let me know where you feel the pain. So it's in the place where you pushed that, that's not a sign. Then P OS is the one with the knees and the appendix is close to the I. So, so if the appendix is inflamed, any maneuver that tends to stretch the I OK, may result in increased right, lower quadrant pain. There are two ways to test this. So and sign one way is to have the patient try to flex the right hip by raising the right leg against the distance of your hand. How I'm going to have you raise your right leg against my resistance and let me know if you have any pain. The second way to test the po A sign is have a patient roll onto his left side, then graft the redacted right leg and extend it at the hip, which is the PS OS muscle increase right lower quadrant pain with either of these neighbors with a positive po A sign I would have acute appendicitis as long as you know, at least one way to test it, that will be more than enough. OK. So in terms of when you're gonna get appendicitis and when you're likely to be thinking that's your diagnosis most common in Children. So, kind of five to early mid twenties. And then there is actually, which this doesn't probably, um, demonstrate it is another piece later on in life, but it's not that common. You're not really gonna see it that much, but it is a slight again. Um, in fact, so the other thing is these Children, the kind of 0 to 5 in the five year old, you might get them kind of speaking back saying something, but it's a lot harder to identify it. It's also harder in women and has anyone pregnant women as well. Yeah. So, and also the investigations that will come into, um, is quite hard. The, so with your, um, so has anyone had a negative appendicitis appendi appendectomy? Right. And you know what it is, think of what it is, it's effectively where the appendix is taken out. But they, then it on histology, it's completely normal and even macroscopic from the surgeon looking at it, they think, oh, it's not, but most of the time you're gonna end out. And I've seen it in quite a few exploratory, um, laparoscopic surgeries where, even though they, they know it's not the appendix, it's probably from the issue, they're gonna still take it out just to rule it out so that the patient doesn't come back later. It's more common in women because of the, um, differential diagnoses because it could also be ovaries, uh, pelvic inflammatory disease. All of those mean that it's quite hard to identify whether it is the appendix. And so you're gonna see more rates of appendicectomy in you. Has anyone seen any pediatric patients being examined for appendicitis? And how, what are you gonna do differently and maybe doesn't really wanna talk, won't really tell you when they're in pain. What can you ask them? Yeah, that's a big one. So if it bumps on the way to the hospital, they'll say that really hurt. Um, I've seen, uh, pediatric surgeons kind of telling them to blow up their tummy again. It's just trying to get that peritonitis sign. Uh, some of them get them to jump up and down again. You're gonna see in all of medicine, a child that's running around the ward and happy to jump up and down. Very different to a child that's kind of sitting in bed not really wanting to move much because any movement makes her tummy hurt. Um, another thing going to be, um, not wanting to eat, asking them again, you're gonna have to make it child friendly. What is your favorite? Not having that conversation? Building the rapport with the child. So then you can ask more. Um, you'll often see surgeons as well asking questions, um, and kind of walk during the exam to distract the any patient, including adults from just tensing their muscles because they're worried about the pain. So, you, you think it might be appendicitis? What are you gonna do? How are you gonna, um, what is your treatments effectively? What can you do for this patient? Yeah. Before that. So that's gonna be your boss that gonna do that. What are you gonna do? You've seen them on the ward? You've seen them on, call you senior doing surgery fluids? Yeah. Rehydrate them along with flu as well. So, you gonna say antibiotics? What else? Pain relief. Yeah. You think they're gonna have surgery? So, what do you have to do if you think they might have surgery? Yeah. Um, so antibiotics if needed, most likely not needed fluids in surgery. They always like Hartman's, um, or depends on your consultant. I know that coming, it being an F one, I was really paranoid about what fluids to put up, but Hartman's in like an emergency kind of acute situation is always gonna be fine most of the time unless they have lots of electrolyte issues. Uh, you can catheterize them some consultants. I don't know how many of you work on surgery here or have seen various consultants. Um, like Mr Payne is quite old school with wanting catheters and abdo xrays and chest xrays and everyone, um, if they're being sick you can give them antiemetics and again, make them know by mouth. How do you make sure, how do you know it's an appendicitis? Ultrasound? Yeah. And what else? What else could it be? What are your differentials? Pancreatitis? Yeah. Yeah. So, when you're thinking about your investigation, always be thinking about the other things you need to be