Arab Board Surgery Clinical cheat sheet

Acute appendicitis: Alvarado score components are migration of pain (1), anorexia (1), nausea/vomiting (1), tenderness RIF (2), rebound (1), fever (1), leukocytosis (1), left shift (1); ≥7 supports operative management.

Small bowel obstruction: air-fluid levels on erect film; CT identifies transition point and strangulation (reduced wall enhancement, pneumatosis).

Large bowel obstruction with competent ileocecal valve risks closed-loop perforation at cecum; cecal diameter >9–10 cm is high risk.

Boerhaave syndrome: transmural distal esophageal rupture; contrast leak, mediastinal air; requires urgent drainage and repair or stenting.

Mallory-Weiss tear: mucosal gastroesophageal junction tear after retching; usually self-limited; endoscopy is diagnostic and therapeutic.

Hartmann procedure leaves a rectal stump and end colostomy; reversal is elective with anastomosis after confirming distal patency.

Peptic ulcer perforation: free subdiaphragmatic air; omental (Graham) patch repair plus peritoneal lavage is standard for unstable peritonitis.

Ranson criteria and Glasgow-Imrie score stratify acute pancreatitis severity; CRP >150 mg/L at 48 h indicates severe disease.

Child-Pugh score: bilirubin, albumin, INR, ascites, encephalopathy; class A 5–6, B 7–9, C 10–15; C contraindicates major resection.

MELD-Na uses bilirubin, INR, creatinine, sodium; predicts 90-day mortality and prioritizes transplant allocation.

Mirizzi syndrome: impacted cystic duct stone compressing common hepatic duct causing jaundice; MRCP/ERCP defines type.

Choledocholithiasis: ERCP with sphincterotomy and stone extraction; if unsuccessful, laparoscopic or open common bile duct exploration.

Pancreatic head mass with painless jaundice: double-duct sign on imaging; resectable if no vascular involvement (SMA/SMV/portal vein).

Splenic injury: hemodynamically stable with contained injury managed nonoperatively with observation; unstable or grade V requires splenectomy.

Post-splenectomy: vaccinate against encapsulated organisms (pneumococcus, meningococcus, Haemophilus) and give penicillin prophylaxis.

Whipple procedure (pancreaticoduodenectomy) removes head of pancreas, duodenum, distal stomach, gallbladder, and distal common bile duct.

ATLS primary survey: Airway with cervical spine protection, Breathing, Circulation with hemorrhage control, Disability, Exposure.

Permissive hypotension targets systolic ~80–90 mmHg in penetrating torso trauma until hemorrhage control; contraindicated in traumatic brain injury.

FAST examines pericardial, perihepatic, perisplenic, and pelvic windows; positive FAST in unstable patient mandates laparotomy.

Massive transfusion protocol: balanced ratios approximating 1:1:1 (PRBC:FFP:platelets); give tranexamic acid within 3 h of injury.

Tension pneumothorax is clinical: tracheal deviation, absent breath sounds, hypotension; treat with needle decompression then chest tube.

Cardiac tamponade (Beck triad): hypotension, distended neck veins, muffled heart sounds; treat with pericardiocentesis or thoracotomy.

Retroperitoneal hematoma from pelvic fracture: apply pelvic binder, angioembolization for arterial blush; do not explore retroperitoneum blindly.

Damage control laparotomy: control hemorrhage and contamination, temporary closure, ICU resuscitation, planned re-look within 24–48 h.

ABI ≤0.90 indicates peripheral arterial disease; ≤0.40 indicates critical limb ischemia; >1.3 suggests noncompressible calcified vessels.

Rutherford and Fontaine classifications stage claudication and critical limb ischemia; rest pain and tissue loss define stage III/IV.

Acute limb ischemia (6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia) requires urgent revascularization within 6 h.

Carotid endarterectomy benefits symptomatic ≥70% stenosis; asymptomatic ≥60–70% considered with low surgical risk and life expectancy >5 years.

