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North Central and East London NCEL Foundation for Finals Obstetrics Tuesday 21st March MCQ and OSCE revision series Gynaecology led by foundation doctors Thursday 23rd March based on real clinical experiences Paediatric Surgery Tuesday 28th March Paediatric Medicine Thursday 30th March 7pm-8pmPaediatric Surgery Dr Jenny WoodLearning Outcomes •Review common paediatric/neonatal surgical presentations: • Appendicitis vs Mesenteric adenitis • Fractures • Pyloric stenosis •Hernias In the style of MCQs to illustrate the topicAppendicitis vs Mesenteric AdenitisA 13 year old girl presents to A+E complaining of generalised abdominal pain for the past few days. What do we want to ask?A 13 year old girl presents to A+E complaining of generalised abdominal pain for the past few days. What do we want to ask? •SOCRATES •Menstrual history - if menstruating, consent for pregnancy testing •Associated symptoms – Nausea, vomiting, fevers •Bowel habit •Lower urinary tract symptoms •Infective history PMHx, DH, - HEADSCauses of Abdominal pain in a child >3yr Emergency Non-emergency Appendicitis Constipation Testicular torsion Gastroenteritis DKA Mesenteric adenitis Sickle cell crisis UTI Ovarian torsion Pneumonia Ectopic pregnancy Pancreatitis Trauma HSP Toxic megacolon Renal stones Tumour IBD GORD – ulcers Ovarian cyst PregnancyA 13 year old girl presents to A+E complaining of generalised abdominal pain for the past few days. What initial investigations are you requesting?A 13 year old girl presents to A+E complaining of generalised abdominal pain for the past few days. What initial investigations are you requesting? •Bedside • Urinary pregnancy test – negative • Blood glucose – 7 • Urine dip – NAD •Bloods – FBC NAD, UEs – NAD, WCC – normal, CRP 15 •Imaging - ?USS or CT AP Appendicitis is a clinical diagnosisAppendicitis vs Mesenteric adenitis Appendicitis Mesenteric adenitis Age of onset 2-18 yrs <20 yrs Pain Central then moves to RIF Generalised Onset Sudden Gradual Prodrome None Preceded by a viral/bacterial infection Fever Yes Yes Associated Nausea and vomiting Nausea and vomiting symptoms Loss of aperitive Diarrhoea Unwell child Management Surgical ConservativeAppendicitis management: Mesenteric adenitis • Emergency hospital admission management: • Abx operative management – IV fluids, • condition- enlarged lymph nodes typically following viral infection • Laparoscopic appendicectomy • Painkillers only if requiredA 12 year old female presents with abdominal pain for the past few weeks. It’s central in nature and associated with a change in bowel habit. She is currently well but mum reports she had the flu recently. What’s the most likely diagnosis? 1. Menstrual pain 2. Ectopic pregnancy 3. Appendicitis 4. Mesenteric adenitis 5. ConstipationA 12 year old female presents with abdominal pain for the past few weeks. It’s central in nature and associated with a change in bowel habit. She is currently well but mum reports she had the flu recently. What’s the most likely diagnosis? 1. Menstrual pain 2. Ectopic pregnancy 3. Appendicitis 4. Mesenteric adenitis 5. ConstipationLimping ChildA 7 year old child presents with a limp. What are you thinking? •Safeguarding –NAI, bruising •Perthes disease •Transient synovitis •TraumaA 7 year old child presents with a limp. Key questions to ask in the history •History of trauma •SOCRATEs of the pain •Infective history •Associated symptomsFractures in Children •Children’s bones • Growth plates • More cancellous bone – spongy bone in the centre of long bones • More flexible but less strong ©Zero to Finals Fractures in Children Children more likely to have buckle fractures due to less strength against compression Children more likely to have greenstick fractures – one side break but the other side of the bone remains intact ©Zero to FinalsSalter Harris Fractures ©Zero to FinalsSalter Harris Fractures Type 1 – Straight across Type 2 – Above Type 3 – BeLow Type 4 – Through Type 5 – CRush ©Zero to FinalsWhat type of Salter Harris fracture is this?What type of Salter Harris fracture is this?What Type of Salter – Harris fracture is this?Fracture management • Always keep safeguarding in mind when children present with fractures. • St• Closed reduction via manipulation of the joint • Open reduction via surgery • Step 2 - stability to allow healing. Fix the bone in the correct position • External casts • K wires • Intramedullary wires • Intramedullary nails • Screws • Plate and screws Pain management Which of these medications cannot be used in children? 1. Paracetamol 2. Ibuprofen 3. Codeine 4. Morphine 5. Tramadol 6. Aspirin Pain management Which of these medications cannot be used in children? 1. Paracetamol 2. Ibuprofen 3. Codeine 4. Morphine 5. Tramadol 6. AspirinA 4 week old baby is developing well and develops perfuse projectile vomiting after feeds. He has been losing weight and the vomit is described as being non bilious. What is the most likely underlying pathology? 