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Hi. Welcome, everyone. We'll just wait for a few more people to join for about three or four minutes, and then we'll get started. Um, let me know if there's any problems seeing these slides or hearing my voice or seeing my face. Um, and we'll make sure everyone's ready to go in about three or four minutes. Grab a drink if you need one. Mhm. Yeah. Okay. So hi. Welcome to anyone that's joined. We'll just wait for everyone to get in, and then we'll get going in a couple of minutes. Can people just give a yes or thumbs up in the chat if they can hear me and see the first slide surviving the surgical referral storm just by now? I'm not speaking to a blank screen, bro. So just give it another couple of minutes and we'll get going. But also, we'll get going. So welcome to the first of the surviving the surgical referral storm series. So they're going to be on Mondays and got urology next week and then trauma Orthopedic the week after that. Um, so let's get started. Um, so I'm Ben. I've done a few lectures with the STS before, and I'm on the education committee. Um, so I'm currently in F four. My F one F two were in leads, and then Harrogate and my surgical jobs on that were eight months of orthopedics. Um and then I had four months and Harrogate on general surgery, covering trauma, orthopedics and neurology on calls as well. I'm currently working in palliative care medicine and probably off to New Zealand next year. So this lecture, we're going to go through a sort of systematic approach to managing referrals from a and on your general surgical jobs. Um, we're going to cover the basics of the common conditions should just be quick revision. Um and then the second section will go over investigations and management expected at an F two level. So, like I said, the first part will be about 40 minutes or so just rattling through a few of the common conditions. Then there'll be opportunity to ask any questions or clarify anything from that will have a short break and then the second half of a bit more interactive and hopefully it more interesting and applicable to work. And we'll go through three case studies, so condition will talk through is bowel obstruction, so just quickly definitions for bowel obstruction. It's a mechanical blockage of the bow, and so it's a structural pathology that stopped the contents and passing through the bowel. It accounts for about 15% of acute abdomen's in the UK, and just because there's confusing names for it, there's also functional obstruction. Um, so where something isn't actually physically blocked, which is often referred to a pseudo obstruction or paralytic ideas. Um, lots of things can cause that inflammation of the electrolytes arrangements or recent surgery are all common causes of a pseudo obstruction. So the cause is of a bowel. Obstruction really depends on where it is. So for small bowel, it's usually adhesions, or sometimes herniations. And for the large bowel most often cancer or volvulus, sometimes diverticular disease. You could also break down causes into where the actual pathology is regarding the bowel wall. So is it in the lumen of the bowel? Um, so something blocking the bowel is in the wall of the bowel, pushing in and blocking? Or is it outside the wall of the bowel again, pushing in and blocking the passage of contents once once the bow is occluded. You then get a proximal, um, dilation of the limb proximity to the obstruction, which starts to increase in size to stand. And if it stretches enough, the war can become a skeptic. And then perforate of particular worries if you've got what's called a closed loop obstruction. So if you've got a blockage and then approximately two that you've got another blockage. So there's nowhere, um, inflammation and gathering of material to go so it can stretch a scheme of water and power free so those will always usually need surgical management. Um, so we'll use the chat function for a bit of interactive teaching throughout. Otherwise, it's just me talking for a while as much as I love the sound of my voice. So just in the chat can people think of some symptoms and then some signs of bowel obstruction. So just think of the basics, give you a few seconds to gather your thoughts and pop it in the chat. Yeah, no bowel movement. That's the cardinal symptoms. Brilliant, Gemma. Anyone else? No wrong answers for that can be wrong answers, But no, no silly answer or silly questions. We'll just keep keep coming in Yeah. Vomiting General pain. Yeah. Yes. And, well, that's great. So no wind so often when we're if someone's constipated and they're not opened their bowels would often clarify that further, whether they're passing any phlebitis, which would be a red sign if they're not. So it's pretty nice. Well done. Um, and distension, Yeah, so that's the signs. So in the symptoms you've got diffuse, usually central and colicky abdo pain, vomiting and absolute constipation with the vomiting, the higher up the obstruction is that earlier you're going to get the vomiting because you're obviously closer. Closer along the bowel to the mouth often starts with gastric contents turning bilious and then, lastly, feculent vomiting. If it's really bad and similarly logically constipation that earlier constipation is going to come in lower down obstructions because you're going to catch that sooner. And then, as you said, signs his abdomen distention. So on your examination, you can find a resident of standard abdomen, which is awfully often generally tender. Um, due to the distention, it's not often that you'll be able to palpate any masses, um, and then, depending on how severe the obstruction is, whether the bowel has started to die or perforate, you may get signs of puritanism. You should always check the hernia or offices. Listen for bowel sounds. That sort of classic textbook, high pitched inkling is a sign of obstruction. But you know, on on A and E classically, you know you're not always going to hear that, and it's It's a poorly sensitive sign, so I wouldn't rely on the absence of that to rule out the diagnosis. A silent about sound when you're trying to listen would be indicative of a serious and then also really important to look at the fluid status of the patient. And there's poor absorption. The bow they've got usually a poor oral intake if they're vomiting. And these patients are often extremely dehydrated and that will will come and start in terms of the management. So when someone is presenting with abdominal pain, vomiting or no bowel movements or wind, what differentials could you possibly think of, Um, in terms of a differential list when you're approaching someone, that sounds like they've got a history of examination of bowel obstruction again. So actually, yeah, I use the chat function for that, and it'll be great if anyone Anwar and Gemma. Of course. Please keep answering. But if anyone else wants to pitch up with some ideas, that would be brilliant as well. There'll be interactive bit throughout. It's not every slide. So any differentials cool? So what? What else could cause someone to have? Generalized? Tummy pain will be constipated. Okay, we'll crack on. So, as we mentioned earlier, pseudo obstruction of political earlier, so have they had recent surgery. Have you got a massive electrolytes arrangement that's causing a failure of the peristalsis of the bowel rather than a natural mechanical obstruction? Are they just constipated? Or as the bowels stopped moving because of the different, more worrying reason, like a perforation. So, um, ulcers, diverticular or cancer? Looking at investigations, it's often really helpful. And I'm sure you guys have learned in medical students or your doctor's release would still think of it in a sort of simple bedside blood imaging and special tests for that. So we use that throughout the lecture, so bedside things like fluid chart, and he said he could be really useful. Um, usual bloods, especially a VBG, um, in e d. Because you can get early warning if they've got signs of ischemia like a raised lactate. And then you can start replacing electrolytes arrangements early because you'll get get that result obviously much quicker than the lab results group and save in case they're bleeding. Um, and if they do need to go to theater, they'll need a baseline group and save anyway. Imaging, um, sort of older investigations like abdominal X ray erect. Um, I'm sorry. The right chest X ray looking for that free air If you're worried about perforation, often e. D. By the time you get there, people have often done an abdominal X ray, but that's quite a poorly sensitive investigation. And if you're worried about perforation, the likelihood is they're going to need a CT, abdominal and pelvis anyway. So there's a shift in practice to just having this Is the initial imaging choice where possible anyway, So the management we can sort of split it into uncomplicated bowel obstruction or complicated um, so complicated Bowel obstruction tends to be, um, anything that's going to require surgery. So if you think something that won't get, I won't get better with bowel rest. Electrolyte replacement. Um, you know, pain killers and anti sickness so that would force the sort of conservative management. So the classic dripping sucks. So urgent fluid recess. So 500 mil bonuses and a set of appointments and then moving on to your maintenance fluids later. And so the complicated bowel obstruction would be things like an ischemic or perforated bowel. So that's not going to get better. If we just