Surgery
Surgery tests the acute abdomen, trauma resuscitation, wound care, hernia complications, and perioperative risk. The exam expects a structured primary survey and clear operative indications.
Core rules
- Trauma: ABCDE first; control catastrophic bleeding, secure airway, decompress tension pneumothorax, then assess disability and exposure.
- Acute abdomen: assess peritonitis, obstruction, perforation, and ischemia; serial examination and appropriate imaging guide surgery.
- Appendicitis: migrating periumbilical pain to right lower quadrant, McBurney tenderness, leukocytosis; ultrasound or CT when needed.
- Bowel obstruction: vomiting, distension, absent flatus, tympanic abdomen; nasogastric decompression and fluids, but fever, tachycardia, or localized tenderness suggests strangulation and urgent surgery.
- Hernia: irreducible or painful hernia with systemic signs needs emergency repair.
Worked example
A 45-year-old falls from a height and becomes dyspneic and hypotensive. Trachea is deviated, breath sounds are absent on the right, and percussion is hyperresonant. This is tension pneumothorax. Immediate needle decompression in the second intercostal space midclavicular line, followed by chest tube, is required before chest X-ray. Reasoning: tension physiology kills before imaging; treatment is clinical.
Traps
- Giving oral contrast in suspected obstruction.
- Waiting for imaging in a patient with peritonitis or tension pneumothorax.
- Missing strangulation in a hernia because pain is controlled.
- Forgetting tetanus prophylaxis and wound exploration.