Surgery & Specialties

Surgery & Specialties for Step 2 CK

Master surgical principles and specialty management with free flashcards and spaced repetition practice. This lesson covers acute abdomen evaluation, perioperative care, trauma management, and subspecialty conditions—essential concepts for USMLE Step 2 CK clinical decision-making.

Welcome to Surgery & Specialties

🏥 Surgery rotations and Step 2 CK questions test your ability to recognize surgical emergencies, understand perioperative management, and know when to consult specialists. Unlike Step 1's focus on mechanisms, Step 2 emphasizes clinical presentation, diagnostic approach, and management decisions. You'll need to differentiate surgical from medical abdomen, recognize complications, understand trauma protocols, and know the basics of major subspecialties including orthopedics, urology, ENT, and ophthalmology.

This comprehensive guide provides a systematic approach to surgical thinking, common presentations, and high-yield specialty topics frequently tested on clinical rotations and Step 2 CK.

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Core Concepts in General Surgery

🔪 The Acute Abdomen

The acute abdomen represents a surgical emergency requiring rapid assessment. Your primary task: surgical vs. medical abdomen.

Clinical Approach Framework:

Component	Key Features	Red Flags
History	Onset, location, character, radiation, timing	Sudden onset, severe intensity, syncope
Exam	Inspection, auscultation before palpation	Peritoneal signs, rigidity, rebound
Labs	CBC, CMP, lipase, lactate, pregnancy test	Elevated lactate, leukocytosis with left shift
Imaging	Upright CXR (free air), CT abdomen/pelvis	Pneumoperitoneum, portal venous gas

💡 Key Principle: Peritoneal signs (guarding, rigidity, rebound tenderness) indicate peritonitis until proven otherwise—this mandates surgical consultation.

Common Surgical Emergencies by Quadrant:

┌────────────────────────────────────────────────┐
│         ABDOMINAL PAIN LOCALIZATION            │
├────────────────┬───────────────────────────────┤
│                │                               │
│  RUQ           │  LUQ                          │
│  • Cholecyst   │  • Splenic rupture            │
│  • Hepatitis   │  • Gastric ulcer              │
│  • Biliary     │  • Pancreatitis               │
│                │                               │
├────────────────┼───────────────────────────────┤
│                │                               │
│  RLQ           │  LLQ                          │
│  • Appendix    │  • Diverticulitis             │
│  • Ectopic     │  • Colon CA                   │
│  • Ovary       │  • Ectopic/ovary              │
│                │                               │
└────────────────┴───────────────────────────────┘

      Epigastric: PUD, pancreatitis, MI
      Periumbilical → RLQ: Appendicitis
      Diffuse: Peritonitis, obstruction, ischemia

🧠 Mnemonic for Acute Abdomen Ddx: "CRAVE HITS"

• Cholecystitis/Cholangitis
• Ruptured AAA/viscus
• Appendicitis
• Volvulus
• Ectopic pregnancy
• Hernia (incarcerated)
• Ischemic bowel
• Torsion (ovarian/testicular)
• Small bowel obstruction

📋 Appendicitis: The Classic RLQ Emergency

Presentation:

• Periumbilical pain migrating to McBurney's point (RLQ)
• Anorexia (almost always present)
• Nausea/vomiting AFTER pain onset
• Low-grade fever (>38.5°C suggests perforation)

Physical Exam Findings:

• Rovsing sign: RLQ pain with LLQ palpation
• Psoas sign: Pain with right hip extension (retrocecal appendix)
• Obturator sign: Pain with internal rotation of flexed right hip (pelvic appendix)

Diagnosis & Management:

• Clinical diagnosis supported by CT (gold standard) or ultrasound (pregnancy/children)
• Alvarado score can help, but high clinical suspicion → surgery
• Treatment: Appendectomy (laparoscopic preferred) + antibiotics
• Perforated: Broader antibiotics, possible drainage if abscess present

⚠️ Common Mistake: Ordering CT in obvious appendicitis delays surgery. If peritoneal signs present with classic history, proceed to OR.

