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Agencies. Um, urology don't, I don't think special surgical specialty gets taught very well. I didn't get any teaching in med school. So I've combined it with a few other things just to kind of tackle these rare topics that we're not really gonna discuss. But we will today. So your case today you've got Anthony quarter old man is to any extreme concerns he discloses there was blood in his ejaculate. Please take a full urological history. Ok. What do you wanna know about Anthony 16, one episode? Never had it before? Was the, was there like a lot of blood? Was it mixed with the urine? Was the whole? No, it wasn't in the urine. It was just fresh blood kind of mixed in? Ok. Um, I don't know any other symptoms that came with this. Um, I noticed I had a bit of testicular swelling as well. Any pain, just generalized pain around the area. Yeah, around the area. I, um, hit it, playing cricket a few months back and it's always kind of hurt since. Cool. Ok. Has the pain been getting worse? No, it's kind of just, it's just something I noticed. I wouldn't say it's a pain. It's more just like I can feel something in there. Have you had a feel to see if you can feel something? Not really, I wouldn't really know what I'm looking for. Have you had any trouble with e calculating? No, no, I've just got a new partner. So, uh, we met on Tinder about a few weeks ago and was this the first time you were having fast or? Uh, no, we've, you know, we've been getting to know each other. Are you both up to date with your screening? Kind of sexual health screening? Oh, no, I've never done that. You've never done that? Do you know if your partner has or? No? So it's ru of Oscar lady, isn't it? And all your water works are fine. Any pain, you know, he didn no, any discharge. No, no, any trouble starting. No. Ok. Um Is the skin around your penis normal? Yeah. Rashes or redness or ulcers or? No, I haven't noticed anything weird like that. How are you feeling generally in your family? Feel a bit tight? Just losing a bit of weight? So that's just me being good. Ok. Has anything similar happened before? How much weight? Have you? Not much? Just a little bit. Have you had any night sweats or fevers? No. Um Yes. Has this happened before? No. Ok. And was there anything preceding anything that any other symptoms or preceding this or anything that you think it could have been a bit bloated. But that's, uh, just generally, as I said, I've been a bit tired. The only thing I can think of is when I hit it about eight months ago, just a cricket ball. So it's quite hard. Did you see anyone for it? I just walked off. Ok. Ok. And in terms of your, are you diagnosed with any other conditions? Yeah. High BP. Have you? Yeah. Have you felt any mass or any density in, uh, your throat? No, as I said, I don't know, I wouldn't know what I was looking for anyway. Oh, I was just gonna ask if you take any medications? Yeah. Ramipril. Do you have any changes to your bowel habits? No, any pain when you, no, any pain when your white people? No, it's an opportunity. Mm. And feeling like you still need to go to the loo after you've been to the loo. No, any recent eye infections. No. No. No, don't try. Oh, yeah. Yeah. Yeah. Yeah. Yeah. Ok. Um, do so, is this your only sexual partner or do you have any other questions? Uh, she's my one at the moment. But, you know, I've, I've met women. Um, ok. Any recreational drug use. No, no, no, no, no. Ok. Smoking. Yeah, I do smoke 10 a day. Ok. But what was there any bleeding when you do? No, no, it was, it, you just, I noticed when that happened. I've never seen it, I've never seen it before. Did it feel like a lot of blood? Like there wasn't there a lot of blood over? Yeah, fresh blood coming out of me. II don't know. I just came straight in. You? Do you have any family history of any kind of testicular or penile problems? Anyone in your family? Not family history? I mean, when I was a kid I had surgery down there. Do you know what that was for? Um, I don't remember my ball. My ball didn't drop for a long time. Ok. Ok. Um, but you denied any night sweats? No. Uh, not at night. And you said was the weight loss intentional. Um, mad, but my weight's always gone up and down. Ok. Do you know how old you were when you had the surgery corrected for your testicle? No. Is it just one? Hm. Well, I think you're worth this. Oh, well, I work as I'm an accountant. I, I'm not around aromatic dyes or whatever it is because you have pretty much covered everything. So, um, this is your history of complaint. One episode of fresh blood. He's never had it before. He's noticed some swelling down there. He's got generalized bloating. Oh, and he's also getting some breast tissue, but he thought while I'm losing weight it will go to disappear. We're kind of touched on all of this. Um, this is the awkward questions that will find a bit of gum because it's always interesting, especially when you've got changes in ejaculate or anything wrong with the penis or testicles. It's good to clear it