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Summary

This 1-hour medical teaching session is designed to provide medical professionals with the knowledge and information they need to confidently see surgical patients. Participants will learn about defining disease, surgical anatomy and pathology, key parts of history taking and examination, investigations to order and consider, initial management, and potential complications, as well as practice their skills with a case study. Teaching is led by an FY2 and other recent FY1s, ensuring that the content is highly relevant. With friendly facilitators and the opportunity to provide feedback, this session is a must-attend for medical professionals seeking to gain confidence in surgical procedures.

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Learning objectives

Learning objectives:

  1. Understand the presentation of acute surgical conditions
  2. Develop knowledge of the key parts of a surgical history and examination
  3. Describe key investigations and which ones to order when
  4. Apply learned knowledge to practice through a surgical case
  5. Understand the basics of management and potential complications in surgical conditions.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

it's time. Hi, guys. Sorry. Welcome to the sessions. We're just gonna let a few more people join and then we'll kick off. All right? We've got plenty of people joining us, so thank you everyone very much for giving up an hour of your time on a Monday evening. Hopefully, it's not going to take that long. Welcome to the surgical sessions from mind the bleep. Uh, this is a brand new initiative that were running in mind. The bleep, um, just designed It's been designed by surgical F Y two, uh, with with the idea of giving you all the knowledge and information you need to see surgical patients as an F I want because there are There are things that we feel we weren't taught properly and that we could have used a lot more experience in that. Someone just could have let us know a few basic things. And so we designed this course with that in mind if I just move on to talk slightly more about the course, So that's exactly it's designed by recent ones for incoming F Y ones. We're not going to be fanning around with the pathophysiology of the sodium gated ion channel. Whatever nonsense, we just want to give you the core info you need so you can go into your surgical job really confident and smash it were super happy to answer. Any questions were very friendly. So if you have anything that you want to feed back from the session or you just want to get in touch, ask something specific. Please do email us on webinars at my nose bleed dot com. Uh, the other thing is that we do need your feedback, so please do give us a do you give us a shout at the end. We've got a QR code, and you just scan that on your phone and failing the feedback. This is so that we can make the session as good as it can be for you. And ultimately, we don't want to waste your time. We're not here to waste your time or our time. We just want to give you everything you want. So if you want more questions, you want more cases. You just let us know on that feedback form, and we will make it so. The general format of these sessions is going to be defining the disease and the things that cause it. We're going to briefly whiz over the anatomy normally and a little bit on the pathology. But like I say, the bare minimum you need to make you safe and competent when you're dealing with surgical patients were then going to address really key things. When you're actually seeing surgical patients like the Clerk, it's the history and the examination, the investigations that you want to be ordering and considering. And then we'll go into initial management. Now, obviously, as a surgical junior, you're not the person making the big management decisions about surgical patient. However, there are basic things that you can do that will really enhance the patients care. And and actually, you know, in some cases, really save their life, you know, talking about antibiotics in the first hour and things like that. And then we'll end all of the sessions by talking about complications of the things that might happen in surgery. We'll talk through a case in every session, and then we'll have some little feedback questions at the end. So without further ado, this is me. Hello? My name is Ben Turner. Not really, Benedict, I'm an academic f I two and I'm interested in the HPI Be vascular, a little bit of research and especially teaching. And as I said before there there are four of us who have set up this course verify once. And it's because basically, we we felt nothing was out there for new starter if I once when we were in this position last year. And so we set up the course to try and to try and fill that gap in the teaching. So the key learning points for this session are going to be understanding the presentation of cute surgical conditions, the key parts of the surgical history and examination, understanding key surgical investigations and which ones to order when and then we'll practice applying those skills throughout in a little case that we've got. So with all of these sessions, I just want you guys to get into your head that your your the surgical F Y one and you're on take because maybe the S H O was off sick or or in your center, F Y ones are expected to do surgical take. It varies from place to place. Just keep in mind that this this is