Cuba General Surgery Specialty State Exam cheat sheet

Preoperative risk: ASA class, revised cardiac risk index (RCRI) ≥3 predicts major cardiac events; delay elective surgery for active infection, anemia Hb <7 g/dL, or uncorrected coagulopathy.

Nil per os: 2 h for clear liquids, 6 h for light meal, 8 h for fatty meal before elective anesthesia (ASA fasting guidelines).

Surgical site infection prevention: administer antibiotic within 60 min before incision (120 min for vancomycin/fluoroquinolone); redose at 2 half-lives or estimated blood loss >1500 mL.

Wound classification: clean (1-2% infection), clean-contaminated (3-5%), contaminated (10-20%), dirty (>30%); determines antibiotic choice and duration.

Fluid resuscitation: 4-2-1 rule for maintenance (4 mL/kg/h first 10 kg, 2 mL/kg/h next 10 kg, 1 mL/kg/h thereafter); assess response with urine output 0.5-1 mL/kg/h.

Postoperative fever mnemonic: within 48 h (atelectasis), days 3-5 (urinary tract, IV line), days 5-7 (wound, anastomotic leak), after day 7 (abscess, deep vein thrombosis).

Enhanced recovery after surgery (ERAS): early oral intake, multimodal opioid-sparing analgesia, early mobilization, no routine nasogastric tube; reduces length of stay and complications.

Nutrition: initiate enteral feeding within 24-48 h after major abdominal surgery when hemodynamically stable; parenteral nutrition only if enteral contraindicated for >7 days.

Inguinal canal borders: anterior wall = external oblique aponeurosis; posterior wall = transversalis fascia and conjoint tendon; floor = inguinal ligament; roof = internal oblique and transversus abdominis.

Direct inguinal hernia protrudes medial to inferior epigastric vessels through Hesselbach triangle; indirect hernia passes lateral to vessels through deep inguinal ring.

Femoral hernia: below and lateral to pubic tubercle, medial to femoral vein; high strangulation risk - repair urgently, often with McVay or plug technique.

Umbilical and paraumbilical hernias: repair if >2 cm defect, symptomatic, or in cirrhotic patients with ascites after medical control; mesh preferred for defects >2 cm.

Ventral hernia repair: sublay (retromuscular) mesh placement has lowest recurrence; component separation for large defects; consider botulinum toxin for loss of domain.

Incarcerated hernia: tender irreducible mass; strangulation signs include overlying erythema, systemic toxicity, and absent bowel sounds - emergent laparotomy and resection if nonviable.

Spigelian hernia: through semilunar line at arcuate line, lateral to rectus abdominis; often interparietal and difficult to palpate - ultrasound or CT confirms.

Obturator hernia: elderly emaciated women with Howship-Romberg sign (medial thigh pain on hip extension); CT is diagnostic, surgery via laparotomy or laparoscopy.

Appendicitis: Alvarado score (migration, anorexia, nausea, tenderness, rebound, fever, leukocytosis, left shift); CT or ultrasound in equivocal cases; laparoscopic appendectomy standard.

Acute mesenteric ischemia: pain out of proportion to exam; CT angiography is gold standard; lactate late marker; early laparotomy and revascularization within 6 h improves survival.

Small bowel obstruction: air-fluid levels on plain film; CT defines transition point; trial of nonoperative management for partial obstruction without strangulation signs.

Colorectal cancer screening: colonoscopy from age 50 (or 45 in high-risk); right-sided tumors present with anemia, left-sided with obstruction; CEA for monitoring, not screening.

Anastomotic leak: suspect with tachycardia, fever, peritonitis, or rising CRP on days 3-7; CT with contrast and prompt reoperation for peritonitis.

Hartmann procedure: sigmoid colectomy with end colostomy for perforated diverticulitis or obstruction; reversal after 3-6 months with acceptable risk.

Hemorrhoids: grade I-III treated with fiber, rubber band ligation, or sclerotherapy; grade IV or thrombosed require surgical hemorrhoidectomy.

Anal fissure: posterior midline, treated with fiber, sitz baths, topical nitrates or calcium channel blockers; lateral internal sphincterotomy for chronic refractory cases.

Acute cholecystitis: Tokyo Guidelines severity grading; early laparoscopic cholecystectomy within 72 h preferred; percutaneous cholecystostomy for high-risk patients.

Choledocholithiasis: MRCP or endoscopic ultrasound when intermediate probability; ERCP with sphincterotomy for confirmed stones; intraoperative cholangiography optional.

Acute pancreatitis: diagnose with 2 of 3 (typical pain, lipase >3× upper limit, imaging); early fluid resuscitation with lactated Ringer, enteral nutrition within 48-72 h.