🩸 Small Bowel Obstruction (SBO)

Etiology:

1. Adhesions (60-70%) - most common, from prior surgery
2. Hernias (15-20%) - incarcerated inguinal/femoral
3. Malignancy (10-15%)
4. Inflammatory (Crohn's strictures)

Classic Presentation: "The 4 Cardinal Symptoms"

• Colicky abdominal pain (cramping, intermittent)
• Nausea and vomiting (bilious early, feculent late)
• Abdominal distension
• Obstipation (no passage of gas or stool)

Diagnosis:

• Upright abdominal X-ray: Multiple air-fluid levels, dilated loops
• CT abdomen/pelvis with IV contrast: Gold standard, identifies transition point

Management Algorithm:

        SBO Suspected
             │
             ↓
    NPO + NGT + IVF + Labs
             │
        ┌────┴────┐
        ↓         ↓
    Partial    Complete
        │         │
        ↓         ↓
    Trial of  Surgical?
    Conservative  │
        │     ┌───┴───┐
        │     ↓       ↓
        │   Signs    No signs
        │   of        of
        │   strang   strang
        │     │       │
        │     ↓       ↓
        │   Urgent  Continue
        │    OR    Conservative
        │           24-48h
        └─────┬─────┘
              ↓
        Resolution?
              │
         ┌────┴────┐
         ↓         ↓
       Yes        No
         │         │
         ↓         ↓
      Resume     Surgery
       Diet

⚠️ STRANGULATION SIGNS (surgical emergency!):

• Fever, tachycardia, peritoneal signs
• Constant (not colicky) pain
• Elevated lactate, leukocytosis
• CT: Bowel wall thickening, pneumatosis, closed-loop obstruction

💡 Tip: "Water-soluble contrast challenge" (Gastrografin) is both diagnostic and therapeutic for partial SBO—if contrast reaches colon in 24h, likely to resolve.

🔥 Cholecystitis & Biliary Disease

Spectrum of Disease:

Condition	Presentation	Murphy's Sign	Management
Biliary Colic	RUQ pain 30min-6h after fatty meal, no fever	Negative	Elective cholecystectomy
Acute Cholecystitis	RUQ pain >6h, fever, nausea	Positive	Cholecystectomy within 72h
Choledocholithiasis	Jaundice, RUQ pain, elevated bilirubin/ALP	Variable	ERCP + sphincterotomy, then cholecystectomy
Cholangitis	Charcot triad or Reynolds pentad	Often positive	Urgent ERCP + antibiotics

🧠 Charcot Triad (Cholangitis):

1. Fever (with rigors)
2. Jaundice
3. RUQ pain

Reynolds Pentad = Charcot + sepsis: 4. Altered mental status 5. Hypotension

Diagnostic Approach:

• First test: RUQ ultrasound (stones, wall thickening, pericholecystic fluid)
• If US equivocal: HIDA scan (non-filling GB = cholecystitis)
• For CBD evaluation: MRCP (non-invasive) or EUS

💡 Clinical Pearl: Elevated alkaline phosphatase out of proportion to transaminases suggests biliary obstruction. If CBD dilated on US (>6mm, or >10mm post-cholecystectomy), think choledocholithiasis.

🌀 Bowel Ischemia

Types & Causes:

Type	Etiology	Presentation	Key Finding
Acute Mesenteric Ischemia	Embolism (afib), thrombosis	"Pain out of proportion to exam"	Elevated lactate
Chronic Mesenteric Ischemia	Atherosclerosis (≥2 vessels)	Postprandial pain, food fear, weight loss	Abdominal bruit
Colonic Ischemia	Low flow states, watershed areas	Left-sided cramping, bloody diarrhea	Thumbprinting on X-ray

🚨 Acute Mesenteric Ischemia - HIGH MORTALITY (60-80%)

Classic Scenario: Elderly patient with atrial fibrillation, sudden severe abdominal pain, minimal exam findings initially, then develops peritonitis.

