Clinical knowledge: medicine and surgery
What the exam asks
The medicine and surgery domain tests pattern recognition of acute adult presentations, safe initial management and recognition of the deteriorating patient. Questions typically give a short vignette, a set of observations, and ask for the next step or the most likely diagnosis.
Core rules
- Use a structured approach (ABCDE) and score the patient: NEWS2 of 5 or more, or 7 in any single parameter, triggers urgent review.
- Sepsis: start the Sepsis Six within one hour when NEWS2 is high with suspected infection - cultures, lactate, urine output, oxygen to target 94-98%, IV antibiotics, fluids.
- Acute coronary syndrome: ECG within 10 minutes. ST elevation in II, III and aVF is an inferior STEMI; primary PCI is the target within 120 minutes.
- AKI (KDIGO): creatinine rise of 26 micromol/L in 48 hours or 1.5 times baseline in 7 days; review nephrotoxins and obstruction first.
- Post-operative fever has a timeline: days 1-2 bleeding or atelectasis, days 3-5 anastomotic leak, days 5-7 wound or chest infection, after day 7 lines and abscess.
Worked example
A 68-year-old smoker has 90 minutes of crushing central chest pain and looks grey and sweaty. ECG shows 2 mm ST elevation in II, III and aVF with reciprocal depression in I and aVL. This is an inferior STEMI: activate primary PCI, give aspirin 300 mg and ticagrelor, and monitor for bradyarrhythmia and heart block. Avoid nitrates if there is right ventricular involvement - hypotension after nitrate is the clue.
Traps
Calling breathlessness an exacerbation of COPD without considering PE or pneumothorax; missing a posterior MI (ST depression in V1-V3); forgetting VTE assessment; correcting hyponatraemia faster than 10 mmol/L in 24 hours.