Pancreatic pseudocyst: fluid collection >4 weeks with defined wall; drain if symptomatic, enlarging, or >6 cm; endoscopic cystogastrostomy preferred.

Liver trauma: hemodynamically unstable - laparotomy; stable - CT and nonoperative management; grade IV-V or ongoing bleeding - angioembolization or packing.

Hepatocellular carcinoma: surveillance with ultrasound ± AFP every 6 months in cirrhosis; resection, transplantation (Milan criteria), or ablation depending on stage.

Whipple procedure (pancreaticoduodenectomy): indications include pancreatic head tumor, ampullary and periampullary carcinoma; postoperative fistula is most common major complication.

Bile duct injury during cholecystectomy: Strasberg classification; recognized injuries repaired immediately by experienced surgeon with Roux-en-Y hepaticojejunostomy.

Thyroid nodule evaluation: TSH, ultrasound with TI-RADS, fine-needle aspiration for nodules ≥1 cm with suspicious features; Bethesda category guides surgery.

Papillary thyroid carcinoma: most common, lymphatic spread; total thyroidectomy ± central neck dissection for tumors >4 cm or nodal disease; radioiodine for high-risk.

Recurrent laryngeal nerve injury: unilateral causes hoarseness, bilateral causes stridor; identify nerve at inferior thyroid artery and ligament of Berry.

Hypocalcemia after total thyroidectomy: monitor calcium and PTH; symptomatic or calcium <7.5 mg/dL requires IV calcium gluconate and oral supplementation.

Primary hyperparathyroidism: elevated calcium with inappropriately normal or high PTH; sestamibi scan and ultrasound for localization; focused parathyroidectomy with intraoperative PTH drop >50%.

Pheochromocytoma: preoperative alpha blockade (phenoxybenzamine) 10-14 days before surgery, then beta blockade for tachycardia; never beta-block first.

Adrenal incidentaloma: assess hormonal function (cortisol, aldosterone, metanephrines) and size; resect if >4 cm, functional, or suspicious imaging features.

Thyroid storm: fever, tachycardia, agitation after stress or surgery; treat with propylthiouracil, iodine, beta blocker, glucocorticoids, and supportive care.

Triple assessment: clinical examination, imaging (ultrasound <40 years, mammography ≥40), and tissue sampling (core needle biopsy preferred over fine-needle aspiration).

Breast cancer staging: tumor size (T), nodal status (N), metastasis (M); sentinel lymph node biopsy for clinically node-negative disease; axillary dissection for positive nodes.

Hormone receptor status: estrogen receptor and progesterone receptor positivity predicts response to tamoxifen or aromatase inhibitors; HER2 positivity indicates trastuzumab.

Breast-conserving surgery plus radiotherapy has survival equivalent to mastectomy for early-stage disease; contraindicated with multicentric disease or prior chest irradiation.

Inflammatory breast cancer: diffuse erythema, peau d'orange, rapid onset; treat with neoadjuvant chemotherapy then mastectomy and radiation; no role for immediate surgery.

Nipple discharge: unilateral bloody or spontaneous requires duct excision or ductoscopy; bilateral milky discharge suggests hyperprolactinemia.

Male breast cancer: usually estrogen receptor positive; mastectomy with sentinel node biopsy; assess BRCA2 status and contralateral risk.

Phyllodes tumor: fibroepithelial lesion with leaf-like architecture; wide local excision with margins ≥1 cm; axillary staging not routinely indicated.

Tension pneumothorax: clinical diagnosis - tracheal deviation, absent breath sounds, hypotension; immediate needle decompression then chest tube; never wait for imaging.

Massive hemothorax: >1500 mL initial drainage or >200 mL/h for 2-4 h; indications for thoracotomy; resuscitate with blood products and correct coagulopathy.

ATLS primary survey: airway with cervical spine protection, breathing, circulation with hemorrhage control, disability, exposure; treat life threats before definitive diagnosis.

Focused assessment with sonography for trauma (FAST): detects pericardial and intraperitoneal fluid; repeat if initially negative and suspicion persists.

Flail chest: ≥3 consecutive ribs fractured in ≥2 places; paradoxical movement; manage with analgesia, pulmonary hygiene, and positive pressure ventilation if respiratory failure.

Damage control surgery: hemorrhage control, contamination control, temporary closure; definitive repair after correction of hypothermia, acidosis, and coagulopathy.

Lung cancer resection: lobectomy with lymph node sampling is standard for stage I-II non-small cell; pneumonectomy reserved for central tumors; assess pulmonary function with FEV1 and DLCO.

Chest tube management: place at 4th-5th intercostal space anterior axillary line; remove when no air leak, drainage <200 mL/day, and lung re-expanded.