the focus were taking on the going through. This is how we're defining what information to try and get across you. So you're the surgical. If I won on take when you see this chat Jason. He's a 36 year old male with no past medical history. Since this morning, he's been unable to eat very much, and he's got this grumbling. Central abdominal pain is pretty sore to touch, he says. He's been sick once, but I'm feeling very nauseous. But but other than that, he hasn't been too bad and he feels a bit hot and sweaty a little bit. Shiver E. Okay, so that's our case that we're going to be thinking about as we work through today. When you're approaching these cases, there are key things during your clerking that you need to try and work through. So in this session we're not going to work through a specific presentation. We're going to work through acute abdomen as a whole, and as part of that, we're going to go through the clerk in quite some detail. So the first of all, we'll be talking about history taking and the sample history specifically for those of you that haven't heard of that. We're going through examination within a two we approach and then we'll be talking about investigations. The bedside bloods in the radiology. Yeah, so key questions in the surgical history are always going to. These are the basic questions that you should ask every surgical patient and should form the core part of your clerking. So it's always going to be nausea and vomiting, whether there's any blood, how much vomit, how much blood, coffee grounds, things like that. That's what we mean by the quality of the vomit. Then, when you're talking about abdominal pain, Socrates basic stuff. But actually the side onset and character of the pain are going to be some of the most useful discriminating questions in your surgical history. You know, if it's a colicky type pain that comes on over a few hours and then then wears off again, you know that's the sort of pain that you get when a hollow organ is cramping around something that's a super useful marker of what the pathology might be. Similarly, if it's a sharp, sudden pain that comes on out of nowhere, that leaves you very much away from colicky stuff. So it's it's super useful. Bowel habits should always be asked about the color of the stool. Whether there's any blood, are they going more regularly? Less regularly. Have they passed any wind or super important surgical questions? Joined this when we're talking about jaundice, remain dark urine pill still yellow skin, yellow scleral icterus all very important as well. And then your constitutional symptoms like fever, weight loss, night sweats, rigors as well can come in under that. And that's important because a lot of surgical presentations are actually balancing sepsis. And so clearly those are symptoms that could be present quite often. So a couple of definitions for us to get our head around first. And I thought we'd start by defining acute abdomen, because when I start as an F one, they said to us, Oh, it's an acute abdomen, but none of us exactly got what that meant. And what they're trying to say is that a sudden onset of severe abdominal pain over a very short amount of time and it's not like it's not the sort of or I've got a sore tummy and it's been getting worse and the pain's moving around. It's really severe abdominal pain. The patients look in pain quite often. They might be Take a cardiac from the pain. Um and so they're They're quite useful Markers, too. Just from the end of the bed, have a look and think. Well, does this person actually have an acute abdomen? The acute abdomen itself is different from peritonitis, So peritonitis is actually a sign that is well, puritanism is a sign that elicited when there's peritoneal inflammation and it causes rebound tenderness or percussion tenderness and also rigidity. So you can have an acute abdomen without peritonitis. But peritonitis is an acute abdomen, if that makes sense. So abdominal pain in In general, we were talking about the site of the pain, and you can see here I think, from this diagram just how important it is to to qualify the site of the pain. So you you know, you've got your classic cause of right upper quadrant pain. There cholecystitis biliary colic. You got your your central causes, like pancreatitis, perforated ulcers, um, and various other things. As you move around the abdomen again. This is this is something that history taking can be less useful for because patients will describe all sorts of places as saying that upper abdomen, they might think the upper abdomen is actually, you know, sort of the super pubic region, and it's best to verify exactly where the pain is by doing by doing your examination and with abdominal pain as well. You know, we've got all those causes on the other page, but it's super important not to forget the nonsurgical causes D. K. A. Addisonion crisis. Uh, there's a whole load of stuff you'll find when you're on. Take that A and E will try and refer to you because all they want to do is get people out of any within four hours. And it's important when you're receiving that hand over just to be a little bit critical of what they're saying. And make sure you've elicited some of those key questions in the history so on to the abdominal exam. So whenever you're examining our patient, whether it's medicine surgery, I t u E d. It's all the same. You're going to use that a to we approach airway breathing, circulation, disability and exposure, and by following that that same pattern every time it allows you to be super thorough and elicit all the appropriate science. So with our patient that we were talking about earlier. Jason are 36 year old male with sort of general abdominal pain. Okay, his airway is patent and he's holding his own. His breathing is okay, but he's breathing a little bit quickly. It's got a respirator. 