Diagnosis:

• CT angiography: Gold standard (occlusion, pneumatosis intestinalis)
• Labs: Metabolic acidosis, elevated lactate, elevated WBC
• Late findings: Bloody diarrhea, peritoneal signs (indicate transmural infarction)

Management:

• Emergent laparotomy with resection of necrotic bowel
• Revascularization if viable tissue present
• Broad-spectrum antibiotics

💡 Remember: "Pain out of proportion to exam" + atrial fibrillation = mesenteric ischemia until proven otherwise. Don't wait for peritoneal signs—by then, bowel is dead.

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Perioperative Care

📊 Preoperative Risk Assessment

Cardiac Risk Stratification (Revised Cardiac Risk Index - RCRI):

1 point each for:

1. High-risk surgery (vascular, intrathoracic, intraperitoneal)
2. History of ischemic heart disease
3. History of heart failure
4. History of cerebrovascular disease
5. Insulin-dependent diabetes
6. Creatinine >2 mg/dL

Risk of major cardiac event:

• 0 factors: 0.4%
• 1 factor: 1%
• 2 factors: 2.4%
• ≥3 factors: 5.4%

💡 Preoperative Testing Strategy:

• Low risk (<1%): No testing
• Elevated risk + good functional capacity (≥4 METs): Proceed to surgery
• Elevated risk + poor/unknown capacity: Consider stress testing
• Active cardiac conditions: Optimize before elective surgery

🧠 Mnemonic for 4 METs activities: "CLimb 2 FLIGHTS, WALK 4 blocks"

• Can you climb 2 flights of stairs?
• Can you walk 4 blocks?

If yes → good functional capacity, proceed to surgery.

💊 Perioperative Medication Management

Medication	Continue?	Notes
Beta-blockers	✅ Continue	Never stop abruptly (rebound risk)
Statins	✅ Continue	Cardioprotective effects
ACE-I/ARBs	⚠️ Hold day of surgery	Risk of refractory hypotension
Aspirin	✅ Continue (usually)	Exception: intracranial, spinal surgery
Clopidogrel	❌ Hold 5-7 days	If recent stent: discuss with cardiology
Warfarin	❌ Hold 5 days	Bridge if high thrombosis risk
DOACs	❌ Hold 24-48h	Based on renal function
Metformin	⚠️ Hold day of	Risk of lactic acidosis with contrast
Insulin	⚠️ Adjust dose	Continue basal, hold short-acting

⚠️ Critical Exception: Patients with drug-eluting stents require dual antiplatelet therapy (aspirin + P2Y12 inhibitor). Premature discontinuation → stent thrombosis → MI/death. If surgery is elective, wait:

• Bare metal stent: 30 days
• Drug-eluting stent: 6-12 months

🩹 Postoperative Complications

Timeline Approach to Post-Op Fever: "The 5 W's"

┌─────────────────────────────────────────────┐
│     POST-OP FEVER TIMELINE (5 W's)          │
├──────────┬──────────────────────────────────┤
│  Day 1   │  Wind (atelectasis)              │
│  POD 0-2 │  💨 Most common cause            │
│          │  Prevention: incentive spirometry│
├──────────┼──────────────────────────────────┤
│  Day 3   │  Water (UTI)                     │
│  POD 3-5 │  🚰 Especially if catheterized   │
├──────────┼──────────────────────────────────┤
│  Day 5   │  Walking (DVT/PE)                │
│  POD 5-7 │  🚶 Check for calf tenderness    │
├──────────┼──────────────────────────────────┤
│  Day 7   │  Wound (surgical site infection) │
│  POD 7+  │  🔪 Erythema, drainage, warmth   │
├──────────┼──────────────────────────────────┤
│  Day 10  │  Wonder drugs (drug fever)       │
│  POD 10+ │  💊 Diagnosis of exclusion       │
└──────────┴──────────────────────────────────┘

💡 Pearl: POD 3-5 fever in post-abdominal surgery patient → think intra-abdominal abscess if patient appears toxic or has peritoneal signs.