rest someone's bowel with an N g or rales tube and you know, give them antibiotics, they're going to need, um, you need surgical management. Also, that closely bowel obstruction that we talked about earlier. If there's two points of obstruction, that's not going to get better with rest, that's only going to get worse. And for things like a irreducible hernia or an obstructing cancer, those are going to need surgical management anyway, Um, so you can't wait on them. And for any patients that have been under conservative management, and that's failed at 48 hours, that tends to be the threshold when you consider surgery. And that would usually be a laparotomy if the diagnosis is unclear, and often the approach would be to resect the part of the bowel and that's blocked and bring it up. So for the stoma, um, interestingly, some patients where you know full laparotomy approaches is going to be too much for them, such as, you know, palliative care, cancer or care of the elderly. You can do an endoscopic stenting instead just to try and just try and open up the obstruction and relieve the symptoms. But you're not treating the underlying cause because you don't think they'll be able to manage that surgery. So we'll move on to colorectal cancer, one of the causes of bowel obstruction. So the question is, Well, if anyone's got any questions, just put them in the chart as we go along. Um, and some of the moderators that are listening as well can answer, or we'll do questions at the end of the first part. So bowel cancer is the fourth most common cancer in the UK, and there are 40,000 cases each year, and it's got the second highest mortality of any cancer, and most common site of cancer is in the rectum. Unfortunately for bowel cancer, most are diagnosed quite a late stage, Um, and so the cause. It's from epithelial cells lining the colon and the rectum and most of them developed from a progression of normal mucosa all the way to an invasive adenocarcinoma, with polyps being that that stage in the mid in the middle. Which is why we've got screening programs. They can be present for about 10 years before they do become malignant, which is why a screening program is great to try to target that time. So risk factors, um, 75% of cancer in the bowel is sporadic, so I don't really think there's a There's an exact cause that we can find and name, um, risk factors that are non modifiable would be your genetics, uh, male sex, older age, family history of inflammatory bowel disease and a past medical history. Um, so can anyone think of the modifiable risk factors that we can all do to try and reduce your risk of bowel cancer again, anyone feel free to pop ideas in the chat? Otherwise, it's going to be me talking for an hour and a half, which is is too much. Yeah, obesity. I've realized that's on the icon to the right, so you can have that one for free anymore. Yeah, smoking pro. So we've got obesity and smoking as you mentioned. Also, alcohol, high fat or processed meat intake. And a low intake of fiber or modifiable risk factors for bowel cancer. So the presentation of cancer depends on where the cancer is in the battle, obviously, because that's gonna dictate when certain symptoms, um, come to light and what the symptoms are. So cancers that are on the right side, um, they often present at a later stage because there's less obvious warning signs tend to be more vague, like weight loss, anemia and bleeding that might not be noticed and and eventually could get to the size where you have a mass in the right iliac fossa. So if we think logically, if that's the right What? What symptoms? Present with the left colon cancer. So cancers that are on the left Yeah, So you could get a mass. Um, I also think what what happens are the left side of our colon. We too? Yeah. P r bleeding brilliant and anything to do with poo because we love talking about poo. And a lot of general surgery is poo. Yeah. Okay. Okay. We'll crack on. So as we mentioned, a mass bleeding and yeah, brilliant bowel changes. Sorry. And yours. Yours comes through, but possibly slightly delayed. But brilliant bowel changes with, you know, constipation or diarrhea or alternating. And that changes early because it's on the left side. You can also get bleeding, colicky pain and bowel obstruction. Late signs of a very advanced disease would be such things as jaundice, compatibility and ascites. So differentials of a cancer. So we're thinking of those symptoms and signs what other diseases might present that way. So inflammatory bowel disease. You can get diarrhea with blood and mucus, which is similar, the difference being that tends to be a younger age of onset and with mucus as well. Hemorrhoids rarely have abdominal pain and discomfort or associated with altered bowel habit and weight loss. Those, you know, weight loss Being a more systemic symptoms. You wouldn't expect to see that with hemorrhoids, Um, and the blood, although it is, you know, do you can get PR bleeding. It's often on the surface of the stool or a tissue. Is someone wipe? So it's important if someone is saying they're they're bleeding from the back passage or they've got blood in the stool. Really try and get to the bottom of that and clarify exactly what they mean. You know, what color is it? Is it mixed in? Is it in the stool on the top? Or is it just when they wipe after going to the toilet? Diverticular disease will come onto important differential I Bs, but you wouldn't expect blood or any masses with that or ischemic colitis. There's another one there, so investigations at the bedside you're definitely going to do a D r e. Um, so that's looking for any mass that you can feel, Um, and also to try and rule out other causes of symptoms. For example, if they've come with bleeding, um, are there any tears there? Or hemorrhoids? Bloods, Usual blood tests, and then see A has no use in screening. But if someone has had bowel cancer, then it's That's an important blood test used in screening to try and predict relapse, um, imaging such as ultrasound and MRI for liver mets. And then usually everyone will get a colonoscopy and a biopsy that's offered to call, you know, without anyone that can tolerate anyone without major co morbidity, Um, and generally a CT cap for staging alternatives. For those that that can't manage a colonoscopy could be a flex sig, a barium enema or sometimes just a your CT colonography. That might be for older patients or patients with with multiple comorbid it so management for cancer. So surgery is obviously the definitive curative option. Um, they need to be referred to an M D T as well. The surgery is usually a regional colectomy, so take the tumor away with adequate margins of healthy bowel. Either side to make sure we've got all the cancer and lymphatic drainage. And then you can either join together so primary in the first stage. Or you can form a stoma with the option of reversing that at a later stage. Their followup will include repeat scans and regular blood tests to try and catch any recurrence. And then there's also radiotherapy and chemotherapy, which have different different indications. For example, very locally advanced rectal companies would probably offer radiotherapy because you can target target that area quite well. And for some cancers, chemo is first line, um, alongside surgery. So one common surgery that you'll you'll see fairly often on on the agenda for jobs. Hartmann's And that's an emergency surgery, usually with for patients with obstruction or perforation. So they completely take out the Rectosigmoid colon, uh, and close to me. So bring the bowel up to the skin and then close the rectal stump off completely and then for bowel obstruction. You can also have, as we talked about earlier stenting, so prognosis is about 50% of five years. UM, 60% will receive radical surgery, and most will be alive at seven years. Following that. And are the grades have been getting better over time. So to prevent thinking back to those modifiable risk factors, you want to reduce your meat, fat, calories, smoking and alcohol, and increase your exercise and your fiber. And there's some evidence that some supplements can reduce the risk of cancer. Um, and then there's also some interesting studies into non steroidals hormone replacement and aspirin. But I won't get into that today because we've got a lot of things to get through. But if you wanted to do any more Googling, they're quite interesting to look into. So next we'll go on to appendicitis. So as as the name, uh, inflammation of the appendix, and it's most common in younger people, Um, so you'll see a lot of Children with it, and you'll see a lot of young adults, often males in their mid to late twenties. It's very, very common Presenting complaint. Um, it's really common. So about 10% of the population will develop appendicitis in their lifetime, and it is the most common cause of an acute abdomen in the UK, so you'll see lots of appendicitis in the D um, the causes of it and sort of the pathophysiology behind it. So it's anything that obstructs the Lumen of the appendix, so that could be a fecal. It's like a hardened bit of stool, um, lymphoid hyperplasia. So any sort of lymph nodes in the area that increasing in size can sometimes block it off or really impacted. Still from the rectum working, working very well in the bowel. So the bacteria get into the wall of the appendix and the appendix itself causing inflammation. Um, the wall of the appendix can become a scheme. It because you've got reduced venous drainage and that inflammation