20 to his option. Sacs are absolutely fine on there. And he's got good air entry bilaterally on his circulation. His heart rate's 104 so he's a little bit tachacardic. His BP is 110 over 70. His cap refills bit equivocal at three seconds. Um, and he doesn't have a cat at the moment. So you don't have any urine output disability wise. GCS is 15 out of 15. His pupils are equal and reactive. His blood glucose was fine on the venous gas, his exposure wise. So he is feberal a temperature of 38.6 and he's also guarding actually now and in the right iliac fossa. By the time you come to see him, um and when you're examining, you do your percussion and you can see that he does actually have some percussion tenderness that you think might be consistent with some localized puritanism. So that's Jason's exam so far. I just thought, given that we're doing a sort of briefing on surgical patients and how to approach the surgical case, we should talk briefly about the PR exam because it's something that I was always a little bit afraid to do for patients when you're not sure whether or not it's going to be indicated, whether or not someone else is gonna ask for it. So we we've listed the indications for a PR exam here. Now it's not exhaustive, but it is also relatively thorough. So you should always be doing a PR exam. If someone is presenting with an acute abdomen and constipated because you know the odds of it being a bowel obstruction or something like that could be quite high. And even if it is simple constipation causing abdominal pain, it's useful to know that with the PR exam okay, you shouldn't use abdominal X rays to diagnose constipation. So best practice for diagnosing constipation and in fact, in the nice guidelines as well. It does say that you should perform a PR exam, Even if it's not always done Observation or not, passing wind is very much the same. You know, you can be thinking about obstruction in this case. And so a PR exam is critical because you if you're trying to confirm the diagnosis of mild obstruction, you want to see that there is no stool in the rectum. Upper gi I bleeds. You're looking for Melena on your PR exam and lower GI bleeds. You're looking for presence of blood as well. Tenesmus is a red flag, symptoms for anal cancer. So should always have a PR exam. Um, generalized guarding where you're not sure of the source, but the patient looks quite unwell. They should always have a PR exam as well. Um, any change in bowel habit or urinary retention? You know, constipation is the number one cause of urinary retention. Um, any kind of incontinence going on from that because obviously fecal incontinence can be because of the constipation. It can be overflowed. And urinary retention can also be due to, uh, urinary obstruction, for example. And, uh, so you can have urinary overflow incontinence from that as well. Perforated, viscous again. You don't know which viscous was perforated. So P r is generally indicated there. And then also, you've got your medical stuff, like back pain with a red flag symptom like, you know, bilateral sciatica. Okay, so that's something to briefly touch on. I think we'd say overall, Uh, the PR exam can seem a little scary to have to do, but it's relatively simple, and patients don't mind. Patients are quite aware that when something is going on with their bowel, they may have to have this exam. So you know that no one's going to be cross at you for having done one. But if you haven't done one where it's indicated, it could be tricky. Okay, so just having dealt with the history and examination there, I thought we should talk about the red flags and when you might want to escalate to one of your seniors once you're clerking a patient. So if the patient has been voluntary guarding I when you press on their tummy, they are just they're so rigid and they're not tensing to try and stop you pushing around that that is a red flag, and that and that needs to be alerted to your senior urgently because that could that dramatically increases the chances of a perforated diskus. Similarly, if the patient has a 10 out of 10 pain and is riding riding around, that's going to be another indication to get your senior like your Reg involved. And finally, if the patient's hemodynamically unstable, you know their septic, they're dropping their BP. That's not something that you should have to deal with alone. And the surgical patients that our septic can become profoundly unwell so quickly you'll need your Reg involved for I T. U and all these sorts of things, and you'll need their clinical experience for when you're dealing with these really sick patients. So in terms of the investigations that you need to get for surgical patients, we split it generally into bedside investigations, blood tests and radiology. So this isn't an exhaustive list here, but these are the things that your job as the F Y one on surgery is going to be to sort out, and this is probably what we'll spend. The majority of our surgical patients are surgical placements doing so. Bedside test. Everyone coming through the door of a any needs an EKG, you know, if they're tachacardic, they