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Thursday Fifteen Road to Finals - Surgery

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Summary

This on-demand teaching session is designed for medical professionals looking to expand their understanding of surgical procedures and diagnostics. The session will tackle 14 critical questions on surgery, a far-reaching topic with many nuances. Led by medical professionals based in Stoke and Hereford, this interactive Q&A format provides real-time feedback and in-depth explanations for each answer. Attendees will have the opportunity to participate in polls for each question, bringing an interactive dimension to the learning experience. The session will cover a diverse range of cases, including cholecystitis, aortic dissection, appendicitis and large bowel obstruction. Relevant slides and recordings will be available after the session, and participants are encouraged to ask questions throughout. This engaging and interactive session promises to be an enriching learning experience for any medical professional interested in deepening their surgical expertise.
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Description

The focus during this session will be on surgery. High yield concepts will be covered through the use of SBA-style questions to ensure you are well prepped for passing finals!

The schedule for the Thursday Fifteen Road to Finals series is as follows:

  • 7th March: Respiratory
  • 14th March: Renal
  • 21st March: Cardiology
  • 28th March: Musculoskeletal and Orthopaedics
  • 11th April: Paediatrics (part 1)
  • 16th April: Surgery
  • 18th April: Neurosciences
  • 25th April: Obstetrics and Gynaecology
  • 2nd May: Dermatology and ENT
  • 9th May: Mental Health
  • 14th May: Gastrointestinal (part 1)
  • 16th May: Gastrointestinal (part 2)
  • 23rd May: Endocrine and Metabolic Health
  • 4th June: Sexual Health and Infectious Diseases

Other events tbc:

  • Paediatrics (part 2)
  • Urology
  • Ophthalmology

Learning objectives

1. To understand the diagnosis and management of acute acalculous cholecystitis. 2. To recognise the clinical manifestation and treatment options of aortic dissection. 3. To understand and correctly diagnose appendicitis using case scenarios. 4. To recognise the surgical options for different medical conditions. 5. To understand the different types of surgical incisions and their relations to respective operations.
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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.

As I'm af one based in Stoke and Harry, you can introduce yourself. Yeah. Hi guys. I'm Harry. I'm a, I'm an F one based in Hereford. Um, so, so today we've got surgery. Um, so we've got 14 questions on. It's quite a big topic. So we try to go to the important things. Same as the last few sessions. We'll do a question with polls, give you 45 seconds to a minute to answer those questions and then we'll go through the answer and the explanations and we'll do it that way as always slides will be available and recordings will be available after the session and, uh, we'll post a feedback form as well at the end of the session as well. Er, any questions just pop them in the chat or shout out, feel free to. So, all right, let's make, start with question one then. So have they got the interactive link? Uh, yeah, so I'm just going to do the policy. So, yeah, they've got it. So. Ok. Fantastic. So, question 1, 60 year old man is admitted to hospital unwell on examination. He's got, he's got right upper quadrant tenderness and he's Murphy sign positive. He's not jaundiced and he's afebrile uh imaging shows a normal caliber bile duct and no stones in the gallbladder. So, what's the most likely diagnosis? And as you may know the poll is completely anonymous. So, put whatever you think. OK. So I've got one response. OK. Next slide, please. So yeah, the answer is a acute acalculous cholecystitis. So the trick in this question is you can get cholecystitis without the presence of stones. So, a calculus cholecystitis would be a stone that's impacted either the neck, um, of the gallbladder or in the cystic duct. And that's where you get your bowel stasis growth of bacteria infection. Um, whereas acalculus, there's no stones and it's usually due to severe illness. Um, and as I'm sure you guys may know, um, in cholestasis, you present with right upper quadrant pain, um, fever and you're also Murphy sign positive and Murphy sign positive is when you place your hand under the patient's right costal margin, you get them to take a deep breath in and out. And what happens is because your gallbladder is attached sort of, um, inferiorly underneath your liver when they breathe back out. And the diaphragm relaxes their gallbladder catches on your hand, which is why you get that sharp, intense pain. So typical investigations you'd want to do is sort of your standard bloods FB CSI F TEC RP CO A particularly if you're thinking about taking them to the theater Um So and, and an ultrasound would usually be at the first line ideally within 48 hours of presentation and um treatment would be cholecystectomy quite commonly, it's done laparoscopically. So take the gallbladder out. Ok. Next question. Uh Next lito. So just don't want you guys to get confused with ascending cholangitis, which presents with fever, vital quadrant pain, but also jaundice and we're sort of moving away from Charcot's try to. Now Raynaud's pentad. Um so that presents with confusion, hypotension and the difference is is in um cholecystitis where you get blockage in this yellow tube. Here, the actual cystic duct cholangitis often presents in the common bile duct, which is why you get these slightly different symptoms. Cool and next slide. So uh next question. So you've got a 40 year old lady presenting to the surgical clinic um with bilateral inguinal hernias, she developed chest pain and suddenly collapses. So as part of her investigation, the chest X ray is ordered which shows evidence of mediastinal widening. So given the most likely diagnosis, what is the optimal treatment? And again, this is what they like to do with their questions. Almost like a two step question where it's not enough to just know what the diagnosis is. But once you know the diagnosis to then be able to give the management or to give the Gold Standard investigation in another