Surgery: Prioritizing Resuscitation, Diagnosis, and Operative Indication
Surgical items test judgment under time pressure. Structure your thinking around three questions: is the patient unstable, is there a surgical emergency, and what is the least invasive definitive management?
Core content
Know the acute abdomen differentials - appendicitis, cholecystitis, pancreatitis, perforated viscus, bowel obstruction, ischemia, and strangulation. Understand trauma priorities (airway, breathing, circulation, disability, exposure) and the role of FAST versus CT in the stable versus unstable patient. Learn wound classification, timing of antibiotic prophylaxis, and principles of anastomotic healing. Familiarize yourself with hernia complications, thyroid and breast lumps, and perioperative risk assessment.
Traps
- Unstable trauma patient: do not send to CT; the operating room or bedside intervention comes first.
- Bowel obstruction: distinguish simple from strangulated; fever, tachycardia, pain out of proportion, and rising lactate push toward surgery.
- Pancreatitis: severity scoring and early fluid resuscitation matter more than immediate imaging in the stable patient.
- Antibiotics: prophylaxis is given before incision, not after.
- Test selection: ultrasound first for gallbladder and obstetric concerns; CT for stable abdominal pathology.
Rule of thumb
If the stem includes hypotension, peritonitis, or free air, the answer is almost always operative or resuscitative rather than "admit and observe." Conversely, if the patient is stable and the diagnosis is uncertain, choose the diagnostic study that changes management.
Worked example
A young man with right lower quadrant pain, fever, and rebound tenderness has appendicitis. If the stem describes generalized rigidity and hypotension, the answer shifts: resuscitate and proceed to the operating room for perforation rather than ordering further imaging.