Pediatric, Plastic and Reconstructive Surgery
Core concepts
Pediatric surgery questions test congenital and acquired conditions: pyloric stenosis, malrotation with volvulus, intussusception, Hirschsprung disease, appendicitis, inguinal hernia, and testicular torsion. Bilious vomiting in a neonate is malrotation until proven otherwise and requires urgent evaluation. Pyloric stenosis presents with nonbilious projectile vomiting, a palpable olive, and hypochloremic hypokalemic metabolic alkalosis. Intussusception presents with intermittent pain, currant-jelly stool, and a target sign; air or contrast enema is diagnostic and therapeutic in stable patients. Plastic surgery covers wound healing, grafts, flaps, burns, skin cancer, hand injuries, and congenital anomalies. Burn resuscitation uses the Parkland formula as a starting estimate, with titration to urine output.
Traps
Do not attribute bilious vomiting to reflux. Do not delay surgery for testicular torsion. In burns, over-resuscitation causes edema and compartment syndromes. A flap with venous congestion looks dark and congested, whereas arterial insufficiency looks pale. In children, compensate well until sudden decompensation.
Worked example
A 30-kg child with a 30% total body surface area burn: Parkland estimate is 4 mL × 30 kg × 30% = 3600 mL in 24 hours, half in the first 8 hours from injury. Titrate to urine output. Rule of thumb: formulas start resuscitation; the patient’s perfusion and urine output guide it.
Professional Practice
Core concepts
Professional practice includes ethics, consent, capacity, communication, teamwork, quality improvement, patient safety, and error disclosure. Valid informed consent requires capacity, adequate information, understanding, and voluntariness. Assess capacity by whether the patient can understand the situation, appreciate consequences, reason, and express a choice. When capacity is absent, use advance directives or a surrogate according to jurisdiction. In emergencies, treat under the emergency exception when delay would harm the patient. Disclose errors honestly and promptly, apologize, explain what happened, and describe prevention. Quality improvement uses system thinking, root-cause analysis, and checklists rather than blaming individuals. Understand confidentiality, mandatory reporting, conflict-of-interest rules, and the difference between research and clinical care.
Traps
Do not confuse disagreement with incapacity. A patient may refuse recommended treatment if they have capacity. Do not assume a family member automatically has decision-making authority. Avoid discussing confidential information in public areas. Conflict of interest and research misconduct must be managed transparently.
Worked example
A patient with capacity refuses a needed operation after a clear discussion. Document the discussion, offer alternatives, and respect the refusal; do not proceed without consent unless an emergency exception applies. Rule of thumb: capacity plus informed refusal equals respect for autonomy.