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So it's not that many people to be fair. There's only like, yeah, six of us. It was, there was like four. Hello. Hello. Um Hope you guys can see me and hear me, um, and see the slides. Um But yeah, I hope you're all doing well. Tonight session is on pediatric surgery. Sounds quite niche, but there is a lot of hopefully decent questions that have a decent chance of coming up in your exams. Um So yeah, so there's just a few of us at the moment. So I'll just give it a minute or two just to see if we can get anyone else filtering in. Um, and then, yeah, and then we'll make a start. Anyone got any questions before we start feel fresh popping in the chart. Um, I've got a few people filtering in now. Good evening, everyone. Hope you're all having a nice time. Had a nice day. Um All right, I'll go through the first couple of slides and then, uh, and then people just join if people can join us to come along. So I think I recognize a few of the names from Tuesday session and last Thursday session. So it's the exact same concept if you've been into one of these sessions before, if you're new here. Um Then, yeah, it's just gonna be a session, hopefully for an hour, maybe a bit longer. But if you need to leave it an hour, that's completely fine. Um, 20 multiple choice questions all taken from past medicine. Um And we've tried picking them out to cover like the main themes. Um, the main high yield sort of things that can come up in your, in your MCQ exams. Um Once you show a question, I put a poll on the screen and you have either 60 seconds or 80 seconds depending how quick everyone else gets their responses in um to put your, put your vote in. Um And then we'll go through the answers and explain why. Um And if you've got any questions, please feel free to put them in the chat any time and we can go through them. Um If you don't have any questions, that's completely fine as well, right? So we'll make a start on the first question. Yeah. So I'll give you 80 seconds. You got 20 seconds, 20 seconds left. It's only a couple of votes so far. There we go. Time. So I was trying to catch you out with this question straight off the bat, but a lot of you've got the right answer so well done. Um So for this one, it's Mesenteric adenitis. Um So what, what that is so mesenteric adenitis is um inflamed lymph nodes, okay, that mimics the pain of appendicitis. Um So it's, it's um so the key thing here. So from the history, it sounds vaguely like it could be appendicitis, right? With young boy, a couple of days of abdominal pain, generalized, um systemically pretty well. Um But the key point of this, this is the key point of this question is the fact that it says he had experienced some cold symptoms one week ago. So, if they've had a viral illness, inflamed lymph nodes about a week later, and that's what can cause. That's what this is. Enteric. Adenitis is. So for appendicitis, um so can present exactly like this kind of vague abdo pain. But in this case, he's eating and drinking normally where as you'd expect him to be off his food and drink and the temperature's normal hair as well. Um for constipation. So it says no change in bowel habit. So unlikely to be that exact same reason for gastroenteritis, you'd expect vomiting and abdominal migraine. It's quite a niche thing. I've never really heard of it until recently. Um It's so very rare and it's just like a headache like migraine pain, but in your abdomen and it's normally associated with people that have a history of migraines. Um But you wouldn't diagnose it was like a first presentation anyway. Um So yeah, right. Next question. So, again, 60 seconds this time, 10 or 15 seconds, 15 seconds, four seconds, final chance. There we go. It's a bit of a mixed response to this for this question. Um Don't worry, majority if you got it though, but don't worry if not. So, this is Meckel's, I think it's pronounced Meckel's Meckel's diverticulum. Um So what that is, but uh mulching of mobile. Um So like diverticular diverticular disease, a diverticula osis in an old person, Meckel's diverticulum, similar ish in a young person uh in a, in a child, except it's a congenital thing. Okay. And it's the most common cause of painless massive pr bleeds in 1 to 2 year olds or those under two years old. Okay. And as you can see from here, it says in the question, stem bleeding from the back passage. So that's like a huge sort of red flag, but it's also a huge sign that it's this condition here. Um Now, if you know Meckel's diverticulum, you might have heard of the rule of twos. Um So that is that is present in 2% of the population, it's normally two inches long, the outpouching. Um it's 2 ft away from the ileocecal valve and um it's present in those that are under two years old. So that's sort of how you can just briefly remember how, what, what sort of condition it is. Um and what it affects um to go through the other ones. So again, appendicitis. So that is right, lower quadrant pain here, but you wouldn't expect the pr bleeding and you wouldn't expect the hemodynamic instability, intussusception. So there was a few of you got this one. So don't worry, there is another question on this later on. So we'll go over a bit more then. But normally it's a bit more severe pain for intussusception. Sometimes in the question stem, it can say the child brings their knees up to the, to the chest to alleviate pain. Um And a classic thing in the question stem, if it's late stage, then there's a red current jelly like store. Um which although there is bleeding here, it's not described as red current jelly like stool, black stool will go through that and a bit more detail later on. Um Puts jiggers polyp osis is a pretty rare thing. So you don't have to worry too much about it if you don't know what it is. Don't worry. Um It's a genetic condition and it's a condition where you're gonna start. If anyone that has it will get polyps all across the about. Okay. So it's a huge risk of colorectal cancer. Now, the thing to remember about it is if you do have this or something, if a patient has this, then they get freckles on the lips, palms and soles and that's how you recognize that condition. Um And a sequel volvulus is where the cecum sort of twists in on itself and blocks the bowel. So you'd expect abdominal distension here and a failure to pass stool or off layers and it doesn't mention either of these. Um So, yeah, hopefully that makes sense. Just let me know in the questions in the comments uh in the in the chat if you have any