Paediatric Surgery 2nd Semester

Question 1

What are the indications for the surgical treatment of varicocele?

Answer 1

Varicocele is a common condition, characterized by abnormal dilatation of testicular veins in the pampiniform plexus caused by venous reflux. It happens more often on the left side due to the 90-degree angle to the left renal vein. Symptoms associated with varicocele include a testicular condition affecting fertility and associated with small testis. Surgical treatment is indicated in the following cases:
1. Infertility: Varicocele is a significant factor affecting fertility in men. Studies have shown that varicocelectomy improves sperm count, motility, and morphology, leading to an increase in pregnancy rates.
2. Pain: In cases where the varicocele is associated with chronic testicular pain, surgical treatment is necessary.
3. Testicular atrophy: If the varicocele is associated with testicular atrophy, surgery is indicated to prevent further damage to the testis.
4. Young age: Varicocele in adolescent males can lead to testicular atrophy and infertility, and early surgical treatment is recommended.
5. Failure of conservative management: In cases where conservative management fails to relieve symptoms, surgical intervention is indicated.
Surgical treatment for varicocele involves ligation of the spermatic vessel, which is either performed through open surgery or laparoscopically. The procedure aims to remove the affected veins and restore normal blood flow. The procedure is performed under local anesthesia, and patients usually go home the same day. Possible complications include bleeding, infection, hydrocele, and recurrence.

Question 2

What are the indications for the surgical treatment of phimosis?

Answer 2

Phimosis is a condition in which the foreskin is unable to retract over the glans of the penis, causing pain, difficulty with urination, and possible risk of infection. In some cases, surgery may be indicated to correct this condition. The indications for surgical treatment of phimosis include:
1. Non-responsiveness to conservative treatments: The first line of treatment for phimosis is conservative management, such as topical steroid creams. If these treatments fail to resolve the condition, surgical intervention may be necessary.
2. Recurrent infections: Phimosis can increase the risk of recurrent infections, which may require surgical treatment to prevent further complications.
3. Difficulty with urination: Severe phimosis can cause difficulty with urination, leading to urinary tract infections, and the surgical correction can alleviate this symptom.
4. Balanitis xerotica obliterans: This is a condition that can cause scarring of the foreskin, making it difficult or impossible to retract. Surgery may be indicated in these cases to prevent further scarring and improve function.
5. Aesthetic concerns: In some cases, parents or patients may request surgical treatment for phimosis for cosmetic reasons.
It is important to note that circumcision is not the only surgical option for treating phimosis. Partial or radical circumcision can also be performed, depending on the severity of the condition and the patient’s age.

Question 3

Undescended testes in a newborn - is the postnatal descent possible? At what maximal age should testes be in the scrotum (physiologically and surgically)?

Answer 3

The incidence of cryptorchidism is approximately 1-5% in full-term newborns and 1-45% in preterm newborns. It is important to address this condition promptly as it may cause complications such as testicular torsion, infertility, and testicular cancer.
It is important to distinguish between palpable and non-palpable undescended testes. Palpable undescended testes are located in the inguinal canal, ectopic or retractile, and can be fixed into the scrotum with a relatively simple surgical procedure. Non-palpable undescended testes, on the other hand, may require further examination under anesthesia and possible laparoscopy to identify their location. In some cases, elongation of vessels may be required before the testicle can be placed in the correct position.
It is recommended that surgery be performed before the age of 12-18 months at the latest to maximize the chances of successful descent and minimize the risk of complications. In newborns with undescended testes on both sides or signs of abnormal sex development, urgent endocrinological consultation and possibly genetic evaluation are required. Bilateral non-palpable testes require observation of abnormalities in genital development.

• Treatment
  ○ Hormonal treatment NOT recommended
  ○ Surgery
  § Re-examination under anaesthesia
  § Palpable -> Inguinal canal place and fix in scrotum
  § Non-palpable -> Laparoscopy to identify location, elongation of vessels might be required, then second procedure to place testicle in correct position
  Non-palpable -> Blind endings, finish exploration as testicle not developed

Question 4

Nonpalpable testis - diagnostic work up.

Answer 4

Non-palpable testis can be classified into three categories: intra-abdominal, inguinal, and absent. The diagnostic workup for non-palpable testis includes a thorough history and physical examination followed by laboratory investigations and imaging studies.

History and Physical Examination:
* Detailed medical and family history.
* Comprehensive physical examination, including genital examination, to locate testis and assess for hernias or other abnormalities.

Laboratory Investigations:
* Serum creatinine, K, and PTH levels to assess renal function and any electrolyte imbalances.
* CBC to assess for any signs of infection or inflammation.
* Urine dipstick to evaluate for any urinary tract infections.

Imaging Studies:
* Kidney-bladder ultrasound (KBUS) to assess for the presence and location of testis, evaluate the size, masses, dilations, and artery blood flow, and identify any associated anomalies.
* MRI and CT scans may be useful in detecting the location of the testis in cases where the KBUS is inconclusive. * Radionuclide scans can also be performed to evaluate the blood flow to the testis.

Dynamic Studies:
* Voiding cystourethrography (VCUG) can be done to assess for the presence of vesicoureteral reflux (VUR) or other abnormalities.
* Hormonal stimulation test with human chorionic gonadotropin (hCG) can be done to identify the presence of testicular tissue.

Question 5

List 5 indications for pediatric nephrectomy.

Answer 5

Pediatric nephrectomy is a surgical procedure to remove one or both kidneys in children due to various medical conditions. Here are five indications for pediatric nephrectomy:
1. Wilms Tumor: Wilms tumor is the most common type of kidney cancer in children and accounts for approximately 5% of all pediatric malignancies. Nephrectomy is often necessary as a part of the treatment protocol.
2. Multicystic Dysplastic Kidney (MCDK): MCDK is a congenital anomaly of the kidney characterized by non-functioning cystic kidney tissue. The kidney may not function and may cause hypertension or other complications, necessitating a nephrectomy.
3. Renal Cell Carcinoma: Renal cell carcinoma is a rare type of kidney cancer that occurs in children. Nephrectomy may be indicated if the tumor is large, growing, or aggressive.
4. Chronic Pyelonephritis: Chronic pyelonephritis is a long-standing inflammation of the kidney caused by recurrent urinary tract infections. If the kidney is severely damaged and non-functional, nephrectomy may be necessary.
5. Congenital Anomalies: Congenital anomalies such as renal agenesis, horseshoe kidney, and ectopic kidney may require nephrectomy in case of complications such as obstruction, infection, or hypertension

Question 6

List at least 2 indications for nephron sparing surgery (NSS) in children.

Answer 6

Nephron sparing surgery (NSS) is a surgical technique that removes a portion of the kidney while preserving the healthy nephrons. Here are five indications for NSS in children:

Bilateral renal tumors: When a child has a tumor in both kidneys, NSS is the preferred approach to minimize the risk of renal failure.

