General Surgery
What General Surgery tests
Surgical questions in the Palestinian Board Part I centre on the acute abdomen, trauma resuscitation, complicated hernia, biliary disease, wound care, and recognition of the patient who needs an operation now rather than tomorrow. The exam rewards a structured approach: resuscitate, diagnose, then decide on timing and route of surgery.
Core rules
- Trauma: primary survey in order - catastrophic haemorrhage control, airway with cervical protection, breathing (needle decompression for tension pneumothorax before any imaging), circulation with IV access and balanced blood-product resuscitation, disability (GCS), exposure.
- Appendicitis is largely a clinical diagnosis; ultrasound or CT is used when the picture is equivocal.
- Inguinal hernia: irreducibility with pain, vomiting or absent flatus suggests strangulation - urgent surgery; do not attempt reduction of a tender irreducible hernia.
- Post-operative fever: timing narrows the cause - day 1–2 atelectasis, day 3–5 urinary or line infection, day 5–7 wound infection, day 7–10 anastomotic leak or abscess.
Worked example
A 62-year-old has right upper quadrant pain, fever of 39 °C, jaundice, confusion and blood pressure 85/50 mmHg. Reason: this fits ascending cholangitis with sepsis (Reynolds pentad). The immediate actions are resuscitation with fluids, blood cultures and broad-spectrum antibiotics covering Gram-negative bacilli and anaerobes, then urgent biliary drainage by ERCP rather than immediate open cholecystectomy in an unstable patient. Cholecystectomy follows once the patient is stabilised.
Traps
Taking an unstable trauma patient to CT before resuscitation; attributing lower abdominal pain in a woman of reproductive age to appendicitis without a pregnancy test; assuming a reducible hernia is safe when it is exquisitely tender; forgetting that analgesia does not mask surgical signs and should not be withheld.