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Start the recording and I think it's loading. Cool. Um Thanks guys for coming for our next session. Um Hopefully it'll be useful. It's going to be focused on tackling the surgical take shifts. Um which I know can be quite scary um starting as an F one. I was definitely very nervous before my first surgical shift. Um So the objectives of today, I just look at the structure of the shifts and how they work with the handovers, um just reviewing how to clock and how to document effectively. Um And then looking more clinically um at some scenarios um to put those to put those skills into practice um to looking at some common surgical presentations. So firstly, the structure of the surgical take shifts. So usually, um what happens is you arrive at eight o'clock and there'll be a handover. Um You'll pass the bleep on from the night team to the day team. Um The handover sort of lasts can is, is very variable really, um can last sort of 15 minutes, I guess depending on how sick the patients are. Um There'll be a ward round um then at five o'clock and then you'll sort of do the jobs for those patients. Um, see new ones. Then at five o'clock there'll be another handover. Um, and the, there'll be a, um, sort of period of time where there's sort of just the on call team operating. Um, and then at 8 p.m. there'll be another handover, um, onto the night team where the bleats will get passed along again. Um, and then the whole process goes sort of in a circle. So good clerking, this is all sort of basic stuff, but taking your history, it's all the same. Um It's all what you've learned from sort of. Ay and since day one really, you want to take history, you want to take the, the presenting complaint, the history of that complaint, their past medical history, drug history, social history. And then examination wise, you want to be looking at the abdomen mostly as well as doing a full set of obs. Um And then the investigations you want to be thinking about are on this table. Um, sort of working up from the basic bedside tests, um, which we all know most patients coming through the front door in sort of the surgical de decisions unit will have all of these be bedside tests done and then the appropriate laboratory tests as well. Um, obviously blood's um critical and then usually there'll be some form of imaging involved as well. Um You obviously then maybe think about giving your impression of what's going on listing some differentials as well as formulating a basic plan for that patient. Before then going on to have go on to discuss the case with a senior and then them also reviewing the patient. So this is just an example of what some good documentation might look like. Um It can get quite messy, but it's really, really useful if you try and keep it needs, it really helps the um the team later on as your notes are actually used sort of to write the, the discharge summary and also just by the teams going on into that, going on into the the patient's admission just to review why they came in. They're very important. All right. So I think Matt's gonna just start with the first case. Oh, this, this is just some um examples of this is just a, a diagram of the abdomen and where you might locate the various types of pain. Ok. So, um I'm gonna go through the, the first uh scenario. Um Just someone's asked in the, in the chat, if it's gonna be recorded yet, this, this event will be recorded. Don't worry, you can, you can access it. We'll also upload the slides also afterwards. So you can have access to all this information. So don't worry too much about sort of making notes and stuff uh as you go. So you can always have a look back at it um at a later date. That's not a problem. Um, ok, so yeah, we're just gonna go through some scenarios now and it would be great. So I'm gonna obviously go through the scenario and ask you guys, um, you can either answer, you know, um on, on your mic or, or through the chat, you know, some, some questions is really good to try and get, get you guys to, to engage and start, you know, thinking about these scenarios, cos these are the most sort of common things you'll be dealing with as an F one, especially, especially on a surgical rotation when you'll spend a lot of time clerking, uh as we've mentioned. So, yeah, this is the first scenario. So we've got a 32 year old male, uh who was admitted with some right sided abdominal pain. Um, so it initially started around the umbilicus sort of area. Um, but has now moved over to the right iliac fossa when you, uh see, come and see the patient, they're also feeling nauseous, but they haven't actually vomited. Um, and they feel feverish and sweaty and they've had one episode of uh, a loose stool as well. Uh, past medical history wise, they're sort of normally fit and well, they don't take any regular medications, um, as a 30 year old living with a partner, um, they do have a decent alcohol history of sort of 10 to 14 units a week and has never smoked. So when you go to examine them, you've got a new score of one here. So, um, main things, uh will be sort of a bit of a tachycardia here at 98. They got a BP, decent BP of 1 14/82. Um, they have a temperature of 38.1 as well. So, uh it's a decent temperature there but otherwise no other concerns on the news. They look quite flushed when you go to see them, but they're immobilizing, um, around the room, they're warm and well perfused on examination. The pulse is regular, good volume. Uh, the chest is clear as well and they have good, good uh, entry. Um, when you exa examine the abdomen, they are quite sort of tender over the right, I left fossa in particular, you've also got some rebound tenderness and they are Rosings positive as well. Uh, their calves are soft, nontender and sort of no, uh, edema or erythema. So we've got some initial, um, bloods, uh, here as well. So we've got a raised white cell count of 13, um, um, a hp of 156 and a raised CRP of 78. Um, but no other of concerns in the bloods. So, taking this, er, case in, into account, is there anything any other investigations particularly that you would like to order for, for this patient? Or is there any questions or, or does anyone have any ideas of what might be going on? Yes. So, Yeah, it's really good if you, if you guys could um put your answers in the chat or, or um shout out um, if you have any thoughts, we'll give you a little bit of time just to think about it. And yeah, so BBD check and update. That's a great idea. Yeah, so we've got um, yeah, I would, yeah, you would definitely do that. Anything else you can think of or does anyone have any ideas of what might be going on or a list of differentials is, is always good when you're larking to not have um one sort of differential in mind is always good. Yeah, maybe you might have that as your top differential but always trying to think. Could it be this, could it be that am I missing something? Um could could this patient have, you know, um sort of two things going on at the same time you don't want to sort of miss things and be too sort of narrow minded. So, yeah, we've got imaging. Yeah, so we'll move