Surgery
General surgery, trauma and perioperative care are examined through "next step" questions: the vignette gives you a stable or unstable patient and asks what you do now. Israeli papers often reuse the same few scenarios - appendicitis, acute cholecystitis, diverticulitis, bowel obstruction, strangulated hernia, and blunt abdominal trauma.
Core rules
- Trauma priorities: catastrophic haemorrhage, airway, breathing, circulation. Pelvic fracture with hypotension → pelvic binder, massive transfusion protocol, and no repeated log-rolling.
- FAST is for the unstable patient; CT is for the stable one. Never send a shocked patient to the scanner.
- Appendicitis: periumbilical pain migrating to the right lower quadrant, guarding, leukocytosis; ultrasound or CT, then appendectomy.
- Acute cholecystitis: right upper quadrant pain, Murphy sign, fever; ultrasound; antibiotics and cholecystectomy.
- Perforation: free air on erect film or CT → surgery, not observation.
- Small bowel obstruction: prior surgery, vomiting, air-fluid levels; nasogastric tube, fluids, and operate if strangulation signs appear (fever, tachycardia, pain out of proportion).
Worked example
A 70-year-old man has left lower quadrant pain for two days, fever 38.6 °C, white count 16,000. CT shows sigmoid diverticulitis with extraluminal air and a localized collection. Reasoning: this is perforated diverticulitis. Extraluminal air plus systemic upset puts him in Hinchey II–III territory. If he is peritonitic or unstable, urgent laparotomy with resection and Hartmann procedure; if stable with a drainable collection, percutaneous drainage plus intravenous antibiotics and bowel rest. Choosing outpatient oral antibiotics is the classic wrong answer.
Traps that cost marks
- Missing the seat-belt sign and a hollow-viscus injury.
- Treating back pain and syncope in an older adult as musculoskeletal when it is a leaking abdominal aortic aneurysm.
- Forgetting hernial orifices in any bowel obstruction.
- Missing compartment syndrome in a limb after fracture.