Critical limb ischemia: rest pain, ulceration, or gangrene with ankle-brachial index <0.4 or toe pressure <30 mmHg; requires urgent revascularization within 24-48 h.

Acute limb ischemia: 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia); Rutherford classification; heparin immediately, embolectomy or thrombolysis.

Abdominal aortic aneurysm: repair if diameter ≥5.5 cm, growth >1 cm/year, or symptomatic; endovascular repair preferred in high-risk patients with suitable anatomy.

Carotid stenosis: endarterectomy for symptomatic stenosis 70-99% (or 50-69% selected); best within 2 weeks of transient ischemic attack or minor stroke.

Peripheral arterial disease: supervised exercise and antiplatelet therapy for claudication; revascularization for lifestyle-limiting symptoms or tissue loss.

Compartment syndrome: pain out of proportion, tense compartment, pain on passive stretch; pressure >30 mmHg or within 30 mmHg of diastolic indicates fasciotomy.

Deep vein thrombosis: duplex ultrasound diagnostic; anticoagulation with direct oral anticoagulant or low-molecular-weight heparin; inferior vena cava filter if anticoagulation contraindicated.

Varicose veins: endovenous ablation or stripping for symptomatic reflux; compression therapy for ulcer healing; assess great saphenous junction with duplex.

Hypertrophic pyloric stenosis: 3-6 weeks old, nonbilious projectile vomiting, olive mass, hypochloremic hypokalemic metabolic alkalosis; correct fluids then pyloromyotomy.

Intussusception: 6-18 months, colicky pain, currant-jelly stool, sausage-shaped mass; ultrasound target sign; air or contrast enema reduction if stable.

Biliary atresia: jaundice beyond 2 weeks with direct hyperbilirubinemia; ultrasound and biopsy; Kasai portoenterostomy before 60 days improves outcome.

Necrotizing enterocolitis: preterm infant with feeding intolerance, abdominal distension, pneumatosis intestinalis; stop feeds, antibiotics, surgery for perforation.

Congenital diaphragmatic hernia: respiratory distress at birth, scaphoid abdomen, bowel in chest; intubate, decompress stomach, delayed repair after stabilization.

Malrotation with volvulus: bilious vomiting in neonate; emergent upper gastrointestinal contrast study; laparotomy with Ladd procedure.

Undescended testis: orchiopexy by 12-18 months to reduce malignancy and infertility risk; evaluate for disorders of sex development if bilateral.

Appendicitis in children: ultrasound first; perforation common; laparoscopic appendectomy; antibiotics alone selected for uncomplicated cases in some protocols.

TNM staging determines prognosis and treatment; sentinel lymph node biopsy for melanoma >1 mm Breslow thickness or ulceration; completion lymphadenectomy if positive in selected cases.

Margin status: R0 (no tumor at margin), R1 (microscopic), R2 (macroscopic); R1/R2 associated with local recurrence and worse survival in most solid tumors.

Neoadjuvant therapy: downstages locally advanced rectal cancer and breast cancer; improves sphincter preservation and allows breast conservation.

Gastric cancer: D2 lymphadenectomy for resectable disease; perioperative chemotherapy improves survival; HER2 testing guides trastuzumab.

Colorectal liver metastases: resect if technically feasible with adequate future liver remnant; 5-year survival up to 40% after R0 resection.

Soft tissue sarcoma: wide excision with negative margins; radiotherapy for high-grade or deep tumors; avoid enucleation which increases recurrence.

Tumor lysis syndrome: hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia after chemotherapy; prevent with hydration and allopurinol or rasburicase.

Palliative care: symptom control and goals-of-life discussion integrated early in advanced cancer; does not reduce survival and improves quality of life.

Difficult airway algorithm: optimize positioning, video laryngoscopy, supraglottic airway, then surgical airway; limit attempts to avoid airway trauma.

Sepsis-3: suspected infection plus SOFA increase ≥2; lactate and blood cultures before antibiotics; 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

Vasopressors: norepinephrine first-line for septic shock; target mean arterial pressure ≥65 mmHg; add vasopressin for refractory shock.

Acute respiratory distress syndrome: Berlin criteria - onset within 1 week, bilateral opacities, PaO2/FiO2 ≤300 on positive end-expiratory pressure ≥5; low tidal volume 6 mL/kg predicted body weight.

Anesthesia monitoring: pulse oximetry, capnography, electrocardiography, blood pressure, temperature; capnography confirms endotracheal tube placement.

Malignant hyperthermia: hypercarbia, rigidity, hyperthermia after volatile agents or succinylcholine; stop trigger, dantrolene 2.5 mg/kg IV, cool and treat hyperkalemia.