on to, we'll move on to the next slide now. So yeah, act um would be um appropriate in this case. So yeah, I mean, as some of you are saying, yeah, appendicitis. Um So those are the sort of main things that we need to sort of think about. Um Nico, you said a CTI mean, there's different things that we can do in, in this case, we can either um do an ultrasound or a CT. Um, and it's, it's important when you're, when you're sort of starting to work in your, in your sort of uh first, you know, f one rotations to really sort of, um, know your department well and know what services are available. Um So quite often, you know, for us, for example, in Taunton, we've got an ultrasound department that's connected right next to where we sort of call out patients. So it's really easy and really quick just to get someone around the corner for an ultrasound and your results are sort of um there straight away rather than having to wait, sometimes you having to wait sort of two hours for act, for example, um when patients are just sort of sat there in pain. Um But yeah, so that would probably be the main thing. So, yeah, we've got bloods, we want a VBG, you also want to take some, just sort of basic investigations as well. So just things like, um, you, they, they've come in with a temperature and some raised inflammatory markers. So thinking, could this be infection of other sources? So haven't they consider doing a chest X ray urine dip? Look for sort of common causes of um raise inflammatory markers, basically, um, that could be causing this. Um. Ok. Is there anything else that anyone would like to, any, any other investigations that potentially people would like to do? Give me a minute? Ok. So, yeah, so the guys who've mentioned appendicitis, that's obviously the, the main thing, uh, the diagnosis in this case. So in terms of your investigations, yes, I'll mention the E BG to check the lactate, do a urine depth. ECGS could just to have a baseline. Um, as, um, it's just important, you know, to look for, um, you know, quite a lot of patients will, you know, come in with, uh, af is a really common actually, uh arrhythmia that is just sort of good to uh have a baseline. And so if they do develop arrhythmias later down in admission, um it's pretty good to have a baseline so you can compare that to it. So, yeah, we've done some bloods and yeah, so we've discussed the imaging a little bit. So ultrasound can be really helpful. Um It's not as sensitive as CT but uh like, like I say, sometimes, you know, it can be quite quick and easy just to get an ultrasound, you'll get the results in sort of 1010 minutes. Um, and that can give you a really good idea. You can also have a look for other different pathologies, especially in women. You can have a look for sort of uh more sort of gynecological er, ovarian type pathologies which can present really similarly. So, um yeah, again, I would consider ultrasound in, in those patients. So we, we got act here, I mean, you know, most surgeons would want a CT and it is obviously the sort of, uh, more sensitive and best imaging modality modality to see if there's any other pathology going on as well. Um, so obviously I'm not a radiologist but we can see the, er, appendix sort of arrowed, er, here and we, what we can see is there's um, what we call fat stranding a around the appendix. So you can see the appendix there and the fat around it has gone sort of a gray color, which is uh edema in this case. So that's a key sign of, of appendicitis. If you're looking at um any sort of CT scans, looking for um inflammation. So you can see the fat on the other side of the, of the scan is quite sort of um normal fat surrounding the bowel, you can see is quite sort of sort of dark sort of black color. Um, but the fat surrounding the appendix itself is, is more gray, which is edematous and a, a sign of appendicitis. Um, obviously don't look at the size of the appendix itself because people can have very differing sizes of, of um appendix. So, um it's mainly uh just having a look at the appendix wall itself to see if it's inflamed or if there's any um, fat stranding around the appendix, er, as shown here. So if you um, yeah, move on to the next side. So the main things about sort of management of appendicitis, it's fairly simple, obviously for you guys and I know you probably know a lot of this already, but, um, the mainstay of, of management isn't append appendicectomy. Um, obviously make sure that they are adequately fluid resuscitated. Um Give them antibiotics if they're, if they're febrile, take, take uh blood cultures to see if they've got any uh evidence of bacteremia, um, as well. Um, do an analgesia, make sure that they are comfortable. Obviously, it's, you know, it sounds like a obvious sort of thing, but it can often be missed and patients can be sat there for quite a long time waiting for scans in quite a lot of pain. Sometimes people won't really sort of actively say that they're in a lot of pain as well to make sure that you are um, on top of this for, for patients. Um, and yeah, there's, there's no real follow up, um, required. It's normally a quite a simple operation, um, is mainly done as a keyhole operation on the next slide, I'll show you, um, it's done sort of as uh laparoscopic now. So, um, obviously this has been around for a long time. I don't need to explain this in too much detail to you guys, but it's just a lot better than an open surgery as patients that are in theater for a lot less time, a lot less, a lot less time under anesthetics and they have a much better recovery. So it's just, um, a lot better and quite easy to do. Um Does anyone have any questions about appendicitis? That's probably the most sort of straightforward case, you know, that we, we, we've started off with. But, um, if you don't have any other questions, we can move on to the next one. Um, well, if there's no questions, we move on to scenario two. So this is a 43 year old female. Um, she's been admitted to ST U with right upper quadrant pain. It started after her big full English breakfast. Um, it starts as colicky and then became constant. Um, and radiates to the right shoulder. She's had similar episodes of this kind of pain before. Um, but they normally last sort of a few hours and then get better again. Um, she s she suffers from hypertension and, um, type two diabetes. She takes Metformin and Ramipril. Um, family history. Um, is the only thing is that her mother and sister both have gallstones. Um, she's obese and lives with her husband at home. Um, she occasionally smokes and she doesn't drink alcohol. So examining her, she's got a news of zero. everything is all her obs are pretty much normal. Um, and she's afebrile, she looks uncomfortable at rest and in pain. Um, she's warm, well, perfused, she got a regular pulse and heart sounds are normal. Um, her chest is clear and she got good air, equal, good, equal air entry. Um, she's got a large body habitus. Um, and her abdomen is soft and very tender and they got hyper quadrant and she's Murphy's positive. Um just in case you don't know, Murphy's sign is just, is the sign elicited on when, um, palpation of the right upper quadrant during inspiration causes a rest of inspiration and pain as the gallbladder touches um, the chest wall. So it's quite a good thing to remember. Um And the bowel sounds are present, her calves are soft and nontender and there's no edema present. Um, initial bloods show mildly raised white cells. A RCR P of 100 and two and slight arranged LFT S with a raised bili and a raised AP say. Um, first of all, let's think about differentials. So, right upper quadrant pain, can anyone give some, um, possible causes of pain in the right upper quadrant in the charm? So people have said bitter colic cholecystitis? Yeah, definitely. Correct. Anything else think about the organs that are in that area? I got the gallbladder. I've also got, yeah, I got cholangitis. Exactly. You got the hepatitis, the liver. Um, so anything kind of liver related, anything gallbladder related can cause pain. There. Pancreatitis also can, even though it's classically kind of epigastric can, it can also cause pain in my quadrant. Um, and also one that's you, you, you rarely see it. You do occasionally as a right lower lobe pneumonia. Um, so what's the most likely differential in this case? We think it's already been said cholecystitis, nils. Got it. Yeah. Um And let's switch the scenario slightly. What about, what about if his patient was visibly jaundiced? Um and had a fever, what would you be thinking about? Then? It has also been said cholangitis. Yeah, exactly. So that will be Charcot triad, which is the triad of pain fever and jaundice. Um So just to distinguish the two cholangitis infection of the bile ducts, whereas cholecystitis infection of the gallbladder, I found that quite confusing. I still sometimes get my up between the two even though I know clinically the difference. Um fine, let's go on to what investigations might, might want to do initially. Yeah. So all of these are good answers. Um, after doing the sort of basic bedside tests, which is the same for all patients, um, we'd want to be doing bloods specifically looking for the C RP. Um LFT S which might be raised. Um And then initially always an ultrasound of the upper upper abdominal organs. Um And then if this is inconclusive, then an M RCP could be useful as well moving on to the management of cholecystitis. Um initial management would be sort of IV fluids and antibiotics. Um And then does anyone know what we'd do if, if the stone, if the stone was actually obstructing in the, in the common bile duct? So we said, um, so we want to do an E RCP, which is a procedure to sort of remove the gallstone. Um It stands for endoscopic retrograde, quite a complicated word orangy. Um So we then want to think about doing um a cholecystectomy um or a lap as people call it, it can either be done hot or cold as it said. Um which means either it's during the initial admission or it's kind of delayed by 4 to 6 weeks after the patient has become um has a after the acute presentation has, um, has resolved in the patient as well. Um, so there's so there is some debate about whether, which is better. Um, in reality, most gallbladders are done sort of cold as such. Um, so delayed in 4 to 6 weeks as an elective procedure. Um, however, and, and if there's, if there's any sort of problems with the patient being septic or comorbidities, then it has to be done called once the patient has recovered. Um, there's also the option to do a cholecystostomy drain, um, which can be done if there's, if the patient's, um, acutely unwell if they're not fit for surgery, um, which is just under, um, ir and it's just a drain which can be inserted into the gallbladder. So the patient doesn't have to undergo, um, a general anesthetic. Um, and there's another side point, has anyone heard of gallstone ileus? Does anyone know what that is? Well, has it a guess? No, fine. It's just a, it's where a gallstone, um, can actually erode through the wall of the gallbladder, um, creating a fistula between the gallbladder and the duodenum. Um, and at least obstruction of the terminal ilium. So it actually presents a small bowel obstruction. Um, it is rare but it, I think I've seen two or three, during my rotation. So it does happen and it is worth considering. Um, so does anyone have any questions about this scenario? If not, we'll move on fine next scenario. So, yeah, go moving on to the next one guys. So this is a 71 year old man who was admitted to the emergency department with severe abdominal pain. Um It's mainly around the sort of middle of his abdomen also radiating to the back. Uh So it started a few hours ago. He, he says that it uh improves when he's leaning forward. Um, but it gets worse when he's sort of taking a deep breath in. You really feel it. Uh He's also nauseous as well um with a reduced sort of appetite over this sort of same time frame. Um, in terms of his background, he's asthmatic. He's got uh some hypertension. He's also had his appendix removed um, 25 years ago. Um, he is taking some salbutamol for his asthma. He's on Ramipril aspirin. Uh He's also got a penicillin allergy. He lives with his wife, normally re er, relatively sort of fit and active, er, for a 71 year old with a decent alcohol history and is, uh, still smoking around five a day trying to cut back, um, on examination. So, we've got a, we've got a new score taken, um, with, with his observations. So he's got a slightly high respirate 24. Um, we've put him on some oxygen, he's got a new oxygen requirement, not normally on oxygen at home. Uh, he's also, er, slightly hypotensive with, uh, BP of 92/58. He's also tachycardic. Um, and he's got a low grade fever of, er, 37.8. Um, when you actually have a look at him, he appears, uh, sort of clinically unwell. He just, you know, looking, looking at him at the end end of the bed, he doesn't look, um, doesn't, doesn't look right. Um, he's got dry mucus membranes, his cap hei times three. Um, but his pulse is regular, heart sounds normal and he's got good air entry by that actually, no sort of focal, er, signs there. His abdomen is, is actually soft. Um, it's sort of tender in the epigastric region and also in the right upper quadrant as well and he is, uh, showing some voluntary guarding as well. Um, so we've got some initial investigations, so we've got an ECG just showing sinus tachy as his heart rate was 125. and we've got some blood tests there for you as well. So you've got a raised white cell count, uh, raised CRP of 100 amylase is, uh, 1500 Bilirubin is 21 A LT 43 APA, 100 g Fr 64. I know we're not giving you the, the reference ranges guys, but you, it, you know, you either, you either know them now or you will know them, you will start to sort of know the normal sort of values really quickly as, you know, when you, when you're working, you just sort of get used to it. Um, so, yeah, we've got some investigations there. Is there any other investigations that you guys would like to do for this patient just to, you know, let you know it will be sim similar to the previous, you know, sort of an, any patient coming with, with, with abdominal pain, you're gonna be doing similar sort of set of, of investigations. Definitely. So, sort of, sort of the sort of main sort of baseline investigations that you'll be doing, obviously, um, when it comes to sort of more specifics or imaging and things like that and that can change. But what are the main investigations that you want to do for this patient or if you don't want any investigations and you know, exactly what's going on then give her some different shows as well. So, yeah. Yeah. Based on bla, yeah. So we've, um, obviously got those there. So, yeah, I mean, it's, they're quite helpful, they can sort of guide you into what you think might be the pathology in this case. Um Does anyone have any differentials again? Like I say, it's, it's really important to have multiple differentials. People can present with abdominal pain in different areas and can present differently. Some people can present with severe pain. Some people can present with no pain at all. Uh and just, just come in with some vomiting and uh sort of reduced appetite sort of thing. So what differentials could this be again, looking at the anatomy, looking at the area where his pain is? Has any anyone got any thoughts? I mean, yeah, to be honest, all all the stuff that we've said already, you know, in terms of the could be cholecystitis, cholangitis. It's important to sort of con consider those things. I think we've said, um, some other things that it could be potentially a bit more sort of central pain, you know, this, this could be a sort of a diverticulitis. It could be a colitis, it could be lots of different things obviously in, in this case, um, one thing in the blood does sort of scream out to you with the amylase. Um, yeah. Yeah. Well, I don't think it was, yeah, we've got acute pancreatitis. Yeah. Another thing is, yeah, is really important not to forget is, uh AAA in this patient, especially with the pain radiating into the back. Um, it's really important to sort of think about, um AAA, look at the sort of past medical history of the patient. Quite often, some people will have sort of a known uh diagnosis. Also, you can have a look at previous scans if you've had previous CT s, previous ultrasounds, you know, for different things quite often, you know, some sometimes people will have an ultrasound for whatever reason and, and they'll comment on the size of the, of the aorta. So also look at the patient's history, go have a full look through their sort of letters and their um, past medical history and previous discharge, summaries have a look at their previous imaging as well. This can be really helpful in um, sort of not missing things and having a look at what, what they've had previously. Um So yeah, I mean, in, in, in this case with, with the amylase of, of 1500 that's pretty good going. So any, um, amylase three times above the, um, upper limit is sort of diagnostic of um pancreatitis, uh sort of main in this case. So, yeah, this is um, pancreatitis. So obviously, um, moving on to the sort of next slide, um, we can talk about some other things. Does anyone have any questions or any, any other investigations or anything they'd like to do at this point? Um That's fine. So, I mean, if you have any questions just put them in the chat. But so yeah, this is, this is a uh example of sort of acute pancreatitis. I know, I assume you guys would have all heard the, I get smashed, er, Pneumonic before. So this is a really useful, if you haven't, uh, seen it before, then I would just take a screenshot or just, er, sort of jot it down. It's a really useful sort of, um, thing to remember and, you know, as soon as you hear it you'll remember it and it's a really good sort of new monitor to remember all the different causes of pancreatitis. So anyone with any raised amylase, you come in, you sort of thinking what, what could be causing it. The main two gallstones and alcohol are the main sort of causes that take up the majority or the large proportion of patients that come in. Also, there's lots of other things, you know, there's even, you know, scorpion bites or autoimmune, uh conditions, steroids themselves can cause it, other drugs can cause it. Um E RCP is the other sort of fairly common. Um cause I think around sort of, I know you've said E RCP before in the previous case of cholecystitis, but it's around 10 to 15% of patients, uh E RCP patients get uh post E RCP pancreatitis. So it's a, it's a, it's quite a lot. And again, I've seen a couple of cases of it already. So, um don't underestimate the that and it can obviously have really big impacts on the patient and you asked not to trust. So, Ams or lipase, I mean, Yeah, it's a really good question. So, I mean, it, it, it, I mean, we, we do amylase at, um, at Taunton, at, at Somerset, um, trust. But yeah, I mean, I'm not sure with other, other trusts if they use amylase or lipase. So I know obviously lipase has a slightly longer, uh, half life or it's, um, slightly, slightly more sensitive test because often patients say they come in with a three day history of pain, they might come in and their amylase might be normal. But two days ago, it might have been, you know, 500 or something like that. So, um, the lipase can be, can be better for that because it sort of, um, it's takes longer to come up and it also takes longer to come down. So it's a bit more um useful in that sense, but we just normally use amylase obviously, again, if there, if there is a delayed sort of history, if the patients coming in, say with, you know, a four day history of this pain started four days ago, really consider that if the amylase is normal, sort of consider that as a, as a sort of differential, could this be pancreatitis? Could this be a delayed presentation if the amylase is normal? Um So I would just sort of, yeah, bear that in mind is a really good question. Um So yeah, I mean, that's so the gone through the main sort of course is, does anyone know or any, have any suggestions about how you would manage this patient or another question is, does anyone know any sort of scoring systems that might be helpful in, in patients coming in with pancreatitis to help sort of assess their either suitability for discharge or assess their uh mortality or which can be really useful. Yes, it is being recorded. Don't worry, don't, don't worry about making notes or anything. Er, the session has been recorded. We'll send you out the slides and the recording as well. So you can always rewatch it and um, have a look. So, yeah, thank you. NK you also a modified Glasgow scale uh can be really helpful. Um I mean, there's, there's loads to be honest and um it's quite unhelpful because there's, there's lots of different sort of scoring systems that are used that are all very sort of similar and do the main sort of jobs. But as long as you've thought about it, it's really good just to, you know, especially when you're presenting to your seniors, if you have a history and you said they've got a Glasgow score of this or they've got a haps score of this is, is really sort of useful for you. So, the, the other, the other scoring system, what we use is called hap S. Um and it's basically to have a look at the risk of mortality of pancreatitis because pancreatitis can be a, can be really