up and its age group as well. You may be considering other differentials. So looking at the symptoms themselves, breaking it down, you, you've got all of this discharge lesions, any itching, sore, genital pain and passing urine and all the urinary symptoms, less urine. It is it changing in color, all of those things? No systemic symptoms and then more going into the sexual contact. When did you last have sex? Are they, is it with a regular partner or is it you were having casual relations again? You've got all of this type of sex? I know it's awkward but being clear, is he just having vaginal sex? Is it anal sex, oral sex? You really unfortunately got a hammer down. I don't know if any of you done a gun placement yet. Don't just don't be afraid. Ask at all. Um Contraception also. Hammer home. He did, he ha did he say if you'd have asked Anthony? You would have said, oh no, I was wearing a condom. So that's how I saw it. Um, sexual partners over the last three months. So you have to cos it's spoke about your notification period. Is that always ask for HIV. Um and well done with recreational drug use. Cos when I was in Birmingham, they had a huge thing of chem sex coming out and loads of things were going around all the fun section. So, yeah, really good. I think you've got all of that and then just the boring stuff. Um, he drinks, never forget alcohol. Of course he has a high BM I relatively, but he's losing weight, unintentionally. Um, accountant. No Children. So no Children is a good question to ask. Especially when you're worried about these kind of things because you can think about long term management because I think you all in your head know the differentials that you're kind of going for. So you're doing your examination who has actually done a scrotal examination? Hum. Or I mean, my boy, well, II remember when I a good boyfriend, you must do it and he was like, absolutely no way. That's the weirdest thing ever. He only denies dairy. It, there's a line. Well, uh good, I mean, it's really good to get used to it. What is the most important thing about just take your examination? Oh, lay lying and standing even more simple than that. Oh, eye level. Even more simple. Yes. Oh, you chaperone and being clear, chaperone, chaperone, chaperone. There are some which in med school, if you don't say I'm just gonna go, would you mind being my chaperone? You're done? So, chaperone, chaperone, chaperone for breast dre testicular, just always ask it straight away. The examination itself is quite straightforward, lying down on the bed and we were taught again, you may be taught different, we kind of did like a post dance. So when you're doing it at eye level, when they're standing to the side, so it again is less uncomfortable. Do you know what I mean by that? No. So if this is your model, you would be then proposing. So knees down like that and then you can use the back of your hand to stabilize the testicle and then by manual palpation, we were told to do it to anchor it and do it. So, yeah, you can anchor it, uh anchor it. We were taught just again just for um maintaining professionalism um and patient dignity to make it less comfortable for them more comfortable for them just to anchor it or your penis and withdraw the foreskin. People get that, you can ask the patient to do these things, you can ask the patient to hold their testicle. But the main thing is you've got to buy manually palpate work your way around thinking of the top going around the the most being in the whole scro is itself or as well. They're the main things you wanna do. It's quite straightforward and it, it actually the main thing is about communication. So having we wrote those kinds of examinations spiel which we rehearsed off by, off by heart, just to say so. So you presented with certain things that may be concerning us about the system. The best thing we can do is examine this, I'd like to have a chaperone. When you're present, you'll be undressed from the waist down again. Just saying that instead of trousers coming off, that's what we always used to say. Learn your spill because on the day you'll be stressed. So the best thing to do is just practice it. The actual examination, no one really looks at, to be honest because it's, you're going to have this, it will be, you'll have an actin and they take the cover off them. It's one of these. Yeah, main thing is chaperone. So these are your basic things that you're going looking for. Does everyone know what these diagnoses are? I don't know what the very middle is. Would that be Chris? Yeah, the middle one is a tumor. What is the top? Right? So, yeah. So epididymal orchitis. So the orchitis swelling of the testicle, epididymitis being just of the epidermal tract usually come together, younger age groups always think of sex, sexual health history, STIs s chlamydia, older generations. Again, things are changing since I was in med school. But ut S kids to be sexual health. Yeah, it's sexual health has really come up s have gone up in the elderly population because of