Pediatric Surgery – Sample Report: Wilm's Tumor
Case Study: Sample Report and tutorial OSCE challenges
BIODATA
Name: A.F
Age: 17 years
Sex: Female
Address: Edele, Auchi
Religion: Christian
Tribe: Etsako
Informant(s): the patient and her mother
PRESENTING COMPLAINT (PC)
She was admitted via the surgical outpatient clinic 2 days ago on account of
- abdominal swelling of one year and 5 months duration.
HISTORY OF PRESENTING COMPLAINT (HPC)
She first noticed a swelling in the right flank of her abdomen1 year and 5 months ago while she was dressing.
The swelling is painless. The initial size was about the size of her fist but it has progressively increased to its present size.
There are no other masses in any other parts of her body.
There is history of frequency and nocturia which started about the same time 2 months ago.
It was insidious in onset. She now passes urine 5-6 times during the day as against 3 times before and 3-5 times at night as against once before and both symptoms have progressively worsened since the onset.
No history of dysuria, hematuria or urgency.
There is no family history of similar condition or other malignancies.
During pregnancy, there was no maternal history of exposure to irradiation, use of herbal concoctions, episode of febrile rash, or use of over-the-counter drugs.
No history of exposure to irradiation in childhood.
No consumption of herbal concoctions prior to onset of symptoms.
No history of trauma prior to the onset of symptoms.
No history of chronic cough or exposure to anyone with chronic cough, consumption of unpasteurized milk, and drenching night sweats.
No constipation, vomiting, abdominal distention or central colicky abdominal pain. No jaundice, dyspnea, cough, bone pain, headache or seizure. No history of fever, weight loss, anorexia or unusual weakness.
Concerned about the swelling, she was taken to a private facility at Auchi where she was clinically evaluated and radiological investigation was done however results could not be ascertained. She was referred to this facility for expert care. On arrival to this facility, she was clinically evaluated; blood samples were taken for investigations and radiological investigation was also done. Based on the findings from investigations, they were informed of the condition and counselled for surgery. She was booked for surgery yesterday.
PAST MEDICAL AND SURGICAL HISTORY
She is not a known hypertensive, epileptic, asthmatic, DM or sickle cell patient, no history of previous significant hospital admission, has not been transfused in the past. No prior surgical history.
DRUG AND ALLERGY HISTORY
She has no known drug or food allergy
PERSONAL AND SOCIAL HISTORY
She neither smoke or takes tobacco in any
form, she does not consume alcohol, she is not involved with substance abuse. She has a good relationship with peers, family members and relatives. Has above average performance in school.
Her Last menstrual period was 10/04/25
FAMILY HISTORY
She's the third of five children in a monogamous family. Her mother is a 47 year old trader and her father is a 53 year old farmer.
REVIEW OF SYSTEM
No dyspepsia, tenesmus, anal protrusion, melena or hematochezia.
No muscle weakness, gait anomaly
Clerking Template & Urology Notes
Clerking Template
Bio-data
- Name
- Age
- Sex
- Address
- Hospital Number
- Date of admission
- Date of clerking
Presenting Complaint(s) (PC)
- State only symptoms in patient's own words. E.g., "Left thigh mass"
History of Presenting Complaint (HPC)
1. Complaint/Symptom Analysis
Use the six key descriptors for each symptom:
- Duration – How long has it been present?
- Location – Where is it felt?
- Onset – How it started or was first noticed
- Characteristics – Quality of the symptom (e.g., sharp, dull, throbbing)
- Progression – Has it changed over time?
- Associated Symptoms – What other symptoms accompany it?
NB: Avoid phrases like "mass was palpable" in history. Palpability is a physical exam finding.
2. Course
- Discuss progression in detail.
- Review system most involved.
- Include timeline with events.
3. Cause
- Probable etiology
- Differential diagnoses (with justification)
4. Complications
- Review of systems that are pathophysiologically connected.
E.g., For renal pathology, check cardiovascular, CNS (hypertensive encephalopathy), hematologic systems (anemia of chronic disease).
5. Care So Far
- What has the patient done?