questions. Um But yeah, we'll move on to the next question, the 10 seconds final chance to get your guesses in. Um And yeah, I've seen you a message I said there should be a record and it should be available. Um We've got our emails on the end on the final slide. Um So you can just shoot me an email if you've not got it, but it should be available on, on the door. Um But yeah, that's the time. Um so well done to those that got it. I wasn't trying to trick you at this time. It was just appendicitis in this case. Um But hopefully, you can see that a lot of the things that we talked about from mesentery colonitis um and Meckel's diverticulum as common up here. So the central acute abdominal pain, okay. It normally starts off generalized and then it will after some more time, it then becomes specific to the right lyric fossa. Uh There's the fever that's present, okay. Uh And there's no history of recent illness. Um There's also leukocytes in the urine. So the rationale there is that, that describes um an infective cause to be honest, I don't think it's that important if it didn't tell you that it wouldn't really change what you put anyway. So the fact that it does tell you it is, uh, not that important, basically, in my opinion, anyway, um, constipation is one of the other things that you could put. So that wouldn't have explained the fever Meckel's diverticulum. So two things here. So one rule of twos, um, he's over two years old. So less likely to come at this age and the more important thing, there's an absence of rectal bleeding. Um So unlikely to be that Mesenteric adenitis as we talked about, there's no history of recent viral infection. So less likely to be that as well. And then pylon nephritis. So it could explain the fever, it could explain the pain and it could explain the leukocytes. So it's not a bad guess. However, with pyelonephritis, like with renal stands, it's more of a line, two groin pain that you would hope that they would put in the question stem and you'd expect urinary tract symptoms like dysuria or increased frequency. And on top of that, the, your analysis would show nitrites because if it just shows leukocytes, that doesn't mean it's a uti. Um So yeah. So hopefully that makes sense right next question. Mhm Yeah. 10 seconds left. 321, there we go. So almost everyone got this one. Uh Don't worry if you didn't, but um well done to those that did. Um So take the patient surgery immediately. That that's the correct answer here. Um So we'll go through it. So the reason why is the G M C Guidance, as it says here, the for people under 18 is that you can always provide treatment either to save their life or to prevent serious deterioration in their health without consent from anyone. If it's in their best interest to save their life or to prevent serious deterioration, then you do not need consent so you can do it. Um You can go go to fit straight away. So to be honest, even if the patient said I don't content to it. And even if the parents said I don't consent to it, you would still be able to take them to fear straight away because she's at risk of death really. Um If you're thinking it's perforated, um obviously, if they, if they didn't consent and the parents didn't consent, then you would just go straight to faith. It be that would be a bit more of a challenge, but you could in in theory. Um So keep trying the parents until the answer. I say urgent clinical need. So yeah, I hope no one would have thought that um get the school to consent to the school can't consent for a page for a child. It's only the child can consent all the parents or a legal guardian. Um consult safeguarding doctor. So it's a wise decision, especially as you're the f one is a wise decision to speak to who's ever in charge of safeguarding or generally to one more senior, but they can't consent for that child. They just be able to give you an opinion and their thoughts on there um and seek urgent court order again, they can't consent on the patient's behalf. They're just mainly giving you advice and clarification. Um So yeah, so hopefully that makes sense. Sure. Oh, we skipped a question. No, that's fine. That's fine. Ignore it says question five. It should be questioned for but yeah, 60 seconds. Yeah. Um I don't know if you've seen it fatter in the chat. But look, Mons just put that. Yeah. Yeah. Just put the video for the video link for the upper gi session if you wanted that 10 seconds left on this one. Have a guess. If not, don't worry. Right. Let's go through this one then soiled into those that got it. So ram stead pile or mild to me. I think that's how you pronounce it. Um So the reason that I've picked this question, the reason I put this question because it's a nice description of what pyloric stenosis is and how it presents. If you've already know what pyloric stenosis is, then that's great. If you don't, don't worry. And, but the classical, well, what it is first is the pylorus is a part of the stomach and it's the part, right? It's the most distal part, that sort of drains into the small bottle. And so like the name implies pyloric stenosis. It's a narrowing of that Pie Laurus. Um So it's slowing down the drainage from the stomach. So sort of the classical features of it in an M C Q or history. Um is vomiting after every feed. The fact that it's non bilious, there's no bile in it because the vomits coming from the stomach, it's not coming from the bowels. Um is projectile. That's a classic description of vomiting and pyloric stenosis. Um The fact that the the infant keeps wanting to feed afterwards just because he's hungry. Okay, there's no food going to going through his system is just being vomited up and an olive sized mass. Um in the right upper quadrant is a classical description as well. So there's loads of classical things in this question, stem a psa cushion splash. I hadn't heard of it for it before I came across this question. So don't worry about it, but just so, you know, if you, if you had this five week old infant and you just gently rocked him side to side and you had a stethoscope over his stomach, you could hear what that means is, you can hear the fluid sort of splashing from one side of the stomach to the other. Um So that's what that means. Um And then yeah, and then it shows the fact that he's had an ultrasound, which is the first line investigation for it. So when is the pyloromyotomy is just the classic, is the, is the first uh management for pyloric stenosis. And what it does is it just slightly splits the muscle and to allow that the Antrim to