example. OK. So no, 20 seconds. OK. Another 10 seconds just have an educated guess if you're not sure. OK. So we're a bit split someone's so we've got an answer for B and answer for D and some answers for E. So next slide, please. So yes. So the key to this one is realizing that this lady presented with an aortic dissection and I decided to be a bit mean because typically when we think of an aortic dissection, you get the typical presentation of a man, an elderly man in public having some tearing chest pain, um the sudden drop in BP and the sudden collapse. Um So this is a minor just to get out of the routine of those sort of clear cut questions. So, yes, you get your sudden onset chest pain in the majority of cases. In some cases, it can be painless, but they'd be very mean to do that. Um You'd usually look for more typically hypotension, but there can be hypotension presenting. Um But what's more important is if in the question stand, they talk about a difference in BP in each arm of more than 20 millimeters of mercury. And that should hopefully set up the light B for this might be an aortic dissection. Um So typical features you'll see in an X ray is a widened median spinum, the abnormal aortic knob, which we'll go over in a second. Um A being sign and also deviation of the tracheal and or the esophagus. Um Further imaging, you'd want to maybe do a CT angiography and you can also do I angiography. So if you go to the next slide, so hopefully, in the top, we can see the CT scan, you can see this creation of sort of the false lumen that you see in aortic dissection quite clear here. So you've got your aortic ascending aorta here and your the ascending aorta, which is a smaller one at the back near the vertebrae. And so when you're sort of looking at CT scans, you can sort of use these two as as your landmark. So your ascending, descending alter in your pulmonary trunk in the middle. Um And according to where the aortic dissection is, will also determine management. So I'm sure some of you may have heard of the Bakey classification or even the Stanford classification for aortic dissection. So you have type one which involves the ascending and the ascending aorta. You've got type two, which involves just the ascending aorta and you've got type B um which involves just the descending aorta and this happens after the subclavian artery. So typically in type A where there's ascending aortic involvement, your patient is more unstable. So you would want to do surgery in this case, an aortic root replacement, replace, replace the valve until you replace the artery. Whereas in type B, they're usually more clinically stable. So you're able to treat um medically with antihypertensive medication is a really important, almost a surgical emergency if you will due to the high mortality rates if this is not picked up and quite seen on admission. So it's a very important. Um ok. Uh next slide, please. Ok. So uh question today. Um a woman is admitted with a 48 hour history of worsening, right? Iliac fossa pain. She's been nauseated and she's had two vomiting episodes. An examination, she's markedly tendon, right? Iliac fossa of localized gardening, vaginal examination is unremarkable urine dipstick is negative. Um Blood tests show a white cell count of 13.5 and a CRP of 70. So what investigation do you think will confirm diagnosis? Ok. Another 10 seconds. Ok. So five seconds have a guess if you're not sure. Ok. So again, we're a bit split some for a, some for B and some for E which is always good. So hopefully most of you, if not, all of you will be able to recognize that this is quite clearly um appendicitis. Um we've sort of ruled everything out. So the pregnancy test is the big one, especially in a woman with a child bearing age, presenting with abdominal pain. Um So if we go to the next slide, please, so, appendicitis typically does not require any imaging and is a clinical diagnosis. So, number of sort of presentations, hopefully, most of you are familiar with the classical right iliac fossa pain and that's due to the localized inflammation. You might have one or two episodes of vomiting um usually people will present with a fever um and um and, and uh increased inflammatory markers. So there's a number of different clinical signs. Hopefully, most of you have heard of a Rosling sign. So you palpate the left iliac fossa and you get rebound tenderness in the right iliac fossa. You've also got so a sign which is extension of the thigh and you turn that laterally and that causes right iliac fossa pain. Um And again, that's irritation of the local tissue. Um And we've also got to sign which is internal rotation of a flex right thigh. So even though it's a clinical diagnosis, you can do sort of further ultrasound imaging to sort of rule out your other differentials. Um So things you might see is a non compressible appendix, um an appendicolith presence within the appendix and you might also get thickening of the walls. Ok. Um Next slide, please. So, differentials. So mesenteric adenitis um similarly presenting with can present similarly um to appendicitis but usually more sort of generally unwell. So things like sore throat is a, is a big one. in, in questions. Um Mack's diverticulitis, again, similarly to diverticulitis happening more in younger, younger kids, but you would also get um rectal bleeding gastroenteritis could be another one. But typically it's a more generalized um symptoms, it could be a uti but again, no urinary symptoms. Um Again, pregnancy is a big one. Um someone's put in the chat about whether it's not ovarian torsion. So the way I understand that ovarian torsion usually is more severe sudden onset pain. Um, and nausea and vomiting is usually a combination with the pain and what you have is this pattern of, um, waxing and waning of the pain. So, pain sort of comes and goes in waves. Um, whereas appendicitis is more of a sort of constant pain. So ovarian torsion is a very good differential including here. Um, treatment will be a laparoscopic appendectomy. Again, in general surgery, laparoscopic approaches are becoming a lot more popular due to being less invasive and better recovery. Um Something that I have seen a couple of times come up in my finals. I'm not sure how much they'll go into it is to just be familiar with your different incisions and what they, the type of incision and also what operation