Anastomotic Leak

High-risk surgeries: Esophagectomy, low anterior resection (colorectal)

Presentation (POD 5-7):

• Fever, tachycardia, abdominal pain
• Elevated WBC, increased drain output
• May present subtly with persistent ileus

Diagnosis: CT with water-soluble contrast (Gastrografin)

Management:

• Small contained leak: NPO, antibiotics, drainage
• Large/free perforation: Return to OR

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Trauma Surgery

🚑 ATLS Primary Survey: "ABCDE"

The first 60 seconds ("Golden Minute") determines survival.

┌────────────────────────────────────────────────┐
│           PRIMARY SURVEY - ATLS                │
├────────────────────────────────────────────────┤
│                                                │
│  🅰️  AIRWAY (with C-spine protection)         │
│      ↓                                         │
│      • GCS ≤8 → intubate                       │
│      • Maintain inline stabilization           │
│                                                │
│  🅱️  BREATHING (ventilation & oxygenation)    │
│      ↓                                         │
│      • Inspect, auscultate both sides          │
│      • Tension PTX? → needle decompression     │
│                                                │
│  ©️  CIRCULATION (hemorrhage control)          │
│      ↓                                         │
│      • 2 large-bore IVs                        │
│      • FAST exam for bleeding                  │
│      • Hypotension = blood loss until proven   │
│                                                │
│  🅳  DISABILITY (neurologic status)            │
│      ↓                                         │
│      • GCS, pupil exam                         │
│      • AVPU scale                              │
│                                                │
│  🅴  EXPOSURE (full body exam + prevent        │
│      hypothermia)                              │
│                                                │
└────────────────────────────────────────────────┘

🩸 Hemorrhagic Shock Classification

Class	Blood Loss	HR	BP	RR	Mental Status
I	<15% (<750mL)	<100	Normal	14-20	Normal/Anxious
II	15-30% (750-1500mL)	100-120	Normal	20-30	Anxious
III	30-40% (1500-2000mL)	120-140	Decreased	30-40	Confused
IV	>40% (>2000mL)	>140	Decreased	>35	Lethargic

💡 Key Concept: Class III-IV shock requires blood transfusion. In massive transfusion, use 1:1:1 ratio (RBC:FFP:Platelets) to prevent coagulopathy.

🫁 Thoracic Trauma: Life-Threatening "Big 6"

Immediate Recognition Required:

1. Tension Pneumothorax

• Absent breath sounds, tracheal deviation AWAY from affected side
• Hypotension, distended neck veins
• Treatment: Needle decompression (2nd intercostal space, midclavicular line) BEFORE chest X-ray

2. Massive Hemothorax

• 1500mL blood or 200mL/hr for 4 hours

• Treatment: Chest tube → thoracotomy if persistent bleeding

3. Cardiac Tamponade (Beck's Triad)

• Hypotension, muffled heart sounds, distended neck veins
• Treatment: Pericardiocentesis or pericardial window

4. Open Pneumothorax ("Sucking Chest Wound")

• Treatment: Occlusive dressing taped on 3 sides (flutter valve)

5. Flail Chest

• ≥2 ribs broken in ≥2 places → paradoxical chest movement
• Treatment: Pain control, pulmonary toilet, possible mechanical ventilation

6. Aortic Disruption

• Widened mediastinum on CXR (>8cm)
• Diagnosis: CT angiography
• Treatment: Urgent TEVAR or open repair

🏥 FAST Exam (Focused Assessment with Sonography for Trauma)

4 windows examined:

1. Perihepatic (Morrison's pouch) - most sensitive
2. Perisplenic (splenorenal recess)
3. Pelvic (pouch of Douglas)
4. Pericardial

Positive FAST in unstable patient = immediate laparotomy

💡 Limitations: Poor sensitivity for hollow viscus injury, retroperitoneal injury, diaphragm injury.

