😀 EASY

In this first of a few question sets, we are going to examine the paediatric patient with a changed bowel habit.  This is a classic presentation that you should get your head around – and features prominently in the UKMLA “Child Health” Section.

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Paed CBH 1

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Question 1

Stem 1 of 4

Three months after hospitalisation for meningoencephalitis, a 5 year-old female presents to her GP (with her father), with unexpected weight gain, persistent fatigue, hair loss (which is troubling her at school) and chronic constipation.

Given the presumed differential, what is the most likely finding of thyroid function testing?
A
TSH high, FT3 high
B
TSH high, FT4 high
C
TSH high, FT3 low
D
TSH low, FT4 high
E
TSH low, FT3 low
Question 1 Explanation: 
This patient has suffered an infective lesion to the central nervous system. It can be surmised the pituitary gland is affected, and therefore a secondary hypothyroidism would fit this picture. This would result in a thyroid function test result that is upstream - so that TSH and free T3, T4 will be down concurrently.
Question 2

Stem 2 of 4

The patient is started on a medication, and monitoring commences. Which medication is most appropriate?
A
Carbamazepine
B
Carbimazole
C
Levothyroxine
D
Mefenemic acid
E
Propothiouracil
Question 2 Explanation: 
The patient should be commenced on synthetic T4 aka levothyroxine. This is monitored monthly until the appropriate dose is achieved with a minimal side-effect profile.
Question 3

Stem 3 of 4

Which parameter should be measured as part of the monitoring of this patient going forward?
A
ACTH
B
FT3
C
FT4
D
TRH
E
TSH
Question 3 Explanation: 
NICE recommends checking TSH levels monthly in this patient until optimal dose is achieved as per above.
Question 4

Stem 4 of 4

If a 47 year-old male were to have a similar presentation, but no infectious history, what would the most likely cause be in the UK?
A
Graves’ disease
B
Hashimoto’s thyroiditis
C
Iodine deficiency
D
Radioactive iodine damage
E
Sheehan’s syndrome
Question 4 Explanation: 
Hashimoto thyroiditis, associated with antiTPO antibodies raised to the thyroid gland, causes a goitre and hypothyroidism. In the western world, it is the most common cause of hypothyroidism. In regions of the world where iodine is deficient in diet, it is - unsurprisingly - iodine deficiency that is the more likely culprit.
Question 5

Stem 1 of 5

A 5 year old male with chronic constipation issues presents with acute abdominal pain (suprapubic). He has had absolute constipation for 36hr. On examination, his abdomen is grossly distended and he is complaining of coliky abdominal pain. His abdomen is tympanic to percussion.

What is the initial investigation in this patient?
A
Abdominal X-ray (AXR)
B
Abdominal ultrasound
C
CT contrast abdominopelvic
D
Pelvic ultrasound
E
Pelvic X-ray (PXR)
Question 5 Explanation: 
Initial investigation to confirm bowel obstruction is a contrast CT abdo-pelvis. Electrolytes and thyroid function tests should be run alongside as altered sodium, potassium and calcium can affect contractility of the enteric nervous system powered smooth muscle cells of the gut wall, also hypothyroidism is a differential for constipation. NB: The Association of Surgeons of GB recommend a CT scan for all acute abdo patients within 24hr (but should be done much sooner).
Question 6

Stem 2 of 5

Which of the following bloods would you order as adjuncts to the imaging first-line?
A
Serum albumin
B
Serum calcium
C
Serum potassium
D
Serum prothrombin
E
Thyroid function test
Question 6 Explanation: 
To help rule out pseudo-obstruction, due to decreased motility, serum electrolytes and thyroid function tests should be performed (ideally with an ABG to check electrolytes and for signs of ischaemia). It would be reasonable to assess clotting and renal status additionally - as not a conduit for diagnosis, they are useful for working up and managing the patient.
Question 7

