UKOM Sp.B cheat sheet

Acute appendicitis: Alvarado score ≥7 supports operative management; CT/USG indicated when score is equivocal (4–6), especially in women of childbearing age.

Acute cholecystitis (Tokyo Guidelines): Grade III (organ dysfunction) requires urgent biliary drainage plus antibiotics; early laparoscopic cholecystectomy within 72 hours is preferred for Grades I–II.

Acute pancreatitis: Atlanta classification - mild (no organ failure, no local complications), moderately severe (transient organ failure <48 h or local complications), severe (persistent organ failure >48 h).

Bowel obstruction: supine and upright abdominal radiographs show air-fluid levels; CT with IV contrast is the test of choice to identify transition point, strangulation, and closed-loop obstruction.

Perforated peptic ulcer: free subdiaphragmatic gas on upright chest film; non-operative (Omental/Graham patch) versus definitive repair depends on stability and peritoneal contamination.

Colorectal cancer staging (TNM 8th edition): T1 invades submucosa, T2 muscularis propria, T3 subserosa/pericolic fat, T4 peritoneal reflection or adjacent organs; N1 = 1–3 nodes, N2 = ≥4 nodes.

Hartmann procedure (rectosigmoid resection with end colostomy) is preferred in perforated left-sided diverticulitis with hemodynamic instability or fecal peritonitis; primary anastomosis with diverting ileostomy is an alternative in selected stable patients.

Liver trauma: hemodynamically stable patients with contrast blush on CT may be managed by angioembolization; unstable patients require operative packing and damage-control laparotomy.

Breast cancer: sentinel lymph node biopsy is standard for clinically node-negative axilla; axillary lymph node dissection is reserved for ≥3 positive sentinel nodes or residual disease after neoadjuvant therapy.

Breast conservation requires negative margins (no ink on tumor for invasive disease; 2 mm for DCIS) plus whole-breast radiotherapy; mastectomy is indicated for multicentric disease or inability to achieve negative margins.

Colorectal liver metastases: resectability requires ability to leave ≥20–30% future liver remnant with adequate inflow, outflow, and biliary drainage; portal vein embolization is used to induce hypertrophy.

Gastric cancer: D2 lymphadenectomy (perigastric plus celiac/splenic/hepatic nodes) is standard for resectable disease; R0 resection with ≥15 nodes examined is the quality benchmark.

Thyroid cancer: papillary carcinoma spreads via lymphatics; follicular carcinoma spreads hematogenously to bone and lung; medullary carcinoma arises from parafollicular C cells and is monitored by calcitonin.

Soft tissue sarcoma: wide local excision with negative margins (R0) is the goal; limb-sparing surgery plus radiotherapy is equivalent to amputation for extremity sarcoma in selected cases.

Hepatocellular carcinoma: surgical resection is preferred for Child-Pugh A patients with solitary tumors and preserved liver function; Milan criteria (single ≤5 cm or ≤3 nodules each ≤3 cm) guide transplant eligibility.

Tumor markers: CEA for colorectal cancer surveillance, CA 19-9 for pancreatic cancer, AFP for hepatocellular carcinoma, CA 125 for ovarian cancer; none are diagnostic screening tests alone.

ATLS primary survey: A (airway with cervical spine protection), B (breathing/ventilation), C (circulation with hemorrhage control), D (disability/GCS), E (exposure/environment).

Hemorrhagic shock classes (ATLS): Class I <15% blood loss, Class II 15–30% (tachycardia), Class III 30–40% (hypotension, altered mentation), Class IV >40% (lethargy, negligible urine output).

Massive transfusion protocol: balanced ratio of plasma:platelets:PRBC approximately 1:1:1; permissive hypotension (SBP ~90 mmHg) until hemorrhage control in penetrating trauma without TBI.

FAST exam detects free fluid in pericardial, perihepatic, perisplenic, and pelvic windows; it is not reliable for retroperitoneal or hollow-viscus injury.