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Orthopedic Emergencies

🦴 Fractures Requiring Urgent Management

1. Open Fractures (Gustilo Classification)

• Type I: Wound <1cm, minimal soft tissue damage
• Type II: Wound 1-10cm, moderate contamination
• Type III: Wound >10cm, extensive damage, vascular injury

Management:

• Immediate IV antibiotics (cefazolin + gentamicin for Type III)
• Tetanus prophylaxis
• Surgical debridement and stabilization within 6-8 hours

2. Compartment Syndrome

Clinical Features ("The 5 P's"):

• Pain out of proportion (earliest sign)
• Pressure (compartment firm/tense)
• Pallor
• Paresthesias
• Pulselessness (late finding - irreversible damage)
• Paralysis (late finding)

⚠️ Critical Error: Waiting for "late" signs (pulselessness, paralysis). Severe pain with passive stretch = compartment syndrome until proven otherwise.

Diagnosis:

• Clinical diagnosis primarily
• Compartment pressure >30mmHg or within 30mmHg of diastolic BP

Treatment: Emergency fasciotomy - do NOT delay!

3. Hip Fracture in Elderly

• Surgery within 24-48 hours improves outcomes
• Femoral neck: Risk of avascular necrosis → hemiarthroplasty vs. ORIF
• Intertrochanteric: ORIF with sliding hip screw

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Urology

🔴 Testicular Torsion

🚨 "Time is testicle" - surgical emergency!

Presentation:

• Sudden onset severe testicular pain
• Nausea/vomiting common
• Absent cremasteric reflex (most sensitive physical finding)
• High-riding testis with abnormal lie

Diagnosis:

• Clinical diagnosis - do NOT delay for imaging if high suspicion
• Doppler ultrasound: Decreased/absent blood flow (but can be falsely reassuring)

Management:

• Manual detorsion: "Open the book" - rotate lateral to medial
• Surgical exploration within 6 hours for viable testis
• Bilateral orchiopexy (contralateral testis at risk)

💡 Pearl: Testicular torsion is most common in neonates and adolescents (12-18 years). If history + exam suggestive, go straight to OR.

🩸 Hematuria Workup

Gross Hematuria Approach:

    Gross Hematuria
         │
         ↓
    Hemodynamically
    stable?
         │
    ┌────┴────┐
    ↓         ↓
   No        Yes
    │         │
    ↓         ↓
 Resuscitate  History/Exam
 CBI if       │
 clots        ↓
             Trauma?
             │
        ┌────┴────┐
        ↓         ↓
       Yes       No
        │         │
        ↓         ↓
    CT urogram  CT abdomen/pelvis
    Grade      +
    injury     Cystoscopy
               │
               ↓
           >40yo or
           Risk factors?
               │
               ↓
          Rule out
          malignancy

Renal Trauma Grading (AAST):

• Grade I-II: Contusion, subcapsular hematoma → observation
• Grade III: Cortical laceration <1cm depth → observation
• Grade IV-V: Major laceration, vascular injury → may require intervention

💡 Management: Most blunt renal trauma managed conservatively. Indications for surgery: hemodynamic instability despite resuscitation, expanding/pulsatile hematoma, renal pedicle avulsion.

💎 Nephrolithiasis

Presentation: Colicky flank pain radiating to groin, hematuria

Diagnostic Test: Non-contrast CT abdomen/pelvis (gold standard)

Management Based on Stone Size:

• <5mm: 90% pass spontaneously - hydration, NSAIDs, alpha-blocker (tamsulosin)
• 5-10mm: 50% pass - trial of medical expulsive therapy
• >10mm: Unlikely to pass - intervention needed

Intervention Options:

• Shock wave lithotripsy (SWL): <2cm stones
• Ureteroscopy: Mid/distal ureter stones
• Percutaneous nephrolithotomy (PCNL): Large/staghorn calculi

🚨 Indications for Urgent Intervention:

• Infected hydronephrosis (obstructive pyelonephritis) → sepsis risk
• Bilateral obstruction or solitary kidney
• Intractable pain/vomiting
• Acute kidney injury

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Otolaryngology (ENT)

👃 Epistaxis Management

Initial Management (Anterior Bleed - 90%):