Stem 3 of 5

A diagnosis of a volvulus is made post-imaging. What is the most common site for this to occur?
A
Ascending colon
B
Transverse colon
C
Descending colon
D
Sigmoid colon
E
Rectum
Question 7 Explanation: 
Up to two-thirds of all volvulus presentations are due to rotation of the sigmoid colon.
Question 8

Stem 4 of 5

The patient is given a nasogastric tube, is ordered nil-by-mouth and given IV resuscitation fluids. What is the next best step for management?
A
Emergency laparotomy
B
Hartmann’s procedure
C
Intramural stenting procedure
D
Nil by mouth and watchful waiting
E
Scope decompression
Question 8 Explanation: 
This first line approach for volvulus has up to a 75% success rate and should be considered first line.
Question 9

Stem 5 of 5

This conservative management has now failed (volvulus is still present). With the risk of perforation growing, what is the next step?
A
McConnell's procedure
B
Hartmann’s procedure
C
Intramural stenting procedure
D
Nil by mouth and watchful waiting
E
Scope decompression
Question 9 Explanation: 
Based on urgency, and severity, the patient should be booked in for a laparotomy for a Hartmann’s operation. Also termed a proctosigmoidectomy, the sigmoid colon and proximal rectum is resected and the remaining anorectal stump is closed. A colostomy is then formed on the distal-most descending colon.
Question 10

Stem 1 of 3

A 5 year-old patient, otherwise well, presents to ED with sharp right lower quadrant abdominal pain of the last three hours. The pain is associated with vomiting and fatigue. An ultrasound is undertaken.

A cluster of enlarged lymph nodes are seen in the right lower quadrant with ileal wall thickening. What is the best-matched diagnosis?
A
Appendicitis
B
Intussusception
C
Meckel’s diverticulum
D
Mesenteric adenitis
E
Spontaneous bacterial peritonitis
Question 10 Explanation: 
This is a classic case of mesenteric adenitis. When a child comes to you with the appendicular presentation, you need to consider the full differential: diverticular disease, appendicitis, mesenteric adenitis, ectopic pregnancy and ovarian disease. In this case, an abdominopelvic ultrasound scan will lend credence to whether you can manage this patient supportively, or step up to diagnostic exploratory laparotomy.
Question 11

Stem 2 of 3

What is the most important differential to consider in this patient?
A
Appendicitis
B
Intussusception
C
Meckel’s diverticulum
D
Mesenteric adenitis
E
Spontaneous bacterial peritonitis
Question 11 Explanation: 
Appendicitis requires exploratory laparotomy with appendicectomy. There is growing research in the non-inferior management of this condition with antibiotics, but this is still in infancy and data is lacking to inform wide practice outside of trials. The ultrasound will show an abnormal appendix with fewer instances of abnormal lymph nodes in the right-lower quadrant for appendicitis versus mesenteric adenitis.
Question 12

Stem 3 of 3

The most-likely differential is linked to an adult-age reduction in the incidence of which disease?
A
Caecal volvulus
B
Crohn’s disease
C
Irritable bowel syndrome
D
Sigmoid volvulus
E
Ulcerative colitis
Question 12 Explanation: 
Weirdly enough, a child having a diagnosis of mesenteric adenitis shows less chance of developing ulcerative colitis later in life. The mechanism for why is unknown.
Question 13
A neonate has not passed meconium in the first forty-eight hours of life. What is the best matched differential?
A
Coeliac disease
B
Congenital hypothyroidism
C
Cow’s milk allergy
D
Cystic fibrosis
E
Sexual abuse
Question 14
A neonate presents with a suprapubic hard abdominal mass, distention, and ribbon stool. What is the best matched differential?
A
Anal stenosis
B
Coeliac disease
C
Congenital hypothyroidism
D
Sepsis
E
Spinal cord lesion
Question 15
A diagnosis of idiopathic constipation is given to a child with chronic decrease in bowel movements. Red flags are ruled out and management is arranged. Which is the next best step? Select all that would be appropriate.
A
Increase fibre
B
Increase physical exertion
C
Ensure good hydration
D
Prescribe movicol
E
Encourage passage - eg with star charts
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