Solitary kidney: In children with a solitary functioning kidney, NSS is used to preserve renal function.

Hereditary predisposition to renal tumors: Children with hereditary predisposition to renal tumors, such as von Hippel-Lindau disease or Birt-Hogg-Dubé syndrome, may benefit from NSS to prevent future renal impairment.

Small renal tumors: For small renal tumors (<4 cm), NSS is preferred to avoid the need for radical nephrectomy and preserve renal function.

Renal masses in patients with impaired renal function: In children with preexisting renal impairment, NSS may be indicated to remove a renal mass while minimizing the risk of further renal injury.

Question 7

You’re GP. A mother with a one year old boy comes to your office, saying the boy’s grandmother recognised phimosis in her grandchild. What do You think about it? How would You conduct a visit?

Answer 7

As a GP, if a mother with a one-year-old boy comes to my office stating that the boy’s grandmother recognized phimosis in her grandchild, I would conduct a thorough medical assessment to confirm the diagnosis and decide on the best course of action. The following steps would be taken during the visit:
1. Medical history: Take a detailed medical history of the child, including previous illnesses, family history of any genital abnormalities, and medication use.
2. Physical examination: Conduct a physical examination of the child to confirm the diagnosis of phimosis. During the examination, I would check if the foreskin can be fully retracted over the glans penis.
3. Distinguish from normal agglutination: Determine if the phimosis is primary, caused by incomplete separation of the foreskin from the glans, or secondary, caused by scarring from previous inflammation or infection. I would also look for any signs of paraphimosis, a condition where the foreskin becomes trapped behind the glans penis and cannot be reduced.
4. Treatment options: If the diagnosis of phimosis is confirmed, I would discuss treatment options with the parents. For primary phimosis, topical corticosteroid ointment is the first-line treatment, applied twice daily, which has over 90% success rate. However, if the condition does not improve after this treatment, circumcision may be necessary. For secondary phimosis, surgical treatment in the form of circumcision is usually recommended.
5. Follow-up: After treatment, regular follow-up is necessary to ensure that the child is healing properly, and there are no complications. I would recommend that the child returns for a follow-up visit after two weeks of initiating treatment.

Question 8

You’re a paediatric surgeon on call. The neonatologist calls You about the newborn that was born today with hydroneprhrosis recognised on the prenatal ultrasound examination. What would you ask the doctor? What would be your next steps?

Answer 8

As a pediatric surgeon, when receiving a call from a neonatologist regarding a newborn with hydronephrosis recognized on prenatal ultrasound examination, it is important to ask the following questions to determine the appropriate next steps:
1. Was the hydronephrosis unilateral (ureter obstruction, submedula part) or bilateral?
2. What is the degree of hydronephrosis?
3. Has a VCUG been performed to assess for VUR?
4. Has a renal scan been performed to assess for differential function of the kidneys?
5. Is the baby showing any signs of obstruction such as decreased urine output or abdominal distension?
Based on the answers received, the appropriate next steps would be:
1. If the hydronephrosis is mild and unilateral, close observation with follow-up ultrasounds may be appropriate. If the hydronephrosis is severe or bilateral, further investigation is needed.
2. A VCUG should be performed to assess for VUR.
3. A renal scan should be performed to assess for differential function of the kidneys.
4. If the baby is showing signs of obstruction, immediate intervention may be necessary to relieve the obstruction and prevent renal damage.
In general, the approach to a newborn with hydronephrosis recognized on prenatal ultrasound examination will depend on the degree of hydronephrosis, presence of VUR, differential function of the kidneys, and presence of obstruction. Early detection and management of these issues can help prevent long-term renal damage and improve outcomes for the child.

VCUG stands for voiding cystourethrogram, which is a radiographic test used to evaluate the function of the bladder and urethra during voiding (urination) and to detect vesicoureteral reflux (VUR).
Vesicoureteral reflux is a condition where urine flows back from the bladder up into the ureters and potentially into the kidneys, which can cause urinary tract infections, kidney damage and renal failure. It is a common anomaly in children, and often detected when evaluating a newborn with hydronephrosis.

Question 9

The role of paediatric surgeon in neurogenic bladder treatment.

Answer 9

Neurogenic bladder is a condition in children where they are unable to control their bladder due to neurological difficulties caused by a spinal cord or general nervous system lesion. The muscle around the bladder and sphincter do not work together due to damage, leading to incontinence, urinary tract infections (UTIs), vesicoureteral reflux (VUR), and renal scarring that may require transplantation after renal failure. The condition is often associated with spinal bifida and is classified into overactive sphincter and overactive bladder. As a result, a paediatric surgeon plays a critical role in the treatment of neurogenic bladder.

Diagnostic Methods:
* Serum creatinine, K, PTH, CBC
* Urine dipstick
* Blood pressure
* KBUS (Kidney bladder ultrasound) = Size, masses, dilations, artery blood flow, stones (lithiasis)
* VCUG
* CT
* MR
* Radionuclide scans
* Dynamic studies

Management of Neurogenic bladder:
* Immediate catheterization -> Empty bladder to prevent bladder distension and further damage
* Antimuscarinic/anticholinergic medication to reduce detrusor overactivity
* Alpha-adrenergic antagonists may facilitate emptying in children with neurogenic bladder
* Botulinum toxin A injection: In neurogenic bladders that are refractory to anticholinergics
* Surgery -> Vesicostomy (opening in the abdomen to drain), bladder augmentation (bladder too small in these patients -> Cut small intestine, cut bladder, suture part of the intestine to the bladder to increase volume)

Question 10

Conservative and surgical treatment of urolithiasis in children.

Answer 10

Urolithiasis, or the presence of stones in the ureters, is a relatively common condition in children, with a prevalence of around 1-2%. In most cases, conservative management with pain management, hydration, and anti-inflammatory medication is sufficient. However, some children require surgical intervention. In this response, we will discuss the diagnostic methods for urolithiasis and the conservative and surgical treatment options.

Conservative Treatment of Urolithiasis in Children:
* Pain management with anti-inflammatory medication and hydration
* Medical expulsive therapy with alpha-blockers to facilitate the passage of stones
* Dietary modifications to prevent the formation of stones, such as reducing sodium intake and increasing fluid intake
* Regular monitoring with imaging and laboratory tests to track the size and location of stones and assess kidney function

Surgical Treatment of Urolithiasis in Children:
* Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break up stones into smaller pieces which can then be passed naturally
* Ureteroscopy with laser lithotripsy is a minimally invasive procedure that uses a small scope to visualize and remove stones in the ureters
* Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure that involves making a small incision in the back to access the kidney and remove stones
* Open surgery may be required in some cases if the stones are too large or located in a difficult-to-reach area

Question 11

Acute scrotum - clinical symptoms, possible causes. Indications for prompt surgery

Answer 11

Acute scrotum is a medical emergency that requires immediate attention and prompt surgery. It can be caused by testicular torsion, which is the twisting of the spermatic cord, leading to closure of the testicular vessels. This can result in discolouration, pain, and the appearance of a blue dot on the skin. Other causes of acute scrotum include trauma, epididymitis, and orchitis. In this response, we will discuss the clinical symptoms of acute scrotum, its possible causes, and the indications for prompt surgery.