ruling out. What else is common? Non surgical diverticulitis. Yes. Anything else could be? Yes. What's really common? It's not surgical at all. May, maybe all of those could be true. What else? Huh? You said that is not surgical? It's non surgical. Yeah. Something like a uti often kids could be just a UTI and I've seen them also hold off on giving them antibiotics until they've managed because kids just don't want to pee when you need them to pee. Um, and they've gone like five hours without antibiotics because they're waiting for the urine dip because they want to see a urine dip when they have an antibiotic. Whether that actually makes a difference and you just with all the antibiotics, but getting a urine dip is useful blood, as you said. So, surgical patients, if you think they're gonna go to theater, you need your group and stage. Um, the GS are always useful because you're looking for the lactate, um, particularly if you think they're sepsis, septic. Again, blood cultures, imaging wise. So ultrasound is definitely true. Some will want a chest xray and abdo xrays, you're not gonna do those in Children. But again, I must to pain. Every patient gets an Abdo x-ray and a chest x-ray doesn't mean that that's normal practice. Um, and then ct again with the kind of patients later on, if you're wanting to rule out diverticulitis or anything or any other obstruction type, you didn't get a CT, that's kind of the only thing we really think about that when they're maybe 60 above. Um and then see your review. So with everything with appendicitis, you're looking for a patient with right hip fossa, pain and tenderness, rosing sign is the more common one, if they're septic and then nausea and vomiting, those are your main things you're gonna be seeing all these patients. Antibiotics is a big thing. Um getting your senior to review so that then they can escalate to whether they need surgery, getting them consented, right? Further management. So now talking about the surgery side, most common operation is a laparoscopic um, appendicectomy. Also, that's the other thing I got picked up on when I was the left. One is appendicectomy, not appen appendectomy because that's the American version which you'll hear on all the films when you start seeing it. Um So it's generally laparoscopic approach. Um That's with three reports. I think I've got a question later about that. But has anyone seen, has anyone seen an appendi disc? So, and have anyone got to scrub in and see what they do? So this is um it's not great, but this is um identifying the appendix. It's most of what's the most common position of the appendix. Yeah. So that's where they found it. This one doesn't actually look that bad. You go down the mean removing fast and then you get one. If you get to know your reg, you can often get to actually place the in the loops. Um, and then food and then you're gonna have it in the middle and hopefully it would be red and go all the way. This will take it directly out before because it's quite small, But often you'll see them, put them into a little bag or the finger of the glove and then get it out that way. Ok. So open versus laparoscopic. Why would you, um, what, why would you pick one or the other? Because they should be, yeah, you're gonna be quicker. It's generally quicker to do open, easy to identify the structures. Um What if you're, you are as a five year old? What are you gonna do in this hospital? You're more likely to open in a kid because especially in an adult specific hospital, your port. So your general port size is a 10 millimeter and then two fives and a 10 millimeter in the kind of abdomen is about this size. You're not gonna have enough space to maneuver so often. If they're too little, you're gonna do it straight to open. Um, the other thing and then also at the extreme age. So both, both, both extremes. If you're too old as well, there are risks and you'll think of any risks of, like if you're too old to have a knee laparoscopic surgery side of perforation, maybe it's more so in an elderly person, you're gonna have more likely to have heart conditions. And so what happens in that type of surgery? You inflate the abdomen with CO2 and then you're gonna get compression of the, um, Vena cava and that reduces your cardiac return and therefore your heart's not gonna pump and you're more likely to get complications from that side. Similar if you're pushing up the diaphragm, the CO2, again, you're affecting your um return. So um in terms of we kind of went through some, in terms of easier visualization, any other benefits of laparoscopic surgery versus so that's on the next, but any other benefits, yeah, only small scars. Although with that, you could then end up with three hernias like minimal hernias, but instead of one, but generally, yes and yeah, so you're gonna be discharging those patients earlier, there's less pain as well, which is probably why discharging them earlier. Um Yeah, so I think really covered most of those. So you it's kind of difficult with the visualization. So it depends on where you're aiming. So if you're opening it up, it's easy to see it all in one place. But with your uh with your laparoscopic scope, you can only see kind of what's in front of you and not your