- Prior medications, hospital visits, traditional care?
Branch Off: “Renal Rest” or “Renal Rests”
Correct term: Renal Rests
These are embryonic remnants of metanephric tissue found within the kidney, or extrarenally (especially in the adrenal region), and can mimic or predispose to nephroblastoma (Wilms tumor). They are part of the nephrogenic rests spectrum.
Pathophysiology of Nephroblastoma (Wilms Tumor)
- Embryologic Basis: Derived from persistent metanephric blastema due to genetic mutations (e.g., WT1, WT2).
- Genetics: Common in WAGR syndrome (Wilms, Aniridia, Genitourinary anomalies, mental Retardation); also Denys-Drash & Beckwith-Wiedemann.
- Origin: Neoplastic transformation of pluripotent renal precursor cells.
- Histology: Classic triphasic pattern:
- Blastemal
- Epithelial (primitive tubules and glomeruli)
- Stromal (spindle cells, skeletal muscle)
- Spread: Hematogenous (lung > liver), rare lymphatic spread.
- Clinical Features:
- Asymptomatic abdominal mass
- Hematuria
- Hypertension (renin production)
- Fever, weight loss
Hypospadias
Definition:
A congenital anomaly of the penis where the urethral meatus opens on the ventral (underside) aspect of the penis proximal to the tip of the glans.
Clinical Features:
- Ventral displacement of urethral opening
- Curved penis (ventral chordee)
- Dorsal hooded prepuce (incomplete ventral foreskin)
- Spatulated glans
- Absent meatal opening at the glans tip
- Spray during urination
- Possible associated findings:
- Undescended testes
- Inguinal hernia
- Ambiguous genitalia
Classification by Meatus Location:
- Glanular – Meatus at the glans tip but ventrally displaced
- Subglanular – Below the glans
- Coronal – At the corona
- Subcoronal – Slightly below the corona
- Distal Penile – In distal shaft
- Mid Penile
- Proximal Penile
- Penoscrotal – At junction of penis and scrotum
- Scrotal
- Perineal
Uncommon Features by Type:
- Proximal types may show bifid scrotum, severe chordee, associated undescended testis
- Perineal may resemble female genitalia in severe cases
Diagnosis
- Clinical – Visual inspection at birth
- Caveat: Never perform circumcision before surgical evaluation (foreskin may be needed for repair).
Associated Conditions
- Cryptorchidism (up to 10%)
- Ambiguous genitalia
- Inguinal hernia
- Disorders of sexual development
If ambiguous genitalia is present:
- Perform karyotyping
- Imaging: Pelvic US to check for uterus/ovaries
- Consider endocrinological work-up
Differentials for Hypospadias
- Megameatus intact prepuce
- Urethral fistula
- Epispadias (dorsal meatus)
- Penile torsion
- Cloacal exstrophy (in complex cases)
- Intersex states
Complications
Psychological:
- Body image issues
- Depression
- Psychogenic impotence
- Social withdrawal
Physical:
- Abnormal urination
- Ejaculatory dysfunction
- Dyspareunia
- Infertility
- Urethral stricture after surgery
Treatment Timing
Correction must be done before age of awareness (18 months–2 years) to:
- Avoid psychological trauma
- Promote normal identity development
- Optimize functional and cosmetic outcomes
Branch Off: Drugs that Can Cause Physiological Impotence (e.g., for BPH)
-
5-Alpha Reductase Inhibitors
- Finasteride
- Dutasteride
Mechanism: Decrease DHT → reduced libido and erectile function
-
Alpha Blockers (less common)
- Tamsulosin
- Terazosin
May reduce ejaculation volume
-
Spironolactone
- Anti-androgenic effect
Branch Off: Causes of Postoperative Fever
Think 5 W’s (Classic Mnemonic)
| Day | W | Likely Cause |
|---|---|---|
| 1–2 | Wind | Atelectasis, pneumonia |
| 3–5 | Water | UTI |
| 4–6 | Wound | Surgical site infection |
| 5–7 | Walk | DVT, thrombophlebitis |
| 7+ | Wonder drugs | Drug fever, transfusion reaction |
Also consider:
- Abscess (especially intra-abdominal)
- Line sepsis
- Drug reactions (e.g., anesthetics, antibiotics)
OSCE-Style Case-Based Questions: Urology and Pediatric Surgery
Case 1: Ambiguous Genitalia in a Neonate
Scenario:
You are called to review a newborn baby whose external genitalia are ambiguous. There is a single opening at the perineum, no palpable testes, and a ventrally displaced urethral opening. The mother is distressed and asks, "Is my baby a boy or girl?"