Clinical Symptoms:
* Discolouration: The scrotum may appear red, blue or black.
* Pain: Severe pain in the scrotum or groin area is common.
* Blue dot sign: This refers to a blue discoloration of the skin overlying the torsion site, visible through the scrotal skin.
* Swelling: The affected testicle may be swollen and tender to the touch.
* Nausea and vomiting: These symptoms may occur due to severe pain.

Possible Causes:
* Testicular torsion: The most common cause of acute scrotum in children and adolescents.
* Varicocele: An abnormal dilation of the testicular veins in the pampiniform plexus caused by venous reflux
* Trauma: Blunt trauma to the testicles or scrotum can cause swelling and pain.
* Epididymitis: Inflammation of the epididymis, which is a structure located at the back of the testicle.
* Orchitis: Inflammation of the testicle due to infection, usually viral.

Indications for prompt surgery:
* Testicular torsion: This requires immediate surgical intervention to prevent testicular damage.
* Suspected testicular torsion: If the diagnosis is suspected, surgery should be performed without delay to prevent testicular damage.
* Failure of conservative management: If conservative management (such as pain relief and antibiotics) fails to improve the symptoms, surgery should be performed.
* Unexplained scrotal pain: If the cause of the pain is unclear, surgery may be necessary to diagnose and treat the underlying condition.

In conclusion, acute scrotum is a medical emergency that requires prompt surgical intervention in cases of testicular torsion, suspected torsion, failure of conservative management, and unexplained scrotal pain.

Question 12

What are the indications for hospitalization of a child with a burn wound?

Answer 12

Hospitalization for a child with a burn wound is indicated based on the severity of the injury and other factors that increase the risk of complications. The following are indications for hospitalization:

Moderate or severe injury: Hospitalization is necessary for children with moderate to severe burns, as these injuries require specialized treatment and monitoring by medical professionals.

Circumferential burn: A circumferential burn is when the burn affects an entire body part, such as the arm or leg. These burns can cause constriction under the burnt skin, leading to blockage of blood flow, and require hospitalization for close monitoring and potential surgical intervention.

Burn injury in an area prone to shock: Burns to areas such as the face, neck, groin, and crotch can lead to airway obstruction and shock. Hypovolemic due to loss of skin, pain, then septic shock due to skin flora colonisation. Hospitalization is required for close monitoring of respiratory and cardiovascular function.

Intentional injury suspicion: If there is suspicion of intentional injury, the child should be hospitalized for further evaluation and protection from further harm.

Electrical, chemical, or inhaled burns: These types of burns can cause extensive damage and require specialized treatment and monitoring. Hospitalization is necessary for proper management and prevention of complications.

Question 13

What are the First Aid procedures in a child with a burn wound

Answer 13

Burns are a common injury in children and require prompt first aid to minimize tissue damage, infection risk, and pain. The following are the first aid procedures for a child with a burn wound:

Assessment: Quickly assess the situation, remove the hot source, and remove the child's clothing to stop the burning process. It's essential to assess the extent and severity of the burn injury, including any signs of airway obstruction.

Pain management: Burns can be extremely painful, and pain management is crucial in first aid. Administer pain relief medication, such as paracetamol or ibuprofen, if available.

Fluids: Burns can cause fluid loss, leading to dehydration, so providing fluids is essential. Offer the child water or an oral rehydration solution, if possible, to replenish fluids lost through the skin.

Cooling: Applying cool water to the burn wound is the most effective first aid method. Run cool water over the burned area for 10 to 20 minutes, ensuring that the water is not too cold to cause hypothermia.

The first aid procedures should be performed immediately to reduce tissue damage, prevent infection and pain relief. The type of treatment needed after first aid will depend on the extent and severity of the burn. In some cases, the child may require hospitalization for further treatment, and it’s essential to assess the child for any signs of airway obstruction or shock.

Question 14

What is the initial hospital burns management (at the Emergency Department / at admission to the ward)?

Answer 14

Initial management of burns in children is crucial in preventing further tissue damage, managing pain, and avoiding complications. The first goal is to assess the severity of the injury and provide first aid measures. The following steps are taken in managing burn wounds:

Assessment and First Aid: The first step in managing burns is to remove the child from the source of the burn and assess the severity of the injury. This involves removing clothing, cooling the affected area with room temperature water or a cool compress, and providing pain relief.

Fluid Resuscitation: After assessment, intravenous fluid resuscitation is started, as burns can lead to dehydration and shock. The amount of fluid given is calculated based on the percentage of the body surface area (TBSA) affected and the weight of the child.

Pain Management: Pain management is crucial in burn management, as burns can be very painful. Adequate pain relief should be provided to ensure the child's comfort.

Monitoring Vital Signs: Vital signs should be monitored frequently, including heart rate, respiratory rate, blood pressure, and oxygen saturation.

Wound Care: After initial assessment and management, the wound is treated according to the extent and depth of the burn. Burns can be treated conservatively with dressing, open wound treatment or surgical treatment such as early burned tissue excision. In the emergency department, wounds are cleansed and debrided. Dressings are applied, and tetanus immunization is given if necessary.

Infection Control: Burn wounds are susceptible to infection, and prophylactic antibiotics should be administered in cases of moderate to severe burns. Wound swabs are taken for culture and sensitivity.

Question 15

What are the typical signs of non-accidental injuries in burn cases?

Answer 15

Non-accidental injuries or child abuse should always be considered in cases of burn injuries in children. It is essential to recognize the typical signs of non-accidental injuries to take appropriate action to protect the child. Some of the typical signs of non-accidental injuries in burn cases include:

Burns of different ages or stages of healing, suggesting that the injury was not accidental
Symmetrically shaped burns, suggesting that they were inflicted intentionally
Burns in unusual patterns or shapes, such as a handprint or a cigarette burn
Burns that are inconsistent with the child's developmental stage, such as burns on the soles of the feet of a child who is not yet walking
Delay in seeking medical attention for the burn injury
Inconsistent history or lack of explanation for the burn injury
Previous or ongoing physical abuse or neglect

It is crucial to consider non-accidental injuries in cases of burn injuries in children and report any suspicion of child abuse to the appropriate authorities. Early recognition and intervention can prevent further harm to the child and provide the necessary support to protect them from further abuse or neglect.