just open up, to give more space for food to pass through. So, a people through with a stoma don't worry about this, but it is the surgical management of Hirschprung's disease. You don't really even have to know that though. To be honest, it's just a case you want to, uh, endoscopic pylori extending is a good guess. Um, it's used in gastric outlet obstruction, but it's more common and gastric cancers. Um, and sort of older people. So you can imagine in a five week old baby, you don't want to put a stent in there because as they grow, that stent is going to be so small compared to the size of the Pylorus. Um, and then hydrostatic or air contrast enema. Um, that's used for the management of interception. Okay. Um, and a heller myotomy that might ring some bells. Um, but that's the surgical management about tackle Asia or likely. Yeah. Yeah. Chalasia, I think that's a pronounce it. Um But yeah, so that's just so, you know, in case that was ringing any bells. So hopefully that made sense. Next question. That was, yeah, 60 seconds problem for the colon check. It's about 15 seconds left, right. I mean, well, then it's a clean sweep everyone has put public harness that's voted in the poll so well done. So I try not to go for, it's too long. But if you, if you didn't know, um, what's going on here. So, firstly, what is development of displeasure of the hip? So I'm sure you probably know you've got in the hip, you've got the acetabulum which is like the cup and then the ball, which is like the head of the femur. Uh it just sits there together and it sort of allows for like the ball and socket joint. Um What's happening in developmental dysplasia of the hip is that this acetabulum or that the cup is flatter than it should be okay. So it means that it's not keeping head in place as easily. So it means it's easier for it to slightly slip out or sub locks or to completely come out and dislocate. Um So what you try to do, so most of these cases will just resolve by themselves. But what you try to do is try to keep the head um within the acetabulum. Um, so that the ligaments have time to strengthen and that will help keep it in place okay. So if it's under six weeks, then it should normally, you just leave it and it should normally resolved by six weeks, the age of the child after six weeks. Um, if it's not resolved, then that's when you give a public harness, okay. And you can give that up to about, I think, yeah, four or five months. And then at that point, if it's still got developmental dysplasia of the hip, then you do surgery. So that is what public harnesses just so, you know, so it just keeps the hips in that position. See you next question, right. A couple of seconds and, right. So, yes, well done. A lot of people got this one so well done for this. Um Yeah, I'm not gonna have a gastro shine X isis. I don't know how to pronounce. I'm sorry. Um But yeah, so the main, the main thing here, um is I hope that for the ones that didn't get, you were sort of between these first two options here. Um The reason that it wouldn't have seen someone's put congenital diaphragmatic hernia, the reason that it wouldn't be that, um because just the location of where, where this whole is. So the holes in the abdomen to the left of the umbilicus and going outside the body. Whereas if it's a diaphragmatic Carney, you'd be expecting sort of inside the inside the body, location of the hair. Um So it's probably easiest to first go through what the difference is between gas truck, gas structures and exam on follow feel should not affect these to, to explain. Um But basically they're both very similar, they're both out pouchings of the bowel, okay. But the difference between them is this one on the left and hopefully you can see my cursor pointing towards, um, has, is covered by the peritoneum that's got covering it comes out with. So it's protecting that bowel that's, um, inside the difference is here, there is no peritoneal peritoneum that's covering it. So it's just exposed to the air and that's what changes the management in this. Um, now, going back to the question stem the way that you normally work out which one it is between them is whether it says there's a protected by the peritoneum, whether it's got a cover, he doesn't say anything about that. So you can't work out between them on that logic. So the other way is a bit more niche, but another way to work out is where the, the whole actually is that it's coming out. So if it's coming out, so it says here a hole in the abdomen to the left of the umbilicus. So if it's lateral to the umbilicus, then it is gastric sh ESIs. Um If it's through the umbilicus itself, so through the belly button, then it's this and it's on fallacies or otherwise known as Exxon phallus, something like that. Um So yeah, so hopefully that makes sense. Um Yeah, just put any questions in the chart. It's not, there's another question on this coming up though. Just put the pole in the Chaps here comes up. It's about 15 seconds to get your boating. Final couple of seconds. If I want to have a final guess coming in. Yeah, everyone seems to be getting this one so well done. So this one is into deception, um, into susceptive in, um, so I'm considered, I'm guessing by the fact that all of you got it, that, you know what it is and there's a few people that didn't vote. So I'm going to assume that you don't know what it is, which is fine. So, just to quickly run through what it is is if you imagine you, you've got your bowel that just runs as a, as a tube. Now, what happens is if some of that tube starts folding back over itself, so it kind of like this. So if you imagine the bowels should just normally run straight as a tube, it's folded back within itself and it cuts off the blood supply to part of it. And that's what causes sort of the extreme pain and the vomiting. Um, the main thing from here though, um, in terms of how to get the diagnosis is so it is a cost called history, but it's from the X ray and the ultrasound that you can really get the diagnosis. Um, it's like I said, you've got the pain with vomiting, which is classical, but you've got this sausage shaped mass on the ultrasound and that is sort of the classical feature of it is that sausage shaped mass, um, on the ultrasound, you can see a target sign or otherwise known as a donut sign, okay. Um And that's, again, that's another feature um, of interception. Um, red current jelly you might, you might have seen in your notes from before. You might have heard, remember me saying earlier on that that is a sign of