severe and people can deteriorate really, really quickly. So, so you don't want to scare you guys. But anyone with, you know, I've, I've, there's been a few cases in, in our trust of, um, sort of fairly young patients who have unfortunately died from, from pancreatitis and they can go downhill really, really quickly. They can look quite well at, you know, sort of, at one point and a few hours later can sort of deteriorate really quickly. So that's why the scoring systems are really helpful because you can sort of see, you know, from their blood tests and things like that. You can do a full sort of screen and say this patient is high risk and it can help you sort of identify patients who should be referred to ICU because these patients can require some significant um sort of um vasopressor treatment and things like that. So, um it's really important that you guys are aware of these things. So I would have a look at the hap score as well. It's a, it's a harmless acute pancreatitis score. It's quite a simple score that um can help you sort of um see which patients like I say require itu admission or which patients it can also help you. If the score is zero, you can consider potentially sort of ambulatory management. So what what I mean by that is um some patients with pancreatitis can be discharged home safely with safety netting advice to come back in if they have worsening symptoms because we haven't discussed management at the moment. But, um, depending on the management, some people can be managed at home, um, with sort of adequate sort of, uh, fluids and analgesia. Um, so I've kind of just given the, given away the, the, the, the answer really for the management. But is anyone other than fluids, analgesia? Is there anything else that anyone might consider antibiotics there? Is there anything else that someone might, you might think about any other management that you would like to do? Yeah, that's really important. And nickel for saying that actually antiemetics um, really easily forgotten. Um, you know, and quite often, you know, you, people will be sick and a lot, a lot of the times um, nurses will prescribe antiemetics, they can do sort of stat doses themselves and sort of sort it themselves, but quite often they're not and again, patients might not ask for it. So it's really important that you think about it, put antiemetics on their P RN and so that they're available with if needed. Excuse me? And um, yeah, that's a really good suggestion. Anything else or is there anything else, any sort of complications that anyone's aware of or anything that, um, you know, and yes, complications of pancreatitis that would be good to sort of know about. So, I mean, the, the main complication is um pancreatic er, necrosis, which is um, basically where you have ongoing inflammation that leads to ischemic sort of infarction of the, of the actual pancreatic tissue itself. And the, and the pancreas sort of sort of dies off, this can be quite a, again, a serious sort of complication and one that requires, you know, senior management, you won't be dealing with this on your own as an F one. But it's just something that's good to be bear in mind and have that sort of thought in the back of the head. Um because this can develop sort of a few days, you know, if someone's admitted with pancreatitis, always think a few days later down the line, could they be developing a a necrosis also? Um So that's basically managed by, again, the same sort of thing. So, fluids analgesia, there is potential for a necrosectomy which is mainly done in sort of um large centers. We sort of refer patients off to Bristol for that. So we don't do that in Taunton ourselves. Cos we don't have the sort of expertise, but it would be a sort of um unit that would do that. So again, you know, involve your seniors have these discussions if, if you're worried, another thing to uh look, look for is uh something called pancre pancreatic pseudocysts. Um Again, they can typically form sort of days to weeks after the initial sort of acute pancreatitis episode. Um And this is why it's called pseudocysts is that they're um a cyst without sort of the epithelial um membrane. So they don't actually have it. They're not a natural sort of cyst with the epithelial sort of lining. But uh there's a, a collection of sort of uh fluid basically. Um And they have a sort of fibrotic wall around the, around the collection. So again, they can be found on, on imaging, on CT scans. So, um quite often, you know, you would do with people coming in with pancreatitis. Um It's important to do a CT scan sort of 55 days or five days to a week after they've presented because that's when you get these complications. That's when you look for necrosis and that's when you look for zero cysts. So anyone with pancreatitis who you do admit, always consider booking act sort of a week into their admission um to look for these complications if they're not improving. Does anyone have any questions about pancreatitis or anything of this case? Otherwise, we'll move on. Cool, we'll move on to the next case. Um Scenario four. Um So this is a um 765 year old female and she's been admitted to ST U with cramping, abdominal pain, nausea and vomiting. So the pain started six hours ago, it came on suddenly and it's described as being crampy, it's generalized, but it's worse around the center of her tummy. She's also had multiple episodes of vomiting, which she described as being green, um which is kind of indicative of bilious. Um, she has not passed any stool in about two days and also she doesn't remember passing wind since yesterday morning. Um, past medical history. She's got high BP. She's got, she's previously had a cholecystectomy, um, after having cholecystitis, um, and she's had a left hemicolectomy as well. Um, she takes Bisoprolol, amLODIPine and she has no known drug allergies. She lives in student halls. She doesn't smoke, she drinks minimal alcohol. Um, so looking at her, she appears to be quite uncomfortable. Um, but her obs are quite reassuring. She's got a slightly raised heart rate and a raised respiratory rate. Um, she appears, um, well, hydrated, um, good pulse and good cap refill time and her heart cells are normal. She's got good air entry bilaterally and no obvious added sounds. Um, moving on to her, examine her abdomen. It is definitely distended, um, and generally quite tender. Um, she's got reduced, bowel sounds, she's not periton. She has apr done, um, which is done with consent, of course. Um, and this finds that that her rectum is empty. Um, there's no blood, no stool and no masses. Um, so they, they, they're, they're the kind of the, the three things you'd want to be looking for on APR exam. Um, she has some initial investigations done including bloods, uh, which shows mildly right, mildly raised inflammatory markers. All right. Um, so what are your differentials at this point? Anyone got, got, got a small bowel obstruction. Yeah. Anyone else got another differential adhesions, correct. Ok. So, I think, um, small bowel destruction, I agree is probably the most likely or bowel destruction in general. Um, given this this presentation