Local anesthetic systemic toxicity: perioral numbness, seizures, cardiovascular collapse; stop injection, lipid emulsion 20% 1.5 mL/kg bolus then infusion.

Transfusion: restrictive threshold Hb 7 g/dL (8 g/dL in cardiac disease); massive transfusion protocol 1:1:1 ratio of plasma, platelets, and red cells.

Informed consent: must include diagnosis, nature and purpose of procedure, risks and benefits, alternatives, and consequences of refusal; document discussion and patient signature.

Informed consent exceptions: emergency when patient lacks capacity and no surrogate, therapeutic privilege (limited), and legally mandated treatment.

Confidentiality: protected health information may be disclosed only with patient authorization or legal requirement; minimum necessary standard applies.

Medical error disclosure: duty to disclose harmful errors to patient and family; apologize and explain; documentation in the record; root cause analysis for system improvement.

Cuba's public health system: universal coverage through the Ministry of Public Health (MINSAP); primary care via family doctor-and-nurse teams; free at point of service.

Surgical audit and quality: track morbidity and mortality conferences, surgical site infection rates, reoperation rates, and mortality; use for system improvement not blame.

Organ donation: Cuba uses presumed consent with family authorization; brain death criteria require clinical and confirmatory testing per protocol.

Professional liability: malpractice requires duty, breach, causation, and damages; documentation and adherence to protocols are key defenses.

Airway assessment: Mallampati class, thyromental distance <6 cm, mouth opening <3 cm, and neck mobility predict difficulty; plan backup devices.

Rapid sequence induction: preoxygenation, cricoid pressure (controversial), induction agent, succinylcholine or rocuronium; indicated for full stomach or aspiration risk.

Spinal anesthesia: contraindicated with coagulopathy, infection at site, hypovolemia, and raised intracranial pressure; hypotension treated with fluids and vasopressors.

Postoperative nausea and vomiting: Apfel score (female, nonsmoker, history, opioids); prophylaxis with ondansetron and dexamethasone for high-risk patients.

Acute kidney injury: KDIGO criteria - creatinine rise ≥0.3 mg/dL in 48 h or urine output <0.5 mL/kg/h for 6 h; avoid nephrotoxins and optimize perfusion.

Mechanical ventilation: lung-protective strategy with tidal volume 6-8 mL/kg predicted body weight, plateau pressure <30 cmH2O, and appropriate positive end-expiratory pressure.

Cardiopulmonary resuscitation: high-quality compressions 100-120/min depth 5-6 cm; early defibrillation for shockable rhythms; epinephrine 1 mg every 3-5 min.

Delirium in intensive care: assess with CAM-ICU; nonpharmacologic measures first; avoid benzodiazepines; treat pain and sleep disruption.

Breast cancer molecular subtypes: luminal A (ER/PR positive, HER2 negative, low Ki-67) has best prognosis; triple-negative has highest early recurrence risk.

Melanoma: Breslow thickness and ulceration are strongest prognostic factors; sentinel node biopsy for thickness >1 mm or >0.8 mm with ulceration.

Thyroid cancer: papillary has excellent prognosis; medullary associated with RET mutation and MEN2; anaplastic is rapidly fatal.

Esophageal cancer: neoadjuvant chemoradiotherapy for locally advanced squamous or adenocarcinoma; esophagectomy with two-field lymphadenectomy.

Pancreatic cancer: only 15-20% resectable at diagnosis; FOLFIRINOX or gemcitabine-based neoadjuvant therapy for borderline resectable disease.

Hepatocellular carcinoma surveillance: ultrasound every 6 months in cirrhosis; diagnosis with multiphasic CT or MRI showing arterial enhancement and venous washout.

Colorectal cancer: mismatch repair deficiency predicts response to immunotherapy; test all patients for Lynch syndrome.

Radiation therapy: adjuvant for breast conservation, rectal cancer, and sarcoma; can cause fibrosis, lymphedema, and secondary malignancy.

Hemorrhagic shock classification: class I <15% blood loss, class II 15-30% (tachycardia), class III 30-40% (hypotension), class IV >40% (profound shock).

Pelvic fracture: apply pelvic binder at level of greater trochanter; exclude urethral injury before catheterization; angioembolization for arterial bleeding.

Splenic injury: nonoperative management for hemodynamically stable grades I-III; angioembolization for grade IV-V with contrast blush; splenectomy for instability.

Liver injury: nonoperative management for stable patients; operative packing and Pringle maneuver for hemorrhage; angioembolization for arterial bleeding.