Question 16

You’re a doctor in the ambulance. You are called to the 10-year old child, who got burnt by a flame from the barbeque in the face. What do You do? What are you afraid of and how do you react?

Answer 16

As a doctor in the ambulance, the first step in responding to the 10-year-old child who got burnt by a flame from the barbeque in the face is to ensure that their airways are clear. After making sure that the airways are clear, I would assess the child for signs of burn shock, including tachycardia, decreased respiratory rate, tachypnea, pallor, cyanosis, oliguria, and disorientation.

In managing the burn wound, it is crucial to determine the extent of the burn injury. Using the palm method, I would estimate the percentage of the child’s total body surface area (TBSA) affected by the burn. Afterward, I would calculate the amount of IV fluid required for initial management of the burn disease. The formula to calculate the amount of IV fluid needed is 4 ml saline * weight kg * % TBSA = mL given in the first 24 hours, with half given in the first 8 hours and the remaining half in the next 16 hours.

I would also assess the burn wound and initiate pain management and fluid resuscitation to prevent further injury. It is essential to manage the burn wound effectively to prevent complications such as scarring, contractures, respiratory complications, and psychological and emotional issues.

Question 17

Burn- local or whole body disease? The problem of burn disease

Answer 17

Burns are a complex problem that can have a significant impact on a child’s physical and psychological well-being. Burns are considered a whole-body disease due to the systemic effects they can cause, including fluid and electrolyte imbalances, immune system suppression, and organ damage. The extent and severity of the burn determine the degree of systemic involvement, which requires careful assessment and management.

Assessment of the burn area in a child is crucial to determine the extent of the injury and the amount of IV fluid needed for initial management. The palm method is used to estimate the percentage of the body surface area that is burnt. It involves comparing the size of the burn to the size of the palm, with each palm equating to approximately 1% of the body surface area. For example, a burn that covers the entire back and buttocks would be estimated at around 18% TBSA.

Initial management of burn disease includes pain management, fluid resuscitation, and renal catheterization to monitor urine output. IV fluid replacement is based on the size and location of the burn and the patient’s weight. The Parkland formula is commonly used to calculate the amount of IV fluid required in the first 24 hours after the burn. It recommends giving 4ml of saline per kilogram of body weight per percentage of total body surface area burned. The first half of the total volume should be given in the first 8 hours, and the second half in the next 16 hours.

The long-term effects of burns can be significant, and the management of complications requires a multidisciplinary approach. Some of the common long-term effects of burns include scarring and disfigurement, contractures, infection, respiratory complications, and psychological and emotional issues. Scar management techniques such as silicone gel sheets, pressure garments, and scar massage can help reduce the severity of scarring. Contractures can be treated with physical therapy and splinting, and in severe cases, surgery may be necessary. Preventive measures such as proper wound care, antibiotics, and immunizations can help reduce the risk of infection. Close monitoring of respiratory function and early intervention are essential for preventing respiratory complications. Psychological support and counseling can help address the emotional and psychological issues that often accompany burn injuries.

Question 18

How do you assess the burn area in a child and how do you assess the amount of IV fluid needed for initial management of burn disease?

Answer 18

Assessing the burn area in a child is an important step in determining the severity of the injury and guiding the initial management of burn disease. The following methods are commonly used for assessing the burn area:

Palm method: The palm method is a quick and easy way to estimate the percentage of body surface area (TBSA) affected by the burn. The child's palm, excluding the fingers, is roughly 1% of their TBSA. The estimated percentage is then used to determine the amount of IV fluids needed.

Lund and Browder chart: The Lund and Browder chart is a more accurate method for assessing the TBSA affected by the burn, as it takes into account the varying proportions of the body surface area in children of different ages.

The amount of IV fluid needed for initial management of burn disease is calculated based on the estimated TBSA affected by the burn. The Parkland formula is commonly used to calculate the amount of fluid required:

4ml saline * weight kg * % TBSA = mL given in first 24h

The calculated amount is divided into two equal portions, with the first half given in the first 8 hours, and the second half given in the next 16 hours.

It is important to note that these methods are not perfect and can only provide estimates of the burn area and fluid needs. Ongoing assessment and adjustment of fluid administration are necessary to ensure adequate hydration and prevent complications such as hypovolemia, shock, and renal failure.

Question 19

10-year-old child drunk unknown caustic substance and vomited multiple times. What should not be done? What’s surgical management? What can we encounter? Are there differences between acids and bases impact?

Answer 19

When a child ingests a caustic substance, it can lead to serious and potentially life-threatening injuries. Here is what should and should not be done in this situation, as well as the potential surgical management and complications that may occur:

What should not be done:

Do not induce vomiting, as this can cause further damage to the esophagus and increase the risk of aspiration into the lungs.
Do not attempt to neutralize the substance, as this can result in a chemical reaction and further injury.

Surgical management:

Endoscopy can be used to visualize the extent of the injury and determine the appropriate treatment.
In some cases, surgery may be necessary to repair damage to the esophagus or other structures.

Potential complications:

Esophageal stricture or perforation
Respiratory distress
Shock
Sepsis

Differences between acids and bases impact:

Acids tend to cause coagulative necrosis, which can result in a more localized injury.
Bases tend to cause liquefactive necrosis, which can result in a more extensive injury.

Question 20

Long-term effects of burns - complications, management.

Answer 20

Burns can result in long-term complications that require ongoing management to minimize the impact on a child’s physical, emotional, and psychological well-being. Some of the most common long-term complications of burns, as well as their management strategies, are discussed below:

1. Scarring and Disfigurement: Burns can often result in scarring and disfigurement, which can have a significant psychological impact on children and adolescents. Scars can also limit the range of motion of joints and cause itching, pain, and sensitivity. Scar management techniques such as silicone gel sheets, pressure garments, and scar massage can help reduce the severity of scarring. In some cases, surgical interventions like skin grafting or laser therapy may be necessary.
2. Contractures: Contractures occur when burned skin and underlying tissues become tight and inflexible, leading to restricted joint mobility and range of motion. Contractures can be treated with physical therapy and splinting, and in severe cases, surgery may be necessary to release the contracted tissues.
3. Infection: Burn wounds are highly susceptible to infection, which can lead to serious complications such as sepsis. Preventive measures such as proper wound care, antibiotics, and immunizations can help reduce the risk of infection.
4. Respiratory Complications: Burns can cause damage to the respiratory system, leading to airway obstruction, bronchitis, and pneumonia. Close monitoring of respiratory function and early intervention are essential for preventing complications.
5. Psychological and Emotional Issues: Children and adolescents who have suffered from burns may experience a range of psychological and emotional issues, including anxiety, depression, and post-traumatic stress disorder. Psychological support and counseling can help address these issues and improve the child's overall well-being.