abuse. No, no, no, no, no. Um just second stage of life. So, yeah. Uh top left anyone torsion. Uh bottom left. Yeah. Middle and bottom, right. Which type in indirect dosing? Oh no, that's not. It is inguinal direct. So it's going through the canal instead of going through the wall, which is more common a seal. So that is where you basically have varicose veins of the testicle. Um So there is an increase in blood flow to the Papini form plexus. Some males just have it. Um it doesn't have to necessarily be something to be. But in this patient, if he had this, in this history, you'd be concerned maybe of a carcinoma of the renal tract or of the um, kidney causing high pressure because the renal uh the testicular vein on the s right. It's if the blood is not in the urine but in, in alone and not never in the. Mm. Well, I was more if it was oh in him, I think we pretty know where he's differentials in this case. Very simply I would stick with sexual disease. So you could say chlamydia, gonorrhea trauma. He's mentioned a cricket ball. Has he had some more trauma? Um And then you have your cancers directly involving the male reproductive tract or a locally invasive. They would be the ones I would go for. Um, but he's, I think he's got so many red flags. We know exactly which path we go to. He's in the right age group. He's got a history of an unscented testicle. He's got signs of excess estrogen. He's kind of unfortunately bar off. But yeah, with your examination, the best way to break all these things down is he on your examinations, if you can't get above it, it's obviously a hernia. You should feel the bowel coming in separate cystic. It could be an eal cyst. Um, so that's why the main thing in your examination is always, never forget to transilluminate really important. Just so you won't be able to do it and it's holding your pen torch close to the skin and then you'll actually get the transillumination if it's solid bars aren't really solid, they kind of feel like jelly is the best way because they say it's meant to be like a bag of worms. But when I have examined it, it's definitely more like jelly type and you feel like when you're doing vena punch, you can feel a vein, same principle. It's a spongy jelly light vein. Um Yeah, and that'll be painful. Then you've got your two special tests which you're going to do in your testicular examination, your cremasteric reflex. Um And if it's pain on that or on elevating the testicles, again, it helps with epidermal orchitis, absent chromic reflex is pre is found in torsion. Yeah. Um Yeah, that's it mainly for the examination. So what we're gonna do for him. Um What imaging would you like to get clue is obviously on that ultrasound. Yeah, it's the best one for a for if you're already living in doubt about a to you want to get an ultrasound, you don't really want to be irradiating these kind of tissues. Um tumor markers are really helpful, especially when you've got seminoma teratomas, get those tumor markers sent off early and then we kind of know where we are. So staging. So speaking to an MDT early, managing his patient, managing his expectations and saying to him as well, do you want to put a spam sample aside early? Is always also a good thing. Uh This is if you just break it down your basic. Have everyone heard a bet? It's a classic M CQ. I always had a few semin. This is the chemotherapy regimen you give um it's a very common one. Yeah, any questions so far about the case, main things to take away from it is asking those difficult questions and getting comfortable asking them. So you don't get flustered because the patient's already going to be flustered. The fact that they've come to A&E is a good thing because a lot of people leave this too long. Um Drilling into your sexual health history, just make sure you're asking the right questions and examination findings, looking at the bigger picture and how you're gonna manage them in the long term. That's the main thing. Time for some questions. These are this week again as it were last session SBA so it'll be the same answers for all of them, but it's just different cases. They're a bit more straightforward this week. Mhm Yeah. Does anyone know um what kind of volume is concerning for retention of urine in the bladder, like 701,000, 500 m, 500 is usually my cut off to catheterize. Um, bladder scanning is really fun and really easy. So you can have a go now and e it's basically an ultrasound that reads how much urine is in the bladder. If you're able to feel it, you just catheterize. Um But if you are going to a bladder scan, you usually around 500 is the cut off. If they are absolutely not able to pass the urine, you can give them the bottle and they can try, but usually 500 is in the back of my mind. What, what's the one I like? There's a, um, there's like a certain cut off. But if they have that, it's like a type of urine retention and then you don't want to remove, you don't want to what you don't. Yeah, you don't want to do a trial without, yeah. For some reason, I, it's usually people who are chronic