must have an EKG to rule out a medical cause on top of their acute abdomen because it is seen and it does happen. Um, also, when they come through the door of A and D, they should have a lateral flow done, or a cove id PCR rapid coated PCR equivalent. You're in the present day and age where Cove it has been associated with such poor, um, surgical outcomes, even for minor surgery, is critically important that we know the the coated status of the patient. And your first step to doing that before you talk to your Reg about a patient that may need to go urgently to theater is you need to make sure that they've got that coated swab down and that they've got a negative lateral flow to set them on the clean pathway to theater. So it's super important. All surgical patients should have a urine dip, and that's because it can give you some useful information about protein or ketones in the urine. Uh, it can also help you rule out other causes of an acute abdomen, for example, pyelonephritis. You know you might get a positive urine dip there, and that would lead you away from some other kind of surgical cause, and you could nicely refer to medics instead. All women under the age of 50 or, if they haven't gone through menopause, must have a urine pregnancy test before admission to the hospital. Okay, it sounds super basic, but it gets missed all the time, and patients will make it to the ward. We'll make it two ultrasound or CT without having had a urine pregnancy test. And if a pregnant lady gets a CT, it's an absolute never event. So it's just worth bearing in mind that that's something you need to ask the E D doctors or the the nurses to do blood test for the surgical patients. So this is a pretty good list, actually, of every blood test you should be ordering for your surgical patient that you think is going to come in and go to theater. So quite often, the emergency doctors, when they're referring there or the nurses will ask them what blood test order and they'll do your standards. They'll do your full blood, count your ear and electrolytes, your liver function test and your CRP, which is good, but for the septic patients they need magnesium's. They need calcium and phosphate. So the bone profile Every surgical patient should have an amylase or every acute abdomen should have an amylase. And that is to rule out pancreatitis, mostly your find with general Intraabdominal pathology and intraabdominal sepsis that the amylase is raised. Okay, it's quite a non specific marker in terms of that, but it won't be raised. This level we talked about of 3 to 5 times the upper limit of normal, which is diagnosis of pancreatitis group and saves every patient who, uh, is Mr Surgical Ward is going to need at least two groups and saves. Uh, before anyone goes to the theater in the UK they have to have a clotting on the system. So that is your pretty good list of of surgical bloods that you need to consider. Obviously, on top of that, you've got things like your venous blood gas. Now some might consider that a bedside investigation or or I know it's a blood test. But that gives you critical information about the acid base status and the lactate, and you'll find that surgeons have quite quite a low threshold for concern with regard to acidosis and things on the blood, because it's unlikely medicine that their patients can become profoundly unwell very quickly, so on to the radiological investigations, every acute abdomen is going to need an erect chest X ray, and that is to look for air under the diaphragm. Uh, they're also going to need an abdominal X ray. If you're suspecting perforated viscous, you can also use an abdominal X ray. As I was talking about to sort of diagnosed constipation, it shouldn't be used like that. But when you're using it to check that they're not obstructed because they haven't passed wind and they're distended, etcetera, that is a reasonable thing to do. The ultrasound abdomen is very helpful, actually, for surgical patients, because it gives you information on the biliary tree and the gall bladder. It can give you a bit of information on the liver. Echotexture. You can sometimes see the pancreas based on the body habitus patient, and it's also useful for kidney, bladder and your it to pathology. So it is worth bearing those in mind. And obviously the ultrasound abdomen is good because it's a no radiation investigation. uh can be used for appendixes. But as well discuss later. You can sometimes run into trouble requesting ultrasound abdomen for the appendix. With with radiologists, everyone likes to joke about surgeons being heavily dependent on CT to diagnose. They're they're various pathologies. I think it's it's not an unfair comment. It's just worth noting that they always said CT, get a CT this get a CT that to us but we But at the very start, we didn't know which ones to order. Now the one you're going to be looking for is a CT, abdomen and pelvis, with contrast because the contrast highlights the walls of the organs that you're looking at of hollow. Viscous is etcetera, etcetera. So it is super important that it's with contrast. You can do a CT abdomen pelvis without contrast, and you would do that for patients that have very poor renal function. But it's not very helpful, so it's definitely worth discussing with your senior before doing that. Other investigations that you may have to get on surgery includes CT angiogram, M R C E P s, for looking at the biliary tree as the higher sensitivity for diagnosing gallstones