Question 21

What are the indications for hospitalization of the child with head trauma?

Answer 21

Head trauma is a common presentation in pediatric emergency departments. It can range from minor to life-threatening injuries. Indications for hospitalization of a child with head trauma include:
1. Skull fractures: Children with skull fractures should be admitted to the hospital for observation and neurosurgical consultation.
2. Cushing’s triad: This is a sign of increased intracranial pressure, and it consists of high systolic blood pressure, low pulse, and low respiration. Children who exhibit Cushing’s triad should be hospitalized and monitored closely.
3. Pupil dilation: If a child has dilated pupils following head trauma, this can indicate increased intracranial pressure and requires immediate medical attention.
4. Cerebrospinal fluid leaking out of ear or nose: This is a sign of a basal skull fracture and requires hospitalization for further observation and treatment.
Management of a child with head trauma includes rapid assessment by a neurosurgical consult, CT or ultrasound, observation, and prevention of hypoxia. Intubation and hyperventilation may be necessary, and neurosurgical treatment may be required depending on the CT scan findings. Follow-up CT scans and neurological examinations are necessary to monitor the child’s progress.

Question 22

What are the symptoms of the Child Abuse Syndrome?

Answer 22

Child abuse syndrome, also known as non-accidental trauma, is a serious and devastating condition that can affect children of all ages. It is important for healthcare providers to be aware of the symptoms of child abuse syndrome in order to properly identify and report cases.
The symptoms of child abuse syndrome can vary depending on the type and severity of abuse, but some common signs include:
* Bruising, especially in unusual locations (e.g. cheeks, neck, ears, buttocks)
* Burns, particularly in patterns (e.g. cigarette burns, immersion burns)
* Fractures or other injuries that are inconsistent with the explanation given by the caregiver
* Failure to thrive or malnourishment
* Delayed development or intellectual impairment
* Unexplained changes in behavior, such as aggression or withdrawal
* Sexual abuse may manifest in different ways, including genital or anal trauma, sexually transmitted infections, or inappropriate sexual behaviors for the child’s age
* Neglect may result in poor hygiene, lack of medical care, or unsafe living conditions
It is important to note that these symptoms do not always indicate abuse, and other factors may be responsible for a child’s injuries or behaviors. However, healthcare providers must be vigilant and follow appropriate protocols to investigate and report suspected cases of child abuse.
If a healthcare provider suspects child abuse, they should:
* Document the findings in detail, including photographs and medical records
* Report the suspicion of abuse to the appropriate authorities, such as child protective services or law enforcement
* Provide necessary medical treatment and supportive care to the child
Offer resources and support for the child and their family, including counseling services and social work referrals

Question 23

First aid and physical examination in long bone fracture

Answer 23

First Aid:
* Provide reassurance to the child and caregiver to decrease anxiety.
* Immobilize the affected limb using a splint or sling to prevent further movement.
* Ice application is effective in reducing pain and swelling but should not be applied directly to the skin.
* Elevate the affected limb above the level of the heart to decrease swelling.
* Analgesics such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain relief.
Physical Examination:
* Before attempting any physical examination, obtain a detailed history of the mechanism of injury and the onset of symptoms.
* Inspect and palpate the affected limb, looking for any deformity, swelling, or tenderness.
* Assess the neurovascular status of the affected limb by checking for pulse, capillary refill time, and sensation.
* Evaluate the range of motion and stability of the affected limb, but avoid excessive manipulation as this can cause pain and further damage.
* Obtain radiographic imaging (X-rays) to confirm the diagnosis and determine the extent of the fracture.
If the fracture is compound or suspected of being so, cover the wound with sterile dressing without any pressure.

Question 24

Radial head subluxation - what is the typical age and mechanism of the injury? How to reduce it?

Answer 24

Radial head subluxation, also known as nursemaid’s elbow, is a common injury in young children, typically between the ages of 1-4 years old. The mechanism of injury usually involves a sudden, forceful pull or traction on the child’s outstretched arm, such as when a parent pulls the child up by one arm or when the child falls on an outstretched hand.
The symptoms of radial head subluxation include sudden onset of pain and loss of function of the affected arm. The child may hold the arm in a flexed position and avoid using it altogether. On physical examination, the elbow joint will be tender and swollen, and there may be a noticeable subluxation of the radial head.
The treatment of radial head subluxation involves reduction, or putting the bone back in place. This is a simple procedure that can be done at the bedside. The following steps are typically followed:
1. Have the child lie down on their back.
2. Gently flex the elbow and supinate the forearm, which means turning the palm of the hand up.
3. Apply gentle axial traction to the elbow, pulling the arm in a straight line.
4. With the elbow still flexed, rapidly pronate the forearm, which means turning the palm of the hand down. This motion will often result in an audible pop as the radial head moves back into place.
5. Verify that the child can move the affected arm without pain or discomfort.

Question 25

The most common localization of bone fracture in children?

Answer 25

The most frequent sites of bone fractures in children are the clavicle, humerus, and femur. In most cases, fractures in children do not require surgery, but proper immobilization is important to allow for proper healing. Greenstick fractures, where the bone bends but does not break completely, are also common in children. When evaluating a child with a bone fracture, it is important to rule out any associated injuries. For example, in a supracondylar fracture of the humerus, the brachial artery may be damaged, so it is important to check the pulse and capillary refill time to assess circulation to the hand. In addition, when evaluating a child with a suspected bone fracture, healthcare providers must rule out child abuse syndrome, as some fractures may be caused by non-accidental trauma. In terms of management, fractures in children usually do not require surgery, but proper immobilization is important to allow for proper healing. Soft braces or slings can be used instead of plaster casting. In some cases, such as with nursemaid's elbow, gentle reduction techniques can be used to correct the injury.

Question 26

What do you have to rule out during work up of a child with the supracondylar fracture of the humerus?

Answer 26

Supracondylar fractures of the humerus are common injuries in children, and it is important to perform a thorough workup to ensure that there are no associated injuries or complications. The following are important factors to consider during the workup of a child with a supracondylar fracture of the humerus: 1. Neurovascular status: Supracondylar fractures can result in damage to the brachial artery, and it is important to check the child's pulse and capillary refill time to rule out arterial damage. If there is any suspicion of arterial injury, an urgent surgical intervention may be required. 2. Associated fractures: Fractures to other bones or joints may also be present and need to be ruled out. An X-ray of the elbow and forearm may be necessary to detect any additional fractures. 3. Soft tissue injuries: A supracondylar fracture can also cause soft tissue injuries such as compartment syndrome, which can be a medical emergency if not addressed promptly. It is important to check for any signs of swelling or bruising and monitor for changes. 4. Assessment of fracture type: Supracondylar fractures can be classified as type I, II, or III based on the degree of displacement. Type III fractures require immediate surgical intervention to ensure proper alignment and healing. Pain management: Pain management is crucial in children with supracondylar fractures. Appropriate pain control can be achieved with nonsteroidal anti-inflammatory drugs, acetaminophen, and/or opioids.

