1. Department of Surgery OSCE: 5 APRIL 2011 Paediatric-, Plastic-& Vascular Surgery
Answer all questions in written on the answer sheets provided
Remember your name and student nr on each page
The OSCE consists of 16 stations,
5 marks each, 5 minutes per station
No cell phone, books or study material may be brought into the examination venue.

2. DEPARTMENT OF PAEDIATRIC SURGERY – QUESTIONS 1 – 5

3. Slide 1 – Paediatric Surgery

4. Questions – slide 1
What is the diagnosis suggested by the X-Ray? Wat is die diagnose wat hierdie X-Straal voorstel?
How do these babies classically present? Wat is die klassieke presentering van hierdie babas?
What are the referring doctor’s duties before transferring this baby? Wat is die verwysende dokter se pligte voordat hierdie baba na ‘n tersiere inrigting oorgeplaas word?
Double bubble sign – duodenal atresia
- No meconium from day 1
- Feeding intolerance.
- Bilious Vomiting
- Abdominal distension
- Associated with Down’s Syndrome and polyhydramnios also associated with cardiovascular abnormalities.
- Episodes of apnoea and bradycardia.
c) Two sides: - Accurate Hx plus examination.
- orogastric tube insertion.
- IV line and fluid resuscitation.
Monitor vitals and keep temperature constant.

5. Slide 2 – Paediatric Surgery

6. Questions for slide 2
A. Give a differential diagnosis? Gee ‘n differensiële diagnose?
B. What do you think is the most probable diagnosis here and how would you treat this girl? Wat dink jy is die mees waarskynlike diagnose hier en hoe sou jy hierdie kind behandel? a)
Capillary Haemangioma (“port wine stain” / Strawberry naevis) – around eye may cause ambliopia, give steroids to prevent cx and observe
Erythema
Soft tissue sarcoma
AV Malformation
Cobb Syndrome
Dabska Tumour
b) Most likely haemangioma
Give corticosteroids 2 mg/kg/day
Atenolol (B-blocker)
Laser therapy for flat lesions
Surgery rarely necessary

7. Slide 3 – Paediatric Surgery

8. Questions for slide 3
A. What is the name of this abnormality? Wat is die naam van hierdie abnormaliteit?
B. Why is this condition clinically important? Hoekom is hierdie toestand klies belangrik?
C. What is the embryological explanation for this condition? Wat is die embriologiese verduideliking vir hierdie toestand?
Meckel’s diverticulum
b) Can cause, intussusceptions, volvulus, Lower GI bleed or diverticulitis.
c) Remnant of vitelline duct (didn’t regress during 5th – 7th week of gestation)

9. Slide 4 – Paediatric Surgery

10. Questions for slide 4 This child presents with a reducible lump.
Hierdie kind presenteer met ‘n reduseerbare swelling.
A. What is the likely diagnosis? Wat is die mees waarskynlike diagnose?
B. When must surgery be done and what does it consist of? Wanneer moet chirurgie gedoen word en what behels dit?
Indirect inguinal hernia
Prompt mx: - prevent cx by elective surgery (testes also run through inguinal canal)
Reduce the bowel
Dissect sac away from cord, ligate neck at internal ring and remove sac
Plicate transverse fascia
Suture conjoint tendon to ing ligament in order to strenthen post wall
Reduce internal ring

11. Slide 5 – Paediatric Surgery

12. Questions for slide 5
This is a 3 week old child who has vomited some bile and shows mild abdominal distension.
Hierdie is ‘n 3 week oue kind wat gal gebraak het en wys ‘n effense buikopsetting.
A. What is the likely diagnosis? Wat is die waarskynlike diagnose?
B. Why is this a surgical emergency? Hoekom is hierdie ‘n chirurgiese noodgeval?
Intestinal Malrotation (corkscrew appearance)
b) Causes obstruction which leads to malabsorption of nutrients.
Could lead to bowel infarction

13. Slide 1a – Paediatric Surgery

14. Slide 1b – Paediatric Surgery

15. Questions for slides 1a & 1b
A. What is the classical history and clinical findings on examination of the patient.
Wat is die klassieke geskiedenis en kliniese bevindinge in die pasiënt.
B. What are the treatment options available for this condition and name the life threatening complications of this condition.
Noem die behandelings opsies beskikbaar vir hierdie toestand asook die lewensbedreigende komplikasies.
Intussception
Previously healthy child; sudden, severe intermittent abdominal pain.
Vomiting, fever, tachycardia
Currant jelly stools.
Fits of screaming and diaphoresis.
Lethargy
Sausage shaped abdominal mass palpable
Pneumatic reduction.
Open reduction.
Complications: Perforation, Bowel necrosis, Shock, Dehydration and malnutrition.

