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SAQ 2

SAQ 2. Describe your assessment of a 1 year old boy brought to the Emergency Department with a 1 day history of bile stained vomiting (100%). Describe your assessment of a 1 year old boy brought to the Emergency Department with a 1 day history of bile stained vomiting (100%). Assessment.

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SAQ 2

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  1. SAQ 2 Describe your assessment of a 1 year old boy brought to the Emergency Department with a 1 day history of bile stained vomiting (100%)

  2. Describe your assessment of a 1 year old boy brought to the Emergency Department with a 1 day history of bile stained vomiting (100%)

  3. Assessment • History • Examination • Investigations

  4. Opening Statement / Key issues • Needs to be relevant to the stem • With Bile stained vomiting must consider Upper GI obstruction • Intestinal obstruction should be suspected in any child with persistent vomiting, distension and abdominal pain. • Reality is that with prolonged or persistent vomiting from any cause it will become bile stained. • Assessment must consider cause and complications. • SBO progress to vascular compromise • With bowel ischaemia, necrosis, perforation and sepsis

  5. Differential diagnosis • Upper GI obstruction (in a 1 year old) • Intusussception • commonest cause SBO 3month-6yrs) • Midgutvolvulus (malrotation) • Incarcerated hernia • Umbilical/inguinal • SBO from adhesions • Hxprevsurgery • Pyloric stenosis • Hirschprungs • Malrotations/abdo wall defects • atresias • Severe gastroenteritis * • Sepsis * • CNS /Resp/ Urinary • Appendicitis* (* Becomes bile stained with persistent vomiting)

  6. History • HOPC • PHX • Medication • Allergy • Social

  7. History • HOPC • Vomiting • Volume/frequency/contents/blood/ • Always bile stained vs becoming bile stained later • Associated features • Pain • intermittent/colicky vs constant • Drawing up legs with pain • Fever • Bowel motion • Blood/mucus/classic red current stool=late Sx • Diarrhoeavs constipation • Other • Relating to symptoms of alternative Dx • Hydration • Intake • Amount & type • Output • Wet nappies /diarrhoea/vomiting • pHx(with examples) • Recent precipitants/ preceding illnesses • Prematurity/comorbidities • Previous surgeries • Development • Med/allergy/social • Need to be relevant to cause /complications/treatments

  8. Examination • General appearance • Vital Signs • Hydration • Abdomen • Other

  9. Examination • General appearance • Pallor / lethargy intermittent or constant (pallor with crying = intusussception) • Recent & current weight • Vital signs • tachycardia, irritable or reduced conscious level, hypotension, tachypnoea • Hypovolemic shock is a late sign • Look at HR BP sats temp GCS RR • Hydration • what findings would indicate significant dehydration ( CRT >3sec, mottled skin) • Look at mucus membranes, tissue turgor, cap refill • Abdomen • Distension • Peritonism • Generalisedvs focal eg RIF with appendicitis • Masses • Sausage shape in RUQ /or crossing midline in epigastrium • Inguinal or umbilical hernia • BS • Tinkling (SBO) • Absent (ileus) • Other • System based looking at cause/complications/alternative Dx

  10. Investigations • Bedside • BSL • FWT urine • Laboratory • VBG • U+E • FBE • Septic work up • Imaging • AXR • US • Air Enema

  11. InvestigationsFeatures of a good answer • Candidateswereexpected to include the followingpoints with satisfactoryrationale • whenand whytheywouldperform the test(s) • whattheywouldbelookingfor • Testutility/ orlikelyyield • Clinicallyrelevantinformation

  12. InvestigationsFeatures of an unsuccessful answer • Candidate performs multiple investigation without adequate explanation • Eg FBE signs of infection • Listed investigations in a self evident fashion • Eg U+ E to check for electrolyte abnormalities • Investigations showing no clinical perspective • Eg CT abdo in child • Omitted key investigations

  13. Investigations • Bedside • BSL • Hypoglycemia with poor caloric intake • FWT urine (+ MCS) • Urosepsis may present with persistent vomiting • Laboratory • VBG • Increased lactate with bowel ischaemia • U+E • Na/K/Cl/BC changes with persistent vomiting • Prerenal impairment with severe dehydration • FBE • WCC >20 or <4 favors bacterial sepsis • Septic work up • Imaging • AXR (+ CXR – free gas or alternative Dx ) • Free gas (perforation) • Dilated loops/AF levels (SBO) • Specific signs of intussusception • Target sign / crescent sign • US • mass with a typical “target” appearance on a cross section, due to multiple layers of bowel, and a pseudokidney appearance on longitudinal scans • Negative findings can exclude intussusception with near 100% accuracy • Alternative Dx ( appendicitis /hernia/torsion) • Air Enema • Diagnostic & therapeutic for Intusussception

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