Questions:
- Describe your initial approach to this patient.
- What physical examinations are essential?
- What investigations would you request and why?
- Explain why karyotyping is essential in this case.
- Should you proceed with circumcision in this patient? Justify.
- What are your differential diagnoses?
Case 1: Ambiguous Genitalia in a Neonate
- Initial Approach: Calm the parents, conduct a full physical exam, delay gender assignment, and involve pediatric endocrinology/urology.
- Examinations: Assess external genitalia (meatus location, scrotal development), check for palpable gonads, anal opening, and any signs of virilization or under-virilization.
- Investigations: Karyotype (e.g., 46,XX or 46,XY), pelvic ultrasound (internal organs), hormone levels (17-OHP, testosterone, LH, FSH).
- Karyotyping: Determines genetic sex, critical in ambiguous genitalia to guide gender assignment.
- Circumcision: Contraindicated until diagnosis is complete — foreskin may be needed for later reconstructive surgery.
- Differentials: Hypospadias, congenital adrenal hyperplasia, mixed gonadal dysgenesis, ovotesticular DSD, androgen insensitivity syndrome.
Case 2: Abdominal Mass in a 3-Year-Old
Scenario:
A 3-year-old female is brought by her mother who noticed a painless, progressively enlarging abdominal mass on the left flank during bath time. No associated fever, vomiting, or constipation. On palpation, a firm, non-tender, non-mobile mass is noted in the left abdomen.
Questions:
- What is your most likely diagnosis?
- Describe the embryologic origin of this tumor.
- What genetic syndromes are associated with this condition?
- Outline your investigations.
- What complications can arise from this tumor?
- How would you differentiate nephroblastoma from neuroblastoma on imaging?
Case 2: Abdominal Mass in a 3-Year-Old
- Most Likely Diagnosis: Nephroblastoma (Wilms Tumor).
- Embryologic Origin: From persistent metanephric blastema due to abnormal interaction with ureteric bud.
- Genetic Syndromes: WAGR (Wilms tumor, Aniridia, Genitourinary anomalies, mental Retardation), Denys-Drash, Beckwith-Wiedemann.
- Investigations: Abdominal ultrasound, CT scan for staging, urinalysis, CBC, renal function tests.
- Complications: Hypertension (renin secretion), tumor rupture, metastasis (lungs), renal failure.
- Neuroblastoma vs Nephroblastoma:
- Neuroblastoma crosses midline, may calcify, arises from adrenal.
- Wilms is usually unilateral, well-encapsulated, smooth contour.
Case 3: Hypospadias Detected on Newborn Exam
Scenario:
During a routine newborn exam, you observe that the urethral meatus is located at the mid-penile shaft. The foreskin is hooded, and there is mild ventral curvature.
Questions:
- What is the diagnosis and type?
- What other anomalies should you check for?
- What is the importance of not circumcising this child?
- At what age should surgical repair ideally be performed?
- What complications can arise if left untreated?
- What psychosocial issues can result in adolescents with uncorrected hypospadias?
Case 3: Hypospadias Detected on Newborn Exam
- Diagnosis: Mid-penile hypospadias.
- Other Anomalies: Undescended testes, inguinal hernia, upper urinary tract malformations.
- No Circumcision: Preputial skin may be needed for urethroplasty.
- Surgery Timing: Ideally between 6–18 months before age of genital awareness.
- Untreated Complications: Urinary spraying, sexual dysfunction, infertility, psychological distress.
- Psychosocial Issues: Anxiety, embarrassment, bullying, negative body image.
Case 4: Post-Operative Fever
Scenario:
A 6-year-old boy underwent surgical repair for proximal hypospadias 3 days ago. He now presents with a temperature of 38.9°C.
Questions:
- List the possible causes of post-op fever in this context.
- What is the relevance of the post-op day?
- What focused clinical examinations should you perform?
- What lab tests would you order?
- How would you manage if wound infection is suspected?
- If fever persists despite antibiotics, what imaging should be considered?
Case 4: Post-Operative Fever
- Causes of Fever:
- Wind (Atelectasis) — Day 1–2
- Water (UTI) — Day 3–5
- Wound infection — Day 5–7
- Walking (DVT) — Day 7–10
- Wonder drugs (Drug reaction) — anytime
- Post-op Day Relevance: Helps identify likely source based on timeline.
- Examinations: Wound site, chest auscultation, catheter site, calf tenderness.
- Labs: FBC, urine MCS, blood cultures, chest X-ray.
- Wound Infection Management: Open wound for drainage, antibiotics, culture and sensitivity.
- Persistent Fever: Abdominal ultrasound or CT to rule out abscess or internal collection.
Case 5: BPH Medications and Impotence
Scenario:
A 65-year-old man is on treatment for BPH and complains of loss of libido and erectile dysfunction.
Questions:
- Which medications is he likely taking?
- Explain the mechanism of impotence caused by these drugs.
- What alternatives could be considered?
- How would you counsel the patient regarding medication side effects?
- Distinguish between physiologic and psychogenic erectile dysfunction.
- Can hypospadias repair lead to similar issues later in life?
Case 5: BPH Medications and Impotence
- Medications:
- Alpha-blockers (e.g., tamsulosin)
- 5-alpha-reductase inhibitors (e.g., finasteride, dutasteride)
- Mechanism: Finasteride reduces DHT, leading to reduced libido and erectile dysfunction.
- Alternatives: Switch to alpha-blockers or consider PDE5 inhibitors if needed.
- Counseling: Explain reversible side effects, explore priorities (urinary vs sexual function).
- Physiologic vs Psychogenic ED:
- Physiologic: Gradual onset, persistent
- Psychogenic: Sudden onset, situational, normal nocturnal erections
- Hypospadias Repair & ED: Scarred urethra, chordee, or psychological impact may impair sexual function.
Case 6: Hypospadias Classification
Scenario:
You are asked to classify three hypospadias cases:
- Case A: Meatus at subglanular location
- Case B: Meatus at penoscrotal junction with bifid scrotum
- Case C: Meatus on perineum with no visible glans
Questions:
- Classify each case based on type.
- Which is the most severe and why?
- Which one is most likely to require multi-stage surgery?
- Which case needs endocrine/genetic evaluation?
- What are the expected long-term complications if left untreated?
Case 6: Hypospadias Classification
- Classification:
- A: Subglanular
- B: Penoscrotal (severe)
- C: Perineal (most severe)
- Most Severe: Case C — perineal, usually associated with DSD features.
- Multi-stage Surgery: Case C (perineal), requires complex reconstruction.
- Endocrine/Genetic Evaluation: Case C (perineal with likely ambiguous genitalia).
- Untreated Complications:
- Difficulty urinating while standing
- Infertility due to abnormal ejaculation
- Psychosexual dysfunction
Case 7: Differential Diagnosis Challenge
Scenario:
A neonate has a ventrally placed meatus, but the prepuce is intact and the penis appears straight.
Questions:
- What is the most likely diagnosis?
- How would you differentiate this from hypospadias?
- What are the key clinical signs that exclude chordee?
- Should this patient be referred for surgical correction?
- Is circumcision safe in this condition?
Diagnosis: Megameatus with intact prepuce
Case 7: Differential Diagnosis Challenge
- Diagnosis: Megameatus with intact prepuce.
- Differentiate: No chordee, meatus is large and distal, foreskin normal.
- Signs Excluding Chordee: Straight erection, no curvature, absence of ventral tethering.
- Surgical Referral: Only if urinary or cosmetic concerns — often managed conservatively.
- Circumcision: Safe, but only after diagnosis — caution if suspicion of hypospadias.