REBOA (resuscitative endovascular balloon occlusion of the aorta) is a temporizing measure for non-compressible torso hemorrhage; Zone I (descending thoracic) for abdominal hemorrhage, Zone III for pelvic hemorrhage.

Damage-control laparotomy: control hemorrhage and contamination, temporary abdominal closure, ICU resuscitation, then planned re-look at 24–48 hours.

Pelvic fracture with hemodynamic instability: pelvic binder at the level of the greater trochanters, then preperitoneal packing or angioembolization depending on blush on CT.

Traumatic brain injury: GCS ≤8 requires intubation; avoid hypotension (SBP <90 mmHg) and hypoxia (SpO2 <90%) to prevent secondary brain injury; hypertonic saline or mannitol for herniation signs.

Rutherford classification of chronic limb ischemia: Category 4 = rest pain, Category 5 = minor tissue loss, Category 6 = major tissue loss; ABI <0.4 suggests critical limb ischemia.

ABI interpretation: 0.9–1.3 normal, <0.9 indicates peripheral arterial disease, >1.3 suggests non-compressible vessels (diabetes, CKD).

Acute limb ischemia (6 P's: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia) requires immediate anticoagulation with heparin and revascularization within 6 hours; Rutherford IIb (sensory loss, muscle weakness) mandates urgent surgery.

Carotid endarterectomy is indicated for symptomatic stenosis ≥70% (NASCET) and for asymptomatic stenosis ≥60–70% in centers with low perioperative stroke rates.

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

EVAR versus open repair: EVAR has lower 30-day mortality but higher reintervention rates; open repair preferred for younger patients with favorable anatomy and long life expectancy.

Varicose veins: great saphenous vein reflux treated with endovenous laser/radiofrequency ablation or stripping; compression stockings are a temporizing measure, not definitive therapy.

Aortic dissection Stanford type A (involving ascending aorta) is a surgical emergency; type B (descending only) is managed medically with blood pressure control unless complicated by malperfusion or rupture.

Hypertrophic pyloric stenosis: non-bilious projectile vomiting at 3–6 weeks, palpable olive, hypochloremic hypokalemic metabolic alkalosis; treatment is pyloromyotomy after correcting electrolytes.

Intussusception: colicky pain, red currant jelly stool, sausage-shaped mass; air or contrast enema is both diagnostic and therapeutic in stable patients without peritonitis.

Biliary atresia: persistent conjugated hyperbilirubinemia in a neonate requires urgent evaluation; Kasai portoenterostomy is most successful if performed before 60 days of life.

Necrotizing enterocolitis: prematurity, feeding intolerance, bloody stools, pneumatosis intestinalis on radiograph; perforation (pneumoperitoneum) is an indication for surgery.

Inguinal hernia in infants: risk of incarceration is highest in the first year; repair is recommended shortly after diagnosis, with urgent repair if incarcerated and not reducible.

Wilms tumor: abdominal mass in children 2–5 years, associated with WT1 mutations and hemihypertrophy; nephrectomy plus chemotherapy per NWTS/COG protocols.

Neuroblastoma: arises from neural crest, elevated urinary VMA/HVA, calcification on CT; prognosis depends on age, MYCN amplification, and stage.

Malrotation with midgut volvulus: bilious vomiting in a neonate is a surgical emergency; upper GI contrast study showing corkscrew sign mandates urgent Ladd procedure.

Burn depth: superficial partial-thickness heals spontaneously in 2 weeks; deep partial-thickness and full-thickness require excision and grafting.

Parkland formula: 4 mL × body weight (kg) × %TBSA burned of Ringer's lactate in 24 hours; half in the first 8 hours from burn time.

Rule of nines (adults): head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%.

Skin graft: split-thickness grafts survive by imbibition (24–48 h), inosculation (48–72 h), and neovascularization; full-thickness grafts provide better color match and less contracture.

Flap classification: random pattern (subdermal plexus) versus axial pattern (named vessel); perforator flaps (DIEP, ALT) spare muscle and reduce donor-site morbidity.