1. Upright position, lean forward
2. Pinch nasal ala for 10-15 minutes
3. If continues → anterior nasal packing or cautery

Posterior Bleed (10%):

• Bleeding continues despite anterior packing
• Blood in oropharynx
• Requires posterior packing or balloon tamponade
• Admit for monitoring (risk of hypoxia, aspiration)

⚠️ Severe/Recurrent: Consider sphenopalatine artery ligation or embolization

🌬️ Acute Epiglottitis

Classic Triad:

1. Drooling
2. Dysphagia
3. Distress (respiratory)

Additional findings:

• High fever, toxic appearance
• Tripod position (sitting, leaning forward)
• Muffled "hot potato" voice
• Thumb sign on lateral neck X-ray (swollen epiglottis)

⚠️ CRITICAL Management:

• DO NOT examine throat - may precipitate complete airway obstruction
• Secure airway in OR with ENT/anesthesia present
• IV antibiotics (ceftriaxone)

💡 Etiology: Haemophilus influenzae type B (now rare due to vaccination), Streptococcus, Staphylococcus

😴 Obstructive Sleep Apnea (OSA)

Diagnostic Criteria (Polysomnography):

• Apnea-Hypopnea Index (AHI) = events per hour
  • Mild: 5-15
  • Moderate: 15-30
  • Severe: >30

Complications:

• Pulmonary hypertension, right heart failure
• Increased cardiovascular risk
• Daytime somnolence → motor vehicle accidents

Management:

• First-line: CPAP
• Weight loss if obese
• Surgical options: Uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement

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Ophthalmology Emergencies

👁️ Acute Angle-Closure Glaucoma

Presentation:

• Sudden onset severe eye pain
• Decreased vision, halos around lights
• Nausea/vomiting
• Mid-dilated, non-reactive pupil
• Firm globe on palpation
• Corneal edema ("steamy" appearance)

Diagnosis: Intraocular pressure (IOP) >21 mmHg (often >40-50 in acute attack)

Immediate Treatment (lower IOP):

Medication	Mechanism	Route
Timolol	Decrease aqueous production	Topical
Pilocarpine	Pupillary constriction (opens angle)	Topical
Acetazolamide	Decrease aqueous production	PO/IV
Mannitol	Osmotic agent	IV

Definitive: Laser peripheral iridotomy (create hole in iris)

💡 Risk Factors: Hyperopia (farsightedness), Asian ethnicity, family history, medications (anticholinergics, topiramate)

🔴 Central Retinal Artery Occlusion (CRAO)

"Eye stroke" - ophthalmologic emergency!

Presentation:

• Sudden, painless, unilateral vision loss
• Afferent pupillary defect (Marcus Gunn pupil)
• Cherry-red spot on macula (fundoscopy)
• Pale retina with "boxcar" segmentation of vessels

Etiology: Embolism (carotid atherosclerosis, cardiac source)

Management:

• Ocular massage (attempt to dislodge embolus)
• Lower IOP: Acetazolamide, anterior chamber paracentesis
• Hyperbaric oxygen (controversial)
• Workup for embolic source: Carotid ultrasound, echocardiogram

Prognosis: Poor - permanent vision loss common. Window for treatment <90 minutes.

🌟 Retinal Detachment

Presentation:

• Floaters ("spots")
• Photopsia (flashing lights)
• "Curtain" or shadow across visual field
• Painless

Risk Factors: Myopia, trauma, prior cataract surgery, family history

Diagnosis: Dilated fundoscopic exam

Management: Urgent ophthalmology referral for surgical repair (pneumatic retinopexy, scleral buckle, vitrectomy)

---

Common Mistakes to Avoid

⚠️ Surgery Decision-Making Errors

1. Delaying surgery for "more tests" in obvious surgical abdomen

• Peritoneal signs = surgical consultation NOW
• CT won't change management if perforation/peritonitis obvious

2. Missing compartment syndrome

• Don't wait for "5 P's" - pain out of proportion is enough
• Pulses can be present with compartment syndrome