process, and if it does become a schematic, it can die, then perforate. And then you've got all this infected and vehicle matter going into the abdominal cavity. And that's when patients can get really unwell with peritonitis. So the presentation of appendicitis is that classic periumbilical pain. So from your visceral innovation of your gut first. So that's referred pain generalized, usually around the umbilical area. And then that moves to the right iliac fossa. Um, as your parietal, uh, innovation starts kicking in. It's worse when you move and how often you see patients that they're really still and they can develop nausea, vomiting, usually after the pain. Some get bowel change as well. And if you if you are reaching the end stage, they can be becoming feverish. And there are lots of signs for a appendicitis. Um, can anyone remember the signs? Be that the name, the name of the sign? Or, you know, the description, or both, if you can. And what other general signs you might find with someone with appendicitis. So in the chat function and anyone else gym and and you are obviously please keep. Please keep answering. Otherwise it's just me. But if there are other people, they're brilliant. Yeah, rebound rows of eggs so as brilliant. Yeah, These are really easy ones. Um and you know, great for med students to see, so yeah, puritanism. So tenderness around the area guarding. Um so, you know, they're They're absolutely tensing the abdominal wall muscles. They you know, they're trying to protect that area from your examination and rebound tenderness. So as you palpate in release, that force of release causes irritation of the area and puritanism. Then you've got a big sign So palpating on the left side, increasing the pain in the right iliac fossa. And that's because it's so irritated that even pressure on the left is stretching that entire peritoneum and irritating the area similar to so a so extension of the right hip. Your appendix is being sort of forced into the so it's major message causing pain and then right at the end and says patients becoming more and more on Well, you've got the sort of the septic picture. So tachycardia, hypertension and pyrexia. Um and I thought it was important to note that although, you know, it's great to see patients that have got the classic or I developed, you know, pain around my belly button that then went to my right side, and it's now really sharp and I'm nauseous. That's really you know, it's quite nice to get because it's such a great clinical diagnosis. But infants, young Children, uh, pregnant and elderly adults are you just have to be aware of presenting it typically so in infants, watery diarrhea and vomiting could be the only signs that you get. And then it's in young Children that it can be very vague symptoms and sometimes just vague abdominal pains. And being off the food is all they'll present with. So examination is really important, um, in the second trimester and was from pregnancy that tenderness and pain can be higher up. The appendix is obviously pushed higher, so it might not be right. Iliac fossa pain and the elderly can often progress really rapidly to sepsis in shock, and so often they're just presenting with confusion. And they're not reporting pain, and it's really difficult to examine them because they're so confused. So it's just important to bear that in mind when you're in a and seeing old people to bear in mind that appendicitis can affect any age and in all kids, um, anyone, any. Any mail, always examine the testicles in abdominal pain because you need to rule out testicular torsion in as a cause and obviously any other causes of abdominal pain from the testes. So, differentials for appendicitis a pretty massive because you've obviously got the main symptom is abdominal pain. So to go into that would take a whole lecture in itself. But it's, you know, often quite useful to split split the causes into which which system or specialty have differentials. So, you know, I won't go through all of these, But are there any guy any causes? Does the patient have a water infection or stones? Um, they actually got an underlying gastro disease. And like we said, uh, urology important to rule out testicular torsion. Brilliant. So investigations. So a pen size is great because, yes, you need to do your usual bedside test. So Abdo pain and females, you want to make sure you're doing a pregnancy test. Um, also, you end up to rule out any UTI and yes, yes, they need blood, but actually bloods can help with the diagnosis. If they've got raised white cells and rate CRP and they've got signs on examination, it helps paint the picture and make you more sets in your diagnosis. But you can have appendicitis with a completely normal white cell and CRP count so it doesn't exclude it. And then usually you know you you don't need to send for imaging if you've made your diagnosis clinically. If it is unclear often an ultrasound as first step because that can no appendix mass or abscess, um, and see signs of inflammation there increasingly, UM, e d is moving towards the urgency is moving towards CTS because it's it's just more sensitive, more specific. And, you know, if it's not appendicitis, your CT will give you information about any other differentials and what might be causing the pain or if there's nothing causing the pain. So management now is, you know, laparoscopic appendectomy, and you know the evidence for that is overwhelming. Over open surgery, it's, you know, it shortens the length of stay for the admission, and you get back to your normal activities a lot quicker. It's got very low and morbidity and mortality, so that that does go up and so uncomplicated appendicitis. You know, it's about one in 1000 that goes up to five. If you perforated. But in the over seventies, because they present so late, that mortality rate can go up to about over 20%. There is some practice of conservative therapy as first, um, in someone that has an appendiceal mass. So that's when the appendix has got so inflamed that it's starting to bring in. Um, you know, the omentum the small bowel and causing it to to stick around the appendix. And there's a large mass and so actually going in, um, trying to take the appendix out with all of that stuck on to it can be quite risky. So most centers would at the moment, treat that conservatively with, you know, fluids, analgesia and Antibiotics IV. And then, you know, weeks down the line would then go in and perform an appendectomy. It's no longer, you know, considered really as a first line for uncomplicated because the failure rate is so high. Um, if you're not sure, it's and the patient's well, active observation is a completely sound management option. Um, and you know, these patients will often be extremely dehydrated, so we'll need fluids. And of course, you need to manage their pain and things like paracetamol and say it's often will cut us. They'll need opiate analgesia. Uh, lots of complications from appendicitis. So like we mentioned, it can perforate, um, following surgery infections. But that's reduced. There's really good evidence for giving operative antibiotics to reduce that. We've talked about Mass. Um, if there is an abscess, you can drain that percutaneous would be ideal. But if if needed to open and then any, you know intraabdominal pathology causing inflammation and needing surgery increases your risk of adhesions later down the line and therefore of bowel obstruction. Brilliant. So we'll move on to diverticulitis. Um, have a drink in my knees and they were going through these quite quickly. But this is really just, you know, the basics and to remind everyone often useful to have a bit of a general refresher before we go in to discuss case study. Yeah, so diverticulitis. So this can be quite confusing when you first start work in general surgery, but it's really important to get the definitions sound in your head, and they may already be very sound in your head, but they weren't sounding mind when I started, and I was getting very confused so a diverticulum is the actual herniation of the mucosa, usually through the weekend colonic muscle. And so that's That's the outpouching. It can be in your small or large bowel, but it's most common in your sigmoid descending. So then, from that you can you can develop problems so well, a diverticular OSIs is just the definition of an asymptomatic diverticular, so that's usually found. Incidentally, you know you'll you'll have people that are seated for, you know, query, obstruction, query this query that and that loads of them will come back with, you know, scattered diverticula, um, in the sigmoid colon. And so that's just the name for someone that has a diagnosis of diverticula. Um, and it gets more common as we get older when it starts. Causing symptoms is when you would call it diverticular disease, and that's about a quarter of people with diverticulums. And if you've got inflammation of the diverticular, then that's diverticulitis. And that can be complicated if that inflammation leads to complications such as, uh, diverticular abscess or perforation of the diverticular, you know, causing widespread um, peritonitis. And then you can also have a diverticular bleed, which is where the has eroded as it's gone through. The weak muscles also eroded into a blood vessel, and that usually causes quite a sudden onset. Large, painless bleed. Um, sometimes they can get slight cramping abdominal pains that comes through the needs to sort of open their bowels, but it is usually painless, so the risk factors for