and the CT k u B for kidney stones. So back to our case again, we can see on the on the bedside test. The urine dip is plus one for blood and plus one for protein for Jason, but it's negative for leukocytes and nitrates. The blood tests white cell count 12.1 CRP is moderately raised at 47.6, and the amylase is 129. So non specific marker of abdominal information that we were talking about slightly up radiology have unfortunately rejected the ultrasound abdomen were requested to verify whether or not that appendix was inflamed. So the key assessment point that we've got so far the key things that you really need to elicit in your history examine investigations are the type of pain and and the character of that pain that we were talking about earlier. Those those three key points site on certain character are really going to narrow down your differential for the surgical patient. The associated symptoms they have. So that might be a change in bowel habit. Might be jaundice might be nausea and vomiting. Lower upper GI bleed. Always worth noting those extra symptoms, the examination findings of where the patients tender the blood tests that we've got. So, uh, always looking at the CRP and white cells on surgery and plus minus any other tests relevant for the pathology. Like if you got hepatobiliary pathology, you're extremely interested in the liver function tests, and then we'll move on to the imaging. So what the results of your or how the results of your imaging verify your differential diagnosis? So it's just worth us touching quickly on getting scans, because for me, it was always the scariest bit of the job. Okay, and it's the number. One thing you have to do is the F one. You'll be shooting around and your war drowned in the morning, and the consultant will say to you, Can you just go and get the CT straight after the wardrobe? So you go down there holding a piece of paper quivering, terrified about the radiologist. He's about to tell you apart, and they can be extremely fierce. I remember there was one who I don't think he ever approved one of my scans, but then I may have been doing things wrong as well, so they can be fierce but don't be afraid of them. The way to deal with them is to keep them on side by phrasing your questions as and for my learning. What would you recommend me doing next time or what? What are we looking for with this test specifically? Or how could I have made that referral a little bit better? So tips for successful scans, as we're talking about, always discuss them with a senior first and check that you know the indication for the scan. It's also helpful if you have that background knowledge of knowing why the scan is generally useful. So you could say ultrasound, Abdomen, please query choledochal if isis query dilated common bile duct, for example, and and that lets you know that lets them know why you're doing it. The best stuff to do is is to maximize the clinical detail you're giving them. So instead of just saying, Well, I'm looking for common bile duct stone. You need to tell them why you're actually looking for it. So the bilirubin is raised at 57. The LP is also up at 217. Okay, that by giving them the biochemical details to allow the radiologist to narrate the story in his own head. As you're going through, you're going to maximize your chances of them approving your scan because they're going to agree with you that yeah, you do need to do the scan in order to make this diagnosis. Describe the situation. Describe how the patient is normally, if your patients very unwell, the radiologist is actually quite understanding and will help you try and get the scan and will suggest or no. Well, maybe you should actually be looking at this as well, and that's happened quite a few times. Always state your query at the end what it is that you're suspecting, what your differential diagnosis is, because otherwise they may well reject it. And if it is rejected, don't be afraid to go and ask. Just check why they've done it and you'll build up your sort of portfolio of phrases that you chuck into scans to make sure that they're going to get they're going to get accepted. So just just briefly, most weeks we will talk a tiny little bit about the surgery that the the the consultants going to be doing for the pathology. We're learning about that week. Um, it's not going to be boring detail about this. That and the other is just going to be like the main stuff and the headlines to take away like, Oops, what happens if the surgeon accidentally mix this or next that or why might this patient have that complication after surgery? Okay, because it's one of those things surgery, where it's an art and a skill that you learn as you go along. And obviously, everyone in different training grades is learning, learning, learning, so things do go wrong. And it's quite important to just have a little handle on what those might be. Um, so some of the very much a favorite question of the surgical consultant going around on the ward ground is what incisions this, uh, you know, what previous can you think of what previous operation this patient may have had? Um, and so we've just got some of the most common incisions with their names here. You can have a flip through those in your own time if you want. Um, of particular note. I guess it's a midline incision, um, the conscious incision for access to the liver, Um, and Rutherford Morrison. Typically for accessing, uh, the external iliac vessels during a kidney transplant. And