Traumatic brain injury: Glasgow Coma Scale ≤8 requires intubation; avoid hypotension and hypoxia; head CT for loss of consciousness or neurologic deficit.

Abdominal compartment syndrome: bladder pressure >20 mmHg with new organ dysfunction; decompressive laparotomy; avoid excessive fluid resuscitation.

Burn resuscitation: Parkland formula 4 mL/kg/% total body surface area lactated Ringer in first 24 h, half in first 8 h; urine output 0.5 mL/kg/h.

Tetanus prophylaxis: wound cleaning; toxoid booster if >5 years since last dose; immunoglobulin for contaminated wounds with unknown status.

Aortic dissection: Stanford type A involves ascending aorta - emergency surgery; type B managed medically unless complicated by malperfusion or rupture.

Ruptured abdominal aortic aneurysm: triad of hypotension, pulsatile abdominal mass, and back pain; permissive hypotension and immediate surgery.

Peripheral bypass graft surveillance: duplex ultrasound at 1, 3, 6, and 12 months; stenosis >70% or velocity ratio >3.5 predicts failure.

Diabetic foot: assess with monofilament and ankle-brachial index; revascularization for ischemia; offloading and debridement for ulcers.

Carotid endarterectomy: performed under local or general anesthesia; monitor for cranial nerve injury, hematoma, and hyperperfusion syndrome.

Venous ulcer: compression therapy is cornerstone; assess venous reflux with duplex; treat underlying reflux with ablation or surgery.

Pulmonary embolism: computed tomography pulmonary angiography diagnostic; anticoagulation; thrombolysis for hemodynamic instability.

Lymphedema: complex decongestive therapy with compression and manual drainage; surgery for refractory cases.

Neonatal bowel obstruction: bilious vomiting is surgical emergency until proven otherwise; differentiate duodenal atresia (double bubble) from jejunoileal atresia (multiple levels).

Meckel diverticulum: rule of 2s - 2% population, 2 feet from ileocecal valve, 2 inches long, 2 types of ectopic tissue; painless rectal bleeding in children.

Hirschsprung disease: aganglionic segment; delayed meconium, abdominal distension; diagnosis with rectal biopsy; pull-through procedure.

Inguinal hernia in infants: high risk of incarceration; repair promptly after diagnosis; contralateral exploration controversial.

Omphalocele vs gastroschisis: omphalocele covered by membrane and associated with chromosomal anomalies; gastroschisis free bowel with no membrane.

Pyloric stenosis: ultrasound shows pyloric muscle thickness >3 mm and length >14 mm; correct alkalosis before surgery.

Testicular torsion: acute scrotal pain, high-riding testis, absent cremasteric reflex; surgical exploration within 6 h for salvage.

Pediatric trauma: most common cause of death in children; head injury most frequent; weight-based dosing and pediatric-specific equipment.

Mirizzi syndrome: common hepatic duct obstruction by impacted stone in cystic duct or gallbladder neck; jaundice and cholangitis; cholecystectomy with careful dissection.

Cholangitis: Charcot triad (fever, jaundice, right upper quadrant pain); Reynolds pentad adds hypotension and altered mental status; ERCP drainage plus antibiotics.

Liver abscess: pyogenic most common; ultrasound or CT-guided drainage plus antibiotics; amoebic abscess treated with metronidazole.

Hepatic adenoma: associated with oral contraceptives; resect if >5 cm or symptomatic due to rupture risk; stop hormones.

Hydatid cyst: Echinococcus granulosus; albendazole before and after surgery; avoid spillage; PAIR technique for selected cysts.

Portal hypertension: variceal bleeding managed with octreotide, antibiotics, and endoscopic band ligation; transjugular intrahepatic portosystemic shunt for refractory bleeding.

Pancreatic neuroendocrine tumors: insulinoma (Whipple triad), gastrinoma (Zollinger-Ellison), glucagonoma (necrolytic migratory erythema); enucleation or resection.

Postoperative pancreatic fistula: amylase-rich drainage >3 times serum amylase on day 3; manage with drainage, octreotide, and nutritional support.

Thyroidectomy complications: recurrent laryngeal nerve injury, hypocalcemia, hematoma causing airway compromise, and tracheomalacia; hematoma requires immediate opening of wound.

Graves disease: total thyroidectomy for refractory disease or compressive goiter; pretreat with antithyroid drugs and beta blockers; iodine before surgery.

Medullary thyroid carcinoma: calcitonin and carcinoembryonic antigen for monitoring; total thyroidectomy with central neck dissection; screen for RET mutation.

Parathyroid carcinoma: severe hypercalcemia, elevated PTH, palpable mass; en bloc resection with negative margins; avoid capsular rupture.