that would relate to. Not only could that come up in your written finals, but in is oy as well. And if you can say that he's got a certain type of surgical scar and lead to what might have been the reason for that, what operation and that will look a lot better. Uh We don't have enough time to go into each individual one. But hopefully that will, when you get the slide, you can have a look at that and sort of do a bit of your own reading about that. Um Cool, let's have a next slide, please. So, um question for so a 75 year old lady um is admitted with a large bowel obstruction. She's investigator of an ABDO CT and it shows an obstructing carcinoma of the ascending colon. Um So what is the best course of action with regards to management? So, do we do a right hemicolectomy and Ileo colic anastomosis. Do we do an ileocolic bypass? Do we do a loop ileostomy by itself? Do we put it in a self expanding metallic stent or do we do a subtotal colectomy and take everything out again, another tricky one but definitely something that I've seen come up and really this one just relates to um your anatomy, which I understand is taught variably well based on which university you've gone to. Ok. OK. Another 20 seconds. Bye. OK. So most people have gone for ace and next slide, please. Good. Yeah. So this one on Thursday we got it right. So it's basically a question of the anatomy. Uh where is the sort of cancer? And what uh and, and, and what would you do with regards to that? So essentially, if you've got c of cancer in the right colon, you want to, right? He Colectomy with an ileocolic anastomosis. So connect the ileum and the colon. If it's in the transverse colon, then you want to do an extended right hemicolectomy and again with an ileocolic anastomosis. Now, if it's at the splenic fracture, so the top right of the, of the colon again, extended right hemicolectomy. Now, if it's in the sort of distal part of the uh splenic fracture, then you want to move to a left hemicolectomy of a colon colon, anastomosis. And as you go down to the left colon, uh same thing again. Now, when you get to the sigmoid colon down towards the bottom, that's when you want to do a high anterior resection. Um when it's the upper rectum, we want to do just an anterior resection. Um So it's when the sigma called a colon and part of the rectum are removed. Um And uh if it's in the lower rectum, just anterior section and the angel verge and abdominal perineal excision of the colon and rectum. So essentially what you want to do is where the cancer is, take as little of the bowel as you come out and then you on to anastomose, which basically means connect the two ends together. Um Yeah. So this one is just about learning your anatomy. If you know where the cancer is, that's um the part you want to take out. Um So next slide, please. And just a quick word, it is quite common. Hopefully, you guys learned it by now, but small versus large bowel obstruction, things to look for on abdominal films. So your large bowel obviously has a much larger than small bowel. Now, the position of the loops, small bowel essential and large bowel peripheral, hopefully that's fairly so explanatory. Um, small bowel usually has a smaller number of loops in the large bowel and fluid levels. Um, so is fewer on the large bowel than the small bowel, the abdominal markings, the valvula convenes versus the haustra. The waves to sort of tell the difference is the valvulae in the small bowel on the left side, it's not the best diagram to see, but they sort of span the whole diameter of the bowel, whereas the Haustra which is hopefully a bit clearer to see only partially across. So for me, that was a very easy way to tell whether you're looking at a small bowel or large bowel. So um diameter um the vo conven versus the house as well. Um On the size of the bar, just bear with one second call, a next slide, please. Ok. Um So a 38 year old man's a me with an episode of sudden collapse and pass your Melina. He's been suffering from uh post prandial abdominal pain for three weeks. Uh And this is most marked several hours after eating. So what's the most likely cause of his bleeding? Is it duodenal also? Gastric it stomach cancer. Is it varice or is it a mall white her? Mhm. Ok. Over 10 seconds. Yeah. Cool. Next slide. So yeah, there's the answer. Yes, Jian also or New Jude also, should I say? Um And yes, the difference between Duodenal and gastric JDN is pain post pang after eating, whereas gastric is pain when eating. Um, so, um duodenal ulcers are also most commonly present in the first part of the duodenum. And so what we've got here is an oppo I believe because of the Pastor Melina secondary to a duodenal ulcer, which is quite often the case and you'll probably see it a lot when you guys um graduate and start working. So you want to look for hematosis and or Melina with a sudden collapse. And there's a number of different reasons for bleeding, esophagitis am W tear, which usually is associated with someone who um has a tear by repeated coughing can always be cancer. And also in this case, it can just be gastritis or it can be esophageal viruses. Um So next slide. Yeah. So if you've got someone who presents with upper gi bleeding, um most trusts have sort of um care bundles or pathways to follow. But especially for the um for is oy scenarios. If you have someone that presents with rup dry bleeding, generally, what you want to do is assess the hypovolemia. So a tachycardic hypotensive patient, if of course, there's visible blood loss, um both mouth and the back passage. So you will need to do apr exam and also review medications. So things like nsaids, steroids, increased risk of developing ulcers and subsequently path ulcers which bleed. And as I said, most trusts have a sort of care bundle and the general principles of care bundles are first of all to rehydrate the patient. So IV access, usually two Cannulas wide ball green cannulas start them on fluids while you're there FBC S using these if TSC A and A group and save because quite often you'll need to scope this patient to find the source and if needed, stop bleeding, you also want to give IVP P as again, a form of gastroprotection, stop any medications which may be contributing to someone's also in this case, um stop any blood thinners. You also want to calculate something called the Glasgow Blackford score. And again, you