then each week we're going to be talking a little bit about the management, and we split the management down into Conservative versus Medical versus surgical management options. Now, obviously, is their F one on call. You can start the first two of these without anyone else, even having seen the patient and general conservative measures that you need to go with, you know, prescribing fluids for your patient. Okay, especially with surgical patients that our septic they may have fevers, um, and be losing more water than usual. They're going to need maintenance fluid, plus a bit of extra replacement. So prescribing something like Hartmann's is brilliant for that medical things, you know it's going to be your sepsis. Six. Making sure your patients got oxygen making sure they've got antibiotics, et cetera, et cetera, and doing all of that within the first hour. And then your surgical stuff is going to be a big things like your appendicectomy. So just a brief note on fluids, because I think this is something that's incredibly poorly taught in med school and that you start sort of you start playing with it on the job, and and no one really ever goes into what should be used when. But generally, the surgical fluid of choice should be Heartland solution. Because it is the most similar to plasma, it's worth noting that it contains a little bit of lactate. And that's why, for your septic patients or your perforated organs or your ischemic organs when you got lactate, it's of 789 10. You shouldn't be giving Hartmann's then because God extra lactic in it. And so it will contribute to the lactic acidosis that will be making the patient feel very unwell. Which is why, in those patients, the standard is giving normal saline and bolus in normal saline for hypertension with normal saline. You can also replace the Potassium IV, Uh, and that is useful, especially if patients aren't eating and drinking. But it's just worth noting that you can't bolus when you put potassium into the solution. Okay, 5% dextrose is another useful one. So the classic mantra was one salty, too sweet, okay? And that was so one bag of Hartmann's with two bags of 5% dextrose over a sort of 24 to 36 hour period, and that covers the pain the patient for their maintenance fluids with dextrose. It's good because you can also give them a little bit of potassium along side. And you don't have to overload them on the sodium front because, you know, normal saline got 154 million miles of sodium. So it's a lot. It's, you know, much more than your daily allowance of requirement. Okay, so at the end of each session, we'll also go a little bit into the complications. Okay? And we in this session are going to deal with some really common presentation is that you'll see POSTOP. So that's POSTOP fever and postop tachycardia, which are actually pretty similar in the way their approach to merge. Then you've got POSTOP constipation, which you will be called all the time about, especially at three in the morning. For some reason where the nurse decides that the patient, for whatever reason, needs to be seen at that second for the constipation, I've still never figured out why that is, and a really important one is POSTOP pain and knowing how to escalate that so post of fever and tachycardia are grouped together because they're generally the same sorts of things that you're looking for. So tachycardia and fever they normally swing together, and your differentials are going to be sepsis. Whether that's a surgical site infection, whether that's a lower respiratory tract infection from pain of the abdominal incision and then not inspiring deeply enough and contracting infection that way. But equally, it could be something medical like a UTI and as the ones on the awards. You guys are going to be the first line of defense in medicine. So it's important that you're thinking about these things because otherwise the surgeons won't, uh, but you've got other differentials for fever or tachycardia like pulmonary embolism. So obviously an important one to watch out for POSTOP things like alcohol withdrawal we've seen on the walls before. But also it's worth just bearing in mind that if it's right after the operation and it's a low grade fever like 37 6 to 37 9, you can get the systemic inflammatory response to surgery causing that kind of phenotype. So do bear that in mind. Your key points for assessing this is going to be getting your A to eat and then getting any micro samples that you can. So that will be two blood cultures. Um, repeating a chest X ray, making sure you've done the the urine screen because those micro results are going to guide your antibiotic therapy. Make sure that the patients have some analgesia and an antipyretic in these instances, and you know your best one. For that, it is going to be paracetamol. Paracetamol IV is obviously not going to be thrown up, and nausea and vomiting can be a significant post doc complication. So, uh, also paracetamol IV has a stronger, has a higher potency and so delivers more analgesia. Your blood gas is going to be another key point to do, and you're tachycardic and federal patients, especially if their respirators are up or they've got a new requirement for oxygen. You really want to see that arterial p 02 and you're also going to want to see your blood pH and lactate just to rule out you know, for example, intraabdominal sepsis from perforation after surgery. Uh, so at this stage, if you're getting a gas, you may as well, repeat the other