3. Assuming negative FAST = no injury

• FAST only detects free fluid (blood)
• Can miss hollow viscus, diaphragm, retroperitoneal injuries
• Unstable patient with negative FAST → DPL or exploratory laparotomy

4. Ordering unnecessary preoperative testing

• Healthy patient <40 years for low-risk surgery: No tests needed
• Order tests only if they will change management

5. Stopping aspirin before all surgeries

• Continue aspirin for most surgeries (cardioprotective benefit outweighs bleeding risk)
• Exception: neurosurgery, ophthalmologic surgery

⚠️ Trauma Management Errors

6. Assuming hypotension is "neurogenic shock" without excluding hemorrhage

• Neurogenic shock: Bradycardia + hypotension (loss of sympathetic tone)
• Hemorrhagic shock: Tachycardia + hypotension
• Rule out bleeding first!

7. Performing needle decompression on wrong side

• Trachea deviates AWAY from tension pneumothorax
• Decreased breath sounds on affected side

8. Waiting for imaging in testicular torsion

• High clinical suspicion = take to OR
• Every hour delay decreases salvage rate

⚠️ Specialty-Specific Errors

9. Examining throat in suspected epiglottitis

• Can precipitate complete airway obstruction
• Visualize only in OR with airway equipment ready

10. Using pilocarpine before steroids in acute angle-closure

• Inflamed eye won't respond to pilocarpine
• Can worsen closure through paradoxical lens thickening

---

Key Takeaways

🎯 Essential Surgical Principles

Recognition:

• Peritoneal signs (rigidity, rebound, guarding) = surgical abdomen
• Pain out of proportion to exam = ischemia or compartment syndrome
• Sudden onset + severe pain = vascular event or perforation

Acute Abdomen Top 3:

1. Appendicitis - periumbilical → RLQ, anorexia
2. Cholecystitis - RUQ pain >6h, Murphy's sign, fever
3. Small bowel obstruction - colicky pain, distension, obstipation

"Can't Miss" Diagnoses:

• Ruptured AAA (elderly, abdominal/back pain, hypotension)
• Ectopic pregnancy (reproductive-age female, abdominal pain, positive βhCG)
• Mesenteric ischemia (atrial fibrillation, pain out of proportion)
• Testicular torsion (acute testicular pain, absent cremasteric reflex)

Perioperative Care:

• Cardiac risk: RCRI score, functional capacity assessment
• Continue: Beta-blockers, statins, aspirin (usually)
• Hold: ACE-I (day of), anticoagulants (days before)
• Post-op fever: Timeline approach (5 W's)

Trauma ABC:

• Airway (C-spine), Breathing (tension PTX), Circulation (hemorrhage control)
• Hypotension in trauma = blood loss until proven otherwise
• Tension pneumothorax: Needle decompression BEFORE X-ray

Orthopedic Emergencies:

• Compartment syndrome: Pain with passive stretch → fasciotomy
• Open fracture: Antibiotics + urgent debridement

Specialty Emergencies:

• Testicular torsion: Detorsion within 6 hours
• Angle-closure glaucoma: Lower IOP, laser iridotomy
• Epiglottitis: Secure airway in OR, don't examine throat
• CRAO: Ocular massage, lower IOP (poor prognosis)

---

📚 Further Study

1. American College of Surgeons - ATLS Student Course Manual (https://www.facs.org/quality-programs/trauma/atls/) - Gold standard for trauma management protocols and systematic approach to injured patients

2. UpToDate - Acute Abdomen in Adults (https://www.uptodate.com) - Comprehensive, evidence-based review of surgical emergencies with diagnostic algorithms and management strategies

3. Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines (https://www.east.org/education-resources/practice-management-guidelines) - Evidence-based guidelines for trauma and acute care surgery scenarios

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🎓 Final Exam Tip: Step 2 CK surgery questions focus on recognition and initial management. Know when to consult surgery (peritoneal signs), when surgery is urgent (6-hour window for torsion/compartment syndrome), and basic trauma protocols (ATLS). You don't need to know surgical techniques—focus on diagnosis and appropriate referral.