Question 27

You are a paediatrician in the province. A panicked mother with a 2 month old infant tells you, the baby fell down from her laps on the floor during feeding. What do you do?

Answer 27

As a paediatrician, the first priority when a panicked mother presents with a 2-month-old infant who has fallen down from her laps on the floor during feeding is to assess the infant's condition for any signs of head trauma, spinal trauma or other injuries. Here are the steps to take: 1. Perform a thorough physical examination to rule out any signs of injury, including: ○ Check for skull fractures ○ Look for any signs of bleeding or bruising ○ Check for any dislocation or fractures in the limbs ○ Examine the spine for any damage ○ Check for any injuries to the chest or abdomen 2. Observe the infant for any signs of distress or pain, including: ○ Consolability ○ Level of consciousness ○ Crying patterns ○ Breathing difficulties ○ Changes in vital signs, such as blood pressure, heart rate, and respiratory rate 3. If there are any signs of head trauma, spinal trauma or other injuries, refer the infant to a specialist for further evaluation and management. Educate the mother on the importance of close observation and monitoring of the infant for any changes in behavior, signs of distress, or other symptoms that may indicate the need for further evaluation or treatment.

Question 28

You’re a paediatric surgeon on call. You get the call from the ER telling they have a 5-year old child hit by the swing in the abdomen. There is a lot of free fluid in the abdominal cavity on US. What would you suspect? What are your further steps?

Answer 28

As a paediatric surgeon, in the scenario presented, my first suspicion would be that the child may have suffered from an abdominal organ rupture, such as a spleen, liver or kidney rupture, as a result of the impact from the swing. It is crucial to act quickly and take the necessary steps to identify and address any potential injuries to prevent further complications and ensure the child's well-being. The next steps I would take include performing an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) assessment and conducting a focused assessment with sonography for trauma (FAST) and CT scan to determine the extent of the injuries. These diagnostic tools can help to identify any specific injuries, such as organ rupture or bleeding, and the appropriate surgical intervention required. During the FAST examination (exam involves looking for fluid in four areas: the right upper quadrant, left upper quadrant, pelvis, and pericardium), I would look for any signs of free fluids, such as blood, intestinal content, or urine, in the abdominal cavity using ultrasound. If the FAST examination detects unstable vital signs or free fluids, immediate surgical intervention is necessary. In some cases, laparoscopy may be required to detect any internal injuries that may not have been detected by the initial scans. It is important to note that abdominal trauma in children can be complex and require specialized care. Therefore, the child should be admitted to a hospital with a specialized pediatric trauma center with a multidisciplinary team including pediatric surgeons, anesthesiologists, and critical care specialists who are trained to provide optimal care for pediatric trauma patients.

Question 29

As a ED doctor you admit 4-year-old bitten in arm and hand by a dog. What’s your management? What should you notice during anamnesis? What to do (and what should not be done) with a long bleeding wound.

Answer 29

First, it is important to perform a thorough anamnesis to assess the severity of the bite and identify any potential complications or risks. This includes obtaining information about the dog's vaccination status, whether the dog is known to have rabies or other diseases, and the details of the circumstances surrounding the attack. In terms of management, the following steps should be taken: * Control any bleeding by applying direct pressure to the wound with a clean cloth or bandage. Do not use a tourniquet or attempt to suck out the venom. * Clean the wound thoroughly with soap and water, and apply an antibiotic ointment to help prevent infection. * If the wound is deep or jagged, consider suturing or stapling the wound to help promote healing and prevent scarring. * Administer a tetanus shot if the child's tetanus status is unknown or if it has been more than five years since their last tetanus shot. * Consider administering prophylactic antibiotics to help prevent infection. * Observe the child for any signs of infection or other complications, and schedule a follow-up appointment to monitor the healing process. It is important to note that if the wound is long and bleeding heavily, it is not recommended to use a tourniquet or to attempt to cauterize the wound, as these measures can further damage the tissue and increase the risk of infection. Instead, apply direct pressure to the wound and seek medical attention as soon as possible.

Question 30

Management of viper-bitten child. What should be done, what can be expected?

Answer 30

Management: * Call for medical assistance immediately if a child is bitten by a viper. * Restrict movement of the affected limb to prevent the spread of venom. * Try to identify the snake, if possible, as this will help with determining the type of venom and treatment. * Administer first aid, such as cleaning the wound and immobilizing the limb, if possible. * Administer an antivenom serum to neutralize the venom. * Treat the symptoms, such as swelling and pain, with medication. * Observe the child for any adverse reactions or anaphylaxis from the antivenom. * Provide supportive care, such as fluid and electrolyte replacement, if necessary. What to expect: * Viper bites can cause significant swelling, pain, and tissue damage. * The child may experience symptoms such as nausea, vomiting, sweating, and rapid heartbeat. * The severity of symptoms depends on the type of snake and the amount of venom injected. With prompt and appropriate treatment, most children recover fully from a viper bite.

Question 31

What are the most common ovarian lesions and what are the indications for their surgical treatment?

Answer 31

In paediatric patients, ovarian lesions are relatively uncommon but can present a diagnostic challenge for clinicians. The most common ovarian lesions in children include simple cysts, dermoid cysts, and germ cell tumors. The indications for surgical treatment of these lesions depend on various factors, including the size, location, and type of lesion, as well as the patient's age and overall health. Simple cysts are the most common type of ovarian lesion in children and are usually discovered incidentally during imaging studies performed for unrelated reasons. Most simple cysts are small and asymptomatic, and do not require surgical intervention. However, if the cyst is large, causing pain or other symptoms, or if it persists over time, surgical excision may be necessary to prevent complications such as torsion, rupture, or hemorrhage. The indications for surgical treatment of ovarian lesions in children include: - Torsion or acute abdomen - Pain or other symptoms such as bloating or abdominal distension - Persistence or enlargement of the lesion over time - Suspicion of malignancy based on imaging or other diagnostic tests

Question 32

What are the rules of a well done biopsy?