interception, but it's a late stage sign of it. Okay. So if you don't see it, it doesn't mean that it's not interception. Michael's diverticular, like I said before would expect to be out bleeding pyloric stenosis. So presents similarly with the vomiting. Um It can also have the target or donuts sign on ultrasound. Um But it's normally in, people are younger than six months. Um You wouldn't expect someone to get 18 months and then just start with pyloric stenosis, okay. Um Judy know the treasure. So treasure is just like a breakdown. It's just a cut basically within the duodenum. Um So you, so you have to loose ends basically. Um And that again presents a few hours after birth. So you would not expect it 18 months down the line. And the the classical feature of that is on abdominal X ray, you get a double bubble sign because you've got the two loose ends, you get double bubble um and incarcerated hernia. So yeah, it could maybe, yeah, unlikely. And there's no soft lump indicating that there's a hernia and incarcerated hernias are normally painless. Um There's pain here him in Children. Um So yeah, there's pain here. So Yeah, next question very even split with the answers here. 15 seconds, 15 seconds left to get you get your choice in. Right. So a few of the majority of you got it, but it's quite an even, even split. Um, so it's a staged closing with completion at 6 to 12 months. Um, so the first thing to work out is what, what is it? So we're even took in on, on phallus eel or gastro, gastro anxious. Um It's either one of those to basically because you've got bowel protruding out of the abdomen um in a neon need. Um So the way, like I said before, the way to work out is even where it's coming out of the abdomen, is it from the umbilicus or lateral to it or does it say what if it's covered in peritoneal or not? So, because it is covered imperative the end, then it's the one fallacy. Well, so hopefully you all got that from the question. Now, the question is then, what is the management of this? Um So, so 11 option that you would have is obviously to go in straight away and just from an operation, just put all those bowel contents back into the abdomen and stitch it up and leave it there. Now, there's two issues with that in Indiana or any very, very young child. The first one is that if you push it all back in, you're gonna put so much. So much pressure in the abdomen, they can push up onto the diaphragm and push up into the lungs and you can get all sorts of respiratory complications from that, which is can be quite deadly. Okay. Um So you don't want to do it from that point of view. Um And secondly, um uh oh yeah, yeah. Secondly, sorry, I just had to go because I forgot that. Secondly, because you're putting the content into the abdomen. Um, if there's too much that goes in there because it's only such a small child, it can be difficult to actually stitch you back up again, which as I'm sure you can imagine is a much worse position to be in with an open bowel, an open abdomen than if you just had the bowel contents protected outside the abdomen. So that's why you do it as a staged closure. So every so often that you keep going back in and you just keep putting a bit more bowel and at a time, but you're not under a huge time constraint because it's covered by peritoneum. So there's less of a risk of an infection going on there. Um If it was gas truck construction icis um where there's no peritoneum covering it. Um Then that's a different story. Okay. Even though it's the sort of same risks, it's just a huge risk of catching an infection if you just leave it out. So you have to immediately covered in cling film and then you want to go to fit as soon as possible. Um, so that would be for Gastro Doc just this and for the older one, um, then it's stage closure. Um, so hopefully that makes sense. Fine. Question number 10, I've just seen your question. The chat. Is it Charmaine? Hopefully that answered your question if it doesn't just put another question in the chat and I'll answer it again if that's helpful. 10 seconds left for this one. Right. Again. The majority of you. Perfect. Yeah. Majority of you got this one so well done. Watch and wait. Ok. Um, so there's a lot of ones, especially with kids, just in general, there's a lot of things where it's, if they're this old, then you can do this. If they're that this old, then do that. Um, for umbilical hernias. Okay. They're very common in young Children and they often resolved by themselves. Um, so as long as there's no other complications going on, as long as no strangulated, it's not strangulated hernia where bowels trapped, then you can just leave it okay. And by three, by three years old, it should really just fixed by itself. If by three years old, an umbilical hernia is still present, then you refer it on to get fixed surgically. Okay. So there's a few questions of other types of hernias and the management slightly different coming up next. But for umbilical hernias, you can leave it till three years old at which point you can do surgery afterwards. And that's just because there's no, in this case here unlikely to cause strangulation and it's likely just to resolve by itself. Okay. Next question. 10 seconds. There we go. Anyone want to put a final guess in, find someone's done it. Yeah. Well done. It's more the person that voted right there and got it so well done. It's review at three months. Um, for this one again, depends how old the child is and whether it's a single undescended testy or bilateral undescended testicle. Um, but I've got a table coming up, so don't worry too much about it. Um But if we go through it, so review at three months for someone that's got a single, like a unilateral undescended testicle, wait till three months, then refer on for surgery is the MCQ classical answer. Now, the one complication with that is the actual guidance from nights has changed. Um So it's slightly different now. So it should be that you see them at 6 to 8 weeks old. If they still have a unilateral um, undescended testicle, then you see them again at 4 to 5 months and if they still have it at that point, then you refer it onto surgery to get fixed or get seen to buy six months old. Okay. So that is the actual proper guidance. But on a lot of MCQ question banks, it'll still say review of three months. So if you've got your exams, your final exams, sort of now, then three months, if you're in year, two year free, then don't worry too much about this one because it'll probably change immediate referral for surgery. So that is