peripheries. Ok. So that's appendicitis. Any questions on that. Ok. Into bowel obstruction. This was something that was drilling quite a lot of what causes a large bowel versus small bowel obstruction. So, can anyone think of the ones for a small bowel obstruction? Yeah, there are three adhesions. Is what? Hm. Oh. that's more large bowel. But get a guess. Is it the same as, uh, could be? Not one of the most common? So, we've got adhesions, hernias. So, kind of like this, but a hernia in internal hernias as well. And then malignancy and then large bowel, um, again, your cancers, your volvulus, which comes in then diverticulitis, which is your most common. Your most can see diverticulitis, um, or a cancer. So, again, starting with what if you do nothing, someone's got an obstruction. What if you did nothing to settle them? Yeah. Yeah. Ischemia sepsis. Those are, yeah, all of them. I have seen it done before where, you know, it's a bowel obstruction, but it's a 90 year old and taking them to theater for kind of a massive laparotomy just isn't going to be beneficial. But it's quite a sad case for you dying of a, uh, obstruction and perforation is not a pleasant way, but it has happened because it would be more risky to operate. So, again, initial management, thinking about your history and exam, what the patient is gonna tell you what you're gonna find from them, what you're gonna do, what your initial treatments are when you're on the ward and then how you're gonna actually make sure this is what you think it is. How is a bowel obstruction gonna present? Yeah. Constipation. Yeah. Vomiting in terms of so I've got it down the bottom about. You are more likely gonna be see, vomiting and small bowel obstruction versus large. Just because hopefully you've got your ileocecal valve that's stopping the backflow. Um, so we've got pain cramping pain, which is kind of from the paras, your abdomen is, your bowel is trying to push forward and it can't fecal and vomiting, particularly if you then got a large bowel obstruction. Um, lack of flatus and your bowels not opening it, severe constipation. So, the lack of flatus is a common one which I'll often ask any patient if you're worried. So, I'm on a GP job at the moment and the ones you're kind of thinking, oh, it could be a bowel obstruction. They're saying they haven't opened their bowels in five days, but they're passing out. So you're instantly less worried. What are you gonna find on your exam? Yeah. Anything else? Ab Yeah. Yeah. Absent bowel sounds. Yeah. Trying to remember what I've got. So, and then, yeah, distended, painful. Um, I got the right, but you're all right. Ok. What are you gonna do? How are you gonna treat this patient? Who's distended? They're in pain. Even if they're on the ward, this can happen or on call and s eu what are you gonna do. Yeah. So I would probably avoid laxatives at the moment just because if you're putting more pressure on something that's blocked and it could just perforate because you can't get past that blockage. The first thing similar to the appendix. What do you want to stop the by mouth? Yeah, that's my first one. Yeah. Fluids because they, no, by mouth. Um, again the ants. Um, and then one of the most important things has anyone heard of like the dripping, suck you on the so drip in terms of putting IV fluids in because I know by mouth and then you're putting a rouse tube in or an NG tube. So you're gonna, yeah. So that will stop the vomiting, which is, again, that's really common. You'll see when you're an F one on the wards, you're putting an NG tube in can stop them having, um, aspirating. And I've seen patients kind of deteriorate because they've aspirated because they've had a bowel obstruction and they've died from that side of things rather than anything to do with the obstruction directly. Um, oxygen if they need it. Again, the drinking suck urine monitoring. Sometimes important, um, pain relief and, um, antics with the pain relief as well. You gotta be quite careful because most opiates are gonna make you constipated. So you've gotta have a balance. Most of them will end up on oral morph. But I see people most like kind of avoiding the codeine side of things and if they can cope with paracetamol ice. Right. So, what are you gonna do? How are you gonna make sure, you know, it's a bowel obstruction? Yeah. Uh, what if anything else, what else are you worried about if they've got an obstruction or really distended? So, how are you gonna make sure it's not a perforation? Chest, x-ray, sore, chest, x-ray, which in real life it's actually a lot harder because most of these patients are really frail and you're not actually gonna get them standing, but in an ideal world, you're gonna get an Ereck chest and an Abdo x-ray, you're gonna do apr exam to check if there's any stool, um, in the rectum, if they're very constipated bloods again, so they could end up going to theater if it is, if it does end up, um, perforating. Um, so you're gonna need a group. And so again, your lactate, um, and then you see in your review. So we went through a few in the anatomy questions. But, so what type, what is this x-ray showing? What sort of obstruction? Good. It's the, it's not, well, it kind of looks like a bee chip but it's