diverticular disease so modifiable ones are similar to cancer. So obesity, really poor fiber diet, any NSAIDs and smoking are both have both been proven to increase the rates of complicated diverticular disease, and then your non modifiable risk factors are age and a family history of diverticular disease. Um, so I thought it was beautiful just to go to the sort of different presentations. Um, so for diverticular disease, usually it's very non specifics. And as the most common place of diverticular is, you know, the sigmoid and uh, left side of the colon is often left side of the abdomen pain the patients get. It's commonly described as being worse with eating. I'm relieved by opening the bowels or passing wind. Usually, the pain is not constant. It's very intermittent and colicky, so it's often something that people will live with. Um and not really get investigated because the symptoms are so vague they can get bloating, constipation and bleeding as well. So, really importantly, there's no systemic symptoms at all and diverticular disease. So next move on to acute diverticulitis so it becomes more clear cut. So they get left lower quadrant pain, which can be intermittent or constant. They get a change in the bowel habit, and the pain is usually described as sharp, and there'll be localized tenderness. When you examine the patient, they can have some systemic symptoms of fever tachycardia, um, they can be off their food and nauseous and vomiting as well. Then, of those patients, if they have developed complications from the diverticulitis, will be called complicated diverticulitis. So that's anyone with physically from the disease, abscesses, perforations, anything any complications with then called complicated diverticulitis. So if someone does create, they'll have signs on exam of that localized Claritin is, um, similar to appendicitis. But then they also have the overwhelming generalized parasites as well. So, you know, guarding everywhere. They're very unwell. Like we said, the bleeding is commonly sudden onset and painless, but may be associated with that urge to defecate. So differentials So we're thinking anything that can cause really the main ST Abdo pain bleeding. Um, so that can be your irritable bowel syndrome, IBD, inflammatory bowel disease, cancers, appendicitis and then kind of pathologies as well. Um, so that's the investigations pretty similar across a lot of the abdomen pain ones. Um, so your bedside ones, like you're in different pregnancy test. You also probably want to do the area as well. If they were bleeding bloods, usual baseline bloods and especially a group, and say that they presented with bleeding imaging would be straight to ct with contrast. And if they are bleeding, you probably want to think about a flex is sick as well. So the management depends on which of those you know, definitions or steps. You are within the spectrum of diverticular diverticular. So if someone has some diverticula OSIs, they've got no symptoms. They don't really need to do much other than if they can manage a high fiber diet that is prophylactic, and we'll mean they're less likely to develop symptoms or inflammation in the future. Anecdotally, in the past, I think, you know, patients have been told to avoid nuts and seeds or anything hard like husks because it could block the entry to the diverticulum and cause that inflammation and infection, you know, similar to the appendix being blocked off. But there's there's no evidence to back that up. Um, remember once going to tell a patient that on a war drowned and then I just had a needle in the back of my mind thinking, Is that actually true? I went to Google it and found out that it's not true at all. So I hurried back to tell him that he could eat nuts because I felt very bad to read him of nuts in his life. Enjoyed them? Um, And then there's some evidence that nonsteroidals, or being on opiate medication long term, could increase your risk of perforation. And then there's definitely no need for antibiotics because they've got no symptoms. And you know that doesn't that has no no use as prophylactic either. Um, so if they are developing symptoms still with that high fiber diet, and you may want to introduce laxatives and good fluid intake for that, um, the pain ladder for pain starting paracetamol and they should probably have a colonoscopy non urgently to exclude cancer if they've been. If they're presenting to a and a um, with systemic symptoms and diagnoses with diverticulitis, often they can be sent home. Um, if the symptoms are very mild, um, and wait and see. Or, you know, if, if they're relatively fit, they could be sent home with antibiotics if they're systemically unwell or immune. Compromised. Usually advised to to stick to clear fluids for the first couple of days and just reintroduce solid foods gradually as they can manage it. Oh, that one step too far. Patients that will need a mission will generally be those that can't manage at home. And be that because of pain relief and not being able to tolerate oral antibiotics. Uh, if you're if you're worried that they are particularly frail or immune compromised if they have tried, you know, home conservative management and that's that's not worked. Or if they presented with complications. Obviously, if you know, if they got large volume bleeding and they dropped the HB, they'll need to come in for transfusion or if they've got features of complicated diverticulitis with perforation, there obviously need to come in. So if they are coming in the management is IV antibiotics. And make sure you're reviewing that early so they're not just sat on the ward with days and days of IV antibiotics. If they don't need fluid recess and maintenance and analgesia, those that will need surgical management are less. It's usually only about 15 to 30% and there'll be patients where, you know IV antibiotics and fluids alone is not going to cut it. So if they've, they've, you know, perforated. And they've got widespread peritonitis or uncontrolled sepsis that isn't getting better with IV antibiotics, um, or complications that require surgical input such as, um, obstruction or fistula. I won't go into these into too much depth, but you can always look back at the slides after the lecture. Um, but abscesses could be, um, given prolonged course of antibiotics or drained percutaneously. Uh, fistula is you'd want to resect. Obstruction can improve as that information resolved, so I would usually wait and see with them and hemorrhage. You'd want to try and get the H be at least above 70. Um, if it is low or above 80. If someone's got through, um, cardiovascular disease obviously stop anything that's thinning the blood and reverse it if you can. And then either you know different methods to stop the bleeding or find the bleeding. Source is described that brilliant. So into pancreatitis is the last case we'll go through and then we'll have a brief break, Um, and just to grab a drink and then we'll come back and do the cases. So pancreatitis, inflammation of the pancreas. Um, the mortality can be quite high for pancreatitis, so mild pancreatitis is 5% and it goes up as it gets more severe. And the most severe cases do actually have a quite a high mortality rate of 30%. And there's no gender difference, and the most common cause is gallstones or alcohol. And I'm sure you will remember the pneumonic I get smashed for the other cause is. But if you do have it in an off ski or you know you are asked on ward around what the cause is, don't just go straight for scorpion venom because you know that's not really causing. The UK Think of the most common things first, So the sort of the mechanisms behind it is that there's premature activation of the enzymes that are meant to be activated when they're out of the pancreas but activated in the pancreas in the pancreas, Um, increase vascular permeability and lots of fluid shifting. These patients will be really, really dehydrated intravascularly and usually require lots of fluid. If the enzymes get into the systemic circulation, they can digest fats and blood vessels. You can get loads of complications from pancreatitis. You know you can get abcesses fluid collections, pulmonary edema, um, ascites. You know all sorts you can get a d. I see. So these patients can get really unwell really quickly. Um, and if it is severe, the pancreas to become can become necrotic. And if it does become necrotic, it's a very high risk of getting infected. And those are the most worrying patients within pancreatitis. So symptoms is the classic severe upper abdomen pain, usually on the left, that radiates straight through to the back. Although less less commonly, it can radiate around to the back, and they usually have a very sudden onset of vomiting. Um, signs if they are unwell with tachycardia or if they've got signs of the other specific cause they have, they have they got jaundice and gallstones And that's what's caused the pancreatitis. Um, it can cause the bowel to become a paralytic, so you may not hear any bowel sounds when you listen to the bow. And just to note, alcohol's a really important part of your history for that. So as before, you're in different pregnancy test pregnancy test and females, and then blood tests are really important in pancreatitis. And hopefully, you know, wherever you work, has a pancreatitis tab with them saved. Um, because they they need really specific ones, like you need to do the glucose, calcium albumen and amylase and try not to forget any of them because if not, you're gonna have to redo