investigations like full blood count through an electrolyte CRP and just check the direction we're heading. And then finally, on these patients, once you've done, you're a TUI. You've got your micro, you've escalated your antibiotics and you've got a gas. That's the time to talk to your Reg and say, Listen, I've done all these things, and if you have done, all those things are going to be super impressed, and then you've escalated to them and let them know what the situation is. Post constipation Very common again. And this is largely things like areas where the bowels been handled in surgery. Um, and so it takes a while for the function to be restored. But equally you can't forget causes like pseudo obstruction and then over administration of opioids and patients being in pain will will also cause some constipation, especially if they've had some kind of rectal operation or anal pathology that can definitely lead to people becoming constipated. Key points to think about are considered doing your PR, and we talked about the indications for that earlier. Always check your electrolytes to rule out pseudo obstruction things like a low potassium can cause pseudo obstruction really easily in the POSTOP patients who already has a little bit of ideas, and his electrolytes are already a little bit deranged. Make sure you determine the cause of the constipation. So you go and assess the patient, and you think it's most likely that you know they've been on or UM or 5 g Q. D s 5 mg Q. D s without any laxative for three days now. You know the cause. Make sure you stated clearly in the notes. And then you know that because you've done that, it's safe to prescribe those laxatives in prescribing laxatives. It's very important to use a stool softener and the stimulant, because if you use something like center by itself, it causes the patient quite a lot of pain by softening the stool at the same time, it allows them to to pass their bowel motions without that increase in pain that can cause. And then finally, if your if your oral stuff isn't working, then it's time for the suppositories and enemas POSTOP pain. I'm sure everyone has seen the W H. O uh, allergy six ladder before, but it does form the basis of the management of pain on the ward's as well. So you're differentials. Anything from normal POSTOP pain that we all expect patients to have to perforation and florid fecal peritonitis. So when the nurse comes and gets you and says this patient is in pain, please, can you come and see them and blah blah blah? It's important to take it seriously, because you'll you'll get that one in 10, where they just look a bit peaky and you instinctively feel worried. And at that point, it's important to remember you're 80. We check their robs, you know, have their BP suddenly dropped, and they become tachacardic at the same time as this pain starting. Get the anti emetics into them. Don't forget about your opiates, but if you're going to give them, make sure you've got laxatives and never give IV morphine on the ward's, because you'll certainly get patients to ask for it. And it's not appropriate to give. It causes a marked increase in degree of respiratory depression compared to oral opiates, so I think that's everything. For our first session on the acute abdomen and introduction to being a surgical F y one. This is a free surgical webinar series that were running with Mind the BLEEP, and it's going to be going for another 15 weeks after this one. Each session, we're going to be doing questions. We're going to be doing cases, and we're going to be looking at the core things that you need to think about when you're seeing the most common and the most serious surgical presentations on tape or on the ward. We've got a landing page on. Mind the BLEEP. You're going to be able to watch these webinars back whenever you want and to accompany each session. There's going to be a like an online information page, and that's just gonna have basically everything we're talking about, but in a written form, so that should you wish to revise it or remind yourself something we said it's all going to be on there. So by doing this, we're hoping to create the first and a really useful resource for F Y ones that they can refer to safely. And then, if you have any questions past that, please just run it by us, will be so happy to talk to you and answer any questions you may have. Okay, we're all super friendly, and we're going to be monitoring the email because we want you guys to get as much out of this course as possible. We'd love you to give some feedback. Now, if if you could just take a few minutes and I'll leave the leave the link up here for a second. Our next session is going to be on lumps and bumps next week. Um, as I was talking about visit mind the black dot com slash surgery for recordings of these webinars are written content. And just give us an email on that email address. Should you have any questions? Um, I'll leave the feedback code up here. Thank you so much for tuning in. I'm just going to check if there are any questions from the live feed now, because I can't see it at the time, so just give me a second. Mhm. Okay. It looks like there aren't any, which is brutal. If anyone has anything, just give us an email. Right on the event, Plage. Whatever it is, we'll pick it up. Please. Please do fill out that feedback code, and I'll be sure to post it on the event afterwards as well. Thank you so much for joining us and we'll see you next week, the next session.