not the actual, that's the coffee beans that this one is a large bowel obstruction and you know it, because again, that size, um, so it's got the, um, which you can kind of see up here. Um, and then it's all, although it's kind of moved into the midline, you can see that this probably was it more around the edge. Um And then this one, what do you think it is? Yeah. So again, now you've got the line, it's a bit more obvious and so that you've got the valve conven, which is also known as P circular and they're kind of larger than three centimeters and central. Um What about this one? The image is a little hard to see more about sacrum. Sorry. What about the, so this is kind of a mixture of both. So you've got the kind of large bowel which is probably this bit here with the her stra but then you've got small bowel and this will often happen if you've got an incompetent ileocecal bowel. So effectively, you've got a large bowel obstruction that has slightly decompressed itself by going through the ileocecal valve. Um And so you've basically got a mixture of both, right? So you mentioned the coffee bean sign that's more this, it is quite hard to see it when you see it. It's, I've always seen it a lot larger and I've seen the operation with a done laparotomy and it's honestly the bowels, not this big, I've never seen bowels so large. Um And you're getting, it's most often a sigmoid ulus. Um You can get it elsewhere. What are you going to do? Uh Yes, like a sig before that or you can often do a rigid sig in the emergency department with a tube, which is effectively, it looks like a catheter that's just gone up the bottom to decompress. Um, and that generally resolves it. Although the other thing to be cautious of is when you're putting in the fetus tube, you're not going too far and you're not perforating the bowel. So this is the outside the bowel. Um, you're only gonna be wanting to insert at 15 to 20 centimeters and it, although you wouldn't be expected to do this as an F one. If you've been shown it, you could be expected to do it. Um, and it's a very messy, um, sort of thing because you get the air flow and the stool that's all being blocked. So the overview, your patients are gonna be those with pain and tenderness, they probably have nausea and vomiting. Their bowels aren't gonna be open and they're not passing any flatus. Um, and you're gonna be wanting to escalate if you are really concerned about them that they could be, um, perforated as well. Most important thing making them no, by mouth and the dripping stuff. So the IV fluids and, um, the, uh, will, uh, or, uh, vial tube to decompress the stomach, preventing them from aspirating. And then you're gonna do your ere chest x-ray and Abdo x-ray, um, with a CT A P and your, if you're clocking, you should be doing APR to check these patients because you'd be chat up by your bosses if you haven't done that. Ok. Any questions on small bowel obstruction or large bowel obstruction? Ok. So the last bit is a bit of a sip. So I need someone to volunteer to be a patient. I need a nurse and a doctor. I know we've got some F ones here because my infection or take the easy job. We got one patient. Anyone want to be doctor or nurse, doctor, a nurse from the med students? Ok. Um So patient lie down there. Well, it'll be team work, don't worry, have in terms of, have you seen um, have you done a s so far, you know, the general process of airway breathing circulation, um, disability and everything else. So you have been asked to see a patient up on me ward. So this is your, it's a six year old male patient two days ago, they had a left hemicolectomy for a tumor in the descending colon and now they've got increased pain and vomiting. Um and the nurses are worried about them. So they've asked you to come up and see then using a six, their respiratory rate is 25. They're saturating. Ok? On room air, they're tachycardic temperature is ok? And their BP is a little low. Ok. Hi, sir. How are you doing today? Are you in clinic? Yes. Where is the clinic? So you've got tummy pain. And so in terms of a bit more history, so often when I go up to a patient, you'll ask a bit more history or you'll look at the notes before you go up and this is where in a little different what you do on the ward, depending how worried you are about them. So, this patient's, uh, not opening their bowels. They had, they got stoma, um, but there's nothing in that. Nothing's come out so far. They increase it back this morning. So after a bowel operation, you're often fine. They'll go from, um, being I by mouth maybe the first day or two, depending on the consultant to being on sips. Um, and then in terms of sips, it's like basically 30 meals a day. So you can sip some water to being on clear fluids. It's as much water or like juice as they want, as long as it's kind of diluted juice to being on, um, free fluids, which is tea, coffee. They can have anything, um, with milk and then, um, and then you'll slowly, and then it'll be light diet and then full diet. So light diet might be kind of soups and things. Um, so this patient's now up to 33 s and you've been drinking happily a way. Um, and you're on a morphine PCA. So anyone know what PCA is? Yeah. Um, so, um, this is what your tummy looks