Answer 32

1. Proper patient preparation: Before the biopsy, the patient should be informed about the procedure, its potential risks and benefits, and what to expect during and after the biopsy. The patient's medical history and any medications they are taking should also be reviewed to ensure that they are appropriate for the biopsy. 2. Appropriate selection of biopsy site: The biopsy site should be carefully chosen to ensure that the tissue sample is representative of the area of interest. The site should be easily accessible, preferably in an area with good blood supply, and not near any vital structures, vessels, or nerves. 3. Proper biopsy technique: The biopsy should be performed using aseptic technique, with appropriate local or general anesthesia, as needed. The biopsy instrument should be carefully selected based on the size and location of the lesion, and the tissue sample should be obtained with minimal trauma to the surrounding tissue. 4. Handling and processing of the tissue sample: The tissue sample should be carefully handled and processed to minimize any damage or contamination. It should be labeled appropriately and transported to the pathology lab in a timely manner to ensure accurate diagnosis. Communication of biopsy results: The biopsy results should be communicated to the patient and other relevant healthcare providers in a clear and timely manner. The results should be interpreted in the context of the patient's medical history and other diagnostic tests, and appropriate treatment should be initiated as needed.

Question 33

Nephroblastoma - typical age and symptoms?

Answer 33

Nephroblastoma, also known as Wilms tumor, is a common type of kidney cancer that primarily affects children. The typical age for nephroblastoma is between 2 and 5 years, with 90% of cases diagnosed before the age of 10 years. The symptoms of nephroblastoma can vary depending on the size and location of the tumor, but some common signs and symptoms include: * Palpable mass: A mass or swelling in the abdomen or flank area may be one of the first signs of nephroblastoma. * Abdominal pain: Pain or discomfort in the abdomen may be present, especially if the tumor is large or pressing on other organs. * Hematuria: Blood in the urine may be present, although this is less common. * Ileus and constipation: Tumors in the kidney may cause ileus or obstruction, leading to constipation, abdominal distension and pain. It is important to note that many children with nephroblastoma may not have any symptoms at all, and the tumor is often discovered during a routine check-up or imaging study for another reason. Diagnosis of nephroblastoma is made through imaging studies, such as an ultrasound or CT scan, and confirmed with a biopsy. Treatment of nephroblastoma typically involves a combination of surgery, chemotherapy, and radiation therapy. The specific treatment plan will depend on the stage and location of the tumor, as well as the child's age and overall health.

Question 34

Nephroblastoma - general treatment rules in Europe.

Answer 34

Nephroblastoma, also known as Wilms tumor, is a common type of kidney cancer that primarily affects children between the ages of 2 and 5 years. The general treatment rules for nephroblastoma in Europe include a multi-modal approach, consisting of surgery, chemotherapy, and radiation therapy, which aims to eradicate the tumor and prevent its spread to other parts of the body. Surgery is the primary treatment for nephroblastoma, and it typically involves a complete or partial removal of the affected kidney. In some cases, the surgeon may also remove nearby lymph nodes or tissue. The goal of surgery is to remove as much of the tumor as possible, while preserving as much kidney function as possible. Chemotherapy is typically administered before and after surgery, and it helps to shrink the tumor and prevent it from spreading to other parts of the body. The specific chemotherapy drugs used may vary depending on the stage and location of the tumor, as well as the child's age and overall health. Radiation therapy may also be used in certain cases to help kill any remaining cancer cells after surgery and chemotherapy. The specific type and duration of radiation therapy may vary depending on the child's age, the location of the tumor, and other factors. It's important to note that the treatment plan for nephroblastoma may vary depending on the individual patient and the specific characteristics of the tumor. Therefore, treatment decisions should be made by a multidisciplinary team of experts, including pediatric surgeons, pediatric oncologists, radiation oncologists, and other specialists, who can work together to provide personalized care and support to each patient.

Question 35

What is the role of a paediatric surgeon in the oncological treatment?

Answer 35

Paediatric surgeons play a critical role in the oncological treatment of children, as they are responsible for diagnosing, treating, and managing a wide range of pediatric cancers and tumors. Some of the key roles of a pediatric surgeon in the oncological treatment include: 1. Diagnosis: Paediatric surgeons are trained to recognize the early signs and symptoms of various types of cancers and tumors, and they can perform diagnostic tests and imaging studies to confirm the diagnosis. 2. Treatment: Once a diagnosis is confirmed, pediatric surgeons work with other medical professionals to develop a comprehensive treatment plan that may include surgery, chemotherapy, radiation therapy, or a combination of these approaches. As part of this process, they will determine the best approach for removing or reducing the tumor, while minimizing damage to surrounding tissues and organs. 3. Management: Pediatric surgeons also play a key role in the ongoing management of pediatric cancers and tumors, which may involve ongoing monitoring, follow-up care, and support for the child and their family. Collaboration: Pediatric surgeons often work closely with other medical professionals, including oncologists, radiologists, and pathologists, to ensure that the child receives the best possible care and treatment.

Question 36

List radiological signs of malignant bone tumor.

Answer 36

Malignant bone tumors can present with various radiological signs that can help with their diagnosis. Radiographic findings can vary depending on the type and location of the tumor, as well as the stage of the disease. Some of the radiological signs of malignant bone tumors include: * Bone destruction or erosion: Malignant bone tumors can cause destruction or erosion of the bone, which can be seen on radiographs as areas of radiolucency or moth-eaten appearance. This can occur due to tumor invasion of the bone or bone resorption caused by tumor-induced osteoclast activation. * Soft tissue mass: Malignant bone tumors can present with a soft tissue mass that is visible on radiographs. The mass can be heterogeneous, with areas of necrosis, hemorrhage, or calcification, depending on the type of tumor. * Cortical disruption or periosteal reaction: Malignant bone tumors can cause disruption of the cortex or periosteum of the bone. This can be seen on radiographs as periosteal reaction, Codman's triangle, or sunburst appearance. These findings can suggest an aggressive tumor with a high potential for metastasis. * Pathologic fracture: Malignant bone tumors can cause pathologic fractures, which are fractures that occur as a result of weakened bone due to the presence of a tumor. Pathologic fractures can be seen on radiographs and are indicative of advanced disease. * Infiltrative growth pattern: Malignant bone tumors can have an infiltrative growth pattern, which can be seen on radiographs as a fuzzy or indistinct border between the tumor and the surrounding bone. This can suggest an aggressive tumor that is difficult to remove completely. Radiological imaging, including X-ray, MRI, CT scan, and bone scans, can be useful in the diagnosis and staging of malignant bone tumors. It is important to note that radiological findings alone are not enough to make a definitive diagnosis, and a biopsy is required to confirm the diagnosis of a malignant bone tumor. - Physical signs ○ Pain ○ Swelling ○ Reduced mobility - Kinds of tumours = Type = Radiological sign ○ Osteosarcoma = Malignant ○ Osteoma = Benign ○ Chondrosarcoma = Tumour growing in cartilage = Malignant ○ Ewing sarcoma = Tumour of bone or soft tissue around bone = Malignant ○ Cyst = Fibroma - Imaging studies ○ X-ray ○ CT ○ MRI ○ Ultrasound - Benign ○ Well demarcated borders (well margined) ○ Doesn't spread outside bone ○ Possible fracture = With cyst close by - Malignant ○ Not well margined = Arrow sign (spikes) ○ Spread out ○ Context triangle ○ Spiculations ○ Bone density changes ○ Soft tissue infiltration = Harder density ○ Multiple lesions More brittle = Easier fracture

Question 37

What are the rules of thumb in testicular tumor surgery (biopsy / orchiectomy)?