and there are kind of four main features about obstruction, um, that we look for in a history. Does anyone know any of them sort of 44 key features which, um, actually all of them are seen in this, in this presentation? So it's quite a good one to kind of have it stuck, stuck in your mind. If not, we can go through them. Um, so vomiting is definitely one, um, abdominal distension. Yeah, exactly. Vomiting ni said it, um, abdominal distension, absolute constipation, um which means importantly, not passing wind or storm. And so it's very important to ask whether they've passed wind. Not a lot of patients won't know, but it's worth asking. Um, and abdominal pain. So, vomiting extension, absolute constipation and pain are kind of the four red flags for bowel obstruction. Um So what investigations would you want to do at this point? Put on a bedside or bloods or imaging? No, I'd want to think, start with doing sort of, yes, someone's did a chest X ray and an abdominal x ray. That's true. So a chest X ray, um, would, wouldn't really be done for bowel obstruction unless we're sort of query whether there's a perforation. In which case, you might see air under the diaphragm um at that point, it would be a kind of an emergency. Um but an abdominal x-ray. Yeah. Um And that's what would be on my next slide. So here's kind of two examples of abdominal x rays which might be taken um in a patient presenting with some, with some history kind of like this. Does anyone know what either of these um are sort of showing the start with the one on the left? Does anyone know what, um, what this is showing? Maybe it's not that obvious. Um, so it is showing kind of a small bowel obstruction picture and you can see the dilation of the small bowel. Um, and you know, it's small bowel cos it's kind of in the center of the abdomen. Um, and you've got the health administrations as well which extend across the entire of the entire of the small bowel, which is different to the, um, val convenes which has seen the large bowel. Um, and it's about, and it's larger than three centimeters. It's kind of hard to tell on this, but it is, I'm telling you that. Um, so we'd be kind of indicative of small bowel obstruction. Um, and you also can see sort of gas which is absent gas in the rectum and large bowel. And then on the right, does anyone know what this is kind of a classic sign? You can see you on ABDO X ray and you do see it in kind of practice as well. Exactly sig more evolve. So it's what we call the coffee bean sign. It usually isn't as sort of coffee bean like as this, but it often is very dramatic when you do see it. Um, and this just occurs from this sort of torsion of the colon around the mesenteric axis. And it's pointing to the, um, left ect fossa. Usually if it's pointing to the right I elect fossa, then that would be more suggestive of the sequel fus. Um, you suggested some investigations, um, other investigations you might want to consider would be these. So obviously, the full set of bloods, amylase always wants to do amylase really with, with abdo pain just to rule out pancreatitis. Um, a group and safe and also crossing here isn't listed. But, um, these are kind of things that we'd want to consider if this patient might be going to a theater, um, really important. So, imaging abdominal X ray sometimes done. But usually if we kind of querying a bowel obstruction picture, we would just jump to a CT Abd pelvis. Um, they're going to probably need one at some point. Anyway, um, it's probably best to just kind of save the radiation and just jump straight to it, but you should probably check with the senior before you do this. So, does anyone know sort of some causes of small bowel obstruction or large bowel obstruction? What are the most common ones? Someone actually listed one of them already s exactly. So the main kind of causes of small bowel obstruction would be sort of adhesions and hernias. They're the two things that we see most often. And then large bowel would be a malignancy, diverticulitis and volvulus. And just note on sort of a closed versus open loop obstruction, which is something that a term you might hear sort of, um, hear on the wards and open loop. just basically means there's one obstructive lesion um without vascular compromise. Whereas a closed loop means there's two obstructive lesions. And there's a kind of a loop of descended bowel in the middle, um, which then is a high risk for perforation. We're running a bit short of time. So I'll move on. Um, so management of small bowel obstruction, um, initially, you conserved trial, conservative management. So sort of antibiotics usually IV sort of amox metro gents. Um And then I don't know if you've heard of the drip and suck technique. It's done a lot um, in the surgical wards. So it's just basically means this means of three things. Um, keeping the patient know by mouth, giving them fluids and putting an NG tubes if A Rs tube down their throat to try and, um, decompress the stomach and prevent aspiration. Um, and it, and it will also help them feel less sick. Um, often conservative management is enough and this can help and this will, um, and this bowel rest will sort of al allow the small bowel obstruction to sort of resolve by itself. Um, if not, then a laparotomy might need to be considered or if there's perforation as well. Um, fine, we're running out of times. We'll move on to the next scenario. Ok. So, yeah, this is the last, last one, guys, we'll go through it, uh, fairly quickly so that you guys get, um, get out on time. So this is a 61 year old uh male who was admitted with left sided uh colicky abdominal pain, er requiring some IV morphine in, in Ed. So, looking into the history, it was a sudden onset, left side of pain started three hours ago, um unable to sort of uh get comfy or sort of keep still uh pain's constant but comes in waves uh and gets better and sort of worse, you know, quite, quite a lot. Uh He also feels uh nauseous uh when the pain comes on as well. Uh In terms of his background, he's um been diagnosed with gout hypertension, diverticulitis and ischemic heart disease. Uh He's taking allopurinol for his gout. Uh He's on some statin and aspirin um as well, but he doesn't have any allergies, lives with his wife and manages um to immobilize sort of independently. Uh So he got a new score of two. So uh he's tachycardic. Uh he's got high respirate. Uh his BP is quite high. He won't be scoring for that. But it's uh 1 80/100. Um And when you go to examine him, he's sort of riding around in pain again. Can't sort of get comfortable. Um But he's got moist mucous membranes. Heart sounds normal. Chest is clear. He's got a good air entry. Um and his abdomen is soft, but it's quite tender over the sort of left sort of flank, uh and uh tender over the renal angle as well. Uh We examined his calves which are soft, non tender and he's got sort of no edema or any obvious edema anywhere. So we do have some initial bloods and we've also got a urine dip as well. So the urine dip shows um positive for blood, uh not, not got any uh sort of nitrates in it. Um We've got a raised white cell count of uh 14, uh C RP of 