like. Ok, so works well. Um, ok, so, yeah, so that's fine circulation, which is, um, this card about 100 I mean, I'm only thinking post surgical. So I think we should do an opt. Yeah. First of all, you got an EG is your EG from the crown? What was it showing? Yeah. So, yeah. Yeah, perfect. And then you wanted an x-ray. Here's your chest x-ray. This is your chest x-ray. What are we thinking? Now? There's no fluids, you can say there is no air in the diaphragm. So there's no BP. Yes. So that's fine. And now you have OK, that's this obstruction. Um um I can do it's large, it's a bit more central. So OK, so obviously you got us towards diagnosis D with the A te so you did, you made sure that was pa what about me? Um we got a whole troy of things that can and you got, you got, you got your nursing colleague get. So I mean is uh OK, saturations are, it's really um just get BP monitor. 100. Yeah. So um is is that based on BP or is it? No, he's normal? Fine. He's not on any medication in background. OK. So his BP low. Um we could, we could start. So because he has been on for the last few days because his BP is a bit. What are we gonna need? Yeah, you're definitely gonna want of this patient. How long does your pre stay last for if you take one of three days on average? So that's otherwise after that, you'll need another sample. Just one more. Um OK. So, so now you've done, so you've listened to a stress often you do in the situation. Obviously you do percussion and also expansion um in circulation. What are you gonna be doing? You've got the ECG, so circulation, check your pulse. That's BP, ecg Look for any, any abdominal disease um check for his hydration status. Yes. Uh I mean, we, we, uh, maybe get an idea as to how much you drink. Yeah, you can do whether his hands feel clammy or cool. Um, yeah, that's just c and then, uh, anything else you see, I didn't think there's anything else I can. Uh, so d disabilities. Um, well, maybe, um, he's responding so he's alert. Yeah. And the baby. Yeah, you got a torch there and then a few more or what be the, is that so? And your temperature? Ok. Is he diabetic? He's not diabetic. His sugar is, uh, probably a bit like, yeah, we can do it anyway to see you s Yeah, so with this sort of patient as well, particularly on surgery, you're gonna want to examine his tummy. And then look because as everyone in the stoma bag a way you can kind of open them up and see. And this one with this presentation you're gonna want to make sure the, his stoma looks pink and healthy, there's no infection around it. It hasn't retracted. Um, and then there's nothing in the back um and also the back very often. Um and then his scar is a little bit but his looks fine. Um And then yeah, you can check for bleeding, you might put APR um ok, well done, you got the diagnosis most importantly. Thank you very much. Ok. And you've got a CT as well and this is what you're gonna see. So did everyone hear what the diagnosis was like? See to me? So this was most likely a POSTOP IES. So, what are POSTOP eyelashes? Has everyone heard of them? Seen them? So, it's an obstruction without mechanical cause. So it's most often POSTOP and as you identified. So he was on the PCA. So the morphine will be playing into it. Any other things that can increase anything else? What increases your risk of POSTOP ile S? Um, low potassium? Yeah. So electrolytes. Good peritonitis. Uh, yeah. Well, that can be a sign of it and yeah, in fact, um, prolonged surgery as well. Um, being elderly, a long procedure. Um, and then your features. So you're not passing any ers nothing in your stoma. Um, you're gonna get very bloated. Um, and yeah, you might be vomiting as well. These are quite helpful in terms of when you're called to see these patients on the ward, what you should be thinking about. So, um, you're gonna be seeing a, like a leak in the connection to the anastomosis 5%. These all average but they could be elsewhere. Um, collections are, or more than five days and then just postop priority which you may not be too concerned about. Um, 1 to 2 days. How do you manage a POSTOP ile? Yeah. How conservative. And what are you, what's your conservative management fluids? Yeah. Yeah. Correcting any electrolytes that may have been off. You're welcome. Yeah. Yeah. So you're gonna put in your nu well, is cheap. Um your fluids, which you said. So it has, have you heard of the um I can't remember what it's called but the kind of management POSTOP that people are kind of starting to use to get patients up and out quicker and they're mobilizing really early. The diet. The kind of way they're managing the diets is also changing. Um So you wanna kind of be mindful of that because this is to prevent POSTOP is um I think it's called the early, it's not early mobilizing. It's got um and then correct and um again, so stopping any um if you on Imodium or kind of laxatives, again, you want to be cautious of. So that's everything any questions about postop is. Thank you very much to everyone. Can you also have a feedback that's really important for us? Um And then for the next session, let them know how to make them better of what you want to learn. Ok. Oh, it was gone sorry. And then thank you again to the MD U for giving us details.