Adrenalectomy: laparoscopic for benign tumors <6 cm; open for large or invasive tumors; perioperative steroid coverage for bilateral resection or Cushing syndrome.

Conn syndrome: aldosterone-producing adenoma; elevated aldosterone with suppressed renin; adrenalectomy or mineralocorticoid antagonist.

Cushing syndrome: 24-hour urinary free cortisol and dexamethasone suppression test; adrenalectomy for adrenal source; pituitary surgery for Cushing disease.

Thyroglossal duct cyst: midline neck mass moving with swallowing and tongue protrusion; Sistrunk procedure removes cyst and central hyoid bone.

Sentinel lymph node biopsy: dual tracer (blue dye and radiolabeled colloid) improves identification; avoid in inflammatory breast cancer or clinically positive axilla.

Ductal carcinoma in situ: noninvasive; treat with breast-conserving surgery plus radiation or mastectomy; sentinel node biopsy if mastectomy planned.

BRCA mutation: prophylactic bilateral mastectomy reduces breast cancer risk by >90%; consider risk-reducing salpingo-oophorectomy for BRCA1/2.

Nipple-sparing mastectomy: oncologically safe for selected early-stage cancers; contraindicated with tumor involvement of nipple-areola complex.

Breast abscess: ultrasound-guided aspiration or incision and drainage; continue breastfeeding if possible; antibiotics for cellulitis.

Gynecomastia: physiologic in puberty and aging; medications and liver disease common causes; surgery for persistent symptomatic cases.

Fat necrosis: firm mass after trauma or surgery; imaging may mimic malignancy; core biopsy if uncertain.

Axillary web syndrome: palpable cords after axillary surgery; managed with physical therapy and stretching.

Peptic ulcer disease: Helicobacter pylori eradication reduces recurrence; urgent endoscopy for bleeding; surgery for perforation or refractory bleeding.

Perforated peptic ulcer: pneumoperitoneum on plain film; omental patch repair (Graham patch) with peritoneal lavage; antibiotics and proton pump inhibitor.

Crohn disease: transmural inflammation, skip lesions, fistulas; surgery for stricture, fistula, or abscess; conservative resection with anastomosis.

Ulcerative colitis: mucosal inflammation from rectum; surgery with proctocolectomy and ileal pouch-anal anastomosis for refractory disease or dysplasia.

Diverticulitis: Hinchey classification; antibiotics for uncomplicated; percutaneous drainage for abscess; resection for perforation or recurrent disease.

Ischemic colitis: watershed areas (splenic flexure); colonoscopy shows mucosal ischemia; supportive care; surgery for gangrene or perforation.

Gastric outlet obstruction: caused by ulcer, malignancy, or pancreatitis; nasogastric decompression; endoscopic stenting for malignant obstruction.

Colonic volvulus: sigmoid most common; coffee-bean sign on plain film; endoscopic detorsion then elective resection.

Surgical wound closure: primary closure for clean wounds; delayed primary or secondary intention for contaminated wounds; drains for dead space or infection.

Suture selection: absorbable (polyglactin, poliglecaprone) for mucosa and subcutaneous; nonabsorbable (polypropylene, nylon) for fascia and skin.

Electrosurgery: monopolar for cutting and coagulation; bipolar for precise hemostasis near nerves; avoid in patients with implanted pacemakers.

Surgical staplers: linear for transection and anastomosis; circular for end-to-end anastomosis; check staple line integrity.

Postoperative ileus: expected after abdominal surgery; nasogastric decompression if vomiting; early ambulation and gum chewing may hasten recovery.

Wound dehiscence: sudden discharge of serosanguineous fluid; risk factors include obesity, malnutrition, and increased abdominal pressure; reoperation for evisceration.

Surgical antibiotic prophylaxis: cefazolin for most procedures; add metronidazole for colorectal; avoid prolonged postoperative antibiotics.

Blood transfusion reactions: febrile nonhemolytic most common; hemolytic reaction with fever, hypotension, and hemoglobinuria requires immediate cessation.

Mechanical ventilation weaning: assess readiness with spontaneous breathing trial; rapid shallow breathing index <105 predicts success.

Sedation in intensive care: target Richmond Agitation-Sedation Scale 0 to -2; daily interruption reduces ventilator days.

Ventilator-associated pneumonia: prevention with head elevation, oral care, and sedation interruption; diagnose with quantitative cultures.

Acute coronary syndrome: ST-elevation myocardial infarction requires reperfusion within 90 minutes; aspirin and anticoagulation.

Diabetic ketoacidosis: fluid resuscitation, insulin infusion, potassium replacement; monitor anion gap and mental status.

Hyperkalemia: calcium gluconate for cardiac protection; insulin and glucose, beta agonists, and dialysis for refractory cases.