what you do if it was bilateral undescended testes and it's only unilateral in this sense review at 12 months. So it's too late here because if you leave them without surgically fixing that and it increases your risk of certain conditions. Now, that is one of the questions coming up. I think it is the next question. So I won't say I won't reveal the answers just yet, but yes, you don't leave. You wouldn't review it at 12 months because it's too late. Um arrange an ultrasound you could do, but it's not going to change the management. Okay. You're still gonna need to review it at three months according to M C Q s and send it off as a referral for surgery if it was still under, send it at that point and refer to urology within four weeks. So that could be valid considering this is the baby's 6 to 8 weeks old, another four weeks would take us to three months. The thing is here is you would only refer to urology once you know they need surgery. See, you've got to see them first at three months as like a GP or as a pediatrician. You got to see them at three months and then if they need the surgery, then you refer a month to urology. Okay. So hopefully that made sense. So yeah, as promised, this is the question five seconds. Everyone seems to have got it well burn. Um Yeah. So for this one testicular torsion in. Okay. So if you leave an understanding testes past three months, if it's unilateral, then you start massively increase in the risk of testicular testicular torsion in testicular cancer and infertility. Um Yeah, those are the three ones. So testicular torsion in testicular cancer and infertility. Um Those are the three big complications that come up. Um If you don't correct an undescended testes. Um Yeah, to secure it. Ocean testicular cancer, infertility. Right. Next question. Yeah. 15 seconds. Oh, 10 seconds. Now, final see, final two seconds. Anyone for the last guess in. Yeah, a few people have got it right at the end. So for this one again, different type of hernia. Um, it's a surgical reduction within two weeks here. Um So because it's a lateral to the pubic tubercle, um, he's describing an inguinal, oh, I'll show you that in a second, showing an inguinal hernia um in this child. And the difference here is for an inguinal hernia in a child, you need immediate surgery. Oh, well, not immediate but surgery pretty quickly because the risk is that become such a high risk that that had type of hernia become strangulated. Okay. So, inguinal hernias, you need to see them quite quickly. Um, whereas an umbilical hernia you're not as worried about. Okay. Um, so specifically, so it has here on the rationale, I'll read it off the screen. I never learned this. Um, so I wouldn't expect, I don't think any of you really need to learn it, but if you were wanting to know how long you need to, you can leave it before you operate for. There's a, there's a thing called the rule of sixes and two's okay. So if they're under six weeks old, then you have to operate within two days. So you just go down one steps or weeks, two days. If they're under six months old, then you operate within two weeks. So months down two weeks and then if they're under 60 years old, then you, you go and you do it in two months, okay. Um The general management you can see on this table so this table you can take a screenshot of it or we'll send the slides afterwards. Um But it's just a nice summary of how quick you need to do things for the different conditions that we spoke about. So if, if I take your eyes down to the bottom here, the inguinal hernia, which we just had a question on there. Generally, if you, if you just want to remember this sort of easier way to think about inguinal hernia. If they're under a one year old, it's urgent referral. Um And if it's older than one, then it's a bit more routine. So I'll repeat it again. So, if it's under, if they're under six weeks old, then it's within two days, if they're under six months old and it's within two weeks and if they're under six years old, six year old, then it's within two months. Um, so, yeah, but you don't have to worry too much about that. So I hope that that table makes sense for you next question. Okay. Just really quickly guys, I'm just gonna put the feedback in for you guys. We've got about 10 minutes. We we will be running just a bit late but not too late. Um I'm just gonna quickly pop the feedback for me and please fill it in and then we'll send in the slides and the recording um after you fill it in. All right, thanks. Um Yeah, perfect. Let me just put the time I'm going and I'll answer your question. Look. So, yes. So the hernia was lateral to the pubic tubercle which it normally is medial for an inguinal inguinal one. I think it's different for Children now that I think that's the, that's the difference that it's different from adults to Children. 10 seconds, a few people have gone early and got it. Alright. Times up, only a few people vote this time to maybe this is a bit of a difficult question. It's one of those if you know it, you know it. If you don't, you don't. But hopefully you'll know it now. So it's high pospech Aidas. Um, is the answer for this one? Um, so circumcisions are done on the NHS, except if it's for religious or cultural reasons, in which case, it's done privately. And that's why they're coming for a referral in this case. And the main thing that you have to rule out like this question is asking for, if it's a newborn, you have to make sure they don't have this condition hypospadias. And the reason for that is, is because if they do, then you, you can often take the foreskin and you use it as part of the operation to repair the defect. So if you don't know what high postpaid ius is, it's, it's a condition here where the urethra comes out at different points of um of along the penis or along different different parts of the track, basically. Um So it doesn't come out like eight times like it would just come out once it just be somewhere along this track. Um So that's why you need to make sure they've not got this condition because you use the foreskin to repair that defect. Okay. Now, the other conditions here, every single one of these is an indicate can be an indication for having a circumcision. Okay. Um So fimosis is when you've just got like a tight foreskin, para fimosis is when the foreskin gets trapped behind the glands of the penis. Um balanitis is like uh yeah, it's like an itch and um swelling of the glands of the penis. So, if it's recurrent, then you can get rid of the foreskin to help with that. And the