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sue



Points : 42144
Join date : 2013-12-26

PostSubject: AMC Clinical exam preparation   Sat Dec 28, 2013 1:29 pm

amc clinical exam


Mr. Jones brings his 3 year old daughter, Amie, to your surgery concerned that she might have swallowed a 10 cent coin..

YOUR TASK IS to:
• Take a focused history
• Examine the child
• Discuss your diagnosis and management plan with the father



HOPC: Amie was in the living area of their house when the father found her playing with a few coins. He was sure that one 10 cent coin was missing. He remembers that there were 5 coins on the coffee table and now there were only 4 and none could be found on the floor or anywhere else in the living room.
Mr. Jones is rather worried that Amie might have swallowed a coin.
PHx., SHx. FHx.: unremarkable
Examination: Generally well looking and happy and alert 3 months old girl. Vital signs normal, mouth and throat o.k., chest clear, abdomen soft and normal.
Investigations:
• X-ray (single AP CXR/AXR): coin confirmed in distal oesophagus!!
DIAGNOSIS: INGESTED FOREIGN BODY / COIN
Ingestion of a foreign object is a common occurrence in the pediatric population as they tend to be curious and put objects in their mouth. Most cases occur in patients under the age of three and the most commonly ingested object is a coin, although there are endless potential candidates.
Many children give a history of a swallowed object, but with others, the incidence is unknown and they may present with gastrointestinal or respiratory symptoms. Gastrointestinal symptoms may include dysphagia, vomiting, gagging, drooling or anorexia. Respiratory symptoms may include choking, dyspnea, wheezing or stridor. The symptoms involved with foreign body ingestion may present days or even months after the incidence, and some objects are even discovered incidentally with images taken for other reasons.
SITES OF ANATOMICAL NARROWING:
• OESOPHAGUS:
Most complications of foreign body ingestion are due to esophageal placement secondary to normal physiologic narrowing of the esophagus. The most common site (70-80%) is at the thoracic inlet (T1) below the cricopharyngeal muscle, which is the anatomical change from skeletal muscle to smooth muscle in the esophagus. It is seen between the clavicles on radiographs. Lodgment (10-15%) may also be at the mid esophagus, where the aortic arch and carina overlap the esophagus on the chest radiograph (T4). An additional place for lodgment (10-15%) is at the lower esophageal sphincter at the gastroesophageal junction (T11).
• PYLORUS: if a FB passes the pylorus it usually passes through the remainder of the GIT
• without difficulty
• ILEOCAECAL VALVE
• MECKEL’S DIVERTICULUM
• SITES OF PREVIOUS SURGER OR GI ABNORMALITIES

MANAGEMENT:
• Reassurance
• Observation for several hours prior to re-X-ray to confirm that the coin has traveled
through the pylorus
• Conservative management and observe for passage of coin for 3 days
• Repeat X-ray if coin not passed within a week
• Review if any symptoms occur


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