want to consent the patient for an endoscopy to try and find the source of bleeding. Um So next slide please. So the GBS score is a sort of risk stratification for upper gi bleeding. And as a general rule of thumb, I believe it's 50% of, yeah, that's it. So people who score six or more are usually greater than 50% risk of needing some sort of intervention. So you want to check the hemoglobin. Uh you want to check the, the urea um their systolic BP um if they're male or female, the heart rate. So again, this idea of hypovolemic shock, if they've got melena, if they've had recent collapse, any background of hepatic disease, and if they've got cardiac failure, and that would usually risk stratify as to how stable your patient is and whether they'd likely need intervention uh cool uh next slide, please. OK. So, question six. iort my question. So you've got a 70 year old female presenting with a painless breast lump, current creches, four centimeter diameter, irregular right breast mass with no other palpable masses. What is the most likely lesion? So, it's an atypical ductal hyperplasia. Is it DCIS, is it invasive ductal carcinoma, invasive lobular carcinoma or is it a lobular carcinoma in situ? And again, another sort of tougher question? Ok. Ok. No, 10 seconds have a go if you're not sure. It's all anonymous. Yeah. Ok. So we're sort of a B and C is what we're thinking. So we're sort of heading in the right direction. So, next slide, please. Ok. So in this case, so in this case, an irregular breast mass in the right outer quadrant is usually an invasive ductal carcinoma. This is the most common form of cancer in older postmenopausal women. Hence um was mentioned in the question time with a lady who's 70 years old and invasive means cancer spread into the standing breast tissues and ductal. The cancer has originated in the milk ducts. So you usually get swelling of all parts of the breast, skin irritation, uh skin dimpling all these sort of per orange um texture. You see breast or nipple pain, you get retraction of the nipple and also discharge redness, skinniness, thick of the nipple or breast skin. And you also get a lump or swelling in the underarm area. So even though even though no, this was in the question stan this is more of a recognition of what would be the most common cause. Um because again, with these questions stick to what's most common. Um So next slide please. So another thing that I just want to quickly go over is treatment because treatment can be quite confusing as to radiotherapy, chemotherapy, mastectomy or local incision. So as a general rule of thumb, mastectomy would be for your worst cancers and wide local incision for your sort of less aggressive cancers. So, a mastectomy would be a multilocal tumor. Whereas wide local incision, a solitary singular lesion mastectomy would be a more central tumor where a wide local incision like in this case. And the question would be a peripheral tumor, large lesion versus a small lesion with the ductal carcinoma is more than four centimeters or less than four centimeters. Now, um with wide local incisions, um surgery, all patients should receive follow up with radiotherapy. However, if the patient is a young female, then usually they'd follow with chemotherapy after surgery and you may often also see questions with regards to the correct drug treatment. So as a rule of thumb, you would use tamoxifen in estrogen positive pre menopausal women, you would use nazo in eastern positive post menopausal women just be aware that there is an osteoporosis risk with um using an trao and you'd use Herceptin or you might see it being called uh trastuzumab in her two positive breast cancer women. So as a rule of thumb, if the the worst cancers, a mastectomy, the less invasive cancers are wide local incision. If you've got a premenopausal woman who's trophin positive, you want to give tamoxifen, post menopausal anastrozole her two positive Herceptin. So hopefully her and her can put two and two together if they're an older lady after surgery, give radiotherapy if they're a younger lady after surgery, give chemotherapy. Ok. Uh And next slide. Cool. So, um this is my last question. So we've got a 60 year old male presenting to the GP with a lump in his groin. The GP examines the lump and notes it protrudes more when the patient coughs taking into account. Um This guy's age and the location of the lump, the GP makes a diagnosis of a direct inguinal hernia. So through which of the structures has James Bow traveled through to be classed as a direct inguinal hernia. It through the deep inguinal ring, the femoral ring, the femoral canal Hassleback triangle or the processor's vaginalis. Say again, another tricky one with inguinal hernias but again, another common question and another test of anatomy. Yeah, I OK. So I know times happens, it can have a go if I'm not sure. No. OK. OK. So we've got majority for a and we've got some for D so next slide, please. So in um in this case, so the answer is D Hasselbach triangle. Um So bye. OK. Sorry. My uh computer is playing up. So the difference between indirect and direct inguinal hernia. So first inguinal hernias occur when the or any hernia, by definition is when part of the abdominal viscera, any of the sort of abdominal contents protrude through a cavity or a hole. Um So, umbilical hernias, femoral hernias, for example, now, the difference between direct and indirect hernia is when. So the direct in the hernia goes through where the peritoneal sac enters the inguinal canal through the posterior wall directly through the wall. Whereas an indirect hernia, the peritoneal sac goes through the inguinal canal and goes through the deep inguinal ring. Ok. So now we need to know again, this is quite tricky with the anatomy, but you need to know your sort of uh borders of the inguinal canal. So the anterior wall is your internal oblique muscle and the avenues of the external oblique, the roof is your transverse fascia and also your internal oblique, the posterior wall is your transverse fascia as well. And the floor is your inguinal ligament. So, if we go to our next slide, so, in a normal patient, you can see the peritoneal and you've got the inguinal canal here, the abdominal musculature here and we can see this cavity right, uh um laterally to the epigastric vessels. So, in inguinal hernia, hopefully, you can see the contents of