Answer 37

Testicular tumors are relatively rare, but they can be very serious if not treated promptly and effectively. Testicular cancer is the most common type of cancer in men between the ages of 15 and 44, and it typically occurs in one testicle, although it can occur in both. The surgical treatment of testicular tumors usually involves a biopsy or an orchiectomy, depending on the nature and severity of the tumor. Here are some of the key rules of thumb for testicular tumor surgery: 1. Biopsy - A biopsy is typically performed when there is a suspicion of testicular cancer. The biopsy should be performed by an experienced surgeon who is familiar with the anatomy of the testicles and the surrounding tissues. The surgeon should take care to avoid nearby blood vessels and nerves, and the biopsy should be done in a clean and sterile environment to minimize the risk of infection. 2. Orchiectomy - An orchiectomy is the removal of the affected testicle and is often the preferred surgical treatment for testicular cancer. It is important that the surgery is performed by a skilled surgeon who is experienced in performing orchiectomies. The surgeon should take care to remove the entire tumor, while preserving as much of the surrounding tissue and function as possible. A prosthetic testicle can be inserted if desired for cosmetic purposes. 3. Postoperative care - After surgery, the patient will need to be monitored closely for any signs of complications, such as bleeding, infection, or swelling. Pain management and wound care are important aspects of postoperative care, and the patient should be advised to avoid strenuous activity and sexual intercourse for a period of time after surgery. Follow-up - Regular follow-up appointments and monitoring are essential for patients who have had testicular tumors, to ensure that the cancer has not recurred and to detect any new tumors early. Imaging studies such as CT or MRI scans may be recommended, as well as blood tests to monitor tumor markers such as alpha-fetoprotein and human chorionic gonadotropin.

Question 38

The neonatologist calls you about the newborn with the lesion in the right adrenal gland recognised on the ultrasound examination? What would you ask the doctor? What would be your next steps?

Answer 38

As a pediatric surgeon, if a neonatologist called me about a newborn with a lesion in the right adrenal gland recognized on an ultrasound examination, I would ask the doctor a series of questions to obtain more information about the case. Based on the information gathered, the next steps would be determined. Below are some possible questions and next steps: Questions for the neonatologist: 1. What is the size of the lesion? Knowing the size of the lesion can help determine whether it is likely to cause symptoms or whether it is small enough to be monitored without intervention. 2. Is it solid or cystic in nature? Knowing whether the lesion is solid or cystic can help determine the likelihood of it being cancerous, as well as the best treatment approach. 3. Is there any calcification within the lesion? The presence of calcification can be a sign of malignancy and would be important to consider when deciding on treatment options. 4. Neuroblastoma stage 4S, typically disseminated, not agressive and can possibly regressess with time without intervention. 5. Is there any associated elevated hormone levels? Elevated hormone levels may indicate a functioning adrenal mass, which would require a different approach to treatment than a non-functioning mass. 6. Are there any other abnormalities detected on the ultrasound? Knowing if there are any other abnormalities detected can help in determining whether the lesion is a solitary finding or part of a larger syndrome or disease. 7. Was the ultrasound performed for any particular reason, such as an abnormal prenatal ultrasound or concerning clinical symptoms? The reason for the ultrasound can help provide context for the lesion and any associated symptoms or conditions. Next steps: * Further imaging studies: If the ultrasound is inconclusive, other imaging modalities such as CT, MRI or nuclear medicine scans may be performed to obtain a better understanding of the lesion and its features. * Consultation with a pediatric surgeon: A pediatric surgeon with experience in neonatal adrenal masses would be consulted to evaluate the case and discuss the best treatment options. * Monitoring: If the lesion is small and asymptomatic, it may be monitored with regular follow-up imaging and clinical assessments to determine if any changes occur over time. Surgery: If the lesion is large, causing symptoms or concerning for malignancy, surgical intervention may be necessary. Depending on the size and location of the lesion, the surgical approach may be an open or laparoscopic adrenalectomy.

Question 39

You are GP. A teenager comes to your office with the pain in the knee. He denies a trauma, the knee joint looks distorted, swollen, painful and its mobility is limited. What can you suspect? What are your next steps

Answer 39

Based on the patient's symptoms, the most likely condition is a tumor or cancer affecting the knee joint. However, there are several other potential causes of knee pain and swelling, including infection, inflammation, or injury. As a GP, your first step would be to perform a thorough physical examination of the knee and take a detailed medical history of the patient, including any prior illnesses or injuries. In this case, since the patient denies a history of trauma, it is less likely that the pain and swelling are due to an acute injury or strain. Instead, you may suspect that the patient has a more chronic condition affecting the knee joint, such as a tumor or cancer. After performing a physical examination, you may also order additional tests or imaging studies to help confirm the diagnosis and determine the extent of the problem. These may include x-rays, ultrasound, CT scans, or MRI scans, which can provide detailed images of the knee joint and surrounding tissues. Depending on the results of these tests and your clinical assessment, your next steps may include referring the patient to a specialist, such as an orthopedic surgeon or oncologist, for further evaluation and treatment. Treatment options for knee tumors or cancer may include surgery, chemotherapy, radiation therapy, or a combination of these approaches. In addition to medical treatment, you may also recommend lifestyle changes or other supportive measures to help the patient manage their symptoms and improve their overall health and well-being. This may include pain management techniques, physical therapy, and other forms of complementary and alternative medicine.

Question 40

You are GP - a teenager comes to you, he self-palpated a hard tumor. What’s your next move?

Answer 40

1. Take a thorough medical history: This would include asking the patient about any past medical conditions, family history of cancer, and any symptoms associated with the tumor. 2. Perform a physical examination: I would assess the size, shape, location, and texture of the tumor, as well as any associated symptoms such as pain or tenderness. 3. Order diagnostic tests: Depending on the results of the physical exam, I may order additional diagnostic tests to confirm the diagnosis and stage of the tumor. This may include blood work, imaging studies such as ultrasound, CT scan, or MRI, or a biopsy to collect tissue for examination. 4. Refer the patient to a specialist: If the tumor is found to be malignant or cancerous, I would refer the patient to an appropriate specialist such as a pediatric oncologist or a surgical oncologist for further evaluation and treatment. 5. Provide emotional support: Receiving a cancer diagnosis can be a traumatic experience for the patient and their family. As their primary care physician, I would provide emotional support and resources to help them cope with the diagnosis and navigate the treatment process.