colonitis, scerotic. A public hands is a complication of littering sclerosis. So you get plaques um over the foreskin and again, that causes tightening and is in the neck and is an indication for circumcision. Um So, yeah, so hopefully that made sense. So hopefully, you know, enough, if it does come up in your exams, question 15. So 60 seconds, 20 seconds. Anyone wants the last minute, guess, don't worry, we'll leave it there. Um Right. So the two people that the people that voted got this one um so early surgical treatment. Um So the, the question is what, what's going on here? Um So I joined this within the 1st 24 hours is pathological, meaning something's wrong. Then if you joined us from day to up to day 14, that's considered normal. Anything, any jaundice that's prolonged. So that's on day 14 or longer after that point. That is pathological again. And as you can see, have born four weeks ago, still jaundiced. Something's going wrong here. So then it comes down to what, what the causes of joined this or prolonged jaundice in a newborn. So I got a list here. So I thought we run through them. So breast milk, jaundice is a common one. And that's just babies that breastfeed. But you can see here, reluctant to take on breastfeeding. So unlikely to be that hyperthyroidism is a cause. But again, it says, you know, it's a firm enlarged liver. So it's not really going to explain that one. So that's less likely prematurity. Um If your premature, that's a cause for it, but it doesn't say anything about have been premature. So it's less likely to be that as well. Um If you've got Alpha One Antitrypsin disorder that can give you joined this. Um But you can see here, it says serum alpha one levels are normal. Um and the heel prick test as well was negative. So that rules out cystic fibrosis. Now, another big common, well, big cause of um neonatal jaundice is biliary atresia. Um So you might have remembered when I said before about Judean or Theresia is when the duodenum is just split into two. Um It's kind of similar like that for biliary atresia. So it's when there's either an obstruction or a blockage or the bile can't travel through the ducts um as easily and that's within the liver and also outside the liver as well. Okay. Um So we'll go through it. If you, if you operate and you help restore that bio flow from an early point. And that's because if you don't restore bio flow, if you keep it building, then you, you will eventually need a liver transplant. Um So you obviously want to avoid that if you can, I have the antibiotics so you could use it post operatively. You may have a sending Collinge itis after the operation that you could use it for, but you wouldn't use it to treat biliary. Atresia, optimizing feeds. So generally pretty good advice, you wanna optimize feeds, especially if she's not been eating much, but it's not going to be the definitive management. It would form part of the management though, of cystic fibrosis in case that was ringing anyone, any bells. Um Also the oxy colic acid, you can give that and it's often given after the operation. But again, it's not definitive management, an infusion of one of the trips in her levels were normal. Um So you wouldn't give that question. 16. Uh huh. 20 seconds, 10 seconds, few people again out here, right. Let's go through it. So, what's going on here now? This is, so the answer is rectal washouts or barrel bowel irrigation. Um But this describes Hirschprung's disease. It's a classical picture of it. Um So if you don't know what Hirschprung's disease is, it's when you've got a section of the bowel, any innovation to it, like the nervous system that runs in the bowel just isn't working, it just isn't uh isn't the ganglion cells as the histology shows. So, if you don't have that innovation of the bowel in a section, then you don't have any Paracelsus and you're just not moving food along in your bowels. Um Now this the reason why I say this is a classical picture of it. Okay. One of the huge risk factors if it ever comes up in your exam questions, it will be in a child with Down Syndrome Down Syndrome, which is the case here. Um, it'll say that they've been constipated and the abdomen is distended. Okay. So constipated, there's just no food moving along the system. Um Meaning that you constipated and obviously you're gonna be distended because it's not moving along, it's just building up. And then the biopsy will show an absence of ganglion cells because like I said, the, the nervous system just isn't there um in that section. So then it comes down to the management of what, what you've got to do. So, rectal washout barrel Powell irrigation. So the definitive treatment is surgery, you just need to chop that section out that's not working. Um But before you do that, you need to wash it out, make sure the bowels clean because otherwise, if you just leave the feces in there, then you're gonna, it's like a breeding ground for infection. Okay. Um Immediate surgery to surgery is the definitive thing. But if you don't wash it out, then it's just a huge chance of getting an infection. Um So you've got to wash it out. First. Conservative management, the condition, there's an absence of nerve cells there. It's not going to improve by itself, high dose steroids, they're not going to improve it, they're not going to bring the nerves back. Um And lax, if again, would not be definitive isn't really advised. I can understand why someone might put it um to get rid of bowel contents, but depending on what um laxative you give, it might not work anyway. Just remember the first line, first line management is bowel irrigation and then surgery fine. So these next questions. So I unfortunately have to leave. But Luckman is going to take over for the last three questions that all on pediatric orthopedics. So um it's probably worth sticking around for if that sounds interesting to you. Um But yeah, I'll say goodbye. So hopefully you've enjoyed it, please for land the feedback at least just pop it in the feedback forms. Um So yeah. Okay. Thank Josh. Thanks for doing the 1st 16 questions. I'll just top it off with the last four. Okay. All right guys. So thank you so much for staying up till this point. I'll just send the feedback form in again if any of you need to leave, but we've just got four questions left and they're all on pediatric fractures. Okay. Um If you can remember your pediatric fractures, there's the Salt Salter Harris type fractures and there's five types, there's the buckle fractures and green stick fractures and these are