retainers because they're just going to flip back. Um, if it's in someone who is just acutely for three days, they're on medications that are causing it, then you just do that. Especially in any urology. Nurses are very good in the community and monitor these things all the time. They have chronic retainers. They, it's a painless retention of urine. So him, he's saying he's got super pubic pain acute, but it's those ones who just leak along. Question two. Ovarian, yeah. Go away. But yeah, ovarian cyst cysts can also tort. So that's why as well with the pain and vomiting is making you more think of that. Um, g get going involved early. It's the only answer to this one. weight gain is obviously very similar with that. You'll be having more women who have got endometriosis, fibroids, ovarian cysts, these kind of generalized pelvic pains with weight gain and abdominal bloating. Um These are all the risk factors for this, but it's the vomiting and abdominal pain is making more go to ac to Yeah, that sounds for that one. Here's the per this is the risk factor you were wanting me to say earlier. Mhm. Bladder bladder cancer. Yeah, there's always those risk factors smoking as well. Just sorry. Ok. Why is it painful? Because I thought it's painless hematuria. That's bladder cancer if it's obstructive is why I put that bone in. Um It's usually painless and you have it mixed. But him, I the reason it was just to throw you off is that it's recurrent uti. So people think that, but actually the reason it's painful is because he's got clot retention. That was why I put the end. But the main thing is is that he's got um rubber industry, smoker hematuria. Yes, he's got UTI S. But until proven otherwise, this is your best. That's why it's a single best answer question rather than an M CQ. Yeah. And that's why with the, oh, gosh, yes. Um, with these cases I always found more in the geriatric patients where we admit them, put them on antibiotics for a long time. Don't be mind you're going to deplete them. So, don't be surprised. And so you can give stat antibiotics to help, you know, this and finally, yeah. Your level now. Yeah. Yeah. You call it whenever it is the patient who cannot move and they are in A&E they're in excruciating pain. It's a stone C TK UB is always going to be, it's that. So in this question, excruciating pain cannot lie still. They're the first ones that we get into that er flanked really out of fossa. So you've got this diagonal pain from the back going forward. Sometimes it goes right into the genitals. So you can have men's saying it goes into their penis. Women's saying it goes into their labium um feeling sick. Some people confuse it with an appendix in a younger patient. Um because of the paleness, sweating, excruciating pain down by the inguinal um fossa. But if they can't make so it's usually a stone would a stricture present like that as well can do if it's acute. But a stricture is usually something that slowly forms over time and they become more backed up urine, but it's more of a colic. That would be my answer to this one. So here's the scenario for today. Again, this is a real life scenario I had about a year and a half ago. Um think of the theme of the session um and just cast your neck a bit wider with this one because you're in A&E you're the sho you've all been promoted um on tape covering um all surgical patients overnight. The nurses call you as a failed discharge. He has come in to A&E Colin is a patient being treated for metastatic cancer who was admitted two days ago for radiotherapy to the rectum and prostate. He was admitted to A&E cos he feels generally unwell and with pain in the scrotum. Um, he's a background of AF and is on Bisoprolol and Rivaroxaban. Can you assume he's a failed discharge? Would you like any bloods or anything doing to him? We're not too, you know, he's failed discharged discharge. Oh, sorry, I didn't realize that. So if you discharge someone from the hospital, um, and they come back within days for the same thing, it's a failed discharge and a and you don't need to see them. So, unless they're really sick, um, but you'll just be called straight away. So he's, uh Colin, he's been treated for metastatic cancer. He was admitted two days ago for radiotherapy to the rectum and prostate. He was admitted to A&E today because he feels generally well and he's got pain in his throat and he's a background of AF and he's on Bisoprolol and Rivaroxaban, please. You, so when you see Colin, he sits, you on the edge of the bed, he's looking pale. He's looking generally unwell. Can you assess him? Yeah. I usually, if it's a new clerk in there, there's nothing but he's, he's looking more. So I think that's definitely the way we're gonna go with this. So he's speaking full sentences. He's able to give you a full history about why he came in. So, and his airway is patent breathing. So, so that's 96%. Um I spray, it's 15. How frequently did you and more we can do in breathing. Um, chest xray listen to his, he's got a bit of decreased air entry to his bases. So would we want to administer oxygen to Colin? Right? That's fine. That's fine. So let's just keep an eye on him as this was a two E it's a constant thing. I want you to get in the phone that every time we move on, we're still thinking of everything else. It's never just tick box, always keep thinking. So we've always got options. If we worry about Colin, we can consider it. But, you know, at the moment, I think we're safe to say we don't need to. So circulation, we move on to that. So BP, yeah, BP, heart rate, heart rate is 96 per minute. He's regular. His BP is 100 and 7/70 his cap refill which did ask for earlier essentially is three seconds. Do we have a first again? Three seconds. What is it, you know, I was just gonna say like, is he warm peripherally? Is he warm? He's very cmm. Cmm and he's pale, you said? Yeah. ECG, ECG. Yeah, I can give you an ECG. OK. So it's a, it's a sinus rhythm. Mhm. Regular. Mhm. You wanna count? I think it's 100 and 50 beats a minute. Roughly. Yeah, some of them are a bit bit, yeah. 150. And is it working? Yeah, regular this p um there's no like left or right. No, no access deviation. Um No pr s it's three little squares. So it's quite a small picture. So it's normal pr S is narrow. Um There's no kind of ST or depression. What is you too? What is, it's a bit slurred but nothing to worry about. 23454. No elevation in doubt. That's what check your baseline. So as an F one, I always used to carry out a piece of paper and I would just come through. So we know where does it come down to all the time? So it's not elevated a slurred because it's going quite fast. Would you say would those be peaked or? No? No. So um with hyperkalemia, always remember with your tea, you should be able to sit on it. 222 peaked waves. So no, it's just conduction. So this is just a sinus tacking. Um, yeah, this is just because the heartbeat is so fast. That's why you start to get these kind of changes. But these are not acute ischemic changes. 33 something. Um, just probably, I don't know. I don't know. Sorry. No, I just need to interpret more. Yeah. That's why it's really good with these scenarios. You just keep seeing them and to get through that pattern thing. And that's why I quite like my step. Why it caught, I biased. It's what I use, but it's just a nice way to break it down. Cos you panic when you see that and it's a aging that I did when you were on a cardiology ward round and I never knew what to say. Yeah, please. But top right hand side, what else do we wanna get in, in two side? Like on both sides in what, what's this called? And then anything you wanna do? What bloods would you like? I work out using I C. What didn't we do in B that might be helpful? Now, not uh we could do a venous gas because as we say, it's 96%. So we don't need the ABG or chest X ray at this time. Um So yeah, so I'll send those all off you. Um It's a certification group. Seven. Cross Match is always a good one to throw in there. So you move on to do. Yeah. Yeah. Yeah. We can definitely send off cultures. So I just speak to Colin, he was fine when he was first talking to you, but he's now getting really confused and he's feeling a bit out of it. He just keeps glazing off as you're trying to assess him. So he's acutely changing before your eyes. Is his BP still? Ok. How does it change? Uh, we'll recycle that now. Um, heart rate is tickling up. It's now 100 and 50 as it was on the ECG uh still cycling doctor. Give me a second. Just no, no bleeding. Yeah, we could do the seps six. So we're taking three. So we've got our blood cultures, we've done a gas. Um and yeah, and then we're giving our three. So do you want to give us some antibiotics? Yeah. Yeah. As Petros guidelines is the term term you wanna coin? So I'll give an Petros guidelines. Um And then do you wanna give him fluids? His BP has just come back as 100 to still at now. So it's gone down a bit. Yeah. What flows? Would you like doctor? Does he have any? No, he doesn't have any history. Heart heart disease is he, he's got af uh he's on Biop Rivaroxaban. So that started with 250 mL. The C is all here and they're like plasma. I always say an emergency. Sodium chloride, plasmalyte is used here and it's used in my last trust. It's it's just, it's basically, it's like Hartman's with a bit of sugar. It's, it's the closest osmotically matched. It's quite expensive just as long as you. But, yeah, do any crystalloid bolus 250 is a safe answer. And as long as you can spill some off, he's fine and we're waiting for our venous gap. Um, um, 15 is usually a stat, but you could just say stat and the nurse will give it 250 won't take long to go through in him. Um, how's his breathing? He's, he's just looking a bit more tired. He was sitting on the edge of the bed when we first came in and now he's just kind of lying on the bed, but we have been assessing him. His stats are trickling down a bit. It's now 94 and his BM is 12.5. Yeah. What would you like to give him? Yeah, definitely. I would because this is a, he's getting sick before our eyes call in. Um, ok, so we're giving you oxygen. Um, it's coming back up. His sat's to 96. His heart, as I say is 100 and 50. Um, and his BP was around 100 systolic. His temperature is 39. Anything else you wanna give him pupils? What, what helps when you've got a temperature at home? Yeah. People forget IV paracetamol 1 g helps bring the fever down cos we don't know what's going on. He, we're worried about him but we don't know yet. So, but so we've redone a we're giving him oxygen. His airway is still potent. He's speaking to you. He's full sepsis, but confused breathing. We've got decreased air energy. Bilaterally. We've got non rebreather on 96%. His respirate is kind of around now 17 circulation, his BP, we've already discussed heart rate. Cap refill is three. We've got his access in and this is his disability. So we're gonna move on to exposure. We're happy to keep continuing to assess. So that was soft, non tender. You a sho the first thing you go for. What did he mention his presenting complaint? Hm. And what did he have before? Why was he a failed to show in radiotherapy to his rectum um and to his prostate. So do we want to examine about that? Yeah, we do. And this is what you find. Does that worry you? Yeah. So he's got a bulla and skin changes um over his gluteal area and on his scrotum, it's involving the perineal area where he's had the radiotherapy. You can feel the skin is kind of falling off underneath you. Um It feels you feel those bubbles under the skin, that bit is very cool, but the rest of the skin is very hot and the rash is very red around this area of blueness. So you start getting worried about to call your boss when the nurse goes doctor doctor here's the V VG you asked for so acid din and he's on. So this is, this is the one before we gave the oxygen. Oh OK treatment. So he's still still OK because he's breathing off. Um can I have like normal values on this? So uh ph normal is 7.35 to 45. So that's low PC two less than six is normal, greater than eight is normal for po two, sodium is a bit low. But um you were aiming for about 135, potassium 3.5 to 4.5 calcium is low. Glucose should be less than 10 on a normal sample, lactate. Is that normal? It's very high 12. You, you know, normal kind of less than one roughly in my head. So he's got a very high lactate with a low Ph. So what has he got? Or acidosis? Lactic acidosis, you can say metabolic because if you look at his bicarb is 12, which is low. Um So he's got a, he's got lactic acidosis. So, and he's got a rapidly spreading red rash. What do you do? You've got this VBG. You've got a patient who's now on oxygen. He's not, he's getting more worse before your eyes. You're, you're an h fluid fluids running. Ok. Yeah, I think it's safe to say you've given antibiotics, you've given paracetamol, you've given fluids, you've given oxygen, you've taken bloods, they're all in the lab, you've done all the monitoring. I think it's safe to say you need help escalate. And to be honest, as soon as you attach the oxygen in the back of your head, you're gonna think to do an sbar. So I'm gonna say, oh I'm gonna be your reg on call. You can all help each other out. What do you wanna, what is going to form your sbar for this patient? So situation of 40 year old male presented with testicular pain and widespread rash from the Plavix and the um testicles on the background all um previous day radiotherapy um through the colon and like colon and prostate. I so he disaturated. Mm uh aseptic. Hm um is um lactate is 12.1 because lactic acidosis. Mhm. Um Yeah, when you when help and everyone have given, no, no, you've done well and I thought that was really good. Everyone always says at the end just come like especially when I used to do it in the proper SIM suites and people used to call on the phone and say I just did help the best way to do it, which is saying something but not saying anything at all. Which is my advice is when you get to the end of your recommendation, I have given antibiotics and fluids, but this patient is still continuing to deteriorate despite my best interventions. Um I think I need some support from the appropriate team. It sounds a bit better than just come, like you say, I'm try like I'm doing all these things but they're still deteriorating. I think I need some support. It just sounds a bit more sophisticated. So the way sbar I, does anyone know what this is this? This is it bad? Mm. A rapidly spreading rash. And when you're feeling it, you feel bully and cretus and the skin is kind of melting away of the scrotum, which is otherwise known as, oh no, four gangrene, correct? It's four years gangrene. Um Yeah, so the way I would do this sbar just to help like get these stretches on your head. So the situation I'd say, firstly, everyone forgets, introduce yourself. Say hi, I'm surgical sho on call. I've just reviewed Colin a 40 year old patient who is um clinically deteriorating with high lactate. And I just want to discuss this patient with you and then the actor or your senior will say, yeah, yeah, tell me about them. So I'll say Colin is a 40 year