Nutrition in critical illness: enteral nutrition within 24-48 hours; trophic feeding for shock; avoid overfeeding.

Brain death: irreversible loss of brain function; require apnea test and confirmatory studies; organ donation discussion with family.

Surgical quality indicators: surgical site infection, venous thromboembolism prophylaxis, mortality, readmission, and patient satisfaction.

Operating room efficiency: first-case on-time starts, turnover time, and cancellation rates are key metrics.

Credentialing and privileging: verify training and competence before granting surgical privileges; periodic reappraisal.

Patient safety: WHO surgical safety checklist reduces mortality and complications; includes sign-in, time-out, and sign-out.

Health economics: cost-effectiveness analysis uses quality-adjusted life years; budget impact analysis for resource allocation.

Medical records: complete operative note includes preoperative and postoperative diagnosis, procedure, findings, and complications.

Risk management: incident reporting systems and morbidity and mortality conferences identify system errors.

Cuba's health administration: MINSAP oversees national health system; provincial and municipal directorates manage local services.

Capacity assessment: patient understands information, appreciates consequences, reasons, and communicates choice; delirium and depression impair capacity.

Advance directives: living will and durable power of attorney for health care; follow patient's documented wishes.

Research ethics: institutional review board approval, informed consent, and risk minimization; Declaration of Helsinki principles.

Organ transplantation ethics: allocation based on medical urgency and equity; avoid commercialism; Cuba prohibits organ trafficking.

End-of-life care: palliative sedation for refractory symptoms; withhold and withdraw life-sustaining treatment per patient wishes.

Medical malpractice: expert testimony establishes standard of care; documentation of informed consent and clinical reasoning is essential.

Professional boundaries: avoid conflicts of interest; disclose relationships with industry; maintain patient confidentiality.

Error disclosure: disclose preventable harm; apologize; explain what happened and what will be done to prevent recurrence.

Primary survey: airway, breathing, circulation, disability, exposure; adjuncts include electrocardiography, pulse oximetry, and urinary catheter.

Secondary survey: head-to-toe examination, history (AMPLE), and imaging; reassess frequently for deterioration.

Hemothorax: chest tube drainage; autotransfusion possible; thoracotomy for massive bleeding.

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

Abdominal trauma: FAST and CT for stable patients; laparotomy for hemodynamic instability or peritonitis.

Renal trauma: CT with contrast for staging; nonoperative management for most blunt injuries; surgery for hemodynamic instability.

Urethral injury: blood at meatus, perineal hematoma; retrograde urethrogram before catheterization.

Tetanus and rabies prophylaxis: assess wound and vaccination status; rabies immunoglobulin for animal bites.

Aortic aneurysm screening: ultrasound for men aged 65-75 with smoking history; repeat every 5 years if normal.

Peripheral arterial disease: ankle-brachial index <0.9 diagnostic; exercise ankle-brachial index for borderline cases.

Acute mesenteric ischemia: superior mesenteric artery embolism common; CT angiography; embolectomy or bypass.

Renal artery stenosis: hypertension and renal dysfunction; duplex ultrasound and angiography; angioplasty for fibromuscular dysplasia.

Subclavian steal syndrome: arm claudication and dizziness; duplex shows reversed vertebral flow; bypass or stenting.

Thoracic outlet syndrome: neurogenic most common; physical therapy; surgery for refractory cases.

Vascular access: arteriovenous fistula preferred for dialysis; assess maturation at 6 weeks; avoid central venous catheters.

Amputation: below-knee amputation preserves knee function; above-knee for nonsalvageable limb; rehabilitation essential.

Congenital pyloric stenosis: metabolic alkalosis with hypochloremia and hypokalemia; correct with normal saline and potassium before surgery.

Duodenal atresia: double-bubble sign; associated with Down syndrome; surgery after stabilization.

Jejunoileal atresia: multiple dilated loops; resection with primary anastomosis.

Meconium ileus: associated with cystic fibrosis; Gastrografin enema diagnostic and therapeutic; surgery if unsuccessful.

Anorectal malformation: assess with perineal inspection; colostomy for high lesions; posterior sagittal anorectoplasty.

Hirschsprung disease: rectal biopsy confirms aganglionosis; pull-through at 3-6 months.

Wilms tumor: abdominal mass in child; nephrectomy with chemotherapy; staging with CT.

Neuroblastoma: adrenal or sympathetic chain; elevated catecholamines; surgery and chemotherapy.

Gallstone ileus: stone in terminal ileum; Rigler triad (pneumobilia, small bowel obstruction, ectopic stone); surgery for obstruction.