Abdominal aortic aneurysm repair indicated at diameter ≥5.5 cm in men or ≥5.0 cm in women, or rapid growth >1 cm/year.

Ruptured AAA triad: abdominal/back pain, hypotension, pulsatile mass; permissive hypotension and immediate operative repair.

Virchow triad for venous thromboembolism: stasis, endothelial injury, hypercoagulability; DVT treated with anticoagulation, not routine IVC filter.

Varicose veins: great saphenous reflux >0.5 s on duplex; treatment options include endovenous ablation, stripping, and foam sclerotherapy.

Thyroid nodule: Bethesda category on FNA guides management; Bethesda V/VI warrants surgery; Bethesda III/IV may need repeat or molecular testing.

Papillary thyroid carcinoma spreads via lymphatics; total thyroidectomy plus central neck dissection for clinically involved nodes.

Recurrent laryngeal nerve injury causes hoarseness; bilateral injury causes stridor and requires immediate airway management.

Hypocalcemia after total thyroidectomy: check calcium and PTH; symptomatic or PTH <10 pg/mL warrants IV calcium and oral supplementation.

Primary hyperparathyroidism: elevated calcium with inappropriately normal/elevated PTH; sestamibi or 4D-CT localizes adenoma; focused parathyroidectomy.

Pheochromocytoma: alpha blockade (phenoxybenzamine) before beta blockade to prevent hypertensive crisis; surgery after adequate preparation.

Adrenal incidentaloma: assess for hormonal hypersecretion and malignancy; size >4 cm or imaging features of malignancy favor resection.

Thyroid storm: hyperthermia, tachycardia, altered mentation; treat with beta blocker, thionamide, iodine (after thionamide), and steroids.

Triple assessment: clinical examination, imaging (mammography ± ultrasound), and tissue sampling (core biopsy) for breast lumps.

BI-RADS categories: 0 incomplete, 1–2 benign, 3 probably benign (short-interval follow-up), 4 suspicious (biopsy), 5 highly suggestive of malignancy.

Sentinel lymph node biopsy uses blue dye and/or radiolabeled colloid; indicated in clinically node-negative early breast cancer.

Axillary lymph node dissection indicated for clinically node-positive disease or failed sentinel mapping; risk of lymphedema.

Breast conservation requires negative margins and adjuvant radiotherapy; contraindicated with multicentric disease or prior chest radiation.

Inflammatory breast cancer: erythema, peau d'orange, rapid onset; neoadjuvant chemotherapy then mastectomy; skin-sparing not indicated.

Estrogen receptor positivity predicts response to tamoxifen or aromatase inhibitors; HER2 positivity predicts trastuzumab benefit.

Nipple discharge: unilateral bloody discharge warrants duct excision or microdochectomy; galactorrhea is usually bilateral and medical.

TNM staging: T tumor size/invasion, N regional nodes, M distant metastasis; stage determines resectability and adjuvant therapy.

R0 resection means microscopically negative margins; R1 microscopic and R2 macroscopic residual disease; R0 improves survival.

Colorectal cancer: adequate lymphadenectomy requires ≥12 nodes for accurate staging; adjuvant chemotherapy for node-positive disease.

Gastric cancer: D2 lymphadenectomy (perigastric plus celiac/splenic/hepatic nodes) improves staging and survival in resectable disease.

Melanoma: Breslow thickness and ulceration determine sentinel node biopsy indication (typically >0.8 mm or ulcerated).

Soft tissue sarcoma: wide local excision with negative margins; radiotherapy for high-grade or close margins; avoid enucleation.

Neoadjuvant therapy downsizes locally advanced tumors and assesses response; used in rectal, esophageal, and breast cancers.

Tumor markers (CEA, CA19-9, AFP, CA125) are for monitoring, not diagnosis; AFP elevated in hepatocellular carcinoma.

Hypertrophic pyloric stenosis: nonbilious projectile vomiting at 3–6 weeks; olive mass, hypochloremic hypokalemic metabolic alkalosis; Ramstedt pyloromyotomy.