the Bloods. Plastic diagnosis would be serum amylase over three times the upper limit. Or, more recently, um, if places can afford it, there's like days, which is a bit more sensitive and specific. ABG is often a really good idea early on because they can be hypoxic. And if there is any necrosis or or, you know, rampant step system that that lactate, it's really important. Um, imaging, ct, abdomen, pelvis, Usually, Um, if the diagnosis is uncertain, you know you can get away with with just your clinical history and blood tests usually would would do the trick. Um, obviously causes itself. If you're worried about gallstones, ultrasound and if they're bleeding, flexible sigmoidoscopy. Um, the blood tests are really important because they all form part of varying scoring systems. One of the most common one commonly used one is the Glasgow. But other hospitals you work in or were working might use different scores. Um, but for the Glasgow, for example, is greater than three is severe so often, if you're, you know, on a war drowned or you're admitting someone with pancreatitis, it looks really good. If you can get ahead of the question coming, which will be you know, what their score and get that in so differentials would be other causes of erased amylase. Um, as listed there, um, small bowel perforation, obstruction really important for that, you know, epigastric or umbilical pain. You'd want to make sure you've ruled out an aortic aneurysm. Um, and you know, medical causes like a typical M, I could present similarly management usually very conservative, focused on hydrating and treating the pain. Those are the main things that you will be asked to do. Pain control is usually really difficult for these patients, Um, and they'll often require very high doses of, um, pain relief up to opiates and sometimes even, you know, onto, you know, patient controlled analgesia, so IV opiate medicine really important to fluid recess. If they're vomiting and it's really bad, you could pop in energy or rows down to relieve that usually place near by mouth. Although there's some evidence that some centers go to use a mentor or feeding as well. So you know by mouth but actually feed, Um, and then some cases will get antibiotics, And that's usually if there's significant necrosis on the CT. Manage the cause if you can. So for gallstones, you want to get in early with an ERCP. If it's due to alcohol, you know, just think. Are they withdrawing from alcohol in the war? Do I need to prescribe anything prophylactically or regularly HD you and I to you for severe cases? Um, and and like I said, surgery is usually say for those with, you know, severe infection in the process or an abscess, and you want to debride the pancreas and put a drain in, um, for those patients they, you know, without without treatment for infection in the process, it's almost always it's fatal. Brilliant. So any questions from those cases pop them in the chat and we will answer them if we meet back here in Maybe you know, enough time to just be careful. Make up, ti. So if if I say we start again in about I don't know three or four minutes and then we've got three case studies to go through and just the more practical side of actually approaching 80 assessing a patient and how you're going to manage that. So hopefully the more interesting half. I just thought it's useful to go through some basics first, So we're all prepared. Yeah, we'll start again in about four minutes. I'm going to make a t. Uh huh. Calcium calcium for pancreatitis is because they can have really severe hypocalcemia. Um, the enzymes that are released and cause fat necrosis, I think somehow bind. Find the calcium, um, and takes it out of the active circulating volume. Um, so they can get quite unwell, and we'll need replacement, and they can also they can also get very low magnesium. Um, need replacement for that, You know, do side effects on the mark are the, um Yeah. Good question. Um, well, I'll answer any others after I bought the cattle. Yeah. Okay. Uh huh. Mhm. Okay. Yeah. So uh huh. Real. Right. We'll get started. And this event isn't sponsored by Yorkshire tea. But I have just realized I'm drinking my tea out of my massive Yorkshire T mark. And I put your shirt back on that. Um, I live in Yorkshire. Let's go. So a and the referral cover. So it depends on your trust, but usually this would be reserved for F two s and above to be on an encore shift where you're receiving the referrals for the specialty. Some some areas may have the registrar receiving the referrals and then passing them down to the to the S, H O s or the You know, if two is called surgical trainees to clerk and review. Um, So, for example, where I worked on surgery as the f two, I worked in a Andy on my uncle shift. The F one would work on aesthetics, So the same day emergency care there'd be sent patients from GP or triage nurses in E. D would move patients there that they thought could be managed in that area, such as gallstones with no systemic symptoms, that sort of thing. Um, and I had a rash of covering all of those areas. You can have lots of different ways of getting referrals. Mine were through bleeps. Um, some will have a phone that they carry with them, and some will have an online portal system. It's then your job to review the patient, depending on on the trust. You know, it's then on on the F two to accept the patient to that specialty or request a different specialty to review. Um, and then you've got to fully cracked the patient in and and or prep them for theater if that's where the patients heading. So I thought it would be really useful to touch on how to receive those calls and referrals. And it's really useful if the patient on the other side of the phone is good at giving information and the handover. Often they're not, or they're stressed. Um, so you know, you can just you can ask for an SVR or, you know you can ask it yourself you know what situation at the moment. Okay, what's the patient's background? What's then you score at the moment. What have you so far? So just get that information from the patient from the person phoning if you can, um, simple things as well. You want what they're working. Diagnosis is at the moment and ask for identify as well. So you know who the patient is. And in terms of that assessment, you know, just, you know, do they look, um, well, what's the pain like? And what's also quite useful is checking who's calling and where from. You know, you might be working somewhere where a and he's really massive, and it's often useful to go and find the person that's referred to the patient to catch up with when you get there. And if there's anything that you think from that phone call that they should be doing before you get there, especially if you've got other patients to see first, you know, don't be afraid to advise over the phone, so you get your information, prioritize your patients and advice on what they should do next, and it can be. I think I found the most stressful thing was deciding who to see first when you had, you know, for people that have been given to see how do you decide who you see first? So I think, just to find a quiet space and just think who would suffer the greatest harm if they didn't see my specialty? Um, the soonest. And if there's multiple people like that, can your senior help you see multiple patients with high urgency? And, you know, if someone is really unwell, do you actually need to see them first? Or can a Andy manage that patient initially, if it's just really good 80 e approach or is it surgery that they need straightaway, In which case you do need to see them? So, just as a little exercise, these are four referrals that you get when you're on call. So the first is an eight year old with a four hour history of abdominal pain, radiant to his left testicle. The second is an elderly man with bleeding and a low BP. The third is a young woman with right upper quadrant pain's radiating around her back. She's got nausea and vomiting, and the last is a 20 year old with right elect for pain and fever. So obviously I'm not going to be mean and ask you to who you see first out of these without a bit more information, because you want more information on the phone. So if I give you a bit more, the 12 year old is also nauseous, and his pain started after he was playing sports at school. Um, it's not going away. It's getting worse. He really just doesn't seem himself. His parents are really worried. The old man has got large amounts of bleeding, and he's also tachycardic. The young women, they say, has come in with biliary colic before so pain from gallstones. Her news is a one, and they're not worried about infection. And the 20 year old has classic sounding appendicitis, and he's stable. So what order would you see these patients in? I wouldn't ask you to share in the chat, but if I just give you, you know, maybe 30 seconds or so just to have a think through how you're going to order these patients and then I'll tell you how I would have done it, which isn't necessarily the right answer is just how my thinking would have worked. Brill. Right? There's some ideas on the chat. Thank you for sharing. So one idea is the 12 year old because the acres a and he can manage that 88 year old, um, someone else is going to go to the 88 year old first and then the boy. So again, no wrong answers. But the way I would prioritize this probably is to go see the boy first, because the man can be managed by a Andy with fluids or, you know, blood products for his low BP. Where is that 12 year