old who two days ago received radiotherapy to the rectum and prostate area for metastatic cancer. He represented attorney today for generally unwell with testicular pain. Um There's a bit of background as well about him despite the in addition to the cancer, he's also got af he's on blood thinners, Rivaroxaban. Um because as a surgical patient, you want to think, do I have to reverse it if it's an emergency on assessment. I could be today to be on this patient, airway is patent breathing. We've administered oxygen. He's got decreased air energy bilaterally, but he's maintaining his SATS circulation is actually up trending his um, heart rate and his BP is dropping. Despite giving fluids, I've taken a full set of bloods including a cru av and cross match and his venous gas has come back with lactic acidosis lactate 12, as I mentioned earlier and he's acidotic with a ph of 1.7 0.12. Um He's got a high fever of 39 and he's becoming more confused with GCS of 14 out of 15. And on exposure, the main um finding I've got for this patient is a rapidly spreading rash of the left gluteal area, perineum and scrotum. There is good eye present in crept. So I have a high suspicion. This patient has necrotizing fas fasciitis specifically for gangrene. Um I think we need to keep this patient starved and talk to see if this patient have surgical requirement. Can you please come and help me assess I've given antibiotics, fluids and analgesia to the patient. That's what I genuinely said. So part of your assessment as an sho is this more goes into bit of practical stuff. Scoring system is always helpful. If you're not sure in this patient, his clinical assessment and his venous class are very suggestive of a necrotizing fasciitis. Um But if you're in doubt and A and you do call a lot about cellulitis that aren't actually, this can help you put together your score. So already glue is actually is less than 10. So not 100 and 80 but I might want the rest of his bloods. But if you're anemic, you've got high white cells, high C RP, it's more than numbers. But a neck fash patient is someone who is clinically deteriorating before your eyes. Like as soon as you see them, you don't have time to mark the rash you can see with your eyes, it's already started to go. Their numbers are off. They usually their BP is tanking. The reason his heart rate didn't go up before it does cos tachycardia reduces. The first line is he's on a beta blocker. So he actually has had a late presentation to is actually very sick to come in and that's why his lactate has got so high. But the only treatment for this you give all the antibiotics in the world is debridement. Um So this is just an example here. Um Usually some, you have to keep the briding until you see healthy tissue. So they call it like a dishwater sign where you'll see like the slough, the tissue is dead. You won't get that healthy capillary bleeding and you just need to keep cutting until you get healthy bleeding. Um Urologists will help preserve their structures with, especially with the fourniers gangrene. But um I've seen with plastics here where they've come and help with the debridement of the other areas if you, he had it going all around his anus. So he had to be defunction cos obviously, if you've got all exposed tissue, you can't go to the toilet. So it's having a catheter put in which I think you can see at the top there. Um, and then eventually they may, you may have to get the general surgery involved to have a stoma temporarily to stop the feces contaminating a field, especially if you're going to then um, flap it. Uh But unfortunately, as it did with my lovely patient, um it's a very, they're very sick already. He's got metastatic cancer and unfortunately, he did pass away cos it is a very serious disease and that's what it is one of the emergencies to be very much aware of when you get that phone call, you don't delay seeing that referral, you see it quickly. Um It's, yeah, it's, it's, it's a scary one to see but one to be aware of. And there's just a bit of stolen from osmosis. A bit about Fournier gangrene. Any questions? I've only seen it a few times, but it is, they get sick very quickly. No questions online is literally just necrotizing fasciitis of the like scrotum and perineal area or is it actually like a different path of it? So there are four that you can argue with um necrosis, fasciitis there are different subgroups of how it causes group A s mixed robes. You can have it with its moment. It's marine. Um Technically, yes, it's its own subgroup. But it's the main thing of describing it. This is a necrotizing fasciitis, but they also have fa gangrene because they all probably have that different bug. But it's mainly this area. It's affecting the actual bugs change and are never true. This is a more real life than what your textbooks will teach you. Thank you, come. So, feedback forms. And if everyone in the comments section this week could just say which um either trust there with or university with location just because we try to see how far was Bement.