basically the four main ones. Okay. Um So Sharmeen was asking what was going on in question 15. So question 15. Uh was let me just check um, before that, let me share my screen first because you guys need to see this. Um Okay. All right. Give me a minute. That's the one chair. Okay. All right. So you guys can see that. Ok. Sorry, Charmaine you were asking about question 15. Let me just quickly go back to question 15. Okay. All right, I'll answer at the end. Um, so we'll just go through. Oh, no, I actually really. Okay. Never mind. Just, just try and uh, do this question if you, if you haven't actually seen the answer, I, I think I definitely gave away the answer but um, just, just give it a go. Yeah, someone, someone definitely saw the answer for this one, but it gets 60 seconds anyway. Oh, we'll make, we'll make this quick. We'll make this 30 seconds. All right. I've got 10 more seconds. Should be nice and quick. Okay. Let's send it there. Right. So the answer for this one is a buckle fracture. Um, some of you chose Greenstick Fracture, which is also a pediatric fracture, but it's not the case in this case. And the reason it's a pediatric, uh, the reason it's a buckle fracture is you see the way the fracture occurs, it's like it collapses on itself. So it buckles like this and you see a nice line in between without any actual visible displacement between the bones. So if you see it like squashed in and then the sites pushing out like that more often than not, it's a buckle fracture. Okay. So it's like it's crushing on itself and the reason this is the case, you know, kids, they're kind of young, their bones are kind of soft. So if they fall with a lot of force pushing into the bone, that's when you get buckle fractures often happens in the wrist. Okay. All right. Let's move on to the next one. Okay. Again, really quick. 30 seconds for this one. Mhm. Alright. 15 seconds, 15 seconds left. All right. 321. Okay. The answer for this one is a greenstick fracture. Um And you can sort of imagine why if you see on the left image, that's actually the image from the front of the fracture, which is why it kind of looks like it's a full transverse fracture. But when you look at it from the side as in the right image or the image on the right, you can see that it's sort of like the reason it's called the green stick fractures. If you can imagine like a piece of vegetable that's kind of green and it's not really brittle and you try to bend it, you know, only, only like a small part of it breaks. It's like a, it's like I can't give an example of a carrot cause and carrot breaks, but imagine like a young leaf or something. And you and you try to bend it, it doesn't break completely, it bends slightly. So that's why it's called a Greenstick fracture. And buckle fractures tend to be because of pressure pressing on the bones like this. But greenstick green stick fractures tend to be a bending force like that. So you get green stick fractures from bending forces and buckle fractures from pressure forces. Okay. All right. Well done. Let's move on question 19 again, really quick. 30 seconds. Yeah. This one might be a tough one if you, if you don't know the ones, but it's okay. Just have a guess. All right. 10 more seconds. Any guesses, a good guess. All right, let's move on. Uh The answer is type two. All right. So it was between two or three. Um And you know, the Salter Harris classification is usually for um fractures that involve the growth plate or fractures that are around the growth plate essentially. Okay. And this is the classification, this is a nice sort of pneumonic we can use um to sort of see to sort of remember what each type refers to. So salter ask for separated growth plates. So the growth plate separates and that's type one A or two is above the growth plates. So that's where the diagnosis is uh is affected. So that's the case in this one. So the fracture of the distal radius involving the growth plate and the distal portion of the diagnosis. So, if you if you remember the bone, the long bone. So the middle of the bone is the diagnosis. The growth plate is the mata fossas and the distal part of the bone is the epithets iss. So it's so it for a long bone, it's epithets Ismet if Asus dia facist in the shaft, mata fossas and then epithets iss okay. So just just to get your bearings and then for type two, it's the dia facist this that's affected. Okay. So, distal portion of the diagnosis. So that's why it's type two. And you can see it from a above the growth plate and then three which is equivalent to L is below the growth plates. So only the epiphany sis is affected in that one. Um for tea or fourth on salter Harris, it's through the growth plates. So it's the metaphysis, the epiphysis and diathesis. All three are affected. Okay. And for the very last one is a range of the growth plates. So the growth plate is basically just crushed and it's gone. Essentially again, this is a lot, you can go through the slides at the very end, but this is just a nice way to remember things. Okay. Hopefully that makes sense. All right. Oh Here's another one, another example of type one or type two or type two and type four or type five. Okay. Now, last question, this is another Salter Harris question. I remember what I said from the last one. Try your best. How do you tell the difference between type one and type five? So I think if I'm not mistaken, there's a bigger gap in type one between um the epiphany Asus and the and the diagnosis, I think. Um and for type two, it's sort of for type five, it's sort of like crushed, like you literally, you can even probably see fragments of the metaphysis or the growth plate. So I think that's how you can tell the difference. But I will reconfirm with you while I wait for you guys to answer this question. All right, keep them answers coming. Got 10 more seconds. All right, well done, well done. People have been listening. So it is type three fractured because if you remember salter. So S one A two L3. So L is lower part of the growth plate. So if you can see really closely here, the you can see the growth plate. Uh let me just use my okay. So you can see the growth plate here and you can see the fracture here. So this is below L below the growth plates. So L is three. So this is type three Salter Harris. Well done, well done. That is right. So coming back to change your, your question between the difference of type one and type five. So a lot of them actually say you, you may not even be able to tell on an X ray, but type one fractures are least likely to