old boy? If you're covering multiple specialties or if you're on jen surgeon, they've incorrectly referred to as possible to caution. You need to see that first, because time is testicle. But I won't go into too much more because we've got a neurology chat next week. Come along. So I see him first, then the 88 year old man, then the young man with likely sounding sinusitis. You could argue that the young man needs a surgical review sooner than the old man. Um, because actually, what the old man needs now is to be stabilized and the young man needs an appendix appendectomy. However, I don't think I could go home if I hadn't gone to the old man who was really, um well, first. So probably him. And then, lastly, the woman with biliary colic. If anything, I probably would try not to even see her and see if they can see if a and he can triage her somewhere else, like cat or a stick. So we'll take our old man as our first case. So he's referred from a and he and he's passing fresh red blood from his back passage. Um, so what else you want to find out on the phone? So what we've gone through before? So you ask those questions and the information you get back is that he's had a few months when he's noticed he's passed some fresh red blood, but it's gotten much worse today and now he's got pain for the first time, and he's opened his bowels five times with with fresh blood mixed into the stool. He's got a background of high BP. He's slightly hypertensive and tachacardic. He looks dehydrated and unwell. So far, A and he had put some fluids up and they've sent off bloods. And you had straight to A and B to see this man. So when arriving to A and P, I think often quite useful is to walk past the patient first and just eyeball them. Because you'll you'll develop quite a good gut sense of, of how worried you need to be and how how quickly you need to get to that patient. If if they look like they can manage, then I'd go check their notes and the online system. What sort of things might you want to gather from their notes from A and B? Or, you know, often there's a shared record online system that you can access certain information from What sort of things might you be looking for before you go and see the patient? So if you use the chart function, yeah, yeah, whether they're on anticoagulation, that's a really good idea. Um, because you're already thinking ahead to your 80 assessment. Um, so things to be thinking about is their past medical history. Um, what sort of medication there on? Yeah. Brilliant. Osama. So yeah. What? Is there anything in the past? Medical history? that could be explaining this presentation and what any have done and really importantly, is whether anyone's ever discussed the escalation status. So are they for resuscitation or not? Um, and what's their level of care if that has been discussed before? So, you know, with this patient, go to I t U. If you've got time really useful to look at what bloods have been done either previously. So you know what their baseline is, Um, or which ones have been sent by a D? Or if you're lucky, or if you're struggling to get around patients, which blood have come back so far and similar to imaging what's been done before? What's a And he requested and has anything come back and then go to the patient and depending on how unwell they are, you're either be going in with your history or you'll be going straight to your 80 exam and trying to stabilize that patient. So in the chat, what what questions? Um, would you want to cover in that history of presenting complaint for this elderly man? You know, definitely. We're going to want to go through things like the rest of the history that I have listed below. Um, but if you just pop in the chat, what What questions are going to want to ask? And it might be quite useful to think back to the Section two, part one and think of some symptoms and signs of previous conditions we've mentioned. I'm trying not to give away the diagnosis. Yeah, painful or painless? Really important. So from the history over the phone, and he's told you that he's got pain, and that's the first time he's had it from today. Yeah, the blood. Brilliant. Osama. Um, so a history around the blood. When does he notice it? What color is it? How much is there? Is it in with the stool on top on a tissue mixed in? Yeah. Onset first episode. So he tells you he had it months ago. For the first time. He's a bit vague. Um, I can't really get much of the history out, but it definitely is has been a significant problem for the past few months, but he hasn't sought help before. Brilliant. Thank you for all of those. So history. You've got most of these. So how long? How much? What's the color has he had a change in bowel habit. Related with that. Is there any relation to his bowels with With that blood, you know, take your classic Socrates pain history, and especially with the associated symptoms part, you want to be asking about nausea and vomiting, any worrying signs like weight loss? Um, or tenesmus, which is, you know, the constant feeling that you haven't evacuated your bowels properly, whether they're passing any mucus along with that blood and whether there's bleeding from anywhere else in the family history section. Cancer and IBD, like you, said in the chat, and I particularly this would be really important to ask. So sorry. This slides a bit wordy, but I just wanted to be information across in one. So the history that you get back is that he's had two months of intermittent fresh red blood. Worse today, he's been constipated with Tenesmus for two weeks. He's lost weight. He's got intermittent colicky bowel pain. He's got no nausea and vomiting, and he's got no issues with the swallow. He's got high BP, chronic kidney disease and COPD, for which he takes the following meds. His father had IBD in the past he used to smoke. He's a significant drinker, no recreational drugs. And he has sent baseline bloods but not requested imaging. And this man is currently for recess. So you examined him? Um, he's breathing fine. His wrists look absolutely fine. He's got the odd crap and his chest is barrel shaped. He's tachycardic now. His BP has dropped even lower. His central capillary refill times three seconds and his tons really dry. He has got slight confusion as you've been speaking to him. So you've given him a GCS of 14? Um, because the rest of his sort of based neurology exam is normal. When you get to his tummy, it's soft. No comparison is, um, he's got a mass in the left lower quadrant with some tenderness over it. Um, D e f is don't ever forget glucose, which you've done. It was eight and then also as part of your examination, less part of AAA. And the more part of, you know, general Surgical think anything else going in or out of the patient. So any drip strains, catheter stoners. So you see, he's got one cannula and as a CF, and he's currently using a five. So what you're going to do? What's what. First, what's your first management or first thing you're going to think of after that? 80. Any ideas? Yeah, So Jamie's thinking that she wants to do a CT, which is a great idea, and Osama is thinking an IV line and resuscitation. So yeah, both great ideas. And I would say, as the first off before you get to your investigations, you need to be thinking about stabilizing that patient based on your exam, because his 80 exam had problems, so his airway and breathing was fine. You don't need to do anything about that. His cardiovascular system. He's got evidence of dehydration. He's approaching shock. His BP is dropping. Since you've been there, E. D has helped you out by putting a slow bag up of fluid. But you want that BP to see if it can come up. So you're going to get a stat Bullis 500 mils, which you're gonna let me just run through with gravity to get that in as fast as you can see, he's got no no heart, heart conditions or overload or putting an email or signs of you know overload on the lungs, so that's safe to do. And you definitely want to do that. You want a second cannula in because you currently only got one. Fluid is short term, and this man is likely going to need need blood because you want to replace, like for like so someone comes and tells you that his HPBs come back and it's 67 you ask them to phone the lab and order some urgent red cells because someone did send a group and say they help you out with that. So you got so you've done your bets for SSI, so you'll be moving on to D, so he's confused. So you want to make sure we do a new examine, You know that you're not missing something else. Things like a confusion screen and collateral history are important, but at the moment, you know there's other problems to sort out. So those are probably just in the back of your mind as a plan for the ward, and he's got concerning examination finding So what next? So that's when quite right, we'll be moving on to think about some differentials. So we first want to think about what could be causing this, because our differentials are gonna going to tell us what we do in terms of investigations and management. So what's your top differentials for this man's presentation today? Mhm malignancy. Yeah. So cancer, then also thinking about, you know, bleeding. Um, and Abda pain. So diverticular inflammatory bowel disease, hemorrhoids and also really important to know. I know the classic, you know, you know, black coffee, ground vomit. And, you know, black stool is indicative of an upper GI bleed. But if someone is presenting with massive large amounts of fresh red blood and they've got human