Cleft lip repair (Millard rotation-advancement) at 3–6 months; cleft palate repair at 9–12 months to optimize speech and midface growth.

Pressure ulcer staging: Stage I non-blanchable erythema, Stage II partial-thickness loss, Stage III full-thickness to fascia, Stage IV to bone/tendon; unstageable when eschar obscures depth.

Hand infection: flexor tenosynovitis (Kanavel signs: fusiform swelling, tenderness along sheath, pain on passive extension, flexed posture) requires urgent surgical drainage.

Femoral neck fracture: Garden classification I–IV; Garden I–II in young patients may be treated with internal fixation, while displaced fractures in elderly patients are treated with hemiarthroplasty or total hip arthroplasty.

Open fracture: Gustilo-Anderson classification; Type I–III; Type IIIB requires flap coverage, Type IIIC involves vascular injury requiring repair.

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

Anterior cruciate ligament tear: positive Lachman and pivot-shift tests; MRI confirms; reconstruction with hamstring or patellar tendon autograft in active patients.

Carpal tunnel syndrome: median nerve compression; positive Phalen and Tinel tests; night splinting and corticosteroid injection first-line, surgical release for refractory cases.

Osteosarcoma: metaphyseal region of long bones in adolescents, sunburst periosteal reaction, Codman triangle; neoadjuvant chemotherapy plus limb-salvage resection.

Developmental dysplasia of the hip: Ortolani and Barlow maneuvers in neonates; Pavlik harness for infants <6 months; closed or open reduction for older children.

Septic arthritis: joint aspiration with Gram stain and culture, elevated WBC and ESR/CRP; urgent arthroscopic or open washout plus IV antibiotics.

Glasgow Coma Scale: eye 1–4, verbal 1–5, motor 1–6; total 3–15; GCS ≤8 indicates severe head injury and need for airway protection.

Traumatic epidural hematoma: lens-shaped, middle meningeal artery, lucid interval; subdural hematoma: crescent-shaped, bridging veins, common in elderly and alcoholics.

Intracranial pressure (ICP) monitoring indicated for GCS ≤8 with abnormal CT; target CPP = MAP − ICP, generally 60–70 mmHg.

Cushing triad (hypertension, bradycardia, irregular respiration) indicates raised ICP and impending herniation; hyperventilation to PaCO2 30–35 mmHg is a temporizing measure.

Aneurysmal subarachnoid hemorrhage: thunderclap headache, CT within 6 hours highly sensitive; lumbar puncture for xanthochromia if CT negative; nimodipine prevents vasospasm.

Brain tumors: glioblastoma (WHO grade IV) has IDH-wildtype and MGMT promoter methylation status guiding temozolomide; meningioma is typically extra-axial and dural-based.

Lumbar disc herniation: conservative management first; surgery indicated for cauda equina syndrome (urgent), progressive motor deficit, or refractory radicular pain.

Shunt complications: obstruction, infection (Staphylococcus epidermidis most common), and overdrainage; shunt series and CSF culture guide management.

Renal colic: non-contrast CT is the gold standard; stones <5 mm usually pass spontaneously; >10 mm or infected obstructed system requires urgent decompression (ureteral stent or percutaneous nephrostomy).

Benign prostatic hyperplasia: IPSS symptom score, PSA, digital rectal exam, uroflowmetry; medical therapy with alpha-blockers and 5-alpha reductase inhibitors; TURP for refractory symptoms.

Prostate cancer: PSA >4 ng/mL warrants evaluation; Gleason score and Grade Group guide risk stratification; active surveillance for low-risk disease.

Testicular torsion: acute scrotal pain with absent cremasteric reflex; Doppler ultrasound shows decreased flow; detorsion and bilateral orchiopexy within 6 hours to preserve testis.

Bladder cancer: painless gross hematuria is the most common presentation; cystoscopy with transurethral resection is diagnostic; muscle-invasive disease requires radical cystectomy or radiotherapy.