the per sac, go lateral to the epigastric vessels through this gap here and it goes through the inguinal ring. Ok. So you're going through the inguinal ring, whereas direct turn you, you're going needle through the gastric vessels and you're going straight through the wall, you're not going through the canal through your cavity, you're going straight through the wall. So what you get is the same sort of outcome. You, you get a hernia, you get protrusion of the peritoneal sac, a sac through the abdominal wall. But the means by which it happens are slightly different. This is probably the best diagram that I could find that helped me get my head around the difference between direct and indirect inguinal hernia. So again, just to clarify a direct inguinal hernia is caused by the abdominal context going directly through the posterior abdominal wall. Whereas the indirect hernia is caused by the contents of the abdomen going through the inguinal vein. So another big difference to differentiate indirect inguinal hernia is if you put pressure over the deep ring in a direct hernia, it does not reduce the hernia because it goes nowhere. It doesn't go through the inguinal ring. Whereas on the other side, the indirect and hernia which goes through the deep inguinal ring, it is reducible. So that's another big difference there. Um your indirect hernias are, are a bit more of an emergency as well as they're more likely to strangulate compared to direct inguinal hernias. So I hope that makes sense. I hope we can bit more confidently differentiate between in and die inguinal hernia. Of course, there's more such as umbilical hernias, femoral hernias, more common in women if that's something to go away and look at. Ok. I think that's me, me done. Thank you, Harry for that. I'll do my questions now. So, um Harry, uh you, I know you can do the quiz. I'll just read it out. So 38 year old woman presents to A&E with severe sharp pain in her right flank which radiates to her groin. The pain appears to come in ways which is described as 10 out of 10 in severity at its worst. Pregnancy test is negative urine dip is positive for blood leucocytes and nitrates. So what would be the ideal investigation? Um Abdominal X ray, ultrasound K UBC T, abdel vs CT KB with contrast or CT KB without contrast. So I'll give you a minute. What? So, so 5050 DNA. Ok. Um So the answer is e it's a non contrast ct ke B. So I'll explain that. Let me just explain it all for those. Uh you would have picked up that it probably was renal stones or renal colic. So, um I've got this diagram to somewhat explain it. That is a stone that exists in the ureter or in the kidneys. Um And normally the stone is, you know, greater than the diameter of the ureter or, you know, the kidney structure. So it can be quite painful. That's why you get that acute pain also with low to groin pain, you're thinking of renal diseases with that. So you're not quite thinking of a uti or pyritis because of the severity of the pain and also there's no fever in the history. Um So in terms of management for renal colic, it's er, pain manage. So the first part is pain management. Um So nsaids is typically what you normally use. Um I think they tend to lean towards diclofenac because Ibuprofen can increase cardiovascular events. Um but any NSAID is fine, you can er also give alpha blockers that causes smooth muscle relaxation, so less compression of the stone. So you've got your investigations, of course, your U and ES your FP CCR P to rule out infection, calcium urate to just understand the nature of the structure. So the reason why it's a non contrast rather than contrast is um contrast is tend to be used if you're looking for abnormality structures in vascular vascular structures. So looking for clots or um you know, sometimes we do CT heads, you do contrast there. Um Now you could say why not just do contrast anyway, um contrast can actually worsen renal function. And I'm not saying this patient had AK I but because there's a renal colic, I'm sure there's some sort of kidney impairment with that. So renal colic or renal stones, you look into non contrast, CT K EV. Um, in terms of treatment, um depends on where it's localized. This is just a matter of memorizing it at the end of the day. Um, so if it's in, er, the kidneys, uh there's less than five millimeters, asymptomatic, you don't do much 5 to 10 millimeters. You do sh shock wave lio tripsy. Um, and then 10 to 20 then you're either thinking about or doing a URE TOSC. Um Yeah, so we'll move on to the next question. So, er question nine, a 65 year old man presents with lower urinary tract symptoms for the past few months. He has problems with urine urgency and has had several episodes of incontinence where he could not reach the toilet in time. He describes good urine flow with no hesitancy or straining. Urinalysis and prostate examination are unremarkable. Which of the following medications is most likely to help alleviate his symptoms. Uh Is it an alpha blocker? Five alpha reductase inhibitor, antimuscarinic desmopressin or loop diuretic? So I'll give you 45 seconds. Yeah. Ok. What we got Francis. So everyone that's answered has select and see. Ok, maybe this question is too easy then. Um Yeah, so the answer was c um you give an antimuscarinic, you give oxybutynin. So let me just run through unions. It's quite simple I find, but it is a common thing that can come up in exams. So do revise it. Um So there's different ways to class urine incontinence, um you've got overactive stress and overflow. So, overactive is increase in the detrusor activity. So I don't know if you can see my mouths, but on the top right is, you know, structures of the bladder that what surrounds the bladder is the detrusor muscle. So, because you're getting an increase of that activity of that muscle, you get the urge of needing to go. Um some patients may not complain of actual incontinence, but they may complain of needing to go to the toilet often and when they do go, they're not actually urinating that much. Um Stress is, it's in the name, whenever you're in a stressful or increased stress upon your bladder, then the, you know, patients get leakage. This is common in postmenopausal women um where they have a weakening of the pelvic floor muscles. So, in the diagram below, um these structures that are towards the neck of the bladder or the sphincters of the