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Okay, back, guys, if you can hear me. So about this we're so close to finish and were persisting. We're done. Video back on. So did you hear my C section of information we've got from Peter and ask everyone what we're going to do about it? Or do you want me to go free? See again? Just the way I can write the beginning of see Perfect. Thanks. So let me know. So here's the C section. So we like that we do are subjective our objective, and we think about action. So his heart rate 1 10 so that's a bit high could be explained by the pain. I'm not too happy with that. Blood pressure's high, but not dramatically high Capillary refill times quite slow for a flameless. But if you worry if it's heart, sounds normal is that it's following. Okay, I probably need to do something now. I don't know what No pitting in the nursing team because of the heart rate been fantastic. Norwegian EKG and you have a look at that and it's just Sinus tachycardia about 1 10, so that's in keeping with that. So what we going to do here? We probably We've got a few problems here and thinking about to be a pro. Probably need to deal with problems before moving on. What does everyone think we're going today? What would you do at this stage? We've got a VBG. We can assume we've put a cannula in to get that BP. G well to you, hopefully drugs to help with the heart rate. So you thinking about rate controlling him? Sarah, is that what we think? What we're going to review in control him is only 1 10. I see it makes sense what you're thinking about. Actually, I don't think heart rates the problem. I think the heart rate is probably compensating because, you know, he's in a lot of pain, but we have got signs that you might be hypo. Believe it because we've got a laxative five Capital roof of time before, so you might think about some fluids again for him, probably. Look, it's in the output by doubt. It's been charted, but we'll look at it. It's his input from the day, and we can ask the nurse himself if he's been passing urine, you get a good place to start. I think I would actually give. Give him some fluids as well. To this, to this patient is what laxative? Find a niece fight for free, shut down as well. And remember that he's in hospital out of his usual environment. Very confused. You can think he's probably not been drinking very much. Actually, it might, because the pain. Why this high fatty? So there's lots of things that we can talk about prolactin me another time. It can be signs of ischemia, for example. It can go up and sepsis. Some drugs can cause it. Adrenaline. I hope he's not getting that on the warts, but salbutamol can cause as well some systemic diseases. So some of the phone this will cause it liver disease. Lots of things can cause it. Actually, that's probably signifies a patient that's actually medically unwell for some reason, and potentially is hypovolemia thinking about the whole picture here is so probably those two things so fluid, challenging, reassess. So, yeah, I think he probably does win himself for it. You got to be careful cause he's quite elderly. Um, check if he's got any signs of overload, but he doesn't. But I think we can get a listen. See how he responds to that. But we'll have a look at wasting given today. So where'd you get fluids of BP's normal high and trying to catch up with the loss? So this is an interesting point. We're always talked to give a fluid bonus if a patient becomes fine intensive. Actually, they might be in the stages. And even before they dropped about pressure on dissimilar, where we've got a patient that is in keeping with Lena and that lactate is very high. So our guidance are trust. I think it says if it's over two weaken, think about through it. But depending on what we think and courses and then we recheck. So, yeah, I think I think he does win himself. If it was just that it was a bit of a chronic Is the pain like the fact that was normal? Hey, was peripherally quite warm and okay. We might just think about just maintenance fluids if he needs it, depending on how much is oral intake being. But I think he probably does just about when, When about If I don't think particularly about moment, you, if you want to speak for senior before giving one, because we have got a normal BP. Good. Um, so we've made on. So we've done something about the heart rate in the lactate. You again to recheck. We can assume here because we discussed earlier. We got to send off some bloods for him because he hasn't had any in a couple of really know what's going to give a full panel, stop some of the little pain in my family's little, but which probably assess in first, we'll certainly look. It's electrolyte. FBC in the Dallas ti's still full and full like the Bloods good moving on today so that GCS is 14 15. The one lost his confusion, but that's his baseline. His blood glucose is is okay. On the rest of the BG, we can say part for the latter is normal. His people's are equal and reactive to light, and he's normal, thermic so nothing really to do Indy. Unless anyone disagrees with me, I'll give you a minute e. So people's equal and reactive to light on the D section we can look at is in urology is where he's moving all of his limbs. So he's got no clear focal neurology. But it's making some facial expressions when you walked, every stuff is turning out to you, since cranial nerves probably look okay, so we're not too worried about about that. We don't have new ones. That confusion get So nothing really to do with the section? Uh oh, God. I forgot to ask you what? What we going to do then? So we get to see how we're going to deal with Peter C section What are are subjective, objective and actionable points. And hopefully this will. You know, it's an answer. Why pizzas gold of these strange abnormalities that we don't