dynamics instability, you need to be considering an upper GI bleed as well. So things like viruses or ulcers. Yeah, quite rightly. The history and the presentation really sounds like this has got a diagnosis of colorectal cancer. So our investigations, which we've gone through before you do a d. R. E. And there's fresh red blood on the finger. There is no other cause, as you can see, bleeding. He's got diarrhea. So you want to send a stool culture to make sure there's not an infected cause for that in the background? Um, definitely be sending a urine M. C. S because he's confused Your bloods, which a and we have already sent. But you want to do some more tomorrow, and I'd probably add on confusion screen in your plan and to make sure you're thinking of the whole patient rather than just the surgery. Um, there is a family history of inflammatory bowel disease, and it's a new differentials, so there'd be nothing wrong with adding a fecal calprotectin on two bloods. Um, you know, he's not a practical investigating for liver mets from our previous slides. So this man quite right, we will be needing a CT, chest, abdomen, pelvis. Um, because you're you've got strong concerns for for malignancy. Um, also with the bleeding, he will need a colonoscopy. And if the CT does show cancer, he'll need a biopsy. But those are things way later down the line that you won't be worrying about on A and E. So this is just a slightly busy slide just to summarize the management. So you're 80 is the thing that you do first. So you want the nurses to be regularly checking his BP. You can give further fluid bolsters if you need, But you just need to be careful that you don't want to dilute his hemoglobin even more than it already is To catheterize him to monitor his urine output and make sure he's on the fluid chart. His medicines that we touched on earlier, um, we'll be clocking him in. So we want to withhold his amlodipine prescribed as regular inhalers as carbon 16. He wouldn't be for VT prophylaxis because he's bleeding and he needs some pain relief. I'd let you seen, you know, admit him under general surgery. And then your plan would be to chase any remaining investigations that either you or any absent you'd be requesting an urgent CT cap, probably unless he's really, really unstable and your senior gets involved. And once the CT angio was the 1st 1st line to find the source of the bleeding and manage that before getting a diagnosis of the cause, um, you put a request in for an urgent colonoscopy. Um, if he can have the chat with you, he's a bit confused, but this gentleman wouldn't really be suitable for CPR. Um, and then you want to communicate the above to the patient, to a and the and the war team because they'll need to move him and then update the family as well. Brilliant that scenario one any, any questions quickly on that before we move on, because probably it's easier for the scenarios to do questions after each one. If there is anything, I'm aware that there's 15 minutes left for two for these next two cases, so I will crack on. And if there's anything else at the end, we can answer questions then. So the second scenario is a six year old lady who comes to A and B with diffuse abdominal pain and vomiting. Jack's asking why the second half the catheter assume meaning cannula. So for anyone with shock. So you know that BP getting close to less than 90. You want to large cannulas in the antecubital fossa. So one here one here. And that's because you might be giving things like fluid, boluses and HB infusion at the same time. And you also don't want to miss out on the opportunity to get a second point in if they're becoming more peripherally shut down. So if you only got one cannula, they're bleeding the bleeding. We're getting more dehydrated and the veins closed up and that cannula busts and you've got nowhere else to go. You'll be wishing you put in the number two, so I just always ask for to if someone's really unwell with hypertension. So, um, snow here, too. You find out on the phone that she's got diffuse, colicky Abdo pain for five days, which is getting worse. It's been two days since she's opened her bowels, and she's now vomiting. She's previously had appendicitis, and she's got arthritis, and you're worried that she's got bowel obstruction and they sent off some bloods. They've given her some analgesia, but they really just want you to come and see her. So you arrive to a and a eyeball the patient and decide that you've got enough time to briefly go through her notes and online system to do the things that we've mentioned before. Um, from the history. When you get to her, you want to be asking her about the type of vomit and whether there's any blood in it. When she last opened her bowels and if she's passing any phlebitis and what her normal bowel habit would be like go into that pain, history and associated symptoms. The main one would be whether there's any abdominal distention for her and then the usual extras at the bottom. So the information that you've got, she's got five days of worst thing to fuse. Colicky Abdul pain. And it's not related to when the bowels are opening. She hasn't opened up for two days, and she hasn't passed any wind. She started with the vomiting, and there's no blood in it. She's not really eating much. Abdomen is the standard. There's no weight loss or blood or the change in the bowel habit. And in her past medical history, she's had an open appendectomy before. Um, she had a Bs. So in 1960 she has arthritis, she's for recess. She's got no regular medicine. She drinks a bit of alcohol, doesn't smoke, so you're 80. Got painting Airway. Her breathing is fine. Cardiovascular, slightly tachycardic, slightly hypertensive and a bit dry. Um, she's no, you know, no confusion. Neuro is fine. Her abdomen is generally tender, but there's no parasitism. It's distended, and her or her neuro courses are clear. When you examine, she's got no drip strains, catheters, stoners, cannulas or anything. And a new score is a three. So like we did for the last patient, there's things to stabilize from that exam. Not quite as bad as the last pap that you want to cannulate this lady while you're calculating, you might as well get off the VBG for lactate while you're there because that will tell you how worried you need to be. And you could send any bloods today and he hadn't sent again. No cardiovascular history or overload. So give the full 500 bolus, um, and assess her response. So what next you got concerning examination findings alongside that history? Um, so we need to think about our differentials just briefly for rhabdo pain. Everyone is different in terms of how they want to approach differentials. You can either think about where the pain is. Um, which will definitely give you some clues. You can go through a surgical sieve, so I like vitamin C, d. E f. And that just goes through different categories. And what could be within that category causing the pain? I won't go through all of these, um, sort of outside the scope of the lecture, but these would be um, you know, these slides be online. If you did want to refer back to them, if someone is post surgery and they've come back into a and the with the complication, um, it's often useful to think you know what surgery they've had. What complication could this be? Um, and you know what? What would you do based off that? So just a reminder. That's our ladies history. Um, So what differentials? What would your top differentials be, this lady? And if the if it's too obvious what's causing that? That cause you know what's caused your top differential? Yeah, bowel obstruction. So why do you think she's got bowel obstruction? What? You know, what would you put your money on if you had to? I know we're going to do a scan, anyway, but, you know, good for learning. Yes. Adhesions from her past medical history with her open surgery, brilliant bowel obstruction in capitals. Yes, and adhesions love it. Previous surgery. Um, so, yeah, bowel obstruction with the cause is there that we went through before other differentials. Although clearly this history does point towards bowel obstruction. Would be constipation. Early perforation, paralytic Alice. So Yep. Investigations bedside. Never forget your pregnancy test, but in this patient is not needed because you can't be Can't be pregnant. So your fluid chart BCG and rectal exam is empty. You want to rule out infection as a cause of constipation because that'll be managed very differently. Bloods and your VBG for early signs of a scheme your electrolytes arrangement that you could start fixing before the bloods are back. Sometimes a. And we'll do an abdominal X ray before you even got there, even though you might not necessarily want it. Um and then, yeah, CT abdomen, pelvis would be your investigation of choice. So she's got uncomplicated bowel obstruction. So drip and suck. So urgent fluid recess first and then maintenance. And as part of that, you probably want to have a urinary catheter and a fluid chart. Replace any off electrolytes. Be that probably IV, given that she can't have anything orally. She's known by mouth, um, arrivals tube. So you're decompressing the intestines and then you consider surgery later. If she was to get more and well with science peritonitis or if there was no improvement with with conservative management, then you know, as before you know you're admitting under general surgery. So, uh, you want to request any further investigations, like the CT chase, any remaining investigations and action meds, she probably