impair bone growth and type five is most likely to disturb bone growth because the the growth plate is basically destroyed. There's nothing else going the bone but in a type one fracture, the growth plate is still there. So that's one difference. I can tell, I'm not sure if you can actually tell the difference on an X ray though even then they won't ask you the difference between type one and type 51 MCQ. So, so don't worry about that. Okay. I'm going to send the feedback link again. Okay. Thank you so much for staying. We've tried keeping it to time this time were, were much quicker this time we're finished before 8 15. Next session we've got is colorectal. So it's a lot of important topics, colorectal, cancer, screening, rectal bleeding, uh IBD. Uh and it's gonna be a good session. Lot of relevant stuff, especially for exams and it's going to be next Tuesday seven and eight PM. Um Please bring your friends along is a nice chill session. I but can you explain the extra again if possible? Of course, I can. Um So uh if you can see from the X ray. So this is the patient's uh this is the patient's right metatarsophalangeal okay joint right here. And then this is one of the tarsal. So you can see from the bone here. So this is the entire bone. Okay, the middle part of the bone here is the diagnosis. This is the epiphany, sis the ends of the bone. This is the metaphysis, which is the growth plate. And you can see here the growth plate right here. The metaphysis, you can see the line here. That's the growth plate right there. Okay. This is the diagnosis. Okay is the middle of the bone and this is the epiphany this. So this is the end of the bone and you can see a small fracture here, okay. And the fracture is in the epithets iss. So it's lower than the growth plate and from the previous ones where we mentioned. So see if you can see l below the growth plate is a type three fracture which is why the answer was a type three salted Harris fracture that makes sense, Brian. So for example, so for example, if, if there was a fracture going all the way up, it would have gone through the entire thing. So if there was a fracture here and there was a fracture here, it it would have gone through the diagnosis and the epiphysis. So through T so S A L T, so that's four. So that's salter Harris type four. Okay. Does that make sense? Does that make sense? Hopefully, that makes sense. Um But yeah, thank you so much for attending. Um I hope hopefully that was helpful. Hopefully, that made sense. Um Please ask any questions, you know, I had to relearn all of this essentially for it to make sense. And I always hated pediatric uh sort of bone fractures. It can come up in exams. But again, i it's not super common. It's just, I think it's just good to know, but it's not super common. I'll stick around for a few more minutes. If you guys have any questions regarding final year or the slides in general or if you have any other questions, you can just email us at the very end. Um As I mentioned before, please join us our next session next Tuesday on Colorectal. There'll be a good one. I'll be, I'll be, I'll be doing that teaching and Josh will be helping me. Um But yeah, thanks so much guys. Enjoy your evening. I'll stay for a few minutes in case you guys have any, any other questions. Oh, and feeling the feedback forms. Thanks. Oh, uh Fatima, if you're still there, um The size of the recording is kind of large. So I don't think I'll be able to send the recording to you. I can send the, I can send the slides. Um Oh, yes, yes. I mean, I'll get back to question 15. I can send the slides to you um and just retry the link and see if it works. Sometimes it works better on Google Chrome. I find that doing it on Safari doesn't work very well. Okay. I mean, let's go to question 15. I kind of forgot what question 15 was because I think Josh did fix with you. Uh okay. Oh, yes. Right. So uh first of all, Sharmeen, do you, do you understand sort of what's going on in, in question? 15? So a baby girl born four weeks ago had persistent John this since um since 48 hours after birth. So she noticed that she's reluctant to take breastfeeding and her urine appears quite dark. Okay. So she's got, so she's got conjugated Billy Ruben. Okay. She's got obstructive jaundice because of the urine that is dark. She's jaundiced. And um you also notice an enlarged liver. So that means there's an obstruction somewhere. Okay. What's going on in this baby girl is that she's got something called biliary atresia. And what that is essentially is if you remember from the upper gi or if you were there for the upper gi session, your gallbladder is basically connected to the common bile duct by your cystic duct and then it forms the common bile duct to going down. So some part of the biliary tree did not form properly and it tends to be some like a congenital cause, okay. Um So it could be multiple parts of the biliary tree that's gone. It could be the common bile duct that's gone. It could be the hepatic duct that's gone. But basically, as long as a part of the common bile duct is informed properly, bio cannot drain, okay. And if bio can't drain, that's what's causing the jaundice and the conjugated Billy Ruben. Because you remember how, if, if you remember how Billy Ruben is excreted, it has to be excreted from the GI system. Okay. That's why there's a connection into the GI system. But if there's no connection into the GI system, that's where you get jaundice. Okay. So this patient has got biliary atresia essentially, even her blood has showed conjugated hyperbilirubinemia. Okay. The reason they're asking about serum alpha one antitrypsin levels in this case is because they're asking about sort of like um because alpha alpha one antitrypsin levels, low or low levels of it can cause liver cirrhosis. So that's what they're testing for. And that is in the case in this case. And just because of the congenital defect, that's why you need early surgical treatment. Okay. Um Because they essentially just need to restore bio flow, they just need to reconnect or reopen the lumen in the biliary tree essentially. Um because the longer you wait, the more damage it does and then you kind of don't want that in a newborn, newborn baby. Does that make sense remain? Hopefully, that makes sense? Right. Anyway, thank you so much for sticking around. Um Hopefully, that was helpful again. Do join us for our next session on colorectal. It'll be good and have a nice dinner guys. Any questions you can just email, email me on Josh. All right. All right. See you