1. Duodenal atresia 2. Ileal atresia 3. Hypertrophy of the pyloric sphincter 4. Achalasia cardia 5. Intestinal malrotation Pyloric StenosisA 4 week old baby presents with vomiting. What would you want to ask mum?A 4 week old baby presents with vomiting. What would you want to ask mum? •Vom• when did it start? • Occurrence in relation to feeding • Contents of vomit • Feeding regime amount , how often, breast/bottle •Associated symptoms •Birth/antenatal history • Type of birth etc • Antenatal scans – any anomaliesPeadiatric vomiting differentialsA male infant born at term appears well following delivery. Six hours later, he is noted to have bilious vomiting. On examination, he seems well and his abdomen is soft and non tender . What is the best course of action 2. Undertake a test feedX Ray 3. Perform serial abdominal exams 4. Arrange an upper GI contrast study 5. Arrange urgent laparotomyA male infant born at term appears well following delivery. Six hours later, he is noted to have bilious vomiting. On examination, he seems well and his abdomen is soft and non tender . What is the best course of action 2. Undertake a test feedX Ray 3. Perform serial abdominal exams 4. Arrange an upper GI contrast study 5. Arrange urgent laparotomy Pyloric Stenosis Unknown aetiology - hypertrophy of the pyloric Diagnosis muscle resulting in gastric outlet obstruction - USS - wall thickness >4mm, length >17mm and diameter >15mm Male predominance 4:1 - NB if prem or neonatal then different cut offs Strong family history common Hypokalemic, hypochloremic metabolic alkalosis Presentation - Projectile, progressive non bilious vomiting Management - Typically 4-6 weeks after birth - Surgical intervention to divide the hypertrophic - Pathognomonic - palpable olive sized lump in muscle RUQ - Pyloromyotomy typically keyhole unless complicatedHerniasA 12 day old infant is brought into the emergency room as they have developed a right sided groin swelling. ● Antenatal history - anomaly scans, congenital abnormalities ● Unwell baby - eating/drinking, weeing/pooing/passing wind ● Temperatures, sweating ● Nausea and vomiting Examination ● Review the swelling - location, size, shape, connected to the testes vs separated ● Examination of external genitalia - male or female and whether phenotypically normal Neonates presenting with phenotypically female external genitalia and inguinal hernias - think could this be complete androgen insensitivity syndrome. - Need informed consent from parents when operating in this case as within the hernia could be undescended testesA 12 day old infant is brought into the ED with right sided groin swelling. On examination the testes are correctly located but it is evident that the child has a right sided inguinal hernia it is soft and easily reduced. What is the most appropriate management? 1. Surgery over the next few days 2. Reassure and discharge 3. Surgery at 1 year of age 4. Surgery once the child is 6 months old 5. Application of a hernia trussA 12 day old infant is brought into the ED with right sided groin swelling. On examination the testes are correctly located but it is evident that the child has a right sided inguinal hernia it is soft and easily reduced. What is the most appropriate management? 1. Surgery over the next few days 2. Reassure and discharge 3. Surgery at 1 year of age 4. Surgery once the child is 6 months old 5. Application of a hernia trussInguinal Hernia Congenital abnormality caused by persistence of the Complications patent processus vaginalis, a peritoneal tube along - Irreduciblity for long periods of time can lead to the path of testicular descent into the scrotum obstruction and strangulation Incidence: 10x more common in boys Management - Any girl with inguinal hernia should be checked - Elective repair on day case list for complete androgen insensitivity syndrome - If irreducible - need hernia reduction then delayed via karyotyping. repair once the swelling has settled Presentation - Repair = ligation of the patent processus - Intermittent swelling of the groin which may reach the scrotum Undescended T estes Testes which are unable to be brought down into the scrotum - Palpable vs non palpable Ectopic testes - palpable but located outside the line of normal descent. Typically in the superficial inguinal pouch or in the perineum Retractile testes - testes can be manipulated into the scrotum and remain there briefly Man-gemTesticular descent can naturally occur up to 1 years of age - After that surgical intervention, exploration of the inguinal canal with testicule places in the scrotum Non palpable - Laparoscopy to locate the testesComplete Androgen Insensitivity Syndrome Genetically Male 46 XY but develop phenotypically female All phenotypic females need karyotyping to check for CAIS. During week 7 of development masculinisation begins with a surge of testosterone and the Wolffian duct system Parents need informed consent when operating on dominates and the mullerian duct system regresses inguinal hernias in these patients as you will be removing their testes In CAIS this masculinisation does not occur: - External genitalia develops phenotypically female with a short vagina and no internal female organs - Internally testes develop CAIS is typically diagnosed at two stages 1. Neonatally with inguinal hernias - which are descending testes 2. Teenage years - no menarcheKey surgical presentations not covered: 1. Intussusception 2. GORD 3. Congenital heart diseaseFeedback Form: