Peds
What is the IVF maintenance rate for children?
First 10kg: 4cc/kg/hr
2nd 10kg: 2cc/kg/hr
Everything else: 1cc/kg/hr
Resuscitation: 20cc/kg
Blood: 10cc/kg
Which ligament attached to the spleen contains the splenic artery?
Splenorenal ligament: splenic artery
Gastrosplenic ligament: short gastric
Splenocolic ligament: unnamed
Splenophrenic ligament: unnamed
27 year old female with a 2 cm papillary thyroid cancer found to have extra thyroidal disease. What is the treatment?
Total thyroidectomy, MRND, radioactive iodine
Indications: Tumors >4cm, extra thyroidal disease, multi-centric or bilateral lesions
Most common cancer after transplant surgery?
Squamous cell carcinoma of the skin
80 year old male admitted for ICH is found to have DVT. What is the next step in management
IVC filter placement
Indications: contraindications to AC, PE while on AC, free floating IVC, iliofemoral or deep femoral DVT, Recent pulmonary embolectomy
Contraindications: Completely thrombosed IVC
3 year old noted to have a reducible bulge at the umbilicus comes to your clinic. What is your recommendation?
Wait until 5 years old. They usually close on their own
Indications for urgent/emergent repair: Strangulated, incarcerated, proboscis hernia
Patient found to have a 1cm insulinoma not involving the pancreatic duct. What is the treatment?
enucleation.
Enucleation: insulinoma and gastrinoma
Formal resection: All other PNETs
7 year old boy presents with precocious puberty. Labs show hyponatremia and hyperkalemia. What is the likely diagnosis?
21 hydroxylase deficiency (most common CAH)
11 hydroxylase deficiency
17 hydroxylase deficiency
which skin lesion is associated with spindle cells arranged in a straw mat pattern?
Dermatofibrosarcoma protuberanza (DFSP)
Patient presents after MVC. Found to have a proximal left mainstem injury. What is the surgical approach to repair this injury?
Right thoracotomy
Right thoracotomy: right mainstem, proximal left mainstem, trachea
Left thoracotomy: distal left mainstem
6 week old with projectile vomiting. Labs show K 2.9, bicarb 35. US shows thickened pyloric wall and elongated pyloric channel. What is the next appropriate step in management?
Resuscitation
Use normal saline bolus first, then switch to D5 NS with 10 mEq K
Hypokalemic, hypochloremic metabolic alkalosis
Can cause respiratory depression due to alkalosis
Surgery: Pyloromyotomy
Remember pie. 3.14
Patient presents 6 weeks after recovering from pancreatitis. Now has bloating, early satiety. CT scan shows large pseudocyst abutting the stomach. What is the treatment?
Endoscopic cystgastrostomy
Asymptomatic or small: conservative
Surgical: laparoscopic or open cyst gastrostomy
Patient is undergoing parathyroidectomy for adenoma. After removal, PTH does not drop 50% at 10 minutes. What is the next step?
Wait another 5-10 minutes
If PTH does not drop, may need to explore ipsilateral gland for double adenomatous disease
Patient presents with an asymmetric, dark, irregular lesion on his arm. Specific treatment for a 3mm deep melanoma?
Excision with 2cm margins and SLNB
SLNB: Perform if clinically negative but if >1mm deep
Patient presents as a stab to the abdomen. He is taken to the OR for an exploratory laparotomy. He is found to have a 30% sigmoid injury. What is the treatment?
Primary repair.
If injury is <50% circumference and nondestructive injury, can primary repair. Otherwise, needs resection.
2 week old with bilious emesis. Found to have malrotation. What is the surgery, and what are the key steps? (will accept 3)
Ladd procedure
1. counterclockwise detorsion
2. division of peritoneal attachments to duodenum (Ladd band)
3. widening of the narrowed root
4. Appendectomy
5. placement of the small bowel to the right and cecum to the left
Patient admitted for acute pancreatitis which is not improving with conservative management. CT shows large fluid collection of gas and is started on abx. What is the next step?
percutaneous/endoscopic drainage
then video assisted retroperitoneal debridement (VARD)
followed by open necrosectomy
50 year old female presents with abdominal pain, weakness and weight loss. CT scan shows a 5cm mass with retained contrast in the left adrenal. What is the diagnosis and treatment (specific)?
Adrenocortical carcinoma. Open radical adrenalectomy
Do not perform laparoscopically due to risk of spillage.
Mitotane for residual, recurrent, unresectable, metastatic
Patient has a small defect of the face. Which graft provides the best cosmetic outcome and why?
Full thickness skin graft. Less prone to secondary contracture of the graft
FTSG: More primary contracture immediately due to greater amount of elastin. also higher risk of hematoma
STSG: Can cover larger space. No need to close donor site
Patient presents as a stab to the left upper quadrant. He is hemodynamically stable. Imaging shows left hemothorax as well as a splenic injury. What is the next step?
Diagnostic laparoscopy to look for diaphragmatic injury.
2 month old presents with abdominal distention. CT shows right adrenal mass as well as liver nodules. She has elevated urinary vanillylmandelic acid and homovanillic acid levels. What is the diagnosis? Bonus: What is the treatment?
Neuroblastoma
Chemotherapy, then possible resection
Important to determine n-myc status
Notable labs: VMA/HVA, metanephrines
Patient with a history of chronic pancreatitis which is not very well managed. Imaging shows dilated PD without disease in the pancreatic head. What is the preferred treatment
Puestow procedure (lateral pancreaticojejunostomy)
Beger: duodenal pancreatic head resection
Frey: core out head, with lateral pancreaticojejunostomy
Patient presents with acne, weight gain, DM, HTN. 24 hour urine cortisol is high. ACTH is low. What are the likely diagnoses and what is the next step?
Adrenal adenoma or adrenal hyperplasia
CT scan. NP-59 scintigraphy may help differentiate
If ACTH is high, need to determine if pituitary adenoma or ectopic producer with dexamethasone suppression test
Patient is found to have metastatic melanoma and is started on Pembrolizumab. What kind of drug is this?
Immunotherapy
Inhibits PD-1 protein on immune T cells which allows the body's immune system to destroy cancer cells
Patient in the ICU who underwent tracheostomy creation 3 weeks ago now has brisk, bright red bleeding. What is the diagnosis and next step?
Tracheoinnominate fistula. Digital compression of the innominate artery against the sternum or overinflating the cuff
Next steps is median sternotomy with innominate artery ligation