16. Slide 2 – Paediatric Surgery

17. Questions for slide 2
A. What is the clinical diagnosis? Wat is die kliniese diagnose?
B. What must you do before you transfer the patient for further care? Wat moet u doen voordat u die pasiënt oorplaas vir verdere behandeling?
Omphalocoele b)
Arrange with paediatric surgeon.
Obtain an airway, O2 therapy.
IV line, infuse Ringer’s with Dextrose.
Keep Warm
Jello-net / keep moist
Keep membrane intact
Prophylactic antibiotics.

18. Slide 3 – Paediatric Surgery

19. Questions for slide 3
A. What is the typical history of a child with hypertrophic pyloric stenosis? Wat is die tipiese geskiedenis van ‘n kind met hipertrofiese piloriese stenose?
B. What are the physical signs? Wat is die fisiese tekens?
C. What are the metabolic disturbances found? What is the operation shown called?
Wat is die metaboliese versteurings wat gevind word? Wat is die naam van die prosedure? a)
Presents at 3-6 weeks of age.
Projectile, non-bilious vomiting. b)
Dehydration and weight loss
Visible peristalsis
Mass may be felt (olive shape)
Abdominal distension c)
Hypokalemic, hypochloremic metabolic alkalosis (due to loss of gastric acid)
Procedure: Ramstedt Pyloromyotomy.

20. Slide 4 – Paediatric Surgery

21. Questions for slide 4
A. This photograph shows a fistula on the anterior edge of the sternocleidomastoid muscle. What is the diagnosis and the etiology? Hierdie foto wys ‘n fistel op die voorkanste rand van die sternokleidomastoide spier. Wat is die diagnose en die etiologie?
B. What are the possible complications and what is the treatment of choice in uncomplicated cases?
Wat is die moontlike komplikasies en wat is die behandeling van keuse in ongekompliseerde gevalle?
A) Dx: Branchial Cleft Cyst
Aetiology: Failure of obliteration of branchial cleft in embryological development.
B) Infection
Fistula
Compression (near carotid and hypoglossal nerve)
Treatment conservative or surgical. Not always possible to resect all, due to proximity to jugular vessels. Thus may recur. Early excision

22. Slide 5 – Paediatric Surgery

23. Questions for slide 5 A. What do you see on this abdominal
X-Ray? / Wat sien jy op hierdie abdominale X-straal?
B. What clinical signs is this newborn presenting with? / Met watter kliniese tekens presenteer hierdie pasgeborene?
C. Give a differential diagnosis (quite a few conditions can be the cause of this abnormal AXR). Gee ‘n differensiële diagnose (‘n paar toestande kan die oorsaak wees van hierdie abnormale X-Straal).
Distended bowel loops with air fluid levels
Distended abdomen
Bilious/fecaloid Vomitus
Constipation
Pain
Dyspnoea / respiratory distress
Dehydration and malnutrition c)
Hernia
Hirschsprungs disease
Intestinal Atresia
Meconium ileus due to cystic fibrosis
Intestinal malrotation
Paralytic ileus

24. Station 4 – Paediatric

25. Questions Slide 4
A. What abnormality is depicted on this CXR? Watter abnormaliteit word in hierdie CXR uitgebeeld?
B. What might be the symptoms of this child? Watter simptome mag hierdie kind toon?
C. What treatment do you suggest? Watter behandeling sou jy voorstel?
Morgagni Hernia (Retrosternal)
Symptoms:
Asymptomatic
Respiratory disstress at birth.
Recurrent chest infections
Intestinal obstruction
Orogastric tube.
Secure airway, usually needs ventilation.
Laparoscopic reduction and repair.

26. Station 5 – Paediatric Surgery

27. Questions Slide 5 A. What is the diagnosis? Wat is die diagnose?
B. What must you do before you transfer the patient? Wat moet jy doen voordat jy hierdie pasiënt oorplaas?
Gastroschesis
IV infusion with Ringer’s with added dextrose.
Orogastric tube. Obtain airway.
Parenteral antibiotics.
Manage hypothermia
Cover defect (As sterile as possible)
Keep in incubator if possible.
Consent if parent not accompanying and also contact details