Renal cell carcinoma: clear cell subtype most common; partial nephrectomy preferred for T1 tumors; radical nephrectomy for larger or centrally located tumors.

Urinary tract infection with obstruction (pyonephrosis) is a urologic emergency requiring drainage; antibiotics alone are insufficient.

Hypospadias: ventral urethral meatus, dorsal hood, chordee; repair at 6–18 months; circumcision should be avoided before repair to preserve skin for reconstruction.

ASA physical status: I healthy, II mild systemic disease, III severe systemic disease, IV severe disease with constant threat to life, V moribund, VI brain-dead organ donor; suffix E for emergency.

Mallampati classification I–IV predicts difficult airway; Cormack-Lehane grade I–IV describes laryngoscopic view; grade III–IV suggests difficult intubation.

Rapid sequence induction: preoxygenation, induction agent (ketamine or etomidate in hemodynamic instability), succinylcholine or rocuronium, cricoid pressure, immediate intubation.

Sepsis-3: sepsis = life-threatening organ dysfunction from dysregulated host response, defined by SOFA increase ≥2; septic shock = vasopressor requirement to maintain MAP ≥65 mmHg with lactate >2 mmol/L despite fluid resuscitation.

ARDS Berlin criteria: acute onset within 1 week, bilateral opacities, PaO2/FiO2 ≤300 mmHg with PEEP ≥5 cmH2O; lung-protective ventilation with tidal volume 6 mL/kg predicted body weight.

Malignant hyperthermia: autosomal dominant ryanodine receptor mutation triggered by volatile anesthetics and succinylcholine; treat with dantrolene 2.5 mg/kg IV and supportive cooling.

Local anesthetic systemic toxicity: stop injection, secure airway, benzodiazepines for seizures, 20% lipid emulsion 1.5 mL/kg bolus followed by infusion.

Perioperative beta-blockade should not be started on the day of surgery; continue chronic beta-blockers; avoid abrupt withdrawal to prevent rebound tachycardia.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; documentation of the discussion is essential.

Four principles of biomedical ethics: autonomy, beneficence, non-maleficence, and justice; when principles conflict, autonomy generally prevails for competent adults.

Confidentiality may be breached when required by law (reportable communicable diseases, gunshot wounds in some jurisdictions) or when there is a serious threat to a specific identifiable person.

Medical negligence requires four elements: duty of care, breach of standard of care, causation, and damages; the standard is what a reasonably competent practitioner would do.

Do-not-resuscitate orders require discussion with the patient or surrogate; in incompetent patients, advance directives and best-interest standards guide decisions.

Research ethics: Declaration of Helsinki and Belmont Report principles (respect for persons, beneficence, justice); institutional review board approval and informed consent are mandatory.

Professionalism includes honesty, integrity, respect for patient dignity, cultural competence, and appropriate management of conflicts of interest.

Mandatory reporting: child abuse, elder abuse, and certain communicable diseases must be reported to authorities even without patient consent.

Levels of evidence (Oxford CEBM): systematic reviews of RCTs at the top, then RCTs, cohort studies, case-control studies, case series, and expert opinion at the bottom.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence; likelihood ratio positive = sensitivity/(1−specificity).

Number needed to treat (NNT) = 1/absolute risk reduction; number needed to harm (NNH) = 1/absolute risk increase.

Randomized controlled trial: randomization reduces selection bias; blinding reduces performance and detection bias; intention-to-treat analysis preserves randomization benefits.

Confidence interval: 95% CI indicates the range in which the true effect lies with 95% probability; if the CI for a risk ratio crosses 1.0, the result is not statistically significant at α = 0.05.

p-value is the probability of observing the data (or more extreme) given the null hypothesis is true; it is not the probability that the null hypothesis is true.

Meta-analysis: heterogeneity assessed by I² statistic; I² >50% suggests substantial heterogeneity; funnel plot asymmetry suggests publication bias.

Diagnostic test: a test with high sensitivity is useful for ruling out disease (SnNout); a test with high specificity is useful for ruling in disease (SpPin).