urethra, um that is kind of where the pelvic floor muscles they sit and you know, support the bladder. So, because you get a weakening of that, you know, er therefore the sphincter muscles and the muscles there are not as strong to retain uh urine in the bladder. Um So yeah, you get it increase in abdominal pressure and that causes leakage. So that would be when exercising or coughing or sneezing, that's when you know you get these symptoms. Er, overflow is less common So that's, er, you know, er, the middle one where you get, um, let's say prostate enlargement patients, a lot of it can be clinical at the end of the day, but you can do bladder diaries, you can do urodynamic studies. Um, and then in terms of management, we go for conservative first, then medical, then surgical. So for urge you do uh bladder retraining that involve having diaries, recording how much you're urinating, encourage them to wait a little bit longer. And then oxybutynine is an antimuscarinic. So it activates the sympathetic nervous system or depresses the parasympathetic, therefore, reducing choose activity for stress, pelvic floor exercises to increase the strength DULoxetine. And then uh there was retropubic midurethral tape procedure which basically is to lift the er urethra anteriorly and superiorly to kind of support it up. So therefore, it can somewhat, you can retain your urine. So that's incontinence. Ok. Question 10. Um A 36 year old male is in the orthopedic ward awaiting for fixation of a left ankle fracture. His history of type one diabetes uh managed with basal bolus regime. His HBA1C is 32 and has no complications. His morning dose of basal bolus insulin are now due. His surgery is scheduled for tomorrow morning. He's nil by mouth from midnight. How should his diabetes be managed? Ok. So do we continue the long acting and omit the short acting at meals. Omit uh omit the long acting and continue short acting, EMA everything reduce the long acting incident by 20% and emit the short acting or do we reduce the long acting by 80%? And emit the short acting insulins? And so I'll give you another, I'll give you 45 seconds to a minute to have a think about that. Well, a couple of people are saying they can't see, um, the slides. Maybe you and refreshes. Yeah, let me try refreshing as, um, give me a second. Mhm. Can you see my slides now? Is that working in Harry? Uh, I can. Yeah, that's better. Cool. Ok. I guess we'll give it another 30 seconds maybe to answer the question and please do ask questions in the group chat. If you have anything, I'm happy to answer as we go. Don't feel like you have to leave it until the end. Ok. So most people have said a but as a couple for d ok. Um, so the answer is d for this one. So, um, I used to get quite confused, you know, there's lots of different rules for, er, generally for preparation for surgery and I would recommend you read, I just wanna go through diabetes. Um, because, uh, I think I found this the most tricky one but it came up in my finals. Um, so it, it's just about remembering some rules because a lot of it is actually just continue as you are. Uh, but there's just specific rules for you to actually remember. So firstly, for longer surgeries or emergency surgeries, um or a patient with poorly controlled glycemic control, you normally have available rates, insulin uh for them during surgery. So that's simple. Um But then let's just assume our patient has got good glycemic control. Um Here's the table I've taken from past medicine, but again, a lot of it is just continue as normal and then we'll just talk about some specific rules to remember. So Metformin in general, you can take it the same, you know, it's take as normal, be the day before and on the day. If you take it BD, that's fine. Continue. If you take it T S3 times a day, then you emit the lunch time dose and then that's the same for the day after. You omit the lunch time if you take at DS, but continue if it's just be ok. And, uh, for sulfa and urea similar to morphine at Metformin, but you just admit your morning dose. Um, and the same the day after as well, you amit the morning this E Gliptin. Stay the same. Your, uh, GOP one analogs. Stay the same. Your Dapa Flosin you emit on the day of surgery and the day after surgery. Ok. Your long acting insulins, Lantus Levemir, you reduce that by 20%. And then these ones, er, and it's actually written here but your short acting insulins, um, like Novo raids, you omit them basically. Um, nn not the day before, but on the day you, you omit them and then I think the day after you continue them, that's my understanding. And then these mixed ones like HumuLIN three, you don't do anything the day before you're half the morning dose on the day of surgery and the day after surgery. So it's just a few rules to remember. I know there's a lot you need to. But, um, if you just take your time to go through this table, it's not too bad at the end of the day to remember it because a lot of it is actually just continuing as you are. So hopefully that makes sense. Uh I put that in because I found this difficult. I still do, you know, trying to remember it. Ok. So, um, question 11 a five week, um old baby boy is brought to the GP for their six week check up GP notices one side of his scrotum is larger than the other. On palpation. There is soft, smooth swelling anterior to and below the testes that tran illuminates. The baby's mother thinks it. It has always looked like that at all times. There's no erythema or signs of infection. The baby is otherwise well and looks comfortable. Uh, which one of the following medications or treatments is most likely to help alleviate his symptoms? So, would you do an urgent surgical repair, therapeutic aspiration, reassure and surgery if not resolved in 1 to 2 years, reassure surgery in 3 to 4 years or arrange a routine surgical referral uh in six months. So give you another 45 seconds or so. I think I ended up copying the question from the one before my apologies. But what is the ideal treatment? Yeah. So it seems split 5050 between A and C A and C. Ok. So the answer is c for this patient, it's just more, you know, remembering what this case is. So hopefully you should have found this was Hydrocele. So the presentation that I gave is actually very similar to how it would be in an adult as well. So Hydrocele is a collection of fluid in the tunica