Intussusception: colicky pain, currant-jelly stool, sausage mass; air or contrast enema is diagnostic and therapeutic if no peritonitis.

Biliary atresia: persistent neonatal jaundice with acholic stools; Kasai portoenterostomy before 60 days improves outcome.

Necrotizing enterocolitis: premature infants with feeding intolerance, pneumatosis intestinalis; perforation or deterioration requires laparotomy.

Inguinal hernia in infants: high risk of incarceration; repair promptly; contralateral exploration not routinely indicated.

Undescended testis: orchidopexy before 12–18 months; risks include infertility and malignancy if untreated.

Malrotation with midgut volvulus: bilious vomiting in neonate; upper GI contrast shows corkscrew; urgent Ladd procedure.

Wilms tumor: abdominal mass in child; nephrectomy with chemotherapy; avoid biopsy if resectable to prevent tumor spillage.

Renal colic: CT KUB is first-line; stones <5 mm usually pass spontaneously; >10 mm or obstruction with infection needs intervention.

Benign prostatic hyperplasia: IPSS and uroflow; medical therapy (alpha blocker, 5-alpha reductase inhibitor) before TURP.

Testicular torsion: acute scrotal pain with absent cremasteric reflex; surgical exploration within 6 h; do not delay for imaging.

Prostate cancer: PSA, digital rectal exam, and biopsy with Gleason score; risk stratification guides treatment.

Renal transplant: living donor grafts have superior survival; calcineurin inhibitors (tacrolimus) are mainstay immunosuppression.

Rejection types: hyperacute (preformed antibodies), acute (cellular/humoral, days to weeks), chronic (graft vasculopathy, months to years).

Bladder cancer: painless gross hematuria; cystoscopy and TURBT; muscle-invasive disease requires radical cystectomy or radiotherapy.

Ureteric injury during pelvic surgery: suspect if oliguria or watery drainage; confirm with creatinine of drain fluid and imaging.

Preoperative risk: ASA physical status, Revised Cardiac Risk Index, and functional capacity (metabolic equivalents) guide cardiac evaluation.

VTE prophylaxis: Caprini score determines pharmacologic and mechanical prophylaxis; early mobilization for all surgical patients.

Enhanced recovery after surgery (ERAS): preoperative carbohydrate loading, opioid-sparing multimodal analgesia, early feeding and ambulation.

Sepsis (Sepsis-3): suspected infection plus SOFA increase ≥2; septic shock requires vasopressors to maintain MAP ≥65 with lactate >2.

Acute respiratory distress syndrome (Berlin criteria): acute onset, bilateral opacities, P/F ratio ≤300 with PEEP ≥5, not cardiac origin.

Informed consent requires capacity, disclosure of material risks and alternatives, understanding, and voluntariness; emergency exception applies.

Withdrawal of life-sustaining treatment: surrogate decision-making follows substituted judgment or best interests; do not require court order.

Surgical error disclosure: duty to disclose harmful errors honestly; apology and explanation support ethical and legal obligations.

Acute anal fissure: painful bleeding with defecation; first-line is fiber, sitz baths, and topical nitrates or calcium channel blockers; lateral internal sphincterotomy for chronic.

Hemorrhoids: internal above dentate line (painless bleeding), external below (pain); grade III–IV or failed medical therapy may need surgery.

Perianal abscess: prompt incision and drainage; perianal fistula may require examination under anesthesia and seton placement.

Fournier gangrene: necrotizing fasciitis of perineum; urgent debridement, broad-spectrum antibiotics, and critical care.

Colorectal cancer screening: colonoscopy every 10 years from age 45–50; FIT annually; earlier with family history or Lynch syndrome.

Low anterior resection syndrome: frequency, urgency, and incontinence after sphincter-preserving rectal surgery; managed with diet, biofeedback, and medication.

Fistula-in-ano (Park classification): intersphincteric, transsphincteric, suprasphincteric, extrasphincteric; determines surgical approach.

Anorectal abscess with systemic sepsis or uncontrolled diabetes warrants urgent drainage and broad-spectrum coverage for necrotizing infection.