Choledochal cyst: risk of cholangiocarcinoma; excision with Roux-en-Y hepaticojejunostomy.

Liver trauma grading: American Association for the Surgery of Trauma grades I-VI; grade VI is avulsion.

Hepatic encephalopathy: lactulose and rifaximin; identify precipitating factors.

Ascites: paracentesis for diagnosis; spontaneous bacterial peritonitis with neutrophils >250/mm3; antibiotics.

Pancreatic ascites: disrupted pancreatic duct; endoscopic stenting or surgery.

Insulinoma: Whipple triad; fasting hypoglycemia with elevated insulin; enucleation.

Gastrinoma: Zollinger-Ellison syndrome; elevated gastrin; proton pump inhibitor and resection.

Preoperative evaluation: history, physical, and testing guided by comorbidities; electrocardiogram for cardiac risk.

Airway management: bag-mask ventilation, supraglottic airway, endotracheal intubation, surgical airway.

Anesthesia depth: bispectral index monitoring for awareness prevention; volatile agents and total intravenous anesthesia.

Neuromuscular blockade: train-of-four monitoring; reversal with sugammadex or neostigmine.

Regional anesthesia: brachial plexus block for upper extremity; femoral nerve block for knee surgery.

Postoperative analgesia: multimodal with acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids.

Fluid management: goal-directed therapy; avoid excessive crystalloid.

Malignant hyperthermia: dantrolene 2.5 mg/kg; cooling; monitor for rhabdomyolysis.

Sentinel lymph node biopsy: blue dye and radiolabeled colloid; identify hot node with gamma probe.

Breast cancer: neoadjuvant chemotherapy for locally advanced; assess response with imaging.

Melanoma: wide excision margins based on Breslow thickness; 1 cm for ≤1 mm, 2 cm for >2 mm.

Colorectal cancer: total mesorectal excision for rectal cancer; circumferential margin important.

Gastric cancer: D2 lymphadenectomy; perioperative chemotherapy.

Esophageal cancer: neoadjuvant chemoradiotherapy; esophagectomy.

Pancreatic cancer: FOLFIRINOX; borderline resectable.

Hepatocellular carcinoma: Milan criteria for transplantation; single tumor ≤5 cm or up to 3 tumors ≤3 cm.

Informed consent: document discussion of risks, benefits, alternatives, and consequences of refusal.

Confidentiality: protect patient information; disclose only with authorization or legal requirement.

Medical error: disclose harm; apologize; implement system changes.

Cuba health system: universal coverage; family doctor-and-nurse teams; free at point of service.

Surgical audit: morbidity and mortality conferences; track quality indicators.

Organ donation: presumed consent with family authorization; brain death criteria.

Professional liability: duty, breach, causation, damages; documentation key.

Health administration: MINSAP oversees national system; provincial and municipal directorates.

Hemorrhagic shock: class I-IV; resuscitate with blood products.

Pelvic fracture: pelvic binder; exclude urethral injury.

Splenic injury: nonoperative management for stable; angioembolization.

Liver injury: packing and Pringle maneuver; angioembolization.

Traumatic brain injury: Glasgow Coma Scale ≤8 intubate; avoid hypotension.

Abdominal compartment syndrome: bladder pressure >20 mmHg; decompressive laparotomy.

Burn resuscitation: Parkland formula.

Tetanus prophylaxis: toxoid booster; immunoglobulin for contaminated wounds.

Aortic dissection: type A emergency surgery; type B medical.

Ruptured abdominal aortic aneurysm: triad; permissive hypotension.

Peripheral bypass surveillance: duplex ultrasound.

Diabetic foot: monofilament and ankle-brachial index.

Carotid endarterectomy: monitor cranial nerve injury.

Venous ulcer: compression therapy.

Pulmonary embolism: computed tomography pulmonary angiography; anticoagulation.

Lymphedema: complex decongestive therapy.

Peptic ulcer disease: Helicobacter pylori eradication.

Perforated peptic ulcer: omental patch repair.

Crohn disease: conservative resection.

Ulcerative colitis: proctocolectomy with ileal pouch-anal anastomosis.

Diverticulitis: Hinchey classification.

Ischemic colitis: watershed areas.

Gastric outlet obstruction: endoscopic stenting.

Colonic volvulus: endoscopic detorsion.

Surgical wound closure: primary closure for clean wounds.

Suture selection: absorbable vs nonabsorbable.

Electrosurgery: monopolar and bipolar.

Surgical staplers: linear and circular.

Postoperative ileus: nasogastric decompression.

Wound dehiscence: reoperation for evisceration.

Surgical antibiotic prophylaxis: cefazolin.

Blood transfusion reactions: febrile nonhemolytic most common.