vaginalis. Um and there's er, there's er, it can be classed into two things hydro. So one is where um especially in younger Children, there can be a connection between the peritoneal sac and actually the tunica vaginalis. I don't know if you can see my screen but you've got your testes and then, oh, sorry, that's the next question. Uh Testes and then just around the testes or epididymis, er, you've got the tunica vaginalis that can connect to the peritoneal er sac. Uh So that's communicating where you've got that drainage. It's very common in young boys, er, who are a few months old, 5 to 10% and it normally resolves by itself. And then you've got non communicating, which is an increase in fluid production in the tunica vaginitis. So, um, you should have known by that this was a hydrocil because it was soft. It's unilateral, it can be bilateral. Um, you can feel above the mass and also it's trans aluminous because if you think about it, it's fluid around, you know, your ball sack. So, and fluid would appear clear if you were to put a light to it. Management. It is conservative. Um, and in adults it is conservative, you don't really do anything unless it's very long standing. But in our case, our patient was uh five weeks after a year or two, then you're looking to do surgical repair and it most likely is because it's this communicating form of hydrocele, non communicating is not as common. So, um and so maybe some people thought it was a, it, it's not urgent. I think it's just recognizing this is a hydrocele and a hydrocele is actually quite common. Therefore, it's not an urgent procedure. You wait for a year or two when they're a year or two old. And then he's like, ok, maybe this knee is surgical correction. OK. Hopefully, I explain that. Um question 12. This is a common question. Uh Mrs Graham, 47 year old female attends A&E with a painful swollen left cough. She had a hysterectomy for cervical cancer. Uh 10 weeks ago, on examination, her left leg is tender along the deep venous system and pitting edema is present. Examination of the right leg is unremarkable. You suspect a DVT she's clinically stable and the radiology department informs you you, you will uh it will be at least five hours until they'll carry out a Doppler ultrasound ad dime is awaited. What is the most appropriate management? Now, do you start low molecular weight prophylaxis? My apologies. B should be low molecular weight treatment. C is start A DOAC D would be discharge and wait for the scan tomorrow and e would be wait for the Doppler ultrasound. So in this case, let's just say B is treatment dose, low microwave heparin. So I'll give you 45 seconds. Mhm. So everyone has um set to sea. Very good. The answer is C um So it was very obvious this was a DVT in this case, but just to explain if you think your DVT, you do well score. Um and you know different things in the scoring system. I don't think you need to necessarily memorize it, but you should get an idea if someone's scoring above two or less than two, but you know it it's age cancer. Um if a patient has recently had surgery um immobile for some period of time, long haul flights, you know those sorts of things. Ok. Um So then if they're scoring greater than two, then yes, you're gonna do um an ultrasound but then if you're waiting, er you do ad dimer, you anticoagulate and wait for the scan. So the D dimer as people would know is um an exclusion test. So if it is negative, then it cannot be a DVT or a PE. Um So that's why you can see on the right D dimer negative. You need to think of another diagnosis. Um Yeah, anything else I need to explain on this side, to be honest. So in our, in our case, uh our patients um because we are thinking this is DVT, this patients scoring over to and we're waiting, you would start treatments for this and treatment for her would be a DOAC. Um one main contraindication. I know for a doc would be if a patient is pregnant, but our patients um is 47 so it's unlikely to be pregnant. Um So if it's provoked, if it's a provoked DVT, you give a diag for three months. If it's unprovoked, then you give it for six months. So for our patient, it is provoked because this patient has recently had surgery and hysterectomy. So therefore you give a doac for three months. Ok. Um So yeah, just be very familiar with this kind of table. I know there's lots of pass me questions on it, but it's a common question about D VTM PE management. Ok. Er question 13, Brian, a 35 year old gentleman on the core a ward and he's been suffering from Melina for a week. His HB is TW is 60 and the consultant has requested you to transfuse John with units of packed red cells within minutes of starting the infusion. Bryan complains of itching and stinging sensations on his trunk. On examination, you observe red, raised welts over his abdomen and chest BP is unaltered from prior to the transfusion. At 1 30/70 temperature is 37 and there was no signs of dyspnea, wheezing, stridor or angioedema. Which one of the following management options is the most appropriate. Do you temporarily pause? A transfusion? Start an antihistamine, permanently pause a transfusion IV fluid recess and informed lab permanently pause a transfusion, I adrenaline, antihistamine, corticosteroid, bronchodilator, supportive care DD, temporary pause. A transfusion start antibiotic or e permanently pause transfusion, give immediate globulin therapy. I'll give you 45 seconds on that. So those that have advanced of all slip to the A. Ok. Uh The answer is a very good. So uh this is lifted from pass med um II, find the best way to remember the blood product transfusion complications is actually just remembering the name. And when I remember the name, then I think here are the symptoms and therefore, I understand what the management is. Um that's the best way around it. So for example, our patients uh is having a uh minor allergic reaction. OK. But we'll go through each one. Uh So a nonhemolytic febrile reaction. So it's in the name a febrile reaction. Therefore, it's a fever type reaction uh to it. So that would be a patient who develop develops fevers and chills. So how do we tend to treat like a Pyrex type picture? Is you would stop or slow down the infusion. That means you, because you've given it too quickly, you give IV paracetamol, normally you monitor symptoms and then you may think about continuing, um, given the blood