really have no explanation for to assess that pain. And how are we gonna assess that pain? Good. So this is our exposure stations will expose the patient, look for bruises and blood gets what has to be get a J abdominal exam. That sounds that sounds like a good idea. That feel. Listen to the abdomen yet again. Teo. A brief abdomen. So Carlos has got a very good idea that maybe we should think about money. Last open, this pounds gets in the hospital. Elderly. Some abdominal pain may be, but we don't really know. Sitting. Explain the pain better. Unfortunately, Peter still calm, really annoying, isn't it? When did he last part here? That's a good point is, maybe that's what's causing it. Pain. Mostly if he's got any, uh, any signs of bladder distension on the abdominal exam? That's the long bones for injury. Good. Yet we can have a quick look at the if we want, and he hasn't fallen on the water. Anything but yeah, scared. It comes in a resection. Good. Oh, really get really good points. So this is what we're going to do. So he's got a diffusely tender to light touch abdomen. So at least we've got a source of his pain now. And it's the light touch is not characteristic, so that's good to start off with. It's got no obvious organomegaly. Uh, that's quite hard to assess because he's driving around and he's confused and he's in pain. There's not no bowel sounds are active it with it is a abdominal aortic. Powerful Normal spoke, so I tried to do a Murphy something but didn't really work, but it didn't seem to be positive. Um, and he hasn't open these panels in four days. Got sick bone. Now what is it is brown with fecal involvement. Ear's. So we've got this patient this clearly in pain. That's hypovolemia based on the information we've got already previously. And now he's got no bowel sounds Fecal involved. It hasn't opened his house in a couple of days. We look at his drug charges. Nothing particularly interesting there. What are we going to do for pizza? There's now we've got We've got problems. So we should deal with obstruction X ray so it can get an X ray. Yet we can do an abdominal film or just start drugs. I'd be interested to see what drugs you want to. So I was like, a reasonable point PR. Yeah. Good. So what we thinking for? For Peter? What? What are our issues? Clinically. What do we think your own getting out CT probably got here is a pseudo obstruction. We thinking about keeping okay, fine, obstruction, obstruction. So I don't think we quite when a PPI see what you mean. Maybe he's got something, but actually, I think this is clinically obstructed. We probably think it's a pseudo obstruction because he's not got loud. You know hyper active bowel sounds. But you know, Poundstone's hasn't opened. Spell it in a few days. You asked the nurse if you had, in fact, on it. If you see tender abdomen on, some probably think he's got an obstruction and this is an eye to me. Why I bring it up is because there's some important things that left one now needs to do a lot of hours that nobody really teaches you. So how are we going to do this? And that's what we've already mentioned. We're going to put an NGO cheapen it, and we're gonna put it on free drainage, and we're going to give him give him some fluids because all of this fluid getting stuck into his bowels that I think is like crepes up his tachycardia and things like that as well, when he's perfectly shut down to probably need some fluids, will correct is electrolytes if you sent them off and that can contribute. So I we need to do here practically to solve this problem. Or rather, who do we need to get in touch with? I'm gonna take silence is we don't know, and that's probably against and clinically Yes, our notes. So what? Ultimately what we need to do here is we'll manage a bowel obstruction. We need to tell our seniors that we've identified it. But your your med read just going to tell you. Well, in that case, then we should probably speak to the surgeon Should we will put in MG been we'll give him some fluids, will speak to the surgery team, and they're probably going to ask for a CT. In the meantime, very good. Get on ultimately. So these are the things I think you probably control. Poor Peter is pain on discussing that we're stopping eating anything, but we implemented some interventional. I think we we're going to reassess it in. We're going to go talk to bottom, see if they see if they had an impact on me and it's based upon them. But ultimately, it's a shame yourself. The point. Get this any questions about our E section there, I'll give you a second, and some people put drugs and notes in the section is we're also for pizza. We might think about things that might be contributing to his ideas. We might want to stop things that might be contraindicated in his eye on your PSA with this hypoinsulinemia. You got any questions? Get science is always a good thing. So I hope that was kind of useful what we've done there. So you you obviously have a really good understanding of a two week, and you'd expect that you're finally a medical students. But what I'm trying to demonstrate is the using real life case is how your eight a week and just guide you when you're feeling quite anxious. Out of that was an often you don't know. I don't know toujeo or it's your first shift. You don't really know. Our hospital works falling back on a native we approach, whether it be in and keep the only patient that definitely runs in a two way approach for a patient that you just don't really know what's going on. It can actually be a really good for that to get an idea of what's going on, what's going on with the patient and actually some of the key points that come up there with things that we don't think about it. All right. We approach previously, so how can we utilize our team around us with that? We can't physically do all those