Surgical quizzes

Question 1

Answer 1

• Skin lesion?
  
  • Strawberry naevus
• Naturally history?
  
  • Rapid growth after birth til 6-12 months
  • Gradually involutes by 5-8 years
• Head?
  
  • Hydrocephalus
• Eyes
  
  • Setting sun sign. Stretching pulls everything up
• Commonest cause?
  
  • Intraventricular haemorrhage due to extreme prematurity, blocks CSF pathways

Question 2

Answer 2

1. Dermoid
2. Along a fusion line between the frontal bone and maxillary process
   
   • A few cells of ectoderm are caught between the fusion line and form a cyst, it grows gradually

Question 3

Answer 3

1. Cleft lip and palate
2. Failed fusion between fronto-nasal process and maxillary process
3. Upper lip, palate, teeth
4. Inability to suck
5. 20 week ultrasound

Question 4

Answer 4

1. Sacrococcygeal teratoma
   
   • Rare but dangerous condition
   • Teratomas are tumours that contain all 3 germ cell layers
2. Myelomeningocele over sacrum - i.e. spina bifida
3. Can cause malignant degeneration of spinal structures shortly after birth
   
   • One of few tumours that can grow to be the size of the patient

Question 5

Answer 5

1. Matted, enlarged lymph nodes so likely lymphoma (cancer)
2. Could it be reactive?
   
   • Normally tender, red, hot, painful
   • Rarely larger than 3cm
   • Therefore this is cancer until proven otherwise

Question 6

Answer 6

1. Recognise development is incomplete
   
   • Investigate them for a disorder of sex development (DSD) before gender is decided
2. Need to refer to a specialist

Question 7

Answer 7

1. Ano-rectal malformation, anocutanous fistula (meconium)
2. Note that 1 developmental anomaly often means more are present elsewhere
3. Surgery
4. Nil by mouth, N-G tube (relieve gas), IV fluids, call surgery, counsel and consent parents

Question 8

Answer 8

1. Pathology is limited by tunica vaginalis (peritoneal extension)
   
   • Recall that surgical causes of acute scrotum (torsion, hydatid of morgagni) are limited to hemiscrotum
2. Torsion of Hydatid Morgagni (appendix, vestigial of mullerian duct)

Question 9

Answer 9

1. Idiopathic scrotal oedema - urticaria or celluitis outside the tunica

Question 10

Answer 10

1. Testicular torsion
2. Yes, so you need to check scrotum of all boys with iliac fossa pain

Question 11

What is the best test (aside from examination) for an acute scrotum?

Answer 11

Scrotal exploration, do not bother with ultrasound

Question 12

Answer 12

1. Torsion of Hydatid of Morgagni
2. 10-12 year olds (onset of puberty results in low level oestrogens)

Question 13

Answer 13

1. Only if it occurs after birth (mostly occurs before birth
2. Perinatal testicular torsion (or tumour)
3. The tunica does not attach to teh scrotum until after descent is complete, so a fetus can spin them.
4. Ix with USS!!!

Question 14

Answer 14

1. The right testis is the same size as the glans, therefore normal, the left testis is big therefore it is either hydrocele or tumour

Question 15

Answer 15

1. Left inguinal hernia
2. Urgently, it has risk of incarceration
3. Dunno… rofl something about external inguinal ring, V shaped, incarceration…

Question 16

Answer 16

1. 2 Openings, duplication of urethra - often blind ending but can extend
2. Smegma deposit between foreskin and glans
3. Between 1 and 3, when foreskin begins to separate and smegma occurs
   
   • Big clue to age!! Always 1-3 years old

Question 17

Answer 17

1. Balantitis
2. E. Coli (usually) have colonised the space between the foreskin and glans - multiply in retained urine causing superficial ulceration
3. Typically between ages 1-5
4. Treat with topic antiseptic

Question 18

Answer 18

1. Paraphimosis - foreskin compresses shaft after retraction leading to congestion of glans
2. Occurs after foreskin separates, so usually in ages 3-5
3. Compress the glans (usually requires sedation/anaesthesia)
4. Recurrence is not common

Question 19

Answer 19

1. Phimosis resulting in ballooning when urinating
2. Can be secondary to poor circumcision, or if traumatic retraction, or balantitis
3. Emergency circumcision
4. Prevented by good perineal hygiene in babies and toddlers, need to displace the E. Coli

Question 20

Answer 20

1. No, it should be investigated for disorders of sex development
2. Only hypospadias when teh scrotum is fused and contains 2 testes, confirming no global anomaly of hormone function

Question 21

Answer 21

1. External angular dermoid in teh commonest site
2. Elective excision

Question 22

1. What is occurring and is it serious?
2. Where is it occurring?
3. What is the likely cause?

Answer 22

1. Bowel obstruction with dilation of proximal bowel
2. Usually due to an issue in the ileum
3. This is a meconium ileus, commonly caused by cystic fibrosis whioch results in stickier mucousy meconium

Question 23

1. What does the Xray show?
2. Do these babies often have other anomalies?
3. How is it fixed?

Answer 23

1. Dilated stomach containing a fluid level (left), and dilated proximal duoodenum (right). double bubble sign of duodenal atresia
2. About 30% have Down’s, others can have anorectal malformation, oesophageal atresia, and Hirschsprung disease
3. Surgery

Question 24

Answer 24

1. Corkscrew sign
2. Shows Malrotation of the small bowel
   
   • Occurs due to abnormal alignment of the midgut after the small bowel returns to the abdominal cavity from physiological hernia in the cord at 10 weeks gestation
3. Baby can be normal at birth because it takes milk to stimulate peristalsis which then causes the volvulus

Question 25

Answer 25

1. Gastroschisis
2. Rupture is on the right side
3. Spermatic cord and testis, note the empty left scrotum
4. Evaporative heat loss from exposed bowel. Profound hypothermia in babies causes sclerema (solidification of subcutaneous fat)
   
   • Manage with wrapping (glad wrap will do), fluids, nil oral, NG tube (decompress), incubate, transfer

Question 26

Answer 26

1. Exomphalos - failure of normal folding
2. Normally have serious other anomalies which may be fatal

Question 27

1. What is wrong?
2. Why is there respiratory distress?

Answer 27

1. Baby with flat tummy, and respiratory distress, has diaphragmatic hernia until proven otherwise
2. Gut prolapses through the diaphragm causing deficient lung development and hence respiratory distress