transfusion or the packed red cells, then you've got minor allergic reaction and anaphylaxis, they're kind of like a grading system. So a minor allergic reaction would be these, um, you know, itchiness or maybe these, you know, angioedema or lumps this IC area uh that develops on the skin, but that's pretty much it. I know they seem somewhat like anaphylaxis reaction, but you can see anaphylaxis is far greater in terms of symptoms. So, for minor allergic reaction, you would temporarily stop the infusion, give an antihistamine because it's just an allergic reaction kind of like, you know, hay fever and then just monitor the symptoms. Uh anaphylaxis. That means obviously these uh, you know, blood products are not ideal for this patient. There isn't a matching of the antibodies and anaphylaxis is hypotension. You know, difficulty in breathing, you're getting wheezing, you're getting these angioedema lumps and flushing. That's when you need to stop the infusion. You need to do your ABCD E and specific, you know, for anaphylaxis is im adrenaline uh, with fluid resource. Ok, acute hemolytic reaction. Er, that's where you get more fever, abdominal pain and hypotension and then from there, you, you uh you stop the infusion, you do your ABCD E and then you start your er fluid result. Then you got Taco and trolley. Um, the way I remember is Taco is circulatory overload. So I think this patient's got too much fluid entering their system and that's because you're probably giving it too quickly. So they're developing fluid in parts of their body. So you get pulmonary edema getting hypertension. So how do you treat it? You need to offload some of that fluid. So you stop the infusion or slow it out of the rate that it is. And then you consider IV uh diuretics to treat that. Ok. And then Tral, it's in the name lung injury, acute lung injury. So therefore, I think of lung damage uh as a result of the transfusion. So you're getting these pulmonary infiltrates that you can see on the X rays. Um you're getting a fever, you're getting chest pain and then you need to stop treatment. ABCD E but more commonly oxygen. So yeah, very good job that everyone got that right. I think this is my last question. Um So 34 year old lady presents to the gynecology department complaining of heavy painful periods and difficulty conceiving. She's concerned as she has a husband who would like to start, who together would like to start a family soon on further investigation, an ultrasound scan reveals a 4.5 centimeter submucosal uterine fibroid, which of the following treatments is most appropriate to treat her fibroids, hysterectomy, trans exam, acid hysteroscopic endometrial ablation, uh intrauterine uh system or a myomectomy. I'll give you 45 seconds on that. OK. So those have answered. So most people are saying e and we've got a couple for B as well. Cool. OK. So the answer is E and I'll walk that through. Why? So um it is to do a myomectomy. So it's patient specific about how you go about treating fibroids. But in terms of knowing why it is fibroids, it's a benign smooth tumor of the uterus or the uterine wall and they can be so placed in different parts of the uterine wall features are menorrhagia. So heavy periods and bulky related symptoms, low abdominal pain, complain of bloating because these fibroids are cause an increase in uh hormone levels. Um And also you may get some urinary symptoms, especially with large fibroids and also where they could be situated if yeah, uh diagnosis is transvaginal ultrasound all the time and then management is different types. Ok. So if we are there to just treat the menorrhagia, er the best um treatment is the I US system. Uh you can use the combined pill, you can use trans exam acid. Um And I can understand why maybe some people thought of using trans exam acid because that's treating the menorrhagia. But in terms of definitively treating this patient, it would be more a myomectomy. Um because it's, it does get rid of the fibroids and there's evidence to show that it doesn't have too much of an effect on fertility risk. So I understand why you may have thought that trans exam acid, it's not a technically IOS is most for menorrhagia, but trans exam acid, I'd say, yeah, you could treat the symptoms, but we also think about fibroids, they develop over time. So we do need to somewhat treat that. And that's why you would more lean towards a myomectomy rather than translam acid, which would just treat the metrh. Hopefully, I've explained that. Um So our patient who wants to remain fertile wants to have a family who do myomectomy. But if they don't, then you can offer a hysterectomy. You've got u uterine artery embolization, but there's actually weak evidence for that to be effective. Um actually treating the fibroids, let alone, you know, preventing further, actually developing. So hopefully, I've explained that difference. Why it's my makes me over trans exam acid. I, so that is all the questions. Uh Let me stop sharing. Cool. And I've released feedback as well to you guys. And as I'm sure you've already heard we are trying to do some research as well, looking at UK Malay, teaching at university. So there's an additional form there if you want to get involved with that, if you haven't filled it in already. Um And we'll hang about for a few minutes if you guys have any questions at all, if you guys fill in the feedback form, not only is it useful for us to and you guys will learn about that when you start working on how important teaching and feedback is, it will help us for our future sessions. And also we'll be able to distribute slides and recordings and all that good stuff. Um Other than that, thank you guys for joining us. Thank you, everyone. We appreciate it. Mhm. Yeah. How many people ended up coming? Can you, are you able to see that or? Yeah, I can see. So there's uh is it uh 14 or 15 altogether? Ok. Not bad. The matter. Are you just doing two teaching sessions then? Have you got more planned? All right. II have I have no idea. Um ok. Um If you guys have any of, ah, questions, um you can reach us on social media and things like that, but we all end it here. The feedback form is there. So if everyone clicks on that and um our next session is actually on Thursday. Um I'm not sure what it is though. It's neuroscience. I'm actually doing it. Oh, yeah, of course. Ok, we'll end ahead and thanks guys. Cool.