can have a DVT prophylaxis. Um, make sure she's got some allergies and antiemetics prescribed. And then you want to communicate all of that to the patient, too, and in the ward to manage the transfer and to your senior that you're accepting someone. And that's your assessment of the case. So we'll do questions right at the end, just so people can get off for dinner if they want now if they want to assume people are eating. So Scenario three is a four year old man with fever, abdominal pain and small amounts of fresh red blood from his back passage over the phone. You told it's his first presentation to any of these symptoms. He has had intermittent left abdomen pain for four days with fever since this morning. He has had it on and off for years, but he's always put it down to constipation. He's never worried about it further. They're really worried about him. He's using a seven. Um, he's normally fit and, well, they're not really sure what's going on. The person on the phone just sounds a bit panicked and think it might be appendicitis that's perforated with sepsis, and they just they want you to see him quickly. So you arrived. And me, he looks really unwell. So you're you're not. You know, I wouldn't be going to sit down and look through all his past medical history. Um, and I just trust what you have told me about what they've done so far. I would want to ask a few questions in the history, though, while I'm doing my 80. If you can multitask. If not, I'll start with the 80 and go to history later. So you want to be asking about his update pain, any exacerbated or relieving factors? Um, and then, you know, in in cancer, these associated symptoms are really important to delve into when you're doing any update pain history. So you get from him. He's had this four days of sharp pain. He's had a fever today, and he's had this pain for years on and off, and it gets worse when he eats. But it does get a bit better as he opens his bowels. He's had intermittent constipation for years, and this is what he put it down to. He's also, for the first time ever, had a small amount of fresh red blood this morning mixed in with his stool. He's not eating, and he's really nauseous. He's completely fit and, well, other than allergy to penicillin. Um, you're a T e. He's takin Nick, but he's managing to maintain his saturations, and there's no findings on his lung is tachycardic, hypertensive, dehydrated and pyrexia? Well, he's got high blood sugar on his abdominal exam. It's extremely tender, especially over the left side. There's rebound, tenderness and guarding. You examine his testes, and they're fine as her as her annual officers. He also has nothing in so probably sounds about repetitive. But this literally will be the bread and butter of being in June. Surge in a and a start with your 80 manage the dehydration, but alongside this will also. Hopefully, everyone's worried about septic shock, so you want to cannulas. You want to send off your bloods and get your ABG or VBG done, which shows a raise Lactate. White cells are 15. These metabolic acidosis HBs has dropped from previous but it's holding 100 and 10 again. No concern. So we're giving 500 more bolus and assessing the response, and then we want to be starting to think about that Sepsis. Six. So, while we're in there, get some blood cultures, start IV antibiotics after you've done that. But importantly for him, not penicillin. So you know Instead, you'll probably be using agents like Deferoxamine Metronidazole and a catheter for his urine output. I wouldn't be too worried about his blood sugar at the moment because that can be high in sepsis. And his examination is really concerning for, um uh, let you know I was going to guess, but I clicked the arrow now diverticulitis, um, with this chaps, diverticulitis be uncomplicated or complicated. Hopefully quite simple on that no one wants to say, because it's too obvious. Complicated. Um, so he's got complicated diverticulitis with perforation, um, investigations that you'll do bedside BCG. I've actually missed off d r e there, but he'll definitely need a d r E because he's had bleeding today. Bloods, as we've talked about groups and say, it's really important and your ABG so you didn't want it, but the ultrasound, the and he ordered before you got there has has come back from that. Um, there's no signs of an inflamed appendix, but they have. They have seen some some active signs of the diverticulum that are inflamed, and they thought they could see free gas, although they haven't stuck by their guns because they say, you know, it's too hard to comment on an ultrasound and this chap special test. He needs an urgent CT abdomen pelvis, with contrast. So just as we're moving on to the management for this, we're nearing the end of the lecture, so you might get a A feedback for me. Just to start filling in from the there is provide feedback. Thank you. So management for this chap, as per the 80 were fluid recessing him. So we're urgently doing that. That's that's the thing that this chap needs most at the moment that 500 mil bolus worked. But you know you're going to give another one. Realistically, he might even need. He might even need three. He might be so unwell that he needs something further, like vasopressors, but he likely will be in surgery before that. And, uh, very smart and the statistical be doing fancy things like that instead of you and A and E. You want to make sure he's near by mouth and that he knows that, and the ward knows that he needs to go to theater and you've done your steps to six. You need to request an urgent CT. And as soon as I get you know, once you get the phone call for that man and you've I bought him, I'd be immediately phoning the Reg to say that you haven't reviewed him. But his history is extremely concerning. And he's using a seven. Um, and you're you know, you're pretty sure he's going to need urgent surgical intervention. And even if they don't, you want your Reg there early. If if someone is that, um, well, and they've been referred to general surgery. Obviously this chap is going to get accepted into general surgery when you're clocking him in the meds. He's not for DVT prophylaxis because he's going to theater. Um, but you do want to make sure he's got some analgesia an antiemetics prescribed and then again communicate at the bottom to patient and E. And in this case, theaters in some hospitals, the Reds will manage that. They'll you know they'll book them into theater, They'll phone the anesthetist. Um, in some hospitals, it maybe down to you. So on top of clerking them in, prescribing all the meds. You also need to go to theaters to book them in and phone anesthetics to ask them to review the patient. So there can be quite a lot of work load in admitting a patient if they need surgery. Especially if you're covering multiple, um, specialties. So thanks for listening. Um, sorry if it was quite a whistle top tour in the beginning, I know you could have a lecture reach on each of those conditions, but hopefully it was a brief overview to help with the cases. Thanks for using the chat to be interactive. It was really nice. Um, so, yeah, to summarize. I'd say as you're getting referrals. So before you're even in a and B, make sure you've got enough information that you can identify the patient and who is referred and that you've got a bit of an idea that you can start forming your differentials before you get there and make sure you've got enough information that you can prioritize your patient workload when you get to any, Um, I bought the patient. If you've got time going through the notes, reviewed them with their history, do an 80 and stabilize them. And this is this really is the most important part of your job as an f two. Um, you know, hopefully and you have done that already, but you'll be saying, seeing these patients day in, day out. So you know, just do the do the simple things well and you'll have a happy reg for me differentials and make sure you're requesting investigations to help guide your diagnosis. So to rule things in or out or your management of your top differential. So don't just go requesting things and that aren't going to help in for my senior early for unwed patients or for those that are definitely going to need to go to theater and then admit with all the jobs that follow up from that so usually clerking booklet, um, prescribing that paper online. Hopefully, most places are online. What investigations are leftover? Any prep you need to do for theater, and to communicate that to everyone that you can think of, Really? You know, that's really valued by the war Team A and E and the patient if they know what's going on. Um and yeah, I just remember that these shifts can be really stressful and that your only one person, so make sure you take breaks even if they're just five minutes in a quiet room in A and B to sort of gather your thoughts because, you know, they can be quite stressful shifts. But hopefully this has given you a bit of a, you know, formula to approach the situation. So thank you very much. Just a shout out for our next lectures will be next Monday. Urology on the Monday after trauma, orthopedics and same time, same place. Um, we'd really, really appreciate feedback. You know, it helps us, um, helps us make these series be as much as what you want as we can. So click the link and do the feedback and thank you very much for coming. Yeah, no problem. Thanks for coming, guys. And thanks for interacting. Makes it much more interesting as a lecturer. All right, Bye bye.