17, slightly raised and um, he's got sort of normal e um EGFR of 65. Do you have any investigations, any other investigations that you would like to do for this patient? Or again, if you, if you think you might know uh what you think is going on any differentials at this point, it's important to note that a lot of these cases, you know, people are coming and presenting with pain in sort of similar locations. Um It's, it can be quite difficult to sort of uh differentiate between this and often patients will come in with sort of pain where you might not expect it. So don't sort of think if it's not the classical history of something, you know, that the patient isn't getting pain in the specific place that you would think they would, don't rule out certain diagnoses. So in this case, they've come in with some left flank pain. So think of obviously what sort of anatomy sort of anatomical wise, what is in that area, but also think, don't um be too narrow minded again and think sort of generally what could be causing this. Um So we've got kidney stones renal colic. Yeah. Anything else? Again, it is really important as an F one. Don't, don't go in with one differential. Obviously, you have your top differential. That's great. And if you're confident, brilliant, but always have other things that you think all might be going on at the same time. For example, you might have two things or always have some other things which you think it could be this less likely, but you might want to rule out. Yeah. Again, divertic diverticulitis is a great shout, especially with this left side of pain. Um That's a really good differential. Definitely want to consider. So considering we are running out of time, we'll sort of move on. But this is, yeah, your typical sort of, um, presentation of, you know, ureteric sort of renal colic. Um So we've gone through some of the investigations. Yeah, which we've done a urine dip again, D VG is just really helpful just mainly to get to have a look at lactate also to have a look if they're sort of particularly uh acidotic or um you can, you can, again, you, you've got your using these straight away on the, on the D VG as well, which can be quite helpful. Done. The bloods limit thinking. So, yeah, imaging. So, yeah, someone mentioned it as well. Yeah, CT K UB is gold standard. We don't really go for an ultrasound in, in these sort of patients. It's sort of best just to go straight for CT again. Um And yeah, yeah. CT K UB non contrast is, is what you would do for, for this patient if you're suspecting uh ureter colic and we've got here on the, on the side. So it's really important uh as you uh for F ones in particular. So any infected obstructed kidney is a urological emergency and you would need to contact the urology team sort of straight away if you're, if you're um suspecting this. So in terms of uh do they have any signs of, of uh of obstruction uh or infection? Do they have signs of py nephritis? See this patient, um you know, are they, are they vomiting? Are they febrile, are they septic? These are the sort of things that you need to think about and make sure you do the basics as an F one, obviously, you know, you might not have the diagnosis on the management plan, but as long as you do get all the information required and you do the basics, that's basically your role as an F one. So, I mean, we can go straight into management. Obviously, we are, um, running out of time a little bit. So, analgesia again, don't forget the basics as an F one. That's your sort of, sort of main role is, is to make sure you get the right investigations and you do the basic management. So that's including analgesia. So, I don't know, I assume people you would have heard of um, giving P RT Clofen is a really, really good uh, analgesia for anyone with, uh renal colic. So, uh, yeah, we normally give 100 mgs of 18 hourly as the dose that we sort of use, uh, in some sets, obviously, um, some patients may have different sort of doses. So have a look at what is sort of recommended in, in your dry, but that's pretty standard and you know, the, the BNF gives you sort of, you can go up to 150 but we sort of just go standard of, of 100. Um And yeah, again, so other things for management, so encourage fluid intake. Um, and the actual sort of mainstay of the management depends on how big the stone is. Firstly and where it is and if it's causing any obstruction. So if it's causing obstruction and you've got hydronephrosis, which is sort of again. So it shows sort of back pressure and uh swelling of the kidneys basically. So, you've got hydronephrosis on the scan and you're worried this could be, you know, infected obstructive kidney. Then again, speak to your senior straight away and, um, because they may need to go for a sort of emergency, um, surgical sort of um, management for that. But generally if they don't have any signs of, of that infected obstructed kidney and they're sort of stable and you, you, you're happy that they're sort of, um, don't need any sort of emergency surgery. Then again, have a look at the size of the, of the stone and where it is. So, depending on the size, it, it can quite often pass on its own if it's fairly small, less than five millimeters likely to passed on its own, uh, if it's slightly bigger than that and typically closer to the renal angle. So the obviously the higher up it is the, the sort of renal tract, the less likely it is to pass on its own. Um But if it's yeah, less than 10 millimeters, then you can consider tamsulosin, which is um, so sure what you guys know is an alpha blocker, you normally give standard dose that we sort of normally give is 400 M micrograms once daily. Um And in these patients, you can offer, obviously, you would speak to the urologist because you wouldn't be doing this as sort of general surgeons or F or F ones in, in particular. So, but there's different management strategies you can use, you can use lithotripsy, which is, um, if there's, yeah, again, if there's no sign of infection, it's quite a good sort of treatment. Um, or if it's sort of bigger stones, you can, um, consider sort of something called PCNL, which is percutaneous Nether Liho Toy, um, which is again, just sort of uh surgical management. And it's important, you know, as N ef one. So people coming into the sort of surgical admissions units, you can sort of decide between with yourselves and your seniors as well. Does this patient need admission or can this patient be managed with analgesia? And can they be brought back to something we call a stone clinic is where sometimes if we can get on top of the patient's pain and the stone isn't particularly large and it's uh in a position where it's likely to pass on its own. So it might be lower down um near the V UJ. So vesicoureteric junction, which is the junction between the bladder and the ureter. Um It's more likely that they'll pass on their own. So sometimes you can say to patients, you have this stone, it's causing you pain, if we can get on top of the pain relief with the diclofenac, which really does work for patients who I really recommend using it. Um You can say to patients if they're happy to go home and sort of come back for sort of outpatient sort of clinic and outpatient management. Then that that was an option for these patients, especially if they're not sort of particularly unwell if they are requiring admission. Obviously, you can admit them for pain relief or you can admit them if they're septic or you can admit them if you think they're needing emergency sort of treatment. But does anyone have any questions about the management? Again, as an F one, you guys need to worry mainly about doing the basics. So giving them analgesia making sure they've got some fluids if they, if they need it, if they're particularly dry or hypertensive and then you can come up with your management plan and it's great if you can do all these things and order the scans and stuff. But your main role as an F one is, is to do the basics and then, and then discuss with your senior in terms of or discussing with urology sort of seniors as well if, if, if that's required. So, yeah, this is just a slide showing. You can obviously see the stone there in the ureter. It's quite, quite a big one and you can also see the sort of um infection behind behind the stone, there's lots of sort of swelling there and um inflammation, which is fairly obvious. Yeah, and there's a few different options as well. So we've got for management. You can also do nephrostomy, which is where you just again stick a drain into the, into the kidney to relieve any of the obstructions. And this can be done similar to, um, cholecystostomy where you put a drain into the gallbladder, you can put a drain into the kidney. If they are particularly sort of unwell and potentially not fit for surgery. You can do, uh, nephrostomy, um, as well, which are quite good options. So, just think about those. Um, but yeah, does anyone have any questions about the management or any questions about, about this case? Otherwise we'll move on and go to the summary if you don't have any questions. So, yeah, I mean, if, if you do have any questions, keep being in the chat, we'll have a look at it, don't worry. But, um, yeah, so just, just to summarize, always sort of stick to your systems, you'll notice that there's five cases here. But the investigations and the actual role of the F one is pretty similar no matter what the patients coming in with. Yeah, it, it's really, it's really important to think of your differentials and, um, think of your management plan, but a lot of the basic investigations and a lot of the management is similar, there's only very small differences in terms of which scan, you might order, you might order a slightly different scan in a slightly different patient or there's a, you might, you know, discuss with someone else, for example, but there's a lot of overlap in these cases, which is, makes your life quite, you know, easy in a sense that you don't have to worry too much when you're larking patients. Um, if you, if you're doing the basics, that's, that's great. Um, so again, make sure you thoroughly explore the nature of the pain patients can present differently. Um, patients, you know, with, um, can present with particularly right upper quadrant pain. You know, you might think this is definitely uh gallstones, but actually, it's sort of referred pain from a kidney stone, for example. So don't um have multiple differentials in your head, don't be fixed on one if you think this is definitely gallstones, you know, don't sort of, you know, look for other things. Do a urine dip, look for any if there's blood in the blood in the urine, for example, could you think, oh, this might actually be something else? Um So don't be sort of narrow minded in your differentials always think, could this be something else? Could this be something close to the area you think causing the pain? So, yeah, remember there can be more than one diagnosis as well. So again, yeah, don't be narrow minded. Um take time to document clearly and logically use um sort of diagrams to show your examination findings. I'm sure you've obviously done this before um can be really helpful. Um And you guys, I assume most of you guys are in final year but if you, whatever year you're in, try and get to, um, the surgical decisions unit or surgical admissions unit to just see patients yourself again, come up with your differentials as you are doing in this sort of teaching session and sort of test yourself and think, oh, I, you know, would have done this differently or could have done that differently, um, when speaking to your seniors and your consultants and, yeah, so you have basic investigations, common medications, like I say, there's a lot of overlap in these cases, especially with people coming in with abdominal pain. So make sure you do the basics and don't forget, don't forget those because that's, you know, what really makes a big difference to the patient, making sure they've got analgesia, making sure they've got antibiotics, for example, um, again, you know, always take time to eat yourself and rehydrate yourself. Don't, you know, um, don't forget about that. That's another important thing is an F one, obviously you'll be on long, on call shifts, on take shifts. Sometimes you can be in the sort of, um, in the unit, sort of clerking and patients and, you know, some are more busy than others. Some shifts can be really chilled and some shifts can be really, really busy. So be prepared for the busy ones in terms of make sure you do take breaks and take time to make sure that you're you know, looking after yourself as well. And finally, I think the main thing is do the basics as an f one, see, the patient do a full history, do a full A to do a full examination and prescribe the basic medications. So the basics of, uh, analgesia and fluids, if you think they need of them and always talk to your seniors if you're unsure, you know, they'll always be happy to help. They might sometimes be a little bit, you know, they might not be that sort of, um, receiving or that sort of open, but they're always happy to help and it's, they're much better. They would much rather you talk to them and discuss patients with them than, than not. So, even if they are busy, so do, do sort of persist and make sure that you are confident and don't, don't do things that are out of your sort of comfort zone. Basically. That's the main things. Does anyone have again? Any questions will probably hang around? Obviously. I know we're so sorry. We're 10 minutes late or if, er, Lisa, you have anything you wanted to add. No, and that's everything. Um, we've got a, um, feedback form. If that's all right, people could scan the QR code and give us some feedback. We much appreciate it. Um, so we can improve the next session. Yeah. If, if you guys do the feedback form, then we'll send you some certificates out as well. To show that you've obviously engaged in this session, which is really helpful for us and you guys as well. So, um, we'll send that out and again, we'll send out the recording as well. So, don't worry